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October-December 2019
Volume 12 | Issue 4
Page Nos. 225-285
Online since Monday, November 18, 2019
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What's new in emergencies, trauma and shock? Using queuing theory to optimize the emergency department triage process
p. 225
Leon D Sanchez, Joshua W Joseph
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Gunshot wounds – From Lebanon, via Syria, to the streets of your city!
p. 227
Timothy Craig Hardcastle
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The 2019 WACEM and academic college of emergency experts india position paper on developing the academic department of space medicine in India – The time has come!
p. 229
Vivek Chauhan, Sagar Galwankar, Kishore K Deepak, Anant Mohan, Randeep Guleria, Sanjeev Bhoi, Praveen Aggarwal
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The 2019 WACEM expert document on the framework for setting up a simulation centre
p. 232
Fatimah Lateef, Shanqing Yin, Madhavi Suppiah
Almost every institution and academic medical center has its own simulation center today. It seems to have become a prerequisite and is incorporated into the guidelines of setting up new centers as well as in the upgrading and enhancement plans of existing institutions. In considering this, it is critical to consider the needs and demands of the healthcare population and staff the center will be serving. Setting up a simulation center is not an endeavor to be undertaken lightly. It entails a sustainable commitment in terms of political will, professional, educational and financial commitments. On the other hand, setting up a simulation center can be the most worthwhile and rewarding experience if the objectives and goals are met and effective learning occurs. The latter is an important element to be considered in the step toward nurturing an effective healthcare practitioner. In this paper, the principle author, who is the Director of the SingHealth Duke NUS Institute of Medical Simulation (SIMS) in Singapore, shares her views and experience of leading a world-class simulation facility. She has been involved in SIMS from its conception and is a strong advocate of medical education and lifelong learning. At the end of this paper, she shares a Checklist which puts together all the important considerations for anyone or any institution what is looking at setting up a simulation facility, a simulation-based training program, or even upgrading and upscaling their current simulation centre.
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The 2019 WACEM expert document on hybrid simulation for transforming health-care simulation through "mixing and matching"
p. 243
Fatimah Lateef, Xin Yi Too
With the multitude of options available under the umbrella of "simulation" today, we have a larger repertoire of choices in our educational journey and outreach. These provide a platform for us to really transform health-care simulation from the traditional, unimodality simulation, to more complex, high fidelity, integrated, and engaging multimodality techniques. The main thrust must be to enhance clinical decision-making in patient care, to solve real-world clinical problems. Hybrid simulation (HS) utilizes at least two different simulation modalities, whereby combining them will enable one type of simulation modality to enhance the other, with the proper alignment, coordination, and interfacing between the modalities. Although the term is often used interchangeably, HS is slightly different from multimodality simulation. The latter refers to the use of multiple types of simulation in the same scenario or place. The main objectives for using HS have to be as follows: (1) for the acquisition of knowledge and skills by the best combination of methodologies, (2) for clinical performance improvement at all levels of care through the creation of as close as possible to real-world situation and problems, (3) to be able to sustain motivation and passion of our spectrum learners in their educational continuum, and (4) to provide a rich, exciting, and stimulating learning platform and environment, which can trigger deep learning and understanding. This article will also share some examples and cases utilizing HS in transforming health-care simulation.
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Utility of point-of-care lung ultrasound for initial assessment of acute respiratory distress syndrome patients in the emergency department
p. 248
A Sanjan, S Vimal Krishnan, Siju V Abraham, Babu Urumese Palatty
Lung ultrasound (LUS) has been extensively used in the evaluation of acute respiratory distress syndrome (ARDS) in the critical care setting. In our study, we aim to assess the utility of point-of-care ultrasound (POCUS)-LUS in the initial assessment of ARDS patients presenting to the emergency department (ED).
Subjects and Methods:
We evaluated a prospective convenience sample of 73 adult patients presenting to the ED. The bedside LUS was performed by the trained emergency physician on patients with undifferentiated dyspnea with a clinical diagnosis of ARDS according to the Berlin's criteria. The four major LUS findings were examined on structured 12-zone LUS. The observed profile consisted of A lines, well-separated B lines, coalescent B lines, and consolidation among patients who were clinically diagnosed as ARDS. These LUS findings may vary depending on the severity of ARDS. The findings were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA).
Of the 73 study individuals, majority were male 46 (63%). The distributions of study individuals were as follows: 27% – mild ARDS, 37% – moderate ARDS, and 36% – severe ARDS. Coalescent B lines are present in about 70.4% and 92.3% of moderate and severe ARDS patients, respectively. Consolidations are predominantly present in moderate (100%) and severe (92.3%) ARDS.
LUS in the initial assessment of patients' with ARDS yielded significant findings in the three clinically designated categories. This study opens up the possibility of using POCUS as an adjunct in the initial assessment of ARDS patient in the ED.
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Is emergency department thoracotomy effective in trauma resuscitation? The retrospective study of the emergency department thoracotomy in trauma patients at thammasat university hospital, Thailand
p. 254
Amonpon Kanlerd, Nattida Sapsamarn, Karikarn Auksornchart
The survival rate after the emergency department thoracotomy (EDT) in trauma patients varies from the previous study as 1.6% in blunt injury and 11.2% in penetrating injury. Most of the data came from Europe, the US, South Africa, and Japan. This study aims to identify the success of EDT of trauma patients at Thammasat University Hospital, Thailand, and to evaluate the effectiveness of EDT. This study may be representative data for Southeast Asia.
Materials and Methods:
This retrospective review of 21 consecutive EDT cases which performed by our staffs and chief of general surgery residents between June 2009 and July 2016. Age, gender, injury mechanisms, injury sites, patient transport methods, initial vital signs, fluids and blood component requirements, resuscitation times, laboratory results, and injury severity scores were all analyzed.
Of the 21 EDT cases, one patient was excluded due to being a nontraumatic case. The remaining twenty patients were primarily young (mean 36.5 years), male (85%), suffering from blunt injuries (75%), of which 45% were predominantly thoracic injuries. Most of the patients presented without any sign of life (75%), and the total time for resuscitation was 43.5 ± 19.6 min. Seven patients (35%) had the return of spontaneous circulation (ROSC) and were successful in being brought to the operating room. Unfortunately, all patients passed away within 24 h of the operation.
