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Current guidelines suggest that cardiac arrest (CA) survivors should be ventilated with 100% O2 after resuscitation. Breathing 100% O2 may worsen neurological outcome after experimental CA. This study tested the hypothesis that graded reoxygenation, with oximetry guidance, can safely reduce FiO2 after resuscitation, avoiding hypoxia while promoting neurological recovery.
Mature dogs underwent 10 minutes of CA and restoration of spontaneous circulation with100% O2. Animals were randomized to 1-hour additional ventilation on 100% FiO2 or to rapid lowering of arterial O2 saturation to <96% but >94% with pulse oximeter guidance. Animals were awakened at hour 23, and the neurological deficit score (0=normal; 100=brain-dead) was measured. Reanesthetized animals were perfusion-fixed and the brains removed for histopathology.
The neurological deficit score was significantly better in oximetry (O) dogs. O dogs appeared aware of their surroundings, whereas most hyperoxic (H) animals were stuporous (neurological deficit score=43.0±5.9 [O] versus 61.0±4.2 [H]; n=8, P<0.05). Stereological analysis revealed fewer injured CA1 neurons in O animals (cresyl violet: 35.5±4.3% [O] versus 60.5±3.3% [H]; P<0.05). There were also fewer fluoro-Jade B-stained degenerating CA1 neurons in O animals (3320±267 [O] versus 6633±356 [H] per 0.1 mm3; P<0.001).
A clinically applicable protocol designed to reduce postresuscitative hyperoxia after CA results in significant neuroprotection. Clinical trials of controlled normoxia after CA/restoration of spontaneous circulation should strongly be considered.
Oxidative stress plays a critical role in ischemia/reperfusion injury to the brain after cardiac arrest/restoration of spontaneous circulation (CA/ROSC). Evidence that oxidative stress is a primary determinant of outcome after cerebral ischemia comes from correlations of markers of oxidative stress with the extent of neuronal death and neuroprotection by antioxidants.1,2 These findings are supported by genetic animal models demonstrating neuroprotection by knocking out those enzymes that promote oxidative stress or by overexpressing antioxidant enzymes that protect against oxidative injury.3 Virtually every cellular and extracellular molecular component is potentially sensitive to damage caused by oxidative stress. Oxidative modification to DNA, RNA, proteins, lipids, and small metabolites occurs during ischemia/reperfusion.4
There currently exists no evidence-based guideline for postresuscitative O2 therapy after CA. Despite the knowledge that oxidative stress can increase neurological injury after resuscitation, clinicians treating CA survivors rarely consider lowering the FiO2. In fact, current advanced cardiac life support guidelines mandate "To improve oxygenation, healthcare providers should give 100% inspired oxygen during basic life support and advanced cardiovascular life support as soon as it becomes available."5 Mounting experimental evidence suggests, however, that routine administration of high concentrations of O2 may contribute to significant neurological injury after CA/ROSC.
Supranormal tissue O2 levels during reoxygenation after exposure of rat cortical brain slices to severe hypoxia are correlated with the severity of neuronal damage.6 Gerbils treated with 100% O2 after 15 minutes of bilateral carotid occlusion sustained increased white matter damage compared with those exposed to room air.7 On a neurochemical level, hyperoxic reperfusion worsens the postischemic oxidized shift in tissue redox state8 and exacerbates brain lipid as well as protein oxidation.9,10 One key protein that is preferentially inactivated during hyperoxic resuscitation is pyruvate dehydrogenase, resulting in increased tissue lactic acidosis after resuscitation with 100% O2 compared with normoxic resuscitation.9,10 Finally, animals ventilated with 100% O2 for as little as 1 hour after 9 to 10 minutes of CA demonstrate significantly worse clinical10,11 and histopathological9 outcomes when compared with animals similarly resuscitated with room air.
Although we and others have found that animals are adequately oxygenated with FiO2s in the range of 21% to 30% after CA, use of such low ventilatory O2 is impractical and dangerous for humans undergoing initial resuscitation. Many of these patients require high FiO2 for adequate oxygenation because of existing pulmonary or cardiac dysfunction. Some evidence also suggests that pulmonary compliance is reduced during CA, thus limiting oxygenation during resuscitation even at high FiO2.12 Moreover, preclinical studies do not support a neuroprotective effect of hypoxic resuscitation.13,14
Preclinical evidence suggests that to limit oxidative brain injury, postresuscitative ventilation should be tailored to minimize hyperoxia while simultaneously avoiding hypoxemia. Widespread use of pulse oximetry allows the clinician continuous access to information regarding patient oxygenation. This study was designed to test the hypothesis that postresuscitative pulse oximetry-guided O2 delivery would minimize neurological injury after experimental CA.
All animal experiments were approved by the University of Maryland institutional animal care and use committee. Single-source adult female beagles (N=17) were studied with our laboratory's well-established model of CA/ROSC.10,15,16 A peripheral intravenous line was established, and anesthesia was induced with pentobarbital (12.5 mg/kg) and maintained with α-chloralose (75 mg/kg) during surgery and preparation. Animals were intubated and mechanically ventilated with room air. Core body temperature was continuously monitored and maintained at physiological levels (rectal temperature >37°C and <38.5°C). Left femoral arterial and venous cutdowns were placed for drug delivery, central venous pressure and blood pressure monitoring, and arterial blood gas (ABG) sampling. A left lateral thoracotomy was performed on all animals.
Ventricular fibrillation CA was initiated with a 250-Hz, square-wave DC pulse to the right ventricle and allowed to persist untreated for 10 minutes. At the end of this period, epinephrine (0.02 mg/kg) and sodium bicarbonate (1 mEq/kg) were administered intravenously, simultaneously with the resumption of ventilation with 100% O2 and the performance of open-chest cardiopulmonary resuscitation (CPR) for 3 minutes, followed by internal defibrillation at 5 J.
Animals were then randomized to receive either hyperoxic (H) resuscitation (100% O2 for 1 hour after resuscitation) followed by ABG-guided adjustments to physiological O2 levels or pulse oximetry-guided, normoxic ventilation (O). O dogs were similarly resuscitated with 100% O2 during CPR in an attempt to reproduce current clinical resuscitation protocols. However, hemoglobin O2 saturation was continuously monitored in these dogs via pulse oximetry measured on the underside of the tongue. Pulse oximetry measurements were always found to be 99% to 100% immediately after ROSC; inspired O2 in this group was then decreased to 50%. Further reductions of 5% of inspired O2 were performed every 2 minutes until O2 desaturation (96%) was noted. This particular value was chosen because clinical studies in humans have demonstrated that pulse oximetry readings of 96% will ensure that the ABG-measured O2 saturation is >90%, thus avoiding both hypoxia and hyperoxia.17 At this point, ABG was measured, and pulse oximetry was no longer used to guide respiratory parameters. With this protocol, inspired O2 was reduced in the O dogs safely to 21% to 30% within 12 minutes of ROSC.
