text:
- Home
- Calendar
- Town Council
- Boards & Committees
- Departments
- Safety & Services
- Maps
- Documents
- Visit
- More...
Calendar of Events
Community Events
FREE FISHING DAYJune 24, 2018
During Free Fishing Days/Weekends, anyone can fish the fresh waters of New York State and no fishing license is required! All other freshwater fishing regulations still apply.
Get all the details at DEC's website: http://www.dec.ny.gov/outdoor/89821.html
Town of Ulysses, NYIf you have questions please contact Carissa Parlato or call (607) 387-5767.
Mailing address:
10 Elm St.
Trumansburg, NY 14886
Fax: (607) 387-5843
© 2019 Town of Ulysses, NY
Sign Up for News & Info
Thank You!
You have been added to our mailing list.
You have been added to our mailing list.


text:
De Tour Transfers provides transfers from Thessaloniki Airport to Nea Kallikratia Halkidiki.Check our low prices and book now your
transfer in less than three minutes. Transfer hassle free with our taxi or mini van from Thessaloniki to Nea Kallikratia Halkidiki with
low prices.The distance between Nea Kallikratia and Thessaloniki airport ( SKG ) is 29 km and the duration of your transfer is aprox.
25 min.

subset: commoncrawl


text:
Pictures Of celebrites
Follow us:
Current location :
Female Celebrites
Brenda Benet's Pictures
Brenda Benet
Brenda Benet (August 14, 1945 – April 7, 1982) was an American television and film actress. Benet was best known for her roles on the soap operas The Young Marrieds and Days of Our Lives.
More Photos Of Brenda Benet
Most Viewed Celebrites
Andrea Barber
Miley Cyrus
Molly Ephraim
Tina Caspary
Camren Bicondova
Daveigh Chase
Milana Vayntrub
Fran Drescher
Megan Fox
O. J. Simpson
Chandler Riggs
Morena Baccarin
Richard Dean Anderson
Alexandra Daddario
Linda Cardellini
Recently Added Celebrites
Chris Zylka
Darrell Zwerling
Alan Zweibel
José Zúñiga
Rick Zumwalt
Jim Zulevic
Albert Zugsmith
Bill Zuckert
Josh Zuckerman (actor)
Michael Zorek
Adam Zolotin
Richard Zobel
Bob Zmuda
Adrian Zmed
Chuck Zito
Random Celebrites
Sarah Silverman
Joseph Hoover
Harry Allen (actor)
China Kong
Laura Marano
Larry Bagby
Jacob Kogan
Jude Ciccolella
Fred Malatesta
Mike Binder
June Gale
Marc Senter
Malcolm McGregor
Linda Marshall
B. J. Porter
Joy Harmon
Mae Middleton
Adam Williams (actor)
Leo Penn
Sebastian Montoya
Terms of Service
Privacy Policies
Online Safety
2015-2016 © picsofcelebrities.com


text:
Surgical correction for disorders or injury to the musculoskeletal system is common clinical situation among individuals who suffer from chronic rheumatologic disease. Rheumatologists, internists, and primary care physicians are often asked to provide perioperative care for such patients, from pre-operative medical evaluation to post-operative follow-up care. Understanding the concerns of the orthopaedic surgeon with regard to such patients can assist in the collaboration. The purpose of the preoperative medical evaluation and subsequent perioperative management is:
A. Timing
The preoperative evaluation should take place, whenever possible, in the office setting several weeks before surgery. While not always possible, for instance in the setting of acute injury requiring surgical correction (i.e. fracture), such anticipatory evaluation allows for sufficient time for discourse with other physicians' involved in the patient's care, for additional consultation and further investigation and, if necessary, for the institution of therapy directed at optimizing the patient's medical status prior to the contemplated surgery. The evaluation's findings should serve as a focal point of communication between all those involved in the patient's care.
B. Guidelines
No consensus exists regarding what constitutes the optimal preoperative medical evaluation. A given patient's needs depend on such factors as: age, functional capacity, existing co-morbidity, and the type of anesthesia and surgery to be performed. However, general guidelines can provide a useful framework for such evaluations.
Except in young patients and those having minor surgical procedures, most patients should undergo a complete medical history and physical examination prior to the surgical procedure. Among the few studies that have been reported, several have failed to demonstrate the value of routine preoperative testing. Nonetheless a number of investigations may be considered appropriate and are commonly performed on patients prior to major orthopaedic surgery. Depending on the nature of the orthopaedic problem and the magnitude of surgery required to correct it, as well as the nature and severity of co-existing diseases, such testing might include a complete blood count, urinalysis and urine culture (for those patients undergoing total joint arthroplasty), and complete blood chemistries. Routine measurement of the prothrombin (INR) and partial thromboplastin times have not been demonstrated to be of value as preoperative investigations. However, in patients requiring anticoagulants after surgery (i.e. those having total joint arthroplasty), a specific exception would seem justifiable. A 12-lead electrocardiogram and chest radiograph are also indicated particularly in the elderly and those undergoing major joint or spine surgery.
One of the primary purposes of the preoperative medical evaluation is the identification of patients at higher risk for post-operative complications. The standard clinical examination is the principle screening method for the detection of conditions likely to affect surgical outcome. However, two rating systems are useful in identifying patients who are most likely to develop postoperative complications.
The best known and most widely used is the American Society of Anesthesiologist (ASA) Physical Status Scale, which has been in use for more than 30 years and which has a high correlation with the patient's post-operative course. The ASA is based on the presence of a systemic disturbance designated as: absent (I), mild (II), moderate (III), severe (IV), or virtually certain to cause death (V); the sub-designation E, denotes emergency surgery.
A second system, less commonly used, focuses only on the risk of cardiac complications. The salient features of this rating system, the Goldman Cardiac Risk Index, along with other more recent observations are discussed in greater detail below.
The following discussion addresses co-morbidities roughly in order of their frequency in the surgical population. Table 1, below, is a useful chart that summarizes medication concerns and reminders related to co-morbid conditions.