The ROSC rate of EDT in this study was 35%, but with no survival benefit. Therefore, we cannot guarantee that EDT serves as an effective life-saving procedure. However, EDT may play a significant role in treating extremis injured patients.
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Neutrophil gelatinase-associated lipocalin as an early diagnostic biomarker of acute kidney injury in snake bite
p. 260
Subramanian Senthilkumaran, Ponniah Thirumalaikolundusubramanian, Namasivayam Elangovan
Snakebite envenomation is a major public health problem in the developing world, and the effects of viper envenomation on renal tissues leading to acute kidney injury (AKI) are well known. However, the usefulness of neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker to detect AKI in viper envenomation cases were not studied much.
Aims and Objectives:
The present study was undertaken to find out plasma NGAL levels and assess its usefulness among the hospitalized
group of snakebite victims in predicting acute kidney injury.
Materials and Methods:
The plasma NGAL level was estimated within 6–8 h of all the 184 cases of viper bites along with other laboratory parameters.
It was elevated much before the elevation of serum creatinine levels, irrespective of the age, gender, and bite to hospital time. The sensitivity and specificity was 99.37 and 96.15, respectively. Elevated plasma NGAL levels in viper bite helped not only to detect AKI early but also assisted to plan for appropriate intervention.
It is suggested to include estimation of plasma NGAL in the point of care testing, especially in emergency settings handling snakebite cases. However, more studies are recommended to find out its serial levels in snakebite cases following different kinds of snake envenomation with different clinical and laboratory manifestations in different age groups and gender belonging to different population so as to arrive at valid conclusions.
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Last breath in the emergency department
p. 263
Aakriti Jain, Noella Nathaniel Sase, Anne Rhea Mathew, Immanuel Judson Paul, Paul Prabhakar Abhilash Kundavaram, Priya Ganesan
Early and aggressive time to intervention has been shown to increase the odds of survival and decrease mortality in critically ill patients. Since emergency medicine is a nascent specialty in India, a review and assessment of the mortality profile in the Emergency Department (ED) would help improve the quality of care.
The aim of the study is to determine the mortality profile and causes of preventable deaths at large ED in South India.
This retrospective chart review was conducted between January and December 2017. Patients admitted with Triage priority 1 and priority 2 of our ED, who died, despite treatment, were recruited in the study. Two ED consultants blinded from each other, independently audited all the charts to determine preventable and nonpreventable causes of death.
There were a total of 69,369 patients during the study period who presented to the ED. Despite resuscitation 189 (0.7%) died, the mortality rate was 2.43%. Cardiac-related (32%) and sepsis-related (31%) causes were the most common cause of death, 23.8% were due to preventable causes and 16.9% of which were due to inappropriate management. In patients with sepsis, the odds of death due to preventable causes were significantly high (odds ratio 4.31, 95% confidence intervals: 1.96–9.47;
< 0.001).
Cardiac- and sepsis-related causes of death, together accounted for most of the mortality. In patients with sepsis, the odds of death due to preventable causes were more than four times higher than those without preventable causes.
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Application of queuing theory to optimize the triage process in a tertiary emergency care ("ER") department
p. 268
Atilio Moreno-Carrillo, Lina María Ávila Arenas, Julián Andrés Fonseca, Camilo Andrés Caicedo, Sandra Verónica Tovar, Oscar Mauricio Muñoz-Velandia
Time from triage to patient care is usually evaluated, but time elapsed between the arrival of patient to emergency room (ER) and triage (pretriage) is not usually measured.
The present study evaluates how the application of the queuing (or "waiting line") theory in the triage process can generate effective strategies to improve patient care in the ER.
Settings and Design:
A "before-and-after" study was conducted in the ER of the Hospital Universitario San Ignacio, a tertiary emergency care in Bogotá, Colombia.
Subjects and Methods:
The pretriage time was evaluated, and queuing theory was applied to the evaluation; according to the results, the number and distribution of the necessary nursing personnel were determined.
Statistical Analysis Used:
The change in waiting times was compared using a paired
In a first 7 months evaluation period, 89,898 patient visits were considered, with an average pretriage time of 22.15 min. According to the arrival distribution by hours and days of the week and considering the results of the calculations made using queuing theory, the number of nurses needed in the service per hour was determined for each day of the week, and schedule changes were implemented without increasing staff. In a second similar evaluation period, 94,497 patient visits were considered demonstrating a reduction of the pretriage time to 7.5 min (mean difference 14.64 min, 95% confidence interval 14.42–14.85,
< 0.001).
The use of queuing theory in the planning of the daily personnel requirements in the triage area of ER can reduce the pretriage time by 65% without incurring additional cost.
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Effect of prehospital transport factors on shock index, serum lactate, and mortality in children with septic shock: A prospective observational study
p. 274
Jhuma Sankar, Rashmi Ranjan Das, Archana Singh
Many children with septic shock either present late or are recognized late due to various reasons. Shock index (SI) is a valuable screening tool in dentifying high-risk septic patients in emergency department. Whether prehospital transport factors affect SI and clinical outcomes has not been evaluated.
Our aim was to evaluate if prehospital transport-related factors such as mode of transport and referral from another hospital affect the admission SI and mortality in children with septic shock.
Settings and Design:
Prospective observational study conducted over 1-year period in the Pediatric Emergency and Intensive Care Unit of a tertiary care teaching hospital.
Subjects and Methods:
Children < 17 years of age were evaluated. Data collection included referral status, mode of transport, physiologic (SI and serum lactate), and clinical parameters.
Statistical Analysis Used:
-test was used for analyzing continuous variables. Chi-square/Fischer's exact test was used for analysis of categorical variables.
< 0.05 was considered as statistically significant.