All animals received intensive care for 24 hours after ROSC according to a standardized protocol. A morphine drip (0.1 mg · kg-1 · h-1, with additional boluses as needed) provided analgesia during intensive care. Pancuronium (0.1 mg/kg) was used intermittently, only as needed, to facilitate ventilation and only after verification that the animal was adequately sedated. Ventilation was adjusted to maintain aPaCO2 of 30 to 35 and a PaO2 of 80 to 100 torr. At hour 20 analgesia was lightened, and animals were weaned from controlled ventilation. At hour 23 morphine was reversed with naloxone (0.4 mg/kg), and the neurological deficit score (NDS) was measured by 2 examiners blinded to treatment protocol. The NDS used has been validated in other laboratories18 as well as ours10,15 and is a multisystem test of 18 parameters in 5 categories (level of consciousness, respiration, cranial nerve, motor, sensory, behavior), yielding a score between 0 (normal) and 100 (brain death). Animals were reanesthetized with pentobarbital and α-chloralose, intubated, and mechanically ventilated.
At hour 24, dogs were transcardially perfused with cold 1% paraformaldehyde in phosphate buffer for 1 minute followed by cold 4% paraformaldehyde for 10 minutes. After the brain was removed from the skull, it was postfixed for 7 days in 4% paraformaldehyde. Coronal blocks, cut so that they contained the entire hippocampus, were postfixed in 2.5% acrolein (EM grade, Polysciences) solution in 4% paraformaldehyde, pH 6.8, for 2 hours. After 24 hours postfixation in the 4% paraformaldehyde, pH 6.8, the blocks were transferred into 30% sucrose. Once the blocks sunk to the bottom of the containers, they were cut on a sliding microtome while frozen on crushed dry ice. The coronal sections were cut 40 μm thick, and 24 series per animal were produced. These sections were kept in cryoprotectant at -20C° until further processing was initiated.19
The sections were placed in 50%, 75%, and 95% ethanol for 5 minutes each and in 100% ethanol for 6 hours. The sections were then rehydrated in 95%, 75%, and 50% ethanol and water for 5 minutes each and treated with cresyl violet solution (FD NeuroTechnologies) for 2 minutes. Subsequently, the sections were placed in 0.1% acetic acid in 75% ethanol for 2 minutes, rinsed in water, dehydrated, and mounted in DPX.
The sections were immersed in 100% ethanol for 3 minutes, followed by 1 minute in 70% ethanol and a 1-minute rinse in water. Slides were then transferred to 0.06% potassium permanganate for 15 minutes. After 2 more rinses, sections were placed in 0.001% fluoro-Jade B (Chemicon International) in 0.1% acetic acid for 30 minutes at room temperature in the dark. After being stained, the sections were rinsed 3 times with distilled water. The slides were dried, immersed in xylene, and mounted with DPX. Sections were examined under a fluorescence microscope with fluorescein isothiocyanate filter sets.
Materials included in the quantitative analyses were taken from the dorsal hippocampus. One hemisphere per animal and 1 coronal block containing the entire hippocampus were selected for quantitative analyses. From a random starting point, a 1-in-24 series of 40-μm-thick sections was stained with cresyl violet or fluoro-Jade B. Cresyl violet-stained sections were used for estimating total neuronal numbers of normal and dying (apoptotic or necrotic) neurons in the dorsal part of hippocampal CA1 regions. Quantitative analyses were performed by a blinded investigator (I.B.) with a computer-assisted image analysis system consisting of a Nikon Eclipse E800 microscope equipped with a MicroBrightField 3-axis, computer-controlled motorized stage; an Optronics 1-CCD digital video camera; a PC workstation; and StereoInvestigator program (MicroBrightField), a custom-designed morphology and stereology software package. Tracings were made from the rostral through the caudal extent of the dorsal hippocampus. A total of 6 tracings were made per hippocampus, per hemisphere, for each animal. After outlining the boundaries of the CA1 fields at low magnification (×4) on the computer graphics display in each section separately, the software placed within each subfield boundary a set of optical counting frames (55×55 μm) in a systematic-random fashion. Cresyl violet-stained normal and dying neurons (ie, necrotic and apoptotic cells) were then counted in optical dissectors 7 μm in depth, according to stereological principles.20,21 All analyses were performed with a Nikon Plan Apo ×100/1.40 oil objective. Cresyl violet-stained normal neurons were defined as large cells with identifiable nuclei and discrete nucleoli. Neurons showing a clear accumulation of dense, globular material in the cytoplasm with evidence of nuclear fragmentation were considered apoptotic, whereas necrotic neurons were defined as cells showing shrunken perikarya and darkly stained nuclei of reduced size. In each region, at least 500 neurons were sampled to ensure robustness of the data.22 Fluoro-Jade B-stained sections were used for estimating the total number of dying neurons in a 0.1-mm3 volume of the dorsal CA1 region with the StereoInvestigator program.
All data are expressed as mean±SE. Physiological parameters were compared with the 2-sample t test. NDS scores were compared with a 2-tailed Mann-Whitney U test. Differences in quantitative histopathology were analyzed with the Mann-Whitney rank-sum test. In all cases, P<0.05 was considered significant.
All animals were successfully resuscitated from CA with a single shock. However, 1 animal was excluded before randomization because of profound postresuscitative hypotension. Careful physiological monitoring was performed for the entire postresuscitative period; comparative analysis focused on the period before and shortly after CA. Detailed results are provided in the Table. There were no baseline differences in any hemodynamic or respiratory parameters between groups before CA. Hemodynamic parameters were also compared at 30 and 60 minutes after ROSC. Although no differences were noted between groups at 60 minutes, mean arterial pressure was significantly higher in the O group at 30 minutes. At 60 minutes (end of hyperoxia), PO2 was markedly increased in the H group, as expected, whereas O-group dogs demonstrated PO2 values comfortably within designated physiological parameters. PO2 remained mildly elevated at 120 minutes in H dogs despite the ABG-guided lowering of inspired O2.
Animals were weaned from controlled ventilation beginning at hour 20 after ROSC. A standardized NDS was then measured by 2 blinded investigators. Graphical representation of individual NDS values is provided in Figure 1. Animals resuscitated with the O protocol demonstrated significantly better neurological outcome than those resuscitated with 100% O2 (43±6 [O group] versus 61±4 [H group]; P<0.02). Six of 8 dogs in group O demonstrated better neurological outcome than any group H animal. In clinical terms, several animals in the O group attempted to stand and drink. In contrast, none of the animals in the H group attempted to right themselves. Several demonstrated purposeless repetitive running motions or opisthotonos.
We used unbiased stereological methods to estimate the difference in neuronal damage between treatment groups. Twenty-four hours after CA/ROSC, we assessed neuronal damage in the dorsal hippocampal CA1 region. At high resolution, dying neurons appear shrunken, with condensed nuclei lacking a nucleolus (Figure 2). Cresyl violet-stained neurons in representative nonischemic control animals appeared normal, as expected. StereoInvestigator analysis of the cresyl violet-stained sections revealed 63.7%±3.1 dying neurons in the dorsal CA1 region after H resuscitation (Figure 3). Although there were abnormal neurons (37.8%±3.7) in the dorsal CA1 region after O-based resuscitation, the fraction of cells exhibiting abnormal morphology was much smaller in the O group (P<0.001). Fluoro-Jade B staining confirmed these results (Figure 2). The number of fluoro-Jade B-positive (dying) neurons in a 0.1-mm3 volume of the dorsal CA1 region of the H dogs was significantly higher than for similar O-reoxygenated animals (6633±356 versus 3320±267; P≤0.001; Figure 4).