Table 1: Perioperative Evaluation and Care*
Continue medications through surgery
Bacteremic surgery may seed endocardium
Continue most medications through surgery, using non-oral forms if necessary
Only severe (diastolic over 110) or malignant hypertension needs control pre-operatively in most cases
Thyroid Disease:
Even young diabetic patients have autonomic insufficiency.
Prolonged anesthetic effect after surgery may suggest hypothyroidism
Gastro-intestinal and Hepatic
Caution with nephrotoxins, including acetaminophen.
NSAIDs: stop 5 – 7 days before surgery (reversible platelet function)
Hold cytotoxic or immunosuppressive drugs before surgery
Consider autologous blood transfusion requirements well in advance of surgery
Continue Anti-convulsant therapy
Polypharmacy common in the elderly; continue medications only if indicated
*MacKenzie, CR, Sharrock, NE. Perioperative Medical Considerations with Rheumatoid Arthritis. Perioperative medical considerations in patients with rheumatoid arthritis. Rhem Dis Clin North Am. 1998 Feb; 24(1):1-17. Reprinted with permission.
A. Coronary Artery Disease
The contribution of cardiovascular disease to the risk of noncardiac surgery cannot be overstated and is, fortunately, the most investigated and well documented arena of perioperative medicine. The literature pertaining to this subject has been extensively reviewed elsewhere and practical guidelines intended to guide physicians involved in the assessment and care of patients in the perioperative have been published.
The predictive value of the routine clinical assessment, including the medical history, physical examination, electrocardiogram and chest X-ray is well established, at least with respect to the identification of the presence of pre-existing cardiac disease. However it is also important to define disease severity, stability and prior treatment as these factors, working in concert with other clinical characteristics such as age, functional capacity (as determined by simple activity questionnaires), co-morbidity (particularly diabetes mellitus, peripheral vascular disease, chronic pulmonary disease) and type of surgery to be performed (major orthopaedic procedures tend to be of intermediate risk) ultimately define post-operative risk.
A series of factors may predict postoperative myocardial infarction, congestive heart failure, and death after orthopaedic surgery.
The major predictors of increased perioperative cardiac risk include:
Intermediate predictors of increased perioperative cardiac risk include:
Minor predictors of increased perioperative risk include:
The indications for preoperative exercise stress testing with or without nuclear scanning or ambulatory electrocardiography (Holter monitoring) are not clear. Ultimately, the decision will depend on the physician's estimates of the effectiveness, risk, and costs of such evaluations. Feasibility also may come into play given the functional compromise of the orthopaedic patient and the frequent need to perform surgery relatively urgently.
Nonetheless, guidelines have emerged from a large body of clinical data.
The relevant therapeutic considerations mainly relate to medication management. Recognition of the protective role of beta-blockade in the perioperative setting is perhaps the most significant advance in perioperative medical care. Based on several definitive studies and general consensus, B-blockade in patients undergoing major noncardiac surgery has been shown to reduce the risk for postoperative cardiac complications (myocardial ischemia and infarction) and mortality.
Questions relevant to this issue are:
(1) Which patients should receive B-blockers perioperatively?
Criteria for deciding which patients should be treated with B-blockers are summarized in Table 2:
Table 2: Recommendations for the Use of Perioperative Beta Blockers*
1. Perioperative beta-blockage should be used in patients with any of these criteria:
2. Use beta-blockade in patients meeting any 2 of the following criteria:
3. Possible contra-indications for beta blockers (often such patients may still cautiously receive beta blockers on a case-by-case basis):
4. Timing and choice of perioperative beta-blockers
*Auerbach AD, Goldman L: Beta Blockers and Reduction of Cardiac Events in Noncardiac Surgery: Scientific Review, JAMA, 287:11, 1435-1444, 2002.
(2) Which B-blocking agent should be used?
Studies demonstrating benefit of B-blockade have used B1-selective agents and within that group of medications, no advantage of any specific agents has been shown. Atenolol 50 mg daily or Lopressor 25 mg bid would appear to be suitable choices.
(3) When should B-blocker use be started preoperatively? Physicians should attempt to begin therapy early enough in order to achieve a degree of B-blockade which would generally require several days. Nonetheless if it is not possible to initiate treatment in this timeframe, the medication can be given intravenously by the anesthesiologist at the initiation of anesthesia. Patients already taking beta-blockers prior to surgery should be advised to continue the medication up to and including the morning of surgery.
Patients taking long-acting nitrates should be given the drug on the morning of surgery as well; cutaneous nitrates can be continued post-operatively until the patient resumes oral intake.
Patients taking ACE inhibitors are at increased risk of circulatory instability, especially if the medication is taken immediately prior to surgery. Thus, the administration of preoperative cardiac medication should be discussed and coordinated with the anesthesiologist prior to surgery.
As with risk assessment, the optimal surveillance strategy for detecting post-operative myocardial infarction has not been well-studied. In patients with no preoperative evidence of coronary disease, detection strategies can be restricted only to those patients who develop signs or symptoms of cardiac dysfunction or ischemia. In those at greater risk for postoperative cardiac complications, surveillance for ischemic events should begin with an EKG immediately after surgery, with additional daily testing on each of the first two post-operative days. While CPK levels are usually elevated due to the muscle trauma associated with surgery, cardiac isoenzymes and, more recently, serial serum troponins are useful in the detection of myocardial infarction, particularly in those patients whose surveillance EKG's reveal changes suggestive of ischemia.
B. Other Cardiovascular Diseases
1. Hypertension
Blood pressure measurements should be taken in the lying and sitting position to determine the maximal orthostatic fall in blood pressure as well as the degree of blood pressure control. Patients are then classified as untreated, hypertensive controlled on medication, or hypertensive despite therapy. As the perioperative morbidity associated with chronic hypertension is largely a function of the presence of the major end organ (cardiac, neurologic, renal) complications, the preoperative examination should focus on assessment of these classic complications of poorly controlled hypertension. Such determinations are relatively easily made from the common preoperative laboratory studies and EKG.