Of 51 children, 21 (41%) were referred from other hospitals. Of these, less than half were transported by ambulance unaccompanied by any healthcare personnel. Twenty-six children (43%) died, of which 15 (71%) were referred. The median serum lactate, SI, and mortality were significantly higher in those referred. On multivariate analysis of factors associated with mortality, elevated SI and/or lactate >4 mmol/L and the "referral" status remained significant after adjusting for baseline variables and illness severity.
Children with septic shock referred from other hospitals had higher SI, serum lactate, and mortality rates. Our study highlights the need for improving prehospital care and transportation in children with septic shock.
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Emergency department interventions and their effect on delirium's natural course: The folly may be in the foley
p. 280
Christopher B Noel, Jamie R Cirbus, Jin H Han
Delirium frequently affects older emergency department (ED) patients and has been associated with accelerated cognitive and functional decline, increased length of stay (LOS), and higher in- and out-of-hospital mortality.
Care provided in the ED may have downstream effects on delirium duration during hospitalization. This study aimed to identify the modifiable factors of ED care associated with delirium duration in patients admitted to the hospital through the ED.
Materials and Methods:
This prospective cohort study enrolled ED patients who were 65 years and older and admitted to the hospital. Delirium was determined in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. All delirious patients and a random selection (17%) of nondelirious patients were also enrolled. ED LOS, opioid administration, benzodiazepine administration, anticholinergic medication administration, and bladder catheter placement were obtained by medical record review. Multivariable proportional odds logistic regression was performed to determine if each of the factors was associated with delirium duration after adjusting for age, dementia, baseline function, comorbidity burden, severity of illness, nursing home residence, and central nervous system insult.
A total of 228 patients were enrolled. ED bladder catheter placement was significantly associated (adjusted proportional odds ratio = 3.1, 95% confidence interval: 1.3 to 7.4) with increased delirium duration after adjusting for confounders. ED LOS, opioid administration, benzodiazepine administration, and anticholinergic burden, however, were not.
ED bladder catheter placement was significantly associated with delirium duration and may present an opportunity for intervention.
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I should have rewound and relistened. I didn't record it. Did anybody else notice that?Spoiler:I don't think Jim will get them killed. Al's prescient statement to Sarah that there would be a time when she would lose Wendell but that time isn't now foreshadowed, to me, that one of them will not survive (probably Wendell, but who knows), but I think they'll all get out of the hospital. Except Jim. Well maybe Jim, too, if it's soon enough.
Also, I have to say I'm really liking Wendell and Sarah, but I really fear Jim is going to get them both killed.
On another note, I hope @TAWX14 who usually starts the Countdown and Rate and Review Threads is doing ok. His Countdown post of September 9 mentioned he was dealing with hurricane issues, and he was MIA Sunday night which is why I started the threads.


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I received my new typhoon H plus and I have been researching on start up and calibrations and things to do before first flight! My question is even before I get out into the field and do a calibrations should I check to see if anything needs to be upgraded first! any suggestions and comments would be appreciated!


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Pictured: Mother, 51, murdered in her Range Rover Evoque in front of her daughter as prime suspect recovers from self-inflicted shotgun wounds
- Woman in her 50s, who was found dead in Shropshire, named as Cheryl Hooper
- A 45-year-old man, from Newport, was arrested on farmland near Sutton
- The suspect allegedly fled the scene before driving four miles away to rural farm
A mother murdered in front of her teenage daughter while sitting in her Range Rover has been described as an 'angel' by her devastated friends.
Cheryl Hooper, 51, was found dead with a fatal gunshot wound to the neck outside her house in Newport, Shropshire.
A 45-year-old man was later arrested in relation to the incident, but he remains under armed guard in hospital where he is being treated for gunshot wounds.
Cheryl Hooper (pictured), 51, was found in her black Range Rover Evoque outside her new home on Friday night
Mrs Hooper, pictured, while attending church, was reportedly killed in front of her daughter
A 45-year-old man allegedly fled a murder scene after Cheryl Hooper was killed in a car
Police and ambulance crews dashed to the property at 11.13pm on Friday after neighbours reported hearing gunshots.
Mrs Hooper's 14-year-old daughter was heard screaming at the scene, 'My mum's been shot, she's dead'.
The suspect is currently being treated at Queen Elizabeth Hospital in Birmingham. Detectives do not believe his injuries to be suspicious.
Friends paid tribute to Mrs Hooper, who they said had married her childhood sweetheart John Hooper, in 2016.
The 14-year-old daughter of Mrs Hooper (pictured) was heard screaming at the scene, 'My mum's been shot, she's dead'
Cheryl and her childhood sweetheart John Hooper, the couple married in 2016
One neighbour said: 'I just can't believe what had happened. It's an absolute tragedy. Cheryl was an angel and she did not deserve this.'
A former school friend, who knew the couple, said: 'I had known Cheryl and her husband since we were at school.
'It was his second marriage and they got married in 2016, but they had been together five or six years. They used to come into the pub quite regularly together.
'I'd see them every few months down the pub.
'Cheryl was an attractive girl and really lovely. It's a complete shock what's happened.
'I've seen some of our old teachers in town and everyone is in complete shock.'
Police block the access road to Guild of Monks Farm in Staffordshire (pictured on Sunday) where a man was found injured after he is believed to have shot and killed Cheryl Hooper
Officers arrived to find Mrs Hooper in a black Range Rover Evoque (pictured) with a gunshot wound to her neck
Another friend added: 'I saw Cheryl a couple of weeks ago, I'd just come back from holiday.
'She seemed in good spirits and we had a bit of a laugh. I just can't believe what has happened.
Superintendent Tom Harding, of West Mercia Police, said officers remain at Mrs Hooper's home.
He said: 'Investigations are continuing into this incident and officers remain in the area while inquiries are carried out.
'We know that members of the local community are shocked and upset by these events, and our officers are on hand to provide reassurance.
'Our thoughts remain with Cheryl's family, who are being supported by specially trained officers at this extremely distressing time.'
Flowers have been left at the scene of the incident which occurred on Farmers Gate
A 45-year-old man, from Newport, was arrested on farmland near Sutton. He is currently in hospital under police guard
The black Range Rover was covered by a forensics tent to preserve the scene against the weather as officers continue to investigate the murder
West Mercia Police currently believe the suspect and Mrs Hooper knew one another.