The results of this study validate and expand the results previously reported in our clinically relevant model of CA/ROSC. We have demonstrated significant clinical10 as well as histological9 neuroprotection afforded to animals resuscitated with room air after 10 minutes of CA compared with similar animals resuscitated with 100% O2 for as little as 1 hour. In addition, normoxic animals showed significantly less protein oxidation in the selectively vulnerable hippocampal CA1 region. In particular, animals resuscitated with room air showed significantly greater enzyme activity and immunoreactivity for pyruvate dehydrogenase,9,23 a key enzyme of metabolism that may contribute to cerebral metabolic derangements for 24 hours or longer after CA/ROSC.24,25
The goal of any preclinical translational trial, however, must be to provide the background information necessary to develop safe, human clinical trials with a reasonable expectation of positive outcomes. Although our earlier studies have been extremely promising and although our large-animal model closely mimics the clinical scenario of human CA/ROSC, the protocol used in those studies would not easily translate to human trials. The animals used were healthy at baseline; as such, we were able to successfully resuscitate all animals without supplemental O2 and then provide minimal O2 support in the postresuscitative phase. In contrast, most humans undergoing CA have underlying cardiopulmonary disease, which would make initial resuscitation difficult, if not impossible, in the absence of supplemental O2.
We thus attempted to design a clinical paradigm whereby supplemental O2 would be provided to all CA victims during CPR in an attempt to maximize initial resuscitation, followed by rapid pulse oximetry-guided lowering of inspired O2 to physiological levels, thus simultaneously avoiding the potentially damaging extremes of both hyperoxia and hypoxia. Although this protocol has proven experimentally feasible, we were concerned at the outset that even a short exposure to supplemental O2 would worsen neurological outcomes because of the well-described respiratory burst of O2 free radicals that occurs almost immediately on reperfusion after complete global ischemia.26
We chose to use pulse oximetry to guide O2 titration rather than ABGs because of its ease of use as well widespread availability in both prehospital and hospital settings. With pulse oximetry guidance, we were able to safely and rapidly lower inspired O2 after resuscitation, reaching physiological levels of arterial O2 within 12 minutes. Animals receiving O2 titration in this manner demonstrated improved clinical as well as histological outcomes. The utility of pulse oximetry in the critical patient is sometimes questioned, with early studies showing a disparity between pulse oximeter-measured O2 saturations and blood gas values.27,28 New pulse oximeter technology,29 however, as well as alternative probe sampling sites,30 have been shown to greatly increase the utility of pulse oximetry in the critically ill patient, making translation of these study results to human trials clinically feasible.
Several limitations of this study should be noted. We used only healthy adult female animals to study CA, a condition that occurs in humans of both sexes with advanced cardiopulmonary disease. The implications of studying cerebral ischemia in female animals only must be considered, especially in light of mounting evidence for the role of sex-defining steroids in the modulation of cerebral ischemic injury.31 Although a similar model of CA/ROSC found no sex-related differences in clinical neurological outcome at 24 hours,32 trials are planned to extend these experiments to male dogs in an attempt to demonstrate neuroprotection independent of sex. We also examined neurological deficit and histological damage at only 1 time point, 24 hours. Although significant neuroprotection was demonstrated at 24 hours, the question must be raised whether oximetry-guided normoxia provides permanent neuroprotection or whether this treatment protocol merely delays the onset of further neurological injury. In an attempt to answer this question, studies are ongoing in our laboratory in an established rat model of complete global ischemia to examine the long-term implications of normoxic versus hyperoxic resuscitation.
Pulse oximetry-guided O2 administration after CA/ROSC safely and rapidly lowers arterial O2 concentration to physiological levels, providing significant short-term neurological protection. Clinical trials of pulse oximetry-guided reoxygenation after CA are indicated.
The authors thank Kyni Jones for expert technical assistance.
Source of Funding
This work was supported by National Institutes of Health grants NS34152 and NS49425.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Last week, Jeezy dropped a new street banger called "GOD" and attached a stirring letter named the "Pastor Young's Letter." The moving letter shares a pensive point of view on the world, while also sharing the announcement of a new album release scheduled for November 13, 2015. The Thug Motivation MC has also released an audio sermon of which he dedicates to the "Street Disciples and Congregation." Listen to the audio above (via hyperlink) and comment below with your thoughts and comments.
"I would like to take this time to address the 'Street Disciples and Congregation' to express my concerns and frustrations on what's going on in our communities all over the world today. With the poverty level at an all time high, it's damn near impossible for one to take care of him or herself without the possibility of prison or death. You have law enforcement officials gunning down unarmed black men. You have misinformed young men gunning down unarmed women, children and men in churches, movie theaters and public events. There's a war going on, but you have to ask yourself, who is the enemy?"
By Kix Staff


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This property has been removed by the agent. It may be sold or temporarily removed from the market
1 bedroom flat for saleBravington Road, London
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A character filled one bedroom period conversion flat which has solid wooden floors, a large master bedroom with loads of natural light, and a large private garden.
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Andy's views
So we're just one extra family about to join the huge 'global mega trend' of rapid urbanisation – one of five such trends identified in research by consulting giant PWC. In case you haven't seen them, the statistics around population shift are nothing short of staggering. We've already passed the point at which the majority of the world's people live in cities. By 2050, the figure is expected to be seventy percent or more. According to the UN, this will happen fastest in Africa.
Inevitably there will be winners and losers. Cities compete with each other economically, at local, regional and increasingly international levels. As they grow in size, each city's attractiveness – and each citizen's quality of life – will depend more than ever on access to efficient infrastructure such as education, housing, transport, energy, water and healthcare. How those vital assets are planned, financed, built, integrated and managed during their lifecycles is a momentous challenge in its own right.
What's all this got to do with public relations? Quite a lot, as it happens. Because this change in human behaviour is unprecedented and it demands a huge rethink about how we plan, manage and sustain urban populations. The amount of engagement and dialogue needed between those who run cities, the citizens who live in them and those who depend on them operating efficiently for their livelihoods are huge.
We'll need to explain and advocate the need for change; to convince and convert those who are change-resistant or in denial. We'll have to listen to objections and use all our skills as communicators to overcome barriers; to marshal the facts and win concessions for the wider good from all vested interests. Public relations professionals who understand and can facilitate this positively will be in great demand.
I've had some insight into this world through my work with the World Business Council for Sustainable Development since 2007. Most recently, I advised on communication for its Urban Infrastructure Initiative. This is a fascinating and pioneering programme which aims to showcase how public and private sectors can collaborate more effectively in building sustainable cities.
It's fair to say that the project initially encountered some scepticism and misunderstanding. But once city leaders entered into dialogue with participating companies, introduced by a clearly neutral 'bridging partner', such feelings were quickly replaced by excitement and a desire to get involved. I'm certain that progress was assisted by the project's promise of transparent governance.