Although controversy exists about whether mild to moderate hypertension (diastolic = 110 mg Hg) increases the risk of surgery, patients whose blood pressure is above this range likely are at greater risk and should be stabilized with anti-hypertensive therapy prior to surgery. Patients who are in satisfactory control preoperatively should continue their medication, taking it on the morning of surgery and subsequently throughout the post-operative period, if their blood pressure allows. However, due to bed rest, fluid losses, and the hypotensive influences of various medications employed in the postoperative setting, some patients may temporarily require less (or no) anti-hypertensive medication.
2. Valvular Heart Disease
Surgical risks in patients with valvular heart disease depend on the valve affected as well as the nature and severity of the valvular lesion. The lesion conferring the highest perioperative risk is hemodynamically significant aortic stenosis. Mitral valve disease and aortic insufficiency, if not severe, are usually well tolerated, although any valvular disease associated with significant left ventricular dysfunction (NYH Class 3 or 4) increases the risk of surgery. Therefore, patients with a significant cardiac murmur, accompanied by signs or symptoms of left ventricular dysfunction, should undergo an echocardiographic assessment preoperatively, particularly if a major orthopaedic procedure is planned. Invasive hemodynamic monitoring perioperatively may be indicated in patients at higher risk.
3. Cardiomyopathies
The chronic cardiomyopathies, whether or the dilated or hypertrophic type, are associated with an increased incidence of post-operative congestive heart failure. Indeed the hypertrophic cardiomyopathies generally are considered a relative contraindication to epidural or spinal anesthesia.
4. Arrhythmias and Conduction Abnormalities
Arrhythmias and conduction diseases may be a marker for underlying pulmonary disease, metabolic abnormalities, or drug toxicity. Therefore, the clinician should search for such conditions preoperatively and institute corrective action, if possible, before surgery.
A problem that arises with some frequency is the patient with chronic atrial fibrillation on long-term anticoagulation. As the risk of embolic stroke in such patients who are not anti-coagulated is low, it is safe to temporarily discontinue warfarin (Coumadin) for a sufficient period of time preoperatively to allow for normalization of the prothrombin time and INR. Five days is generally sufficient.
C. Pulmonary Disease
Chronic obstructive lung disease (chronic bronchitis, emphysema) and asthma are the two most prevalent forms of chronic pulmonary disease and, as such, are the pulmonary problems seen most frequently in the preoperative setting. They are also demonstrated major predictors of post-operative pulmonary complications, which may be pulmonary or non-pulmonary.
Minor pulmonary complications (atelectasis, bronchitis) are increased in patients who smoke (See PDF on "Managing Smoking Cessation for Healing"), who have a chronic cough or have abnormal spirometry. The risk of severe post-operative pulmonary complications (pneumonia, respiratory failure) is increased mainly in those patients with marked impairment in lung function (FEV1<1.5 liters). Among the non-pulmonary factors which contribute to the risk of post-operative complications are age, obesity, longer duration of anesthesia, over-sedation, and poor patient effort.
The risk of perioperative lung dysfunction depends, in large part, upon the type of surgery performed. Patients with severe lung impairment can tolerate minor procedures, even under general anesthesia. The risk of pneumonia following major peripheral surgery (such as hip or knee surgery) is low, even in the patients with chronic lung disease. (This is in marked contrast to intra-abdominal or intrathoracic surgery, which is associated with a high risk of atelectasis or pneumonia in patients, particularly in patients with severe COPD.)
Regional anesthesia for surgery on the extremities circumvents many of these problems. However, interscalene block may transiently paralyze the ipsilateral diaphragm and reduce the FVC by 30-40%.14 Therefore patients with COPD undergoing shoulder surgery, in which interscalene block is frequently employed, should have pulmonary function studies performed preoperatively. In patients with severely impaired pulmonary function (FEV1 < 1 leter), interscalene block should be avoided altogether. Otherwise, patients with COPD fare well with this anesthesia, especially in the sitting position.
Patients who have been using bronchodilators on a chronic basis before surgery should be given their standard dosage the night before surgery; bronchodilator therapy should be administered post-operatively either systemically or by nebulizer. Incentive spirometry and early mobilization are helpful in the prevention of post-operative atelectasis.
D. Endocrine Problems
1. Diabetes Mellitus
Diabetes is the most important endocrine disorder encountered in surgical patients. Diabetics are at slightly greater risk of postoperative death, a consequence of their greater prevalence of ischemic heart disease. Further, diabetics with autonomic insufficiency (manifested by postural hypotension, impotence, nocturnal diarrhea) may be at risk for sudden cardio-pulmonary arrest postoperatively.
The control of the serum glucose tends to be the focus of medical management postoperatively, and numerous approaches to diabetic therapy have been reported. A common approach for insulin users is the so-called "sliding scale" regimen; one-half to two-thirds of the patient's usual morning long-acting insulin dose is given on the morning of surgery together with 5% dextrose. Supplemental short-acting insulin is then given as dictated by finger stick blood sugars four times a day. This regimen is continued until the patient resumes oral intake. A different regimen is indicated for patients taking oral hypoglycemic agents: these medications can be taken the day before surgery and resumed when the patient is eating, except for chlorpropamide (Diabinese), which should be discontinued several days before surgery because of its long half-life.
2. Chronic Corticosteroid Therapy
Since many rheumatic disease patients take corticosteroids, prophylaxis against adrenal insufficiency and management of the patient's corticosteroid therapy in the perioperative setting are critically important. Patients believed to be at increased risk for adrenal insufficiency include: those currently taking > 20 mg hydrocortisone daily, those who have taken such doses for > two weeks in the preceding year, and those who are receiving replacement corticosteroid therapy for known adrenal insufficiency.