Vicky Allen, 34, said: 'I heard screams, I don't know what time it was exactly. I was in bed and just thought it was people coming back from up town.
'In the Range Rover we could see the shotgun hole through the back window. It's not nice.'
Donna Campbell, 38, lives by the woman, and said: 'I heard two bangs and thought it was fireworks to start with.
'Then I heard screaming, looked out the bedroom window and saw a silver Range Rover wheel spinning off.
'I looked and a young girl was screaming 'my mum's been shot, my mum is dead'.
Police have carried out a finger tip search at the scene of the incident in Farmers Gate
The house, on a newly-built estate which is still being constructed, looks onto a grass and playpark area
'I phoned 999 and went out to see if I could help. The girl was just crying that her mum was dead and one of the other neighbours was on the phone to the police.
'He was asking if I could check the lady in the car for a pulse but by that point the ambulance and police were just arriving.
'They had only been here about three weeks. You don't expect it.'
Debbie Beamond, 48, who lives in the area, said: 'A man had a snood on over his face and was walking around here.
'You don't expect it round here, it's a quiet road - it's new. The poor girl's daughter that was in the house, they had only just moved in.'
A neighbour said: 'In the Range Rover we could see the shotgun hole through the back window - it's not nice'
Forensic officers converse at the scene on Farmers Gate in Newport, Shropshire
Debbie Beamond, 48, who lives in the area, said: 'A man had a snood on over his face and was walking around here. I don't know whether he had anything to do with it - loitering around'
Superintendent Sue Thomas, from West Mercia Police, said: 'At this time we believe the suspect and the deceased were known to each other. We are treating this as an isolated incident.
'I understand that this incident will be concerning for the local community, and I'd like to reassure them that we will have extra officers in the area over the coming days to carry out enquiries and to provide reassurance.
'We would ask anyone with any information which could assist with the investigation or who may have any concerns to please come forward or to speak with a local officer.
'Our thoughts remain with the family of the victim, who is being supported by specially trained officers at this time.'
Anyone with information should call 101 and quote incident 725s of 26 January 2018 or call Crimestoppers anonymously on 0800 555 111.
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Warehouse Worker (695516)
Last Updated: 2019-11-26
Employer: UPSLocation: Newark, DE
Find out what you'll become as a Package Handler at UPS. In this fast-paced warehouse job, you'll lift, lower and slide packages up to 70 lbs. You'll typically work 3 ½ – 4 hour shifts, approximately 17 ½ – 20 hours per week in this part-time or seasonal role…
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14 TEMPORARY Fulltime positions 2/1/2020 to 11/30/2020 – Lay sod, mow, trim, plant, water, edge, rake, blow leaves, mulch, weed, prune, fertilize, dig, haul topsoil. Use blower, mower, line trimmer, rototiller, shovel, rake, hoe, wheelbarrow. No edu. or exp. nec. – will train. Must be able to lift/carry 50 lbs…
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text:
Deborah Beach Giordano
© September 4, 2017
Exodus 3:1-6 ~ told by Deborah
While shepherding his father-in-law's sheep, Moses led them through the wilderness to Horeb, the mountain of God. And there the angel of God appeared to him in a fiery blaze from within the dry brush.
Moses saw that it was on fire but didn't burn up. He said, "That's amazing! I've got to go over there and take a closer look at that, and see why the brush doesn't burn up."
When God saw that he had gone out of his way to see it, God called to him out of the brush, "Moses, Moses!"
And he answered, "Here I am."
God said, "Don't come any closer! Take your shoes off, because you're standing on holy ground." God went on, "I am the God of your father, the God of Abraham, the God of Isaac, and the God of Jacob."
And Moses hid his face, because he was afraid to look at God.
Yikes. Moses and the burning bush: that's an unpleasant tale to tell during this Summer of Conflagration, when vast swaths of our forests and open spaces are aflame or have burned. Reading the passage I say to myself: Moses certainly should notice a fire on the hillside "and go out of his way to see it" — and put it out before it spreads.
For those of us living in the dry western United States, fire in an open space is a bad thing. A very bad thing.
Who is This?
What are we to make of an image of God that provokes alarm and even outright fear? Isn't God our Friend, our Comforter, our Shelter in times of trouble? Who is this who announces Godself with flames — and later, as we know, with pillars of smoke and fire? Anyone who has seen those kinds of pillars rising on a hillside or from within a forest knows they are terrible to behold: signs of fierce destruction and great danger.
Yet for the Israelites in the time of Moses, columns of smoke and flames served as evidence of divine guidance and protection as they trekked across the wilderness, and fire was understood as God's primary manifestation — even though this ferocious power could break the boundaries and turn against them (see Numbers chapters 11 and 16).
For the people of Israel, "to walk in the Way of the Lord" was like keeping a pet tiger: at any time it might get loose and devour those around it. It was impossible to control.
And that's scary. It is an alarming concept for most of us; it isn't the way we are used to thinking about God. It is a vision of the Almighty as dangerous, wild, and free. Unmanageable. Impatient. Impetuous.
The God of flame and smoke cannot be controlled or contained. It engulfs and overwhelms. This extraordinary power can strike without warning; illuminating, igniting, inspiring — wherever — and whomever — It will.
Fearful and Glorious
The fiery aspect of God helps us to understand "the fear of the Lord" as a term for worship. It describes the human experience of the Utterly-Other: of divine majesty; a recognition of the awesome power of God that eclipses all that mere mortals can achieve or imagine; a terror-provoking encounter with the Ultimate that transforms into "a peace that surpasses all understanding."
This "fear" is not servile cringing, but awe-beyond-astonishment: what philosopher Rudolf Otto described as an encounter with an "awe-inspiring mystery." It is fascination, enchantment: we are overwhelmed, gloriously aware; caught up in the Presence of something far greater than ourselves.
It was the experience of the fiery aspect of the Divine that sparked Moses' curiosity ("I need to see what that is,") and set him off on a journey that changed his life and the lives of literally hundreds of millions of people who followed. The encounter both terrified and energized him: here was a God of great strength and long history, one that could be relied upon; a Power that warmed and illuminated…. but could also overwhelm — and even destroy.