Three years later, all participants (ten cities on six continents and 14 multinational companies) have been pleasantly surprised to find a positive spirit of genuine collaboration, professional development and mutuality of interest. Each city team received bespoke reports outlining how they can accelerate their progress towards building a sustainable, more resilient community. Some are already acting on those recommendations. Motivating the desired action is, of course, just as critical in such programmes as it is for any smaller scale and less ambitious public relations campaign.
If it hasn't happened already, the chances are your organisation will be touched increasingly by the mass migration of people from countryside to city. The individuals and organisations who can position themselves well in this new urbanised world, or indeed at the centre of any of the other global mega trends, will have much to gain.


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Since 2004, the government of Ethiopia has made a bold decision to strengthen and expand its primary health care system by launching the Health Extension Program (HEP). While the scaling up of the HEP is necessary to achieve the aim of universal access to primary health care, close attention should be paid to the performance of the program. Using a data envelopment analysis this study aimed at (i) to estimate the technical efficiency of a sample of health posts in rural Tigray, ii) to identify those factors which might be explaining the efficiency results.
Efficiency was measured using a data envelopment analysis model. A Tobit model was performed to identify factors associated with efficiency. Seven rural districts (out of 35) were purposely chosen. Input/output information was collected from the database of the Tigray Health Bureau during July 2007-June 2008. Information was also collected on environmental factors that might influence the efficiency outcomes through a structured questionnaire from the correspondent district health officers.
Analysis was based on data from 60 health posts. The mean scores for technical and scale efficiency were 0.57 (SD = 0.32) and 0.95 (SD = 0.11) respectively. Out of the 60 health posts, 15 (25.0%) were found to be technically efficient constituting the best practice frontier. Thirty eight (63.3%) were operating at their most productive scale size. In the regression analysis, none of the variables was significantly associated with the efficiency outcome.
There is a need to review the management of the health information system in the region. The findings have also revealed that only a quarter of the health posts are working efficiently and pointed the need for improvement. A closer monitoring of the health extension programme is required in order to achieve the best possible performance.
The last World Health Report (2008) has made a strong call to all the countries to direct their health systems towards the values of primary health care reflected in the Alma Ata declaration 30 years ago: social justice and the right to better health for all, participation and solidarity. Primary health care is considered to offer a comprehensive framework about how health systems can become more equitable, inclusive and fair [1]. To achieve these goals, good performing health systems regarding quality, access and efficiency are required.
Being the principal objective of a health system to improve people's health, one of the chief functions the system needs to perform is to deliver health services. It is therefore considered a major failing of the system when due to lack of efficiency, health interventions do not reach the populations that would benefit from them [2].
While the problem of scarcity of resources in the health systems, both human and financial, is a well acknowledged problem in the Africa region, there is a growing recognition that inefficiencies within the health care system abound [3]. Solving this lack of efficiency on the delivery of health services is not only an issue related to the sustainability of the health care system, but an immense responsibility of decision-makers to ensure that health delivery works best with the available resources.
Ethiopia is a federal state decentralized to regions. The main role of the Federal Ministry of Health is the development of policy including guidelines; resource mobilization, capacity development activities and technical support to regions. Regional Health Bureaus are responsible not only to adapt policies and guidelines to local situation, but to plan, monitor and evaluate the performance of the health system, to conduct operational research and to provide technical assistance to the districts. The districts are mainly the implementers of the plans. The health system in the country consists of a four-tier system; the Primary Health Care Unit (PHCU), the district hospital, the zonal hospital and the regional referral hospital. A PHCU is the grass-root level, which give preventive and curative health services for an average of 25 000 people. It includes a health centre and five satellite health posts [4].
Since 2004, the government of Ethiopia has made a bold decision to strengthen and expand its PHC system by launching the Health Extension Program (HEP). The HEP is designed to achieve significant basic health care coverage in the country over five years through the provision of a staffed health post to serve approximately 5 000 people. The aim of this new community-based health care delivery system is to improve access and equity in health care through a focus on sustained preventive health actions and increased health awareness. Every health post is staffed by two females Health Extension Workers (HEWs), who are high school graduated with an extra of one year training course. The training program for the HEWs includes 16 major packages under five components: (i) hygiene and environmental sanitation (i.e. construction, usage and maintenance of sanitary latrine), (ii) family health service (i.e. family planning, vaccination), (iii) disease prevention and control (i.e. HIV, TB, malaria), (iv) health education and communication and (v) nutrition. At this level, antipyretics, oral dehydration salts and antihelminthic and antimalarial drugs are available. Voluntary health workers (VHWs) (community health workers and traditional birth attendants) support HEWs in the health education activities of the different components in the community [5]. By May 2008, there were 24,500 HEWs trained and deployed which is 82% of the 30,000 target of the Ministry of Health in 2010/11 [6].
While the scaling up of the HEP is a necessary step to achieve the aim of universal access to primary health care, close attention should be paid to the performance of the program. Using a data envelopment analysis this study aimed at (i) to estimate the technical efficiency of a sample of health posts in the region of Tigray, ii) to identify those factors which might be explaining the efficiency results.
Tigray is the most northern regional state of Ethiopia bordering Eritrea and Sudan. The region covers 54,572 square kilometers ranging from low-arid to high-land (above 2200 masl) areas. Tigray is divided into 47 districts (woredas) which are grouped into six zones. Tigray has approximately 4.3 million inhabitants, most of them (81.2%) living in rural areas. The dominating religion in the region is Orthodox Christian (95.5%). In Tigray, 95% of the population is Tigrayan and their language, Tigrigna, is the working language in the region. The majority of the population works with agriculture. Famine and drought regularly strikes the region [7].
The health system in Tigray is essentially the same as in the rest of Ethiopia. There are five zonal hospitals, six district hospitals and one referral hospital in Mekelle, the capital. Malaria is the number one diagnosis for outpatient cases, followed by malnutrition and diarrheal and acute respiratory infections. The Regional Health Bureau initiated in 2005 an ambitious plan to achieve the universal coverage of the HEP. Currently, there are 1,220 health extension workers in Tigray and the coverage has increased from 30% in 2006/7 to above 70% in 2007/8 [8].
To measure efficiency in health care organizations, two different frontier estimation methodologies, stochastic frontier analysis (SFA) and data envelopment analysis (DEA) are widely used in high income countries [9]. While there is no clear consensus to the best method to measure health facilities efficiency, several studies from low-income countries have pointed out the better suitability of the DEA for contexts where there is insufficient health sector information and particularly when the economic data is missing [10,11].
DEA is a non-parametric linear programming methodology for evaluating relative efficiency of each production unit among a set of fairly homogeneous decision-making units, e.g., district hospitals, health centres, etc. It sketches a production possibilities frontier (data envelop or efficient frontier) using combinations of inputs and outputs from best performing health facilities. Health facilities that compose the "best practice frontier" are assigned an efficiency score of one (or 100%) and are considered technically efficient compared to their peers. The efficiency of the health facilities below the efficiency frontier is measured in terms of their distance from the frontier. The inefficient health facilities are assigned a score between one and zero. The larger the score the more efficient a health facility is [12].