Traditionally, such patients have been given a so-called "stress-dose" therapy when undergoing major surgical procedures:
This approach has been called into question recently however by a report concerning patients undergoing orthopaedic procedures. In this small, non-randomized study, patients given only their baseline doses of glucocorticoid demonstrated no clinical or laboratory evidence of adrenocortical insufficiency postoperatively, suggesting that the commonly employed "stress doses" of corticosteroid may be unnecessary, at least in patients undergoing orthopaedic surgery. In patients undergoing minor procedures (i.e. surgery on the distal extremities) or those requiring regional or local anesthesia, a single preoperative dose of 100 mg can be considered sufficient coverage because the normal metabolic response (i.e. additional adrenocorticoid secretion) to minor surgery is minimal.
E. Gastrointestinal Disease
Gastrointestinal problems, both exacerbations of chronic conditions or problems arising de novo, may complicate the post-operative period and produce significant morbidity. Peptic ulcer disease, a reasonably common problem in the orthopaedic/rheumatic disease population due to the high usage of non-steroidal anti-inflammatory agents, may become active after surgery; it is particularly problematic in patients who require anticoagulation prophylaxis, such as those who have undergone arthroplasty.
Therefore, patients with a history of peptic ulcer disease, GI bleeding or active symptoms of dyspepsia should receive prophylactic H2-blocker therapy throughout the post-operative period. In the presence of a strong clinical suspicion that an active peptic process is ongoing, the surgery should be canceled, a work-up performed, and treatment instituted before proceeding. In patients at risk for the development of GI bleeding after surgery, serial stool guaiacs are a good surveillance approach.
Development of an abdominal ileus is a relatively common postoperative complication, albeit not one restricted to patients with chronic gastroenterological problems. An important predisposing factor is the postoperative use of aggressive narcotic-based analgesics, coupled with an over zealous reintroduction of oral intake in the early phase of recovery. Careful consideration should be given as to the optimal timing of the resumption of oral intake of both liquids and solids, and potent narcotic therapy should be weaned down as quickly as possible, particularly in patients with chronic gastrointestinal complaints and conditions
F. Genitourinary Conditions
As a consequence of bed rest, the use of narcotics and epidural anesthesia, and the presence of prostatic disease, urinary catheters are frequently placed in patients after major orthopaedic surgery. In general, such catheters should be removed at the earliest possible time after surgery and a surveillance urine culture performed to rule out the development of a urinary tract infection. If urinary catheters are removed within 48 hours of surgery and urinary retention is avoided, the risk of urinary tract infection is small.
Prostatic disease leading to urinary outflow obstruction is a common problem in men after orthopaedic surgery. In patients with significant chronic symptomology, urologic consultation should be obtained prior to surgery and therapy (including TUR) performed, if deemed necessary. In patients with a propensity to urinary retention and those with enlarged prostate glands who report obstructive symptomology, therapy with agents such as terazosin (Hytrin) and tamsulosin (Flomax) could be instituted before or at the time of surgery.
In patients with a history of nephrolithiasis, dehydration should be rigorously avoided so to help prevent development of acute renal colic.
G. Infectious Complications
The risk of infection in a prosthetic joint is of great concern in patients undergoing total joint arthroplasty. Efforts to prevent and detect any infectious process is of utmost importance. The skin and urinary tract are sites of specific concern, and infection can be ruled out by a careful physical examination and routine preoperative urine culture. In addition, formal dental consultation may be appropriate in patients with poor oral hygiene and dentition.
Prophylactic antibiotic therapy for total joint arthroplasty patients should begin< 2 hours before surgery and continue for 24 hours. The recommended protocol at Hospital for Special Surgery involves cefazolin 1 gram q8h (total of three doses) or, in penicillin allergic patients, vancomycin 1 gram q12h (total of two doses).
H. Neurologic Problems
1. Confusional States
Elderly patients are at significant risk for the development of confusional states after surgery due to a confluence of factors arising in the perioperative setting, including sedatives, analgesics, anesthesia, fever, metabolic derangements, and the disorienting effects of an unfamiliar environment. For example, in patients undergoing emergent surgical repair of a fractured hip, 30- 50% have been reported to develop significant changes in cognitive functioning. Although such changes are usually a transient phenomenon, clinicians should focus on the detection and treatment of correctable causes that may present in this unusual fashion, particularly in the geriatric patient population. Such causes include: metabolic disturbances (hyponatremia, hypoxemia); offending medications (which might well be discontinued); infection; and acute conditions (respiratory failure, myocardial infarction, cardiac arrythmias, congestive heart failure, pulmonary and fat embolism syndrome, etc.)
Likewise, elderly patients and patients with underlying neurological dysfunction (e.g. alcoholism, Parkinsonism) are at increased risk for postoperative delirium. Formal neurologic consultation and work-up is occasionally necessary though generally unrevealing.
2. Neuropraxias
The neuropraxias arise more often after upper and lower extremity surgery as they are generally a compression phenomenon resulting from prolonged positioning of the extremity during surgery or casting. Early detection and intervention is critical to the ultimate outcome in these circumstances. Therefore, all those involved in postoperative care must keep this problem in mind. Patients with antecedent neurological disease are at increased risk of neuropraxia.
I. Emotional/Psychiatric Problems
Patients who live with the consequences of chronic rheumatic diseases or orthopaedic problems may suffer emotional difficulties due to chronic pain, disability, and limitations in career opportunities, social interactions, and personal relationships. Because surgery is a significant life stress, such individuals may require additional emotional support perioperatively. Further, some patients may be taking or require anti-depressant or anti-anxiolytic medication. In the relatively rare patient who is being treated with monoamine oxidase inhibitors, it is recommended that the medication be discontinued preoperatively and the anesthesiologist alerted to the situation. Patients on these agents are at risk of marked circulatory instability with general anesthesia and certain narcotics, especially meperidine.
Specific clinical problems that may be encountered and benefit by perioperative management are discussed here roughly in order of how often they are encountered.
A. Thrombo-embolic Disease
Prevention of thromboembolic phenomenon after orthopaedic surgery is the most thoroughly studied of potential postoperative complications. Pulmonary embolism, perhaps the most dreaded complication of orthopaedic surgery, remains an important cause of postoperative mortality. Numerous protocols have documented efficiency in minimizing this risk.