For the rest of his life Moses would struggle with the enthralling Presence that spoke to him from within the flames. It was a rocky relationship filled with disagreements and disappointments and difficulties — and sometimes Moses' temper got the best of him. In the end, the great Task was left to be finished by another.
Moses' story isn't one of "happily ever after": it is complex, complicated, uncomfortable. It holds no promises that a life of faith will be one of simplicity and ease. Instead, it tells of a God who surprises, shocks, and alarms those who are called to serve.
It is the story of an utterly unpredictable God.
And For Us?
So what does it mean to us? How does this testimony about an unpredictable God of fire and smoke relate to our experience and belief in One who is gracious and merciful, loving and compassionate?
Or does the question itself reveal our temptation to confine God; to narrow the Divine's capabilities and characteristics to a few familiar and comforting aspects? It has become a cultural pattern to view the world in the least generous way, as one thing or the other: it is either/or, this/that, black/white — and never both/and. The God of fire and smoke destroys these false limitations and breaks down arbitrary divisions: this God transforms a stuttering shepherd into an inspiring leader; turns a sea into dry land; creates a single people from a collection of runaway slaves.
When God showed the fullness of Godself to Moses, it was all goodness. And the revelation was accompanied by an assertion of autonomy: God will do as God chooses, not in obedience to any demands we may make or regulations we set forth. God cannot be controlled or contained:
Moses said, "Please, I beg You, show me Your glory!" And God said, "I Myself will make all My goodness pass before you, and will proclaim My Name to you; and I will be gracious to whomever I will be gracious, and I will show compassion on whomever I will show compassion."
~ Exodus 33:18-19
The God of fire and smoke, the God of the Exodus, is also the God of Extraordinary Grace and Abundant Compassion whose power can transform lives and change the world. God is not either/or, but All in All.
May we have the courage to, like Moses, "turn aside" (from our assumptions) and see the awesome, extraordinary, glorious power and grace of our God.
Virtual hugs and real-time blessings,
Deborah ♰
Suggested Spiritual Exercise:
Where do you experience the power of God?


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text:
Dietary Patterns and Their Relationship with Frailty in Functionally Independent Older Adults
Unidad de Investigación de Atención Primaria-OSIs Gipuzkoa, Osakidetza, 20014 San Sebastián, Spain
Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), 48902 Barakaldo, Spain
Instituto de Investigación Sanitaria Biodonostia, 20014 San Sebastián, Spain
Kronikgune- Centro de Investigación en Cronicidad, 48902 Barakaldo, Spain
Centro de salud de Beraun, Osakidetza, 20100 Rentería, Spain
Centro de salud de Alza, Osakidetza, 20017 San Sebastián, Spain
Author to whom correspondence should be addressed.
Nutrients 2018, 10(4), 406; https://doi.org/10.3390/nu10040406
Received: 30 January 2018 / Revised: 20 March 2018 / Accepted: 22 March 2018 / Published: 24 March 2018
(This article belongs to the Special Issue Nutrition and Ageing)
The impact of dietary patterns rather than single foods or nutrients on health outcomes is increasingly recognized. This cross-sectional study examines the dietary patterns of 527 non-institutionalized functionally independent older people aged ≥70 years from Gipuzkoa (Spain). Sociodemographic characteristics, health status, anthropometric measures and dietary data are collected. Multiple correspondence analysis (MCA) and cluster analysis are performed to identify dietary patterns and groups of individuals. Frequency of selected food items and compliance with food recommendations are included in the MCA. A high proportion of the sample population are overweight or obese, whereas only 3.3% are at risk of malnutrition (determined with the Mini Nutritional Assessment). Frail individuals (n = 130), measured with the Timed-Up and Go test are older, have a lower educational level, are more obese, present a poorer health status (more depressive symptoms, polypharmacy and falls, among others) and worse compliance with food recommendations than robust individuals (n = 392). Three groups of individuals are identified: cluster one (n = 285), cluster two (n = 194) and cluster three (n = 48). A gradient of increasing frailty and poorer health status is observed from cluster one to cluster three. The latter also shows the poorest dietary pattern, regarding dietary recommendations. The use of an easy-to-use tool to assess diet allows detection of differences among the three clusters. There is a need to increase awareness on the implementation of nutritional screening and a subsequent dietary assessment in primary care settings to provide nutritional care to elder, and moreover, frail individuals. View Full-Text
Keywords: nutrition; diet; frailty; older adults►▼ Show Figures
Figure 1
This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
MDPI and ACS Style
Machón, M.; Mateo-Abad, M.; Vrotsou, K.; Zupiria, X.; Güell, C.; Rico, L.; Vergara, I. Dietary Patterns and Their Relationship with Frailty in Functionally Independent Older Adults. Nutrients 2018, 10, 406.
AMA StyleShow more citation formats Show less citations formats
Machón M, Mateo-Abad M, Vrotsou K, Zupiria X, Güell C, Rico L, Vergara I. Dietary Patterns and Their Relationship with Frailty in Functionally Independent Older Adults. Nutrients. 2018; 10(4):406.Chicago/Turabian Style
Machón, Mónica; Mateo-Abad, Maider; Vrotsou, Kalliopi; Zupiria, Xabier; Güell, Carolina; Rico, Leonor; Vergara, Itziar. 2018. "Dietary Patterns and Their Relationship with Frailty in Functionally Independent Older Adults." Nutrients 10, no. 4: 406.
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text:
Another away match against two solid opponents,
Claire Kloska made her Senior experience pay off on the tricky Silver course at Swan Lake in Plymouth. Claire drove the green on the par 4 seventh hole and tapped in for birdie and finished with a solid 42 for the day. Claire was Medalist out of the 15 players that competed.
This team is close to breaking though and doing some great things with 3 Seniors and loaded with Freshman and Sophmores ready to make there move and contribute to this very deep and talented team.
Lexi Kilcoin 44
Rose Veldman 48
Katie Kloska 50
Mackenzie Schmeltz 50


text:
How to Get Rid of a Double Chin?