Osei et al (2005) have summarized the main strengthens and weakness of the methodology. The former includes: (i) it can handle multiple input and multiple output models/scenarios typical of hospitals and health centres; (ii) it does not require an assumption of a functional form relating inputs to output (as regression methods do); (iii) health facilities are directly compared against a peer or combination of peers; (iv) inputs and outputs can be very different units; (v) it does not require information on prices of inputs and outputs. The DEA has also some drawbacks: (i) it attributes any deviation from the "best practice frontier" to inefficiency, while some could be due to statistical noise, e.g. epidemics or measurement errors; (ii) given that DEA is a nonparametric technique, it is difficult to conduct statistical tests of hypotheses concerning the inefficiency and the structure of the production function [11,13].
Total efficiency is a combination of technical efficiency (TE), which reflects the ability of a unit to obtain maximal output from a set of inputs, and allocative efficiency, which reflect the ability of a unit to use the inputs in optimal proportions, given their respective prices. Due to the lack of economic information in this study, the calculation of the allocative efficiency was excluded. TE attempts to address two questions depending on whether it has input- or output-orientation. In input-oriented TE focuses on reducing input quantities used for a given level of outputs. On the other hand, in output-oriented TE the focus is on expanding output quantities with a fix amount of inputs. The choice of the approach is recommended to be based on which side of the orientation (input or outputs) the decision makers in the health facility have more control over [12]. In this study, we apply the output orientation model which addresses the question: by how much can the outputs be proportionally increased without changing the inputs quantities? The rational behind this selection was: i) the deployment of human resources (inputs) at the health post level is decided at national level without much influence capacity from the local level; ii) most of the chosen outputs are under control of the health post; HEWs have the mission to induce demand for preventive health care services (family planning, antenatal and delivery care) and promotion activities (education, visits by CHWs) and to create awareness about health services utilization at community and household level.
TE comprises both pure technical and scale efficiency components. Thus, a second consideration in estimating a DEA model is whether to assume constant or variable returns to scale (VRS). Under constant returns to scale (CRS), the interest is in productivity regardless of the scale of operations. VRS might be preferred if the interest is on the extent to which the scale of operations affects productivity or when not all units of analysis are considered to be operating at an optimal scale. Inappropriate size of a health facility (too large or too small) may sometimes be a cause for technical inefficiency. This is referred to as scale inefficiency and takes two forms - decreasing returns to scale (DRS) and increasing returns to scale (IRS). DRS implies that a health facility is too large for the volume of activities that it conducts. In order to operate at the most productive scale size, a health centre exhibiting DRS should scale down its scale of operation. In contrast, a health facility with IRS is too small for its scale of operation. If a health centre is exhibiting IRS, it should expand its scale of operation in order to become scale efficient. A health facility that is scale-efficient is said to operate under constant returns to scale [13,14]. Our analysis was carried out under the assumption of VRS.
In the production process, health facilities turn inputs (factors of production) into outputs (health services). Inputs are usually divided into broad categories of labour (staff), materials (drugs) and capital (equipment). Despite there is a general consensus that the ultimate measure of output should be the change in the population health, practical difficulties (such as issues of measurement, access to data and health changes attributed to health care) make intermediate outputs a preferred option [11,15]. In our study the DEA model was estimated with a total of ten variables: two inputs and eight outputs. The two inputs were: (i) number of health extension workers and (ii) number of voluntary health workers (traditional birth attendants, community health workers). The eight outputs for each individual health post included: (i) number of health education sessions given by HEWs; ii) number of completed (three) antenatal care visits; (iii) number of child deliveries; (iv) number of persons that repeatedly visit the family planning service; (v) number of diarrheal cases treated in children under-five; vi) number of visits carried out by the community health workers; vii) number of total new patients attended and viii) number of malaria cases treated. The choice of inputs and outputs was guided by the components of the HEP.
The data used in this study are for the Ethiopian fiscal year 2000 (July 2007 - June 2008). Seven districts (out of 35 rural districts) were purposely chosen because of logistic reasons. These reasons were related to the quality of data available at the Tigray Health Bureau and the accessibility to the environmental variables at district level. One of the initial districts was rejected due to low quality data and substituted by another one. Input/output information was collected from the database of the Tigray Health Bureau.
Information was also collected on environmental factors that might influence the efficiency outcomes through a structured questionnaire from the correspondent district health officers. Personal characteristics of the HEWs such as marital status, pregnancy in the previous year, number of children and being born in the same subdistrict (tabia) were chosen to account for the individual variability of the health posts. Structural factors such as the population of the tabia, the distance to the health centre (in minutes walking) and the political support from the tabia's chief (little, moderate, high) were considered to account for population demographics, accessibility and political commitment respectively.
The technical efficiency scores were computed using the open-access Data Envelopment Analysis programme, version 2.1 (DEAP 2.1) designed by Coelli [16]. In order to use the less possible number of variables, a correlation analysis was conducted among the output variables. With a Spearman correlation coefficient greater than 0.6, none of the output variables was associated. To study whether there were extreme outliers which could affect the efficiency scores, we ran DEA analyses that dropped out each efficient health post one at a time from the analysis. The similarity of the efficiency ranking between the model prior to deleting any efficient health posts and the new models, was then tested by using the Spearman rank correlation coefficients. If the health posts are influential, a value of 0 would be obtained indicating no correlation. A value of 1 (or -1) would imply no influence of outliers on health post efficiency. This is a procedure called jackknifing and it tests the robustness of the DEA results in regard to outlier health posts [15,17]. To identify factors associated with the efficiency, the estimated technical efficiency scores obtained from the DEA was considered the dependent variable and regressed against the set of environmental variables using a Tobit model [13,18]. Coefficients with positive signs would indicate a positive correlation with efficiency. One might expect that being born in the tabia, being single, not pregnant last year and not having children would be associated with efficiency. Regarding structural factors, more population, less distance and more political commitment would also be positively correlated. This analysis was performed with Stata 10.0.
A total of 87 health posts belonging to seven districts fulfilled the requirements to be included in the sample. Health posts not operating in the previous year were excluded. Information from 27 (31.0%) health posts was incomplete or inconsistent, and thus analysis was based on data from 60 health posts. Summary statistics of the variables of interest are presented in Table Table1.1. The results of the jackknifing analysis yield the value ranges of Spearman rank correlation coefficient from 0.90 to 1, which were significantly different from zero. This suggested that no efficient health post influenced the efficiency of the other health posts.
The VRS technical and scale efficiency scores for individual health posts are given in Table Table2.2. Overall, the mean efficiency scores for TE and SE were 0.57 (SD = 0.32) and 0.95 (SD = 0.11) respectively. Out of the 60 health posts, 15 (25.0%) were found to be technically efficient constituting the best practice frontier. Twenty seven (60%) of the inefficient health posts had a TE score of less than 50% (Figure (Figure1).1). The average TE score for the 45 inefficient health posts was 42% (SD = 0.23) meaning that these health facilities could potentially produce 58% more outputs using their current input endowment if they were to operate efficiently.