Prevention begins at the time of the procedure. Expeditious surgery reduces the risk of deep venous thrombosis following operations such as total hip replacement. The type of anesthesia employed is also important; epidural anesthesia reduces the risk of proximal deep venous thrombosis following total hip replacement by two- to threefold and also reduces the overall risk of deep venous thrombosis by at least 20%. Other intraoperative interventions, such as hypotensive anesthesia and intraoperative heparin administration, further reduce thrombogenesis.
Mechanical means of reducing risk of thromboembolism also have proven efficacy and include pneumatic compression boots, foot pumps, compression stockings, foot flexion/extension exercises, and early ambulation. These maneuvers are safe, effective and do not increase the risk of bleeding.
The mainstay of treatment is anticoagulation, although its benefit is becoming more controversial. Prophylactic anticoagulation is begun immediately following surgery. Regimes include warfarin (Coumadin) with a target INR in 2.0 to2.5 range, formerly subcutaneous heparin 5000 units BID-TID, and more recently low molecular weight heparin. A new low molecular weight heparin, fondaparinux (Xantidar), has been reported to be even more effective in the prevention of venous thrombosis than enoxaparin (Lovenox) in patients undergoing total joint arthroplasty and after hip fracture repair. Aspirin is also effective when combined with other modalities and continues to have its proponents.
A multimodal approach, relying on a combination of intraoperative modalities, postoperative mechanical devices, early ambulation, and low intensity postoperative anticoagulation, is preferred for the majority of patients by most experts and clinicians.
B. Hip Fracture
Hundreds of thousands of patients are admitted to hospital in the United States annually for treatment of a fractured hip, resulting in major costs to society, to patients, and to their families. Within the first year of fracture, 20% of elderly hip fracture patients die, compared to 9% of age-matched, non-fracture patients. Further, one-sixth of patients who survive one year after fracture are confined to long-term care facilities, while another one-third continue to require assistive devices or the help of others to manage their daily activities. Therefore, after a fracture of the hip, most patients experience permanent impairment in functional capacity and the rates of permanent institutionalization are high. Risk factors thought to increase the need for nursing home placement include living alone prior to the fracture, having no children, and female gender.
The majority of hip fractures occur in frail, elderly women with osteoporosis who have sustained a fall. Indeed, falls are the most common antecedent event in these circumstances, and fractures are the most common serious fall-related injury. Risk factors for hip fracture include: increasing age, poor general health, maternal history of hip fracture, a history of hyperthyroidism, poor depth perception, use of psychoactive medication; sedentary lifestyle, low bone mineral density and, of course, osteoporosis.
Hip fractures can be divided into two major categories: intracapsular fractures of the femoral head and extracapsular fractures (intertrochanteric or subtrochanteric). The current approach to treatment is surgical, utilizing either internal fixation (pinning) or prosthetic joint replacement. Although a matter of ongoing debate, more severe (i.e. displaced) intracapsular fractures of the femoral head are often treated with prosthetic joint replacement because they may result in a serious compromise to the blood supply of the femoral head leading to osteonecrosis, collapse of the femoral head, and secondary osteoarthritis. Internal fixation is the usual surgical approach to displaced femoral neck fractures. However, in the frail, elderly patient with lower anticipated functional requirements and life-expectancy, such fractures may treated with total joint arthroplasty as well.
C. Fat Embolism Syndrome
Fat embolism syndrome is not uncommon after total joint arthroplasty, particularly in patients undergoing simultaneous bilateral procedures. Time of onset is variable; hemodynamic instability may develop almost immediately (presaged by a rise in pulmonary artery pressure when the prosthesis is cemented) or more insidiously over the first two to three postoperative days. In the latter group, it is often very unclear what is happening early on because patients gradually become moderately to severely hypoxemic after surgery, may be hypotensive and, in the case of the elderly, often become confused. Hematologic abnormalities such as transient thrombocytopenia are commonly seen. Frank adult respiratory distress syndrome may develop, require aggressive supportive measures (i.e. intubation), and become life-threatening.
Treatment is supportive and includes the administration of increased concentrations of inspired oxygen (possibly via ventilator), the prevention of pulmonary hypertension by fluid restriction and the use of diuretics and venodilators, and the prevention of pain. Corticosteroid therapy has not been demonstrated to be of benefit and is not recommended.
Pulmonary artery catheterization may be helpful to guide therapy; if the pulmonary artery diastolic pressure is maintained at <20 mm Hg, respiratory insufficiency is usually prevented. In severe cases, systemic manifestations of fat embolization may occur and become associated with myocardial infarction or severe brain injury. Whether this represents transpulmonary transfer or passage of fat through a patent foreman ovale is unknown.
D. The Difficult Neck
Some patients with rheumatoid arthritis, generally those with advanced and aggressive disease, may manifest significant cervical spine involvement with instability arising from atlantoaxial or subaxial subluxation. This complication presents both important risks to the patient undergoing surgery and significant challenges for the anesthesiologist, particularly if endotracheal intubation is required. These patients have an increased risk for cord compression during intubation or from uncontrolled neck movement during positioning for surgery.
Cervical spine instability should be ruled out prior to surgery with flexion/extension films in those patients with neck pain or crepitus on range of motion testing, radicular symptoms, or arm and/or leg weakness. Affected patients should wear a soft cervical collar to the operating room, both for neck immobilization and as a warning to all involved not to over-manipulate the neck. When possible, epidural or spinal anesthesia should be employed.
Additional problems arising from the rheumatoid disease process include involvement of the temporomandibular joint, which may limit jaw opening, and arthritis of the cricoarytenoid joints. Because these problems also may influence the choice of airway management, the anesthesiologist should be informed preoperatively about these manifestations of the disease process as well.
The rigid cervical spine of the patient with ankylosing spondylitis may also present technical challenges for the anesthesiologist during intubation. A fiberoptic method is often employed in this clinical context.