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Desktop-as-a-Service Designed for Any Cloud ? Nutanix Frame
[ Thanks to Gaël Duval for this link.
Gaël Duval writes:
Many of Linux-Mandrake's users who don't need to buy the boxed
product have requested to give money directly to support the
development of all parts of the distribution.
As a result, we have opened a donation page on http://www.linux-mandrake.com/donations/
The rule is that you have to choose a project that you want to
support, and then you choose the amount you want to give. The money
will then be directed to the project you choose. The more you
donate, the more people can be hired to improve Linux-Mandrake and
other free-software projects! :-)
Gaël Duval
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text:
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How can they achieve the achievements of this mysterious thief? Well … You just need to play the game to find out. 😉
KleptoCats is waiting for you!


text:
If you have information about this name, share it in the comments area below!
Numerology information Sumi:
Name Number: 8 Meaning: Outer, Body, Physical, Ambition, Power, Progress, Career, Success, Respect, Fame, Means, Karma
Definition funny of Sumi:
The true victor
You claimed you were the winner, but everyone knows you were not the Sumi
pure and beautiful.(Japanese)
1. A strong and beautiful woman
1. Sumi Das, Sumi Jo, hapa Sumi, Sumi-e....... amor Sumi justo de I.
1. the most awesome person ever!! 2.something or someone that is really cute
Songs about Sumi:
Ej sumi las sumi las by Piotr Majerczyk from the Album Ej se ino tyrli, tyrli (Highlanders Music from Poland)
Kad je lovac u sumi by Sprecanski talasi from the Album Moju malu zabrinula kriza
Lolita u finskoj sumi by Mel Camino from the Album Kapadokija
Nevljica sumi (Instrumental) by Ansambel bratov Poljansek from the Album Zlate polke in valcki
Proljetni miks - Proljece u sumi / Veselje ptica by Mali Sesvecani from the Album DO-RE-MI - Suma plese
Raga Jai Jawanti (Ram Sumi Le) [Medium Jhaptal] [feat. Pranesh Khan] by Rita Sahai from the Album North Indian Classical Music (Khayals & Bhajans) [feat. Pranesh Khan]
Shesh Thikana [feat. Razib & Sharmin Sumi] by Rajan Saha from the Album Bristhti Tomay Dilam
Books about Sumi:
The Sumi-E Book by Yolanda Mayhall (Aug 1, 1989)
Sumi-e: The Art of Japanese Ink Painting by Shozo Sato (Jun 10, 2010)
The Sumi-E Dream Book: An Impressionist Approach to the Art of Japanese Brush Painting by Yolanda Mayhall (Jan 1, 2003)
Sumi (Vagabond Illustration Collection) by Takehiko Inoue (Sep 16, 2008)
Sumi-e Kit by Shingo Syoko (Mar 2002)
Sumi-E Just for You: Traditional One Brush Ink Painting by Hakuho Hirayama (Jan 15, 1980)
Japanese Ink Painting: The Art of Sumi-e by Naomi Okamoto (Dec 31, 1996)
Movies about Sumi:
Zen Breakthrough: Making Contemporary Experimental Art with Sumi Brushes, Reed Pens and Mixed Media 2011 G - Runtime: 2 hrs 25 mins Starring: Bill Buchman Directed by: Burning Oaks
A SUMI-E DREAM JOURNEY 2001 - Runtime: 53 mins Starring: yolanda mayhall Directed by: ted mayhall
7 Lessons on Sumi Ink and Watercolor on Rice Paper By Henry Li - Runtime: 11 hrs 8 mins
Nausicaa of the Valley of the Wind / REGION 6 DVD / Audio: English, Japanese, French, Simp. and Trad. Chinese... R - Directed by: Hayao Miyazaki
Sumi Jo / Beautiful Challenge - 20th Anniversary 2007 -
A Sumi-e Dream Journey with Yolanda 2001 - Runtime: 53 mins Starring: Yolanda Mayhall Group Directed by: Yolanda Mayhall Group
The Traditional Crafts of Japan Vol 8 Brushes and Sumi Ink Nara Writing Utensils -


text:
Equiprobable mappings in weighted constraint grammars
Arto Anttila, Scott Borgeson, Giorgio Magri
direct link: http://ling.auf.net/lingbuzz/004670
June 2019
We show that MaxEnt is so rich that it can distinguish between any two different mappings: there always exists a nonnegative weight vector which assigns them different MaxEnt probabilities. Stochastic HG instead does admit equiprobable mappings and we give a complete formal characterization of them. We compare these different predictions of the two frameworks on a test case of Finnish stress.
|[ pdf ]
(please use that when you cite this article)
|Published in:
|SIGMORPHON 2019: 16th SIGMORPHON Workshop on Computational Research in Phonetics, Phonology, and Morphology (best paper)
|maxent, stochastic harmonic grammar, finnish word stress, phonology


text:
Places along the route
Neusiedl am See
Neusiedl am See
"Wind, water and wine" - is the motto of the approximately 97-km-long tour of discovery. It runs from the shores of Lake Neusiedl to the Danube floodplain, between vineyards and idyllic cellar streets, past historic sites and modern wind farms. The discovery tour combines Burgenland and Lower Austria, the cycling network-Lake Neusiedl to the Danube Bike Tour, nature with culture and technology.
IMPORTANT: There are currently road blocks due to the construction of wind turbines in the municipalities Schardorf, Petronell-Carnuntum and Rohrau. Please note for your safety the signage when en route!
The "Discovery Tour - Danube meets Lake Neusied " is a joint project of Burgenland and Lower Austria. Points of interest in both states are connected through it and offer the cyclists in addition to the experience of nature, cultural experiences as well. The route runs through the following places: round course, Neusiedl am See - Parndorf - Neudorf bei Parndorf - Gattendorf - Pama-Kittsee - Berg - Edelstal - Prellenkirchen - Petronell-Carnuntum - Rohrau-Gerhaus - Pachfurth - Bruck an der Leitha - Bruckneudorf - Parndorf - Neusiedl am See
Water is a constant companion on the 'Discovery Tour'. The tour starts in Neusiedel am See. The Lake Neusiedl region is a UNESCO World Heritage Site and home to the National Park Lake Neusiedl. After the width of the Parndorfer Platte, one finally reaches past the Kittsee and Berg, the community Edelstal. Here one finds sprouting natural mineral water, which is known under the name Römerquelle (Roman Springs).