Of the total health posts in the data set, 38 (63.3%) exhibited constant returns to scale. In other words, they were operating at their most productive scale size. The rest 22 were considered as scale inefficient though most of them were close to the optimal size (85.0% had a score higher than 0.90). The scale inefficient health posts had an average SE score of 90% (SD = 0.14) implying that if these health posts had an optimal size, output would have increased by about 10% without increasing the input consumption. Eleven (18.3%) health posts manifested increasing returns to scale and another 11 (18.3%) decreasing returns to scale.
The results of the Tobit model for examining determinants of health posts' efficiency are given in Table Table3.3. The individual variables being born in the tabia, marital status and pregnancy status were negatively associated with efficiency. Against our expectations, this means that a better performance was found in health posts where the HEWs were not locally born, both were married and had been pregnant last year. Lower efficiency scores corresponded to high number of children, less population, little support from the tabias'chief and less distance to the health post. Reasons why a greater distance from the health post is associated with a greater efficiency are not clear. None of the variables, however, was found to affect significantly the technical efficiency of the posts.
The first main finding of this study is related to the lack of quality of the health information available at the central level of Tigray Health Bureau. The information of all the health posts of one district and 27 health posts of the other seven districts could not be used. Reasons need to be further explored but they could be attributed to inadequate data collection and reporting from the HEWs or inadequate data entry at the central level.
The second main result is the poor performance of this sample of health posts with most of them (75.0%) carrying out activities at less than optimal levels. Health posts could therefore increase on the number of preventive and curative activities with the resources they currently have. Though previous research in Tigray has shown a certain satisfaction of the community with the health services provision by the HEWs [19], the study was focused in only one district not covered in our sample. Most of the health posts were however operating to their most productive scale sizes (CRS) for the outputs produced which suggest that the human resources allocated to the health posts (2 HEWs and around 13 VHWs) might be enough at this stage.
In recent years, an increase number of studies have been conducted measuring efficiency using DEA in Africa, few however at the primary health care level. In Kenya, a study found 56% health centres to be technically inefficient and 70% scale inefficient [20]. Seventy per cent of primary health care clinics in rural South Africa were found to be technically inefficient and 84% scale inefficient [21]. Another study in Sierra Leone reported that 59% of the 37 peripheral health units were technically inefficient [22]. Two studies from Ghana and Seychelles have recently been published; the former showed that 65% of the health centres were technically and 79% scale inefficient while the latter found that 41% and 59% of the health centres were run inadequately for technical and scale efficiencies [14,23]. While data between countries are not comparable because the selection of input/output variable is context-based and the socio-economic conditions of the different countries vary enormously, the low scores observed in our study raises concerns about the efficiency of the HEP in the region.
The regression analysis did not identify potential factors associated with the efficiency of the health posts. A study conducted at the initial stages of the HEP in the country pointed out some of the reasons that could be explaining our findings. The challenges mentioned included the harmonization of the staff patterning at the health post level, and the lack of clear guidelines on relationship with other workers at the community level, on career structure, transfer and leave of absences. The reporting and health management information system was also a great weakness [24]. Further research will be required in order to confirm if these issues are relevant for Tigray.
Several limitations should be noted. First, output data were collected in order to represent the broad range of activities of the HEWs; however, the selection of other outputs might have produced different efficiency outcomes. Second, the information on input prices could not be collected and thus, the allocative efficiency not estimated. Third, inputs and outputs were gathered for only one period which made not possible to observe any impact of the HEP. Four, given that the study was conducted in a sample of districts the generalization of the results to the Tigray region should be taken cautiously. Two final limitations are related to the regression method used. Since there is no generally accepted method for taking into account environmental variable in DEA models, a Tobit regression model was adopted; we are aware that concerns regarding its applicability have been raised [13]. The relative small size could have hidden some statistical significant relationship between the environmental factors and the efficiency scores.
This study has shown the need to review the management of the health information system in the region. The findings have also revealed that only 25.0% of the health posts are working efficiently and have indicated those health posts that need improvement. The potential for a better performance of the different components of the HEP is of great public heath importance given the scarce resources and poor health indicators of the region. Discussions have already initiated within the Tigray Health Bureau in order to improve the situation. In line with other research, DEA has shown to be an easy, affordable and accessible tool to assess the performance of health systems. The government of Ethiopia is making an enormous effort to extend affordable primary health care services across the country. This achievement however should not be done in detriment of its efficiency. Whether these results apply regionally or nationally should be explored and the performance of the HEP carefully monitored.
The authors declare that they have no competing interests.
MSS developed the idea, analysed the data and drafted sections of the manuscript. HL collected the data and participated in drafting sections of the manuscript. All the authors read and approved the final manuscript.
The pre-publication history for this paper can be accessed here:
We thank the Tigray Health Bureau for making the data available. This work was partly supported by the Umeå Centre for Global Health Research, funded by FAS, the Swedish Council for Working Life and Social Research (Grant no. 2006-1512). We are also grateful to the reviewers for their comments.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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from Aesop's Fables:
A Crow, half-dead with thirst, spied a pitcher and flew to it in joy. But when he arrived, he discovered that only very little water was left in it, and he could not reach far enough down to get at it. He tried evrything he could think of to reach the water, but all his efforts were in vain. Then a thought came to him and he took a pebble and dropped it into the pitcher. he collected as many pebbles as he cold find and dropped them one by one into the pitcher, until the water gradually rose to the brim and he was able to quench his thirst and save his life. Moral: Necessity is the mother of invention.
Ink drawing with digital color, 2006. One of my favorites from this series! See more at my oline porfolio www.stephaniesmith.com
This image is one of many story images of birds and animals featured in my calendar Legendary Tales: Myths and Legends


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A choral/hip-hop theatre work about coming of age in an age of guns, (Be)longing is coming to New Haven in 2017 as part of the Festival. Created by Byron Au Yong and Aaron Jafferis at the Center for the Arts at Virginia Tech, (Be)longing has grown into a national initiative asking how we recover from violence and prevent its recurrence. Activate (Be)longing is a series of events leading up to the Festival and during the performances of (Be)longing intended to expand the conversation around the show's central questions and activate the New Haven community.
Audition for the Choir (singers, rappers and beat boxers encouraged to apply!)
February 12 from 2-4pm, 15th Floor Conference Room, Key Bank Building, 195 Church Street, New Haven.
Rehearsal Schedule: One Saturday afternoon per month until mid-May, then 2-5 times per week, depending on role, weekday evenings and Saturday afternoons, until tech/performances June 13-18. Unpaid.


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I know I said this last month too, but I really mean it this time.
Guys, I don't know if you got the memo, but we're in March. Woah.
Um, can someone please work out how to slow down time? It feels like I've blinked and we're in March. How has this happened? Soon, I'm going to be staring my birthday (April 27th, FYI) in the face.
Before I dive into what I want to achieve in March, I thought I would review February for a hot minute. Ready for this?
Popular Posts From February
- 10 Reasons Why Being Single Sucks
- Monthly Goals: February 2016
- If We Were on a Coffee Date | Vol. 15
- 10 Reasons Why Being Single is Awesome
- 8 Things Single Girls Should Do on Valentine's Day
February Stats
- 1,672 views
- 936 unique visitors
- 777 followers
- 109 likes
- 66 comments
- 8 new blog posts
Recap February Goals
- Join a gym //
exercise four times per week// try a fitness class
- Finish reading Big Magic + start writing book review(s)!!