E. Immunosuppressive/Anti-Inflammatory Therapy
In rheumatic disease patients, the question often arises as to what, if anything, should be done about their regimens of methotrexate and other immunosuppressive agents. Little data exists to guide recommendations for immunosuppressive therapy in the perioperative setting. Whether or not such agents increase the potential for infection or delay wound healing is uncertain, but it has become common practice and seems prudent to discontinue such therapy one to two weeks prior to surgery and then restart it approximately one to two weeks post-operatively. Acute disease flares resulting from the abrupt discontinuation of immunosuppressive therapy for such brief periods are unusual and can usually be managed with corticosteroids.
Anti-inflammatory therapy, particularly aspirin, should be discontinued five days before the surgical procedure because their anti-platelet effects may increase the risk of bleeding. This does not appear to be necessary with the new COX-II inhibitors, such as celecoxib (Celebrex) and rofecoxib (Vioxx), as they do not interfere with platelet function.
F. The Integument
As a result of chronic therapy (i.e. corticosteroids, immunosuppressive agents) or as a manifestation (i.e. decubitus ulceration) of the debilitating consequences of underlying rheumatic disease or orthopaedic condition, skin integrity may be compromised before and after procedures in patients undergoing orthopaedic surgery. In addition, delayed wound healing and a propensity to infection may result from these influences. The early institution of preventive measures to combat the development of decubitus ulcers (particularly of the heels and buttock region) is vital to an uncomplicated post-operative course.
G. The Eye
Patients taking chronic optic medication should have their eye drops instilled prior to surgery, especially if a prolonged procedure is anticipated. The one exception to this recommendation involves the use of phosphodiesterase inhibitors in the treatment of glaucoma. These agents may prolong the action of the neuromuscular blocker succinylcholine. This is particularly pertinent in patients with Sjogren's syndrome who require artificial tears to prevent perioperative conjunctival injury.
Patients in the prone position are at risk for ocular injury secondary to external pressure. Patients with underlying vasculitis of the optic vessels are at particular risk of ischemic injury to the eye. Thus the anesthesiologist must take particular care to position the patient carefully avoiding excessive pressure on the eye and provide appropriate eye protection.
The ultimate purpose of the preoperative medical evaluation and perioperative care in general is to improve patient outcome. Through the preoperative identification of comorbidities and other relevant problems, treatments that improve the patient's capacity to withstand the rigors of surgery and its aftermath can be implemented early, often before the surgery takes place. As perioperative medicine has become a field of inquiry in its own right, the clinical characteristics that predict those patients at risk have become increasingly more defined. Indeed, intervention trials directed at reducing post-operative complications are more frequently being conducted, leading to significant reductions in postoperative morbidity and mortality. Perhaps no group of patients has benefited more from these advances than the often frail, elderly, and functionally compromised patient suffering from one of the rheumatic diseases.
Posted: 9/14/2004


text:
SACRAMENTO – Assemblymember Jim Frazier, D-Discovery Bay, issued the following statement Thursday in response to alleged unlawful ex parte communications between the State Water Resources Control Board and the Department of Water Resources regarding the proposed Delta tunnels outlined in complaints filed by Delta region local governments, public agencies and advocacy organizations.
"If these allegations are true, it attests that DWR has been illegally manipulating the process in favor of the disastrous tunnels project and doing it behind closed doors. I'm appalled that the State Water Board would show such bias and not represent the whole state but only a portion of the state.
These allegations are more of the same unethical, unprofessional and illegal behavior by DWR that we have seen in the past, exposed by a recent State Auditor's report.
The public, especially residents of the Delta, deserve to have confidence that the process is fair, transparent and focused on what is best for all Californians, not just the interests of a few.
I am grateful to the local governments and advocacy organizations in the Delta for bringing these apparent violations – discovered through a Public Records Act request – to light. I join them in calling for a full investigation into the prohibited communications alleged in the complaints."
Assemblymember Frazier represents the 11th Assembly District, which includes the communities of Antioch, Bethel Island, Birds Landing, Brentwood, Byron, Collinsville, Discovery Bay, Fairfield, Isleton, Knightsen, Locke, Oakley, Pittsburg (partial), Rio Vista, Suisun City, Travis AFB, Vacaville and Walnut Grove.


text:
The attorney-client privilege is alive and well. In a little-noticed opinion, the District Court for the Northern District of Georgia dismissed a legal malpractice claim against a law firm. Taking all the allegations of the Complaint as true, the Court held that the "Defendants were hired to provide legal advice which they did. Securities lawyers are not informants for the SEC." In the wake of the multitude of current opinions suggesting that attorneys become gatekeepers for the SEC or the public in general, this opinion reaffirms that a lawyer's duty is to his or her client – not to others. Hays v. Page Perry, LLC, No. 1:13-CV-3925-TWT (N.D. Ga. March 17, 2015).
In 2008, Page Perry, LLC, a law firm, began representing Lighthouse Financial Partners, LLC, an investment services firm, with respect to SEC and state securities licensing and registration requirements. The retainer agreement made clear that Page Perry's responsibilities did not include compliance matters. During the representation, Page Perry attorneys conducted two "mock audits" in which they identified deficiencies in Lighthouse's accounting, including that Lighthouse was impermissibly in custody of client funds. Page Perry advised Lighthouse to take actions to fix the deficiencies.
In December 2011, the Georgia Securities Commissioner notified Lighthouse of a planned audit and in March 2012, the SEC subpoenaed the manager and majority owner of Lighthouse, Benjamin DeHaan. Page Perry represented him before the SEC. In June 2012, Page Perry withdrew as counsel for Lighthouse. With DeHaan's consent, Page Perry then reported his criminal activity to the SEC. In 2013, DeHaan pled guilty to one count of wire fraud.
The Receiver for the LLC then sued Page Perry for malpractice alleging, among other things, that the law firm should have notified regulatory authorities of the violations committed by DeHaan and Lighthouse and that such notification could have mitigated the ensuing damage. The Court rejected all of the Receiver's arguments.