Wind – Simultaneously as modern technology dominates the flat landscape, this is also evident when driving from Neusiedl direction Parndorf in the huge wind farm. In Prellenkirchen we encounter the issue in the Wind Information Center again: by appointment here you can learn all about wind and energy.
From Prellenkirchen, the route leads to Petronell to the stunning nature of the Donau-Auen.
Throughout this tour, historical discoveries are also part of the experience. In Petronell, Roman antiquity awaits in the Archaeological Park Carnuntum. Numerous historical jewels accompany the further along the route - such as Castle Rohrau, the medieval center of Bruck / Leitha or the Roman country villa in Bruckneudorf. From there, the route leads via Parndorf back to Neusiedl.
Wine: From water, it's not far to wine. Along the comfortable route cozy wine bars, wine taverns and cellars invite for a tasting of the famous wines from the vineyards of Carnuntum and Neusiedl. Also numerous Restaurants Nearby serve culinary delights.
More information at:
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Every wednesday, from 10am to 12noon, upstairs in Alsager public library, a group meets for informal, friendly, social chess.
You will not see chess clocks. But, you will see tea, coffee, and biscuits in very comfortable convivial surroundings.
Usually, there's at least 5 boards running - so you never have to wait long for a game after dropping by.
It's advertised in Cheshire East council web pages as a suitable place to learn chess, and I cannot think of a nicer place to learn
- it's a really lovely meet which makes me wish I was retired! I get along as often as I can. I especially like that some of the players visit local hostelry afterwards for further refreshment.


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26 October 2006 Edition
Remembering the Past
26 October 2006
Máire Drumm Free article
Irish unity - Need for more strategic thinking at EU level
26 October 2006
Last week saw a major one-day conference at the European Parliament to discuss how the EU can assist the process of Irish unity. The conference, which brought together academics, MEPs and an all Ireland delegation of Sinn Féin activists and elected representatives, looked at lessons from other countries. There were contributions from German academics and Cypriot MEPs on their experiences of unification and prospects for unity respectively. Free article
Moyross - problems are surmountable
26 October 2006
With a number of recent shootings, two young children seriously injured in a firebomb attack last month and families feeling forced to move out of the area, the Limerick housing estate of Moyross has been in the news headlines for all the wrong reasons. Here, ELLA O'DWYER speaks to Sinn Féin Limerick East general election candidate Maurice Quinlivan about the reality of life in Moyross and the nature of the problems faced by local residents. Free article
Letter to the Taoiseach
26 October 2006
I have always been a great believer in writing to the Taoiseach. Who else are you supposed to tell if the PSNI is using CS gas against Catholics in Strabane or Lurgan? Free article
Media View
26 October 2006
Who fears to speak of Sinn Féin? Most of the hacks and their media masters can only warm to a Sinn Féin story if it involves a former prisoner (and his/her record), a distorted quote that indicates support for violence, or unspecified and unsubstantiated allegations of criminality. But political campaigns, a Dáil speech on the health service or the grilling of a government minister about cronyism does not fit into the tabloid caricature of a republican politician and must therefore be ignored - or even worse, it should be distorted to the point where other political parties are credited with republican initiatives. Free article
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Power, madness and economists
26 October 2006
Last week, Sinn Féin MEP Bairbre de Brún was on the Newstalk radio station to talk about an important one-day conference organised by the party at the European Parliament to discuss how the EU can assist in ending partition and in the process of Irish unity. Jim Power, Chief Economist with Friends First and self-styled Sinn Féin bête-noir, was unleashed by Newstalk to destroy de Brún's arguments. Free article
The Matt Treacy Column
26 October 2006
It always provides a chap with food for thought when one hears that one is a topic of conversation in South Armagh. Many's the invitation to dinner in Camlough - strictly black tie - that has been fingered tentatively as the invitee pondered on whether his friendship with an avuncular fellow from Lisburn had raised suspicions, or did they just like the cut of his jib. Free article
The Fifth Column
26 October 2006
An Phoblacht's famous weekly satirical column. Free article
26 October 2006
Tharla a lán rudaí iontacha i mo shaol le déanaí. Tá má ag glacadh leis na deiseanna nua 's iontacha i mo dhomhan. Tá mé ag dul leis an bomaite. Tá mo shaol lán le grá, go háirithe in Copperface Jacks gach Aoine. Tá clann is cairde iontach agam. Rith mé sé mhíle anocht laistigh de 48 bomaite - sin míle gach 8 bomaite, don chéad uair i gcceathair bhliain. Free article
Téad an Tachtaire ag Teannú
26 October 2006
Le linn dom páirt a ghlacadh i dturas de bhuíon Éireannch a thug cuairt ar an mBruach Thiar sa Phalaistín, is léir go bhfuil an scéal ag dul in olcas do mhuintir na Palaistíne leis an gcos ar bolg a imríonn Stát Iosrael orthu. Tá saol sóisialta, polaitiúil agus eacnamúil na bPalaistíneach á dtachtú ag na hIosraelaigh de réir a chéile le go mbeidh siad in ann a n-aisling Síónach a chur i gcrích. Aisling na Síónach is ea tromluí na bPalaistíneach ar ndóigh! Free article


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Alexandru Vakulovski was born in in Antonești, Ștefan-Vodă, Republic of Moldova. He is a writer, editorialist, scenarist, and translator. No form of authority is accepted by the population. That is right, we do no like to stay in the line for documents, visas, at the military. I saw Maia Sandu and Andrei Nastase in Lorena Bogza's TV show indignant at the parlance of Iurie Leanca. I was surprised, because Leanca.