Explore a part of Auckland I have never seen/haven't visited in a while
- Stop using my phone/laptop by 10:30pm every night
- Try three new recipes from a cookbook // start meal prepping again
Start scheduling content for the blog// post four times per week Participate in two Twitter chats
4/11 goals completed
- Apply to renew my passport
- Start Adrienne's 30 Day Yoga Challenge
- Sponsor a blog that I love (or sort out sponsorship for April) // blog every day for a week
- Start the Kayla Itsines BBG (for real this time)
- Finish reading Big Magic (also for real this time)
- Try two new recipes
- Keep my room clean for a whole week (this would be a real accomplishment)
- Hit my pomodoro goals every day
Tell me…
- What are your goals for March?
- How do you feel when you don't accomplish as much as you had hoped?
- Do you believe sharing goals helps you accomplish them?


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Media Field Sales - Somerset
Do you enjoy building new relationships with clients? Are you motivated and driven? Do you have an interest, passion or knowledge of the Media industry?
Juice are excited to offer this fantastic opportunity to be part of a dynamic Bristol based Media company.
This is an excellent opportunity for an energetic, passionate and driven Field Sales Executive who is looking for a new exciting opportunity to excel and develop within a career in Media Sales.
Within this key role you'll be using your sales expertise to assess the customer's needs, provide expert product knowledge and exceptional experience for the client throughout the whole sales process.
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Research and identify new business opportunties
Produce quotes and generate leads
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Use provided technology and products to enhance the experience the customer receives through a presentation.
In return you will receive a competitive salary package with generous bonus scheme, company car, and a fantastic buzzing team who love socialising!
If this is the next step in your career - please contact Summer at Juice Recruitment today!


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Janus Capital Group, Inc (JHG) Releases Quarterly Earnings Results, Beats Estimates By $0.13 EPS
Janus Capital Group, Inc (NYSE:JHG) released its earnings results on Tuesday. The company reported $0.68 EPS for the quarter, topping the consensus estimate of $0.55 by $0.13, MarketWatch Earnings reports. Janus Capital Group had a net margin of 13.76% and a return on equity of 9.51%. The firm had revenue of $384.80 million for the quarter, compared to the consensus estimate of $394.97 million. During the same quarter in the previous year, the firm earned $0.21 earnings per share. The company's quarterly revenue was up 49.7% compared to the same quarter last year.
Janus Capital Group (JHG) traded up 4.11% during midday trading on Tuesday, reaching $35.48. 1,094,212 shares of the company were exchanged. The firm's 50 day moving average price is $32.63 and its 200-day moving average price is $32.57. Janus Capital Group has a 52 week low of $8.14 and a 52 week high of $35.85. The stock has a market capitalization of $3.88 billion, a P/E ratio of 27.92 and a beta of 1.59.
The firm also recently declared a quarterly dividend, which will be paid on Friday, September 1st. Investors of record on Friday, August 18th will be paid a dividend of $0.32 per share. This represents a $1.28 dividend on an annualized basis and a yield of 3.61%. Janus Capital Group's payout ratio is 57.00%.
Several equities analysts have recently commented on JHG shares. Bank of America Corporation reissued a "neutral" rating and issued a $31.00 target price on shares of Janus Capital Group in a report on Wednesday, May 31st. Zacks Investment Research raised shares of Janus Capital Group from a "hold" rating to a "strong-buy" rating and set a $39.00 price target on the stock in a research note on Friday. Credit Suisse Group initiated coverage on shares of Janus Capital Group in a research note on Thursday, June 1st. They set a "neutral" rating and a $33.00 price target on the stock. Keefe, Bruyette & Woods initiated coverage on shares of Janus Capital Group in a research note on Wednesday, May 31st. They set a "market perform" rating and a $32.00 price target on the stock. Finally, J P Morgan Chase & Co initiated coverage on shares of Janus Capital Group in a research note on Friday, June 9th. They set a "neutral" rating and a $33.00 price target on the stock. Seven equities research analysts have rated the stock with a hold rating and two have given a buy rating to the company's stock. The stock has an average rating of "Hold" and a consensus price target of $34.34.
Receive News & Ratings for Janus Capital Group Inc Daily - Enter your email address below to receive a concise daily summary of the latest news and analysts' ratings for Janus Capital Group Inc and related companies with MarketBeat.com's FREE daily email newsletter.


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The Garlic Root is the root of the garlic bulb and can be used for a flavoring in dishes. They have an earthy-mild-nutty-slightly sweet flavor and stringy texture and can be used as a garnish, in Aïoli, Pesto Sauce, salad, and vinaigrette.
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On the campaign trail, Donald Trump promised to revive American manufacturing, get tough on trade with China, cut taxes and invest in infrastructure. Do those proposals recall other visions for economic development over history? Economics correspondent Paul Solman speaks with historian Adam Tooze of Columbia University to put the president-elect's proposals into perspective. Continue reading
If Hillary Clinton makes it to the White House, a lot of eyes will be on her list of do's and don'ts. Continue reading
NEW HAVEN, Conn. — When New Haven Mayor Toni Harp gazes out her office windows, she can see across the street to Yale University's idyllic buildings and grounds — none of which are on her city's property tax rolls. Continue reading
Leaked excerpts of Trump's 1995 tax returns showed huge losses that the real estate mogul could have used to offset other income and zero out his income tax liability for many years. Continue reading
Tax plans for the two candidates remain far apart. Here are summaries of their proposals.
Continue reading
The New York Times obtained several pages of Donald Trump's tax returns, showing losses so large the may have allowed him to avoid paying federal income taxes for 18 years. Continue reading
Federal financial aid for college is often underutilized due to the complexity of required paperwork; however, 90% of students who do complete the Free Application for Federal Student Aid (FAFSA) enroll in school. This year, the FAFSA is being streamlined in the hope of increasing participation. Hari Sreenivasan speaks with Kim Cook, executive director of the National College Access Network. Continue reading
Since Monday night's debate, Donald Trump's taxes and tweets have drawn rapt attention. Syndicated columnist Mark Shields and New York Times columnist David Brooks join Hari Sreenivasan to discuss the "bizarreness" of the week's campaign developments, Hillary Clinton's struggle to win millennial voters back from third-party candidates and the congressional decision to override a presidential veto. Continue reading
After uncovering an illegal deal, the European Union ruled that Apple pay over $14.5 billion in back taxes to Ireland. The EU's antitrust regulator found that the country and the tech giant had made an agreement that allowed Apple to pay less than 1 percent in corporate tax for over a decade. Apple plans to appeal the decision. Hari Sreenivasan speaks with EU Commissioner Margrethe Vestager. Continue reading
The company went on to say that the European Commission is trying to "rewrite Apple's history in Europe, ignore Ireland's tax laws and upend the international tax system in the process." Continue reading


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Give us a call to get our secret deals 1-800-468-3578
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MyLaoHome Guesthouse is in the heart of Luang Prabang, walking distance from Wat Mai and Royal Palace Museum. This guesthouse is within close proximity of Mount Phu Si and Royal Palace.