The Court found no legal precedent that suggested Page Perry had any duty to report out the fact that Lighthouse was not in compliance with all regulations. Even if the Georgia Bar Rules did impose a duty (which they did not), they did not require reporting out. Georgia Bar Rule 1.13(b) required reporting to the "highest authority that can act on behalf of the organization." Page Perry did so when it advised DeHaan, the manager and majority owner of Lighthouse, of the non-compliance. In contrast, Georgia Bar Rule 1.13(c) states that notifying an external agency is "permissive, but not mandatory." Thus, the Georgia Bar Rules did not require reporting out.
The Court, citing its earlier order, reiterated that requiring Page Perry to divulge client confidential information to the regulators "would have dire consequences for the attorney-client relationship." As the Court said:
Under the Plaintiff's proffered duty, the risk of civil penalties would cause attorneys, out of self-preservation, to err on the side of disclosure when in doubt. Consequently, such a rule could even deter potential clients from seeking advice from a lawyer.
In response to the Receiver's arguments, the Court ruled that disclosing information on DeHaan would have violated Lighthouse's privilege and also that the crime-fraud exception, which is an evidentiary principle, did not somehow create a duty for Page Perry to affirmatively disclose privileged information.
Finally, the Court summarily rejected the Receiver's arguments that Page Perry conducted an inadequate mock audit and that it was malpractice for Page Perry to represent DeHaan before the SEC. The Court's conclusion protects the attorney-client privilege: "The Defendants were hired to provide legal advice which they did. Securities lawyers are not informants for the SEC. The Plaintiff's legal theory is profoundly flawed."
Lawyers should be wise counselors and zealous advocates. They should not be "informants" for the public or any government regulator without careful consideration of their ethical obligations to their client.


text:
My Tech Top 10: Colleen Quinn
Hi, I'm Colleen, and I'm a design blogger with a technology problem. I often find myself drawn to the quirky lines of vintage tech (I have fond memories of my first computer- a Timex Sinclair 1000) though I confess I usually prefer the utility of more modern pieces. Once I find a piece of tech that I love, I rarely replace it until I absolutely have to, so some of my top 10 are practically dinosaurs these days. I am fortunate that my day job takes me around the world, so I am a sucker for gadgets and gizmos designed to make travel easy and fun. I like to leave the office at the office, so my blogging and other creative endeavors are generally done from the comfort of my couch; thank goodness for laptops and wireless routers!
Top Row:
• Kindle: Though I cannot imagine any e-reader will ever completely replace books for me, the Kindle is nevertheless a lifesaver for anyone who travels. This little wonder device is substantially easier to haul around the world than a stack of books, and if I finish the books I planned for the trip, dowloading to the Kindle is a lot cheaper than scouring the airport bookstore for English language offerings. Lightweight and oh so functional, the Kindle is definitely the biggest surprise piece on my list; when I first got it from Amazon, I never imagined how essential it would become.
• LG LH40 47″ LCD HDTV: OK, I'll admit that my husband is responsible for this piece of tech, but wow is it pretty. He appreciates the picture quality when watching sports and movies; I love it for all the home shows on BBC Lifestyle (no HGTV in Saudi). This TV is lightweight and super easy to use; toggling back and forth between the various inputs (OSN cable, AFN, DVD, and VCR) is a snap and I definitely notice less blur than in other similar TVs. I never thought I would be a big TV person, but this one has certainly made me a convert.
• Toshiba Satellite M305D S4830: I bought this laptop with the first money I earned blogging so I confess I have a sentimental attachment, but I've never once regretted the purchase (even given that the OS is Vista). I bought my first Toshiba laptop in 1998, my second in 2003, and this one in 2008. That first laptop is no longer in use (though it does still run with Windows 98 no less), but the second continues to serve my needs by giving Mom easy access to email, IM and Skype. I love that I can tinker with this laptop if necessary- I already added a chip to max out the memory, and will likely replace the hard drive at least once before I pass this machine along to Mom in a couple of years.
• Linksys WRT54G Wireless Router: Truthfully, I have no particular attachment to this actual router, but man oh man do I love my wireless internet! As I mentioned above, I prefer to do my home computing sitting on the couch so being tethered to a network cable just doesn't work for me. I've had this router for a good number of years; there may be sexier, more powerful options out there, but as long as this keeps working, I'll keep using it.
• Vtech DECT 6.0 Cordless Phone System:I'm living overseas with a work-issued cell phone, so a landline to call home is essential. When we arrived, the phones in the house were 20 year old former office phones with the shortest cords I have ever seen. After a few days of sitting on the floor in the corner to talk to Mom, I hopped online and picked up this system which comes with 4 handsets and includes a digital answering machine. Sound quality is great even on an overseas call, and the handsets are super-light.
Bottom Row:
• Remington Sleek n Curl Digital Ceramic Hair Straightener & Revlon Tourmaline Ionic Hair Dryer: Though I dream of being a wash and go kind of girl, my coarse curly hair plus an extremely humid climate makes that an impossibility some days. This hair dryer is great for my hair- the unseen diffuser attachment is a boon on the days I'm embracing the curl. For days when I'm feeling the need for a sleeker do, this ceramic hair straightener is the perfect addition to my morning routine- just one quick pass and even my thick and curly hair is straight and shiny.
• Philips Micro HiFi System: I picked up this compact Philips stereo years ago during a great sale at Target- the optional iPod cradle was included for free! This system has a very small footprint and can also be wall-mounted if space is really at a premium. I love that I can throw in a CD or plug in my iPod; I've even had a friend bring over a party mix on a USB thumb drive. Simple and stylish, this stereo was a great find.
• Samsung GO Netbook: I gave my husband this bright orange netbook last Christmas and promptly fell in love. The color, the weight, the fact that it pops inside most of my purses- how could I resist? Now that we are overseas, my husband basically uses this as a desktop with an external monitor and keyboard, but when we travel, it is the perfect little partner to ensure we have access to family and friends back home.