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Plahotniuc, working visit to Strasbourg. He met with the Secretary General of the Council of Europe. I have said several times that the negotiations were mimicked and there was never wanted a sole candidate. I selected a few samples of his letter to Plahotniuc, without getting tired of looking expressions of speeches, more sparkling.
However, what does not frighten us, it frightens many who were and are governing. These two demagogues criticized me when I said that they mimic the negotiations and today see the truth.
Alexandru Vakulovski
Alexandru Vakulovski Average alxandru They began their road to the presidency with a great hoax and a mockery to people. I looked curiously for Iurie Leanca's comment from the social network, which has scandalized Maia Sandu Andrei Nastase, even the journalist Vasile Butnaru:. I thought that the times when the Communists were using this trove are gone.
Renato Usatii is behind the crime commited by Proca, not Vlad Plahotniuc. They have a lot to repair after the communist and post-communist disaster. Mafia shot, political revenge or terrorist state attack?
Now they will come to tell you that look, even announced their candidacy before the vote can still withdraw and come up with a single candidate, that is still a mockery to men.
What else to say about the Dodon candidate? Refresh and try again. Thanks for telling us about the problem. More than half of the kindergartens from Moldova were renovated from the same source, and the program is not ending this year. As a general rule we do not censor any content on the site. It's targeted a senior official. In the situation that Moldova wastes most of the European Union money, thanks to Romania, which regularly sends aids and vakulovsji, funds for reforms and renovation – Romanian, even connected with gendarme, sounds like love, not like hatred.
The professional spring clean in Maia Sandu's clan. Renato Usatii is valulovski the crime commited by Proca, not Vlad Plahotniuc.
Alexandru Vakulovski is currently reading. Alexandru Vakulovski rated a book it was amazing. Mafia shot, political revenge or terrorist state attack? Both now play their book of life, dreamed too much to abandon this position. Missing a small detail: The Reunion of the EU right wing opposition: The problem is different: Only flag comments that clearly need our attention.
Jul 04, Even the money for pensions and wages are coming from the loans from Romania. Just a moment while we sign you in to your Goodreads account. It is the opinion of a politician who joined the campaign, nothing extraordinary, in any case a "theater of the absurd".
Want to Read saving…. Sign in with Facebook Sign in options.
These people cannot understand one simple reason: Not that we would have liked the police or militiamen, however Romanian gendarme became a symbol of aggression for communists. That is right, we do no like to stay in the line for documents, visas, at the military commissariat or, God forbid, at the police office. For us now is scarier the word cop, not to mention the militiamen, however Romanian gendarme sounds even sympathetic.
Want to Read saving… Error rating book.
He met with the Secretary General of the Council of Europe. Jan 16, Plahotniuc, working visit to Strasbourg. Published alexadnru September 05, Series by Alexandru Vakulovski. Alexandru Vakulovski rated a book it was amazing Jurnalul fericirii by Nicolae Steinhardt. The Romanian gendarme brings reforms, unlike green men sent from Moscow and one embarrassing tip in Gagauzia.
The Reivers by William Faulkner.
cu Andrei Tema Pizdet -Alexandru Vakulovski() by Adrian Dinu | Mixcloud
As well as writes Moni Stanila in an editorial: The MDA-Russia diplomatic war: Moartea lui Bunny Munro by Nick Cave. All that have told Maia Sandu and Andrei Nastase two weeks ago that they will come with a right candidate, was just a cheap demagoguery.
Attempted murder of Plahotniuc. We take abuse seriously in our discussion boards. I think people can already make important conclusions about the seriousness of these two candidates.


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The NNYAHS Agricultural Museum will host the Annual Tractor Caravan on Friday, August 16, assembling at 9:00 a.m. The caravan will be traveling a 15-20 mile route starting at the Museum at 10:00 a.m., stopping for lunch midday, and returning to the Museum grounds at 4:00 p.m. This event is open to participants who wish to drive their antique tractors as part of the caravan. "Slow Moving Vehicle" signs must be properly displayed. Advance registration is required for lunch reservations.
Camping facilities are available. The Museum Gift Shop will be open, and buildings will be open for tours.
Admission is FREE from 10:00 a.m. to 4:00 p.m. for the Tractor Caravan participants. For more information contact the Agricultural Museum Office 315-658-2353 or email [email protected]
Location: LaFargeville, NY - 30950 Route # 180
Contact: Stone Mills Agricultural Museum
Phone: 315-658-2353


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Saturdays from May 18th to August 17th
The popular New Rider Training Program is aimed at individuals new to bicycle riding or individuals that haven't ridden in a long time. The objective of the program is to help you learn how to better use your bicycle, become comfortable riding in a group, become comfortable riding on country roads, and build up your
stamina to be able to ride the 33-mile route on the Wabash River Ride in late August.
Weekly training rides starting May 18th, 2019 at 10 am - all are welcome!
The first four Saturdays will be on the West Lafayette Trail System. We will gradually increase the distance to about 11 miles (a little over an hour ride). From June 16th onward we will gradually add road riding to the trails and slowly work up to longer rides that will include a snack or lunch break.
This program is aimed squarely at novice riders. So whether you are new (or returning) to cycling, new to club/group rides, or just generally don't go very fast, this is for you!
If you are riding 10-15 miles on your own; you might want to join the program part way through. You are welcome to join us at any time during the summer. The Training Program rides will be listed on the Club Calendar under T.P. along with the start point and the expected milage.
The Training Program is being coordinated by Gary Brouillard who is a long time club member and the E ride coordinator for the club. Throughout the summer a number of other club members will help or lead parts of the
program. Throughout the summer as individuals improve their strength and skill we will direct you to other club rides that you might enjoy. We are hooked on bicycling as an enjoyable exercise and sport and would like to
help introduce you to cycling.
You do not have to be a member of WRCC to take part in the Training Program. The way the program is structured if you can't make all of the sessions you should be able to catch up quickly. There is no cost for the Training Program, all you have to do is show up with a bike and a helmet.
If you have questions or concerns please feel free to contact Gary at firstname.lastname@example.com or at 765-742-7994. If you are on Facebook, please follow our event page!
click here for the New Rider Training Program schedule as a PNG file


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