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Take in the views from a terrace and a garden and make use of amenities such as complimentary wireless Internet access.
Business, Other Amenities
Featured amenities include dry cleaning/laundry services, a 24-hour front desk, and luggage storage.


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(412) 564-4610
Email: firstname.lastname@example.com
Our Continued Mission
The P+P Mission is and will always be to aid in comfort, safety, and independence of its customers while also staying affordable for any budget. Whether your needs are for commercial, private health, or individual use, P+P's products like the PICC Line Protector help people in need become more comfortable and safer while dealing with unfortunate circumstances caused by illness, accident or surgery. Absolute customer satisfaction and unlimited personal attention to each one of our clients is the backbone of our lasting and proven business model.
About Us
The Four Focal Points of P+P
Providing custom medical supplies for those who need them the most was an idea conceptualized in a hospital bed by someone living the pain and aggravation caused by injury and illness. Trying to lead a normal life but not being able to keep your arm clean or dry can make an already trying time, even more difficult. P+P Custom Medical Supplies realized this and decided to solve this common problem. Now people have a safe, dependable and affordable option while recovering or dealing with the involvements of their accident or illness.


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- Home
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- I Play
I PlayAED29.00 Jump to: Details - Specifications - Reviews
I Play - David McPhail
Publisher: Roaring Brook Press
I Play
Our shipping terms
Early Learning
(a) Deliveries are made between Saturday and Thursday and will be undertaken by a third party appointed by Virgin for and on behalf of Virgin. Virgin makes every effort to dispatch Products on time. If the ordered Products are not delivered within the time period Virgin specified in the confirmation email, please contact Virgin's Customer Services quoting the order reference contained in your order confirmation email.
(b) Delivery occurs when the ordered Products are delivered to the delivery address you specified when placing your order. At this point, responsibility for loss, breakage and damage passes to you. Ownership of Products purchased passes to you when payment is received by Virgin in full. You will be asked to sign for acceptance of the Products which will note that the Products are correct and have been received in good condition.
(c) If you are not at the delivery address, Virgin will assume that any adults that are present at the delivery address are authorized by you to take delivery of the Products that you have ordered. If above criteria are not met or if there is no one at the delivery address, Virgin will not leave the Products at the delivery address. Virgin will contact you to arrange an alternative delivery time.
(d) Please note that the delivery people will only deliver the Products to your front door.
Virgin does not deliver to any residence outside of the United Arab Emirates.
Product details
From David McPhail comes a board book of early concept words. In I Play, a charming bear demonstrates children's favourite action verbs, allowing children to replicate Bear's movements and learn the words for the things they do every day. These new board books are not only handy, fun guides for early learning concepts, but also the youngest readers' introduction to the whimsical world of David McPhail.
|Number of Pages
|Cuddly but never cloying and with a vintage flavor that readers will love, these characters are all real winners. "School Library Journal""


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Sierra Properties offers many different management packages that are 100% customizable to you and your particular property. We manage many different property types, including condos, single family homes, multi family buildings and commercial real estate.
There is no better deal then our full management package. Included in this is:
- Tenant placement & screening
- Rent collection (and sending the money to you)
- Eviction/other legal paperwork
- Monthly reports showing financial activity in property
- Frequent property check ups
- Paying of bills (mortgage, taxes, home owners association, etc.)
We never charge you until there is a tenant in your property. This is our assurance to you that we do our work before we get paid. Our rates are extremely competitive and all of our clients save money when they switch over from realtors, other property management companies and even self management. This is because we put all of our resources behind finding the right tenant as fast as possible in order to maximize your income.


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Bleaching My Feet
Warning: Graphic content below. Of the severed-mouse-head variety. Don't worry, no gross pictures… Only adorable ones. … An actual conversation with the Husband today: Ring Ring Andy: "Hey Love, what's up?" Me: "OH MY GOSH! Wait, wait let me get … Continue reading
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Why Every Girl Needs a Kitten
Turn down your hearing aides and prepare for epic cuteness. The screeching and giggling is about to start: I especially love her "machine-gun" laugh. Gets me every time. P.S. Mo says his name is Bubble (not to be confused with Bubbles).
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Aiming to create a true classic, New York-based skate shop DQM teamed up with Vans to produce the "Square Ones" collection. While we've recently inquired this audience about the popularity of all-red shoes, the status of white shoes seems comparably ineffable – immortal, even. Like a pair of blue jeans, the perfect white T-shirt, or a motorcycle jacket, DQM designed this special footwear collection to stand up to the test of everyday wear. Lightweight cotton ripstop fabric outfits the Authentic, Old Skool and Sk8-Hi silhouettes, detailed with tracer cord and a cushy Ortholite insole at the interior. Enjoy a look through at timeless release from DQM and Vans, releasing August 7 in-store and online.
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Last night The Reed Space held an event to celebrate the release of the ever-illustrius singer/songwriter John Mayer's new album, Born and Raised. Mayer himself hosted the event, which marked the opening of a pop-up shop featuring photography by Gari Lamar Askew II, exclusive merchandise, and co-branded projects with Staple Design, Moleskine Notebooks, Reigning Champ, Barrett Alley, Incase and The North Face.
Mayer sipped Vita Coco and snacked on Endless Summer Tacos as he chatted with fans and industry professionals about his forthcoming album. It was a laid-back and intimate setting inside the shop. Just outside on Orchard Street, however, there were upwards of 300 people not-so-casually waiting to catch a glimpse of the wonderland that is John Mayer's body.
Gari Lamar Askew II's photo exhibit will be up throughout the week and all the pop-up products are available for purchase at The Reed Space store.


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After a wait of 17 long years, Nokia 3310 will finally be available in the Indian market. Nokia has started shipping the devices and has confirmed the same by a tweet
Nokia 3310. Picture courtesy/YouTube
The 17- year-long wait seems to get over soon. Nokia has started shipping the iconic Nokia 3310 and the device is almost ready to hit stores.
Nokia took it to social media to confirm the shipping of the unbreakable device.
Your 17 year wait is over, now shipping. #Nokia3310 pic.twitter.com/xJAJgwApAB— Nokia Mobile (@nokiamobile) May 5, 2017
Nokia 3310 was first unveiled in MWC 2017 held in Barcelona last February. The latest device is a modified version of the older one, which sports 2.4-inch QVGA display, 1200 mAh battery, and standby talk time of up to one month.
Nokia 3310. Picture courtesy/YouTube
The phone will be available in four different colours- Red, Yellow, Blue, and Grey. It is expected to carry a price tag of around Rs 3,500 and should hit the Indian market this month.
Tech: Nokia launches Nokia 6, Nokia 5 and Nokia 3 smartphones in India13-Jun-2017
Tech: 'Beloved' Nokia 3310 goes on sale in India today via offline stores18-May-2017
Nokia 3310 to be available in India from May 18 for Rs 331016-May-2017
Nokia 3310 price and launch date revealed online26-Apr-2017
Nokia 3310 to launch in India soon24-Apr-2017
Nokia 3310 to go on sale in India before Android phones10-Mar-2017