• Rival CrockPot: Between my day job and my online commitments, I rarely find the time during the week to cook, so my Crock Pot is a lifesaver. Throw in a bunch of ingredients in the morning, turn it on low, return home to perfectly cooked dinner- no wonder this technology has stood the test of time! I love soups and stews and curries out of the Crock Pot, and my husband makes a mean beef stroganoff when he's in the mood. If you haven't used a slow cooker recently, I highly recommend you give it a try; mine is certainly well worth the cabinet space it occupies.
• Canon Powershot SD800IS: Last but certainly not least, this Canon digital point and shoot is by far my favorite piece of technology. Sleek and lightweight, this camera replaced an older Canon Powershot; I chose it for the image stabilization feature and the variety of preset shooting modes. I love the Night Snapshot and Aquarium options, and the fact that I can force the flash both on and off. Though I would love a digital SLR, the fact is that this tiny camera fits in the back pocket of my jeans and so is the perfect way to capture almost any moment.
Technology/device I'm most looking forward to in 2011: I would love to see Verizon get the iPhone. Though my account is on temporary hold while I'm overseas, I've been with Verizon since I first got a cell, and there is no way I'm switching to AT&T even for the iPhone. The other device I would like to see is an Android tablet that can really compete with the iPad. I had an HTC Droid phone before I left the U.S. and would love to see that technology applied to a tablet (though I'll stick to reading books on my Kindle).
Tech or tech organizational tip: My tip is to consider extending the lifecycle of your tech when you can. Before replacing a computer, try maxing out the memory and adding a new harddrive. Before you buy any new device, ask whether you need it or just want it- a hard distinction to make sometimes for folks who are technophiles. When you do decide to replace a piece of tech, try to pass it along to family, friends or charity rather than just tossing it in the trash. If you truly can't find anyone who wants a given item, there are recycling options which can at least reduce the environmental impact of the disposal.
I never leave home without: My Canon Powershot SD800IS. It is always in my purse or pocket, ready to capture the perfect sunset, a funny moment with friends, or even proof that my car was not in fact parked in a no parking zone (yep- I successfully challenged an expensive DC parking ticket thanks to this camera). This point and shoot is small yet mighty, a real winner in my book!


text:
Welcome visitor
This site is to inform you about my work as a physician, my background and fields of interest
In the health library the visitor may find some patient information about specific disease entities and/or treatments. In the link department different websites can be visited and abstracts downloaded.
Curriculum Vitae:
Paul E. Zollinger (Swiss born 1961, Zürich) grew up in the Netherlands and graduated from the Gymnasium (Mill Hill College, Tilburg/Goirle) in 1979. He studied chemistry, philosophy and medicine at the State University of Leiden, where he obtained his medical degree in 1990 with honours (cum laude).
Surgery & Traumatology: at the Free University Hospital, Amsterdam until december 1992.
Urology: in the Ligtenberg Hospital, Amersfoort 1993.
Surgery: in the Red Cross Hospital and Burns Center, Beverwijk 1994-1995.
Orthopaedic surgery: in the Leyenburg Hospital and the Juliana Children's Hospital, The Hague 1996-1999.
Paediatric orthopaedic surgery: in the Sophia Children's Hospital, Erasmus University, Rotterdam 1998.
In December 1999 he became a registrar in orthopaedic surgery. In 2000 he worked in the surgical, orthopaedic and trauma unit of the Reinier the Graaf Group in Delft and Voorburg.
In 2001 he joined the orthopaedic department of the Rivierenland Hospital, Tiel, the Netherlands and has been a member of the medical board (2003-2009). He works in association with his orthopaedic friends Maarten Ellis, Chantal van Hal and Halil Ünal in the joint venture 'Tielse Orthopaeden Inc.'.
He has held chairs to the 17th annual meeting of the European Orthopaedic Research Society (EORS) in Madrid, Spain (2008) and to the 2nd International Conference on Drug Discovery & Therapy in Dubai, UAE (2010).
He has been a guest editor for The Open Orthopaedics Journal (2010). Furthermore he is a reviewer for different international (orthopaedic) journals.
He is a member of the Executive Board of the Netherlands Orthopaedic Association (NOV) since February 2015.
More About Paul E. Zollinger MD PhD »
Specialties and fields of interest
Arm, Elbow, Foot and Ankle, Hand and Wrist, Hip, Knee, Shoulder
Arthritis, Arthroscopic Surgery, Joint Replacement, Osteoporosis, Pain, Sports Medicine, Trauma/Fractures
Contact Information
Barbara Polikliniek Elisabethdreef 4 Culemborg, NLD 4101 KL Phone 0(031)345565600 Fax 0(031)344632903
Other staff in my practice
Chantal T.H. van Hal
Halil Ünal
This site has been viewed 16,130 times.


text:
Gov. Rick Perry speaks during the 2013 NRA Annual Meeting in Houston, Texas. Photo by Justin Sullivan/Getty Images
Rick Perry apparently knows when to fold 'em.
The Republican governor of Texas announced Monday he would not run for a fourth full term, despite it being the "greatest job in modern politics." But Perry left open the possibility he would mount another presidential bid in an attempt to revamp his image following his disastrous first effort.
"I remain excited about the future and the challenges ahead but the time has come to pass on the mantle of leadership," Perry said.
It was several minutes into the event, which reporters said remained a closely guarded secret until the end as to what he would do, before it was clear that Perry was announcing his retirement. He rattled off what he views as his accomplishments. He pledged his focus would remain on Texas and said that any future plans he "will announce in due time." Instead, he said he will spend the next 18 months working to create more jobs.
Jay Root writes for the Texas Tribune that it's the first open race for the state's governorship since 1990, and that a Perry retirement from Texas politics unleashes "years of pent-up ambition" below him.
The move comes as Democrats are attempting to boost their own standing in the Lone Star State, and as the state legislature attempts to send Perry a measure banning abortions from being performed more than 20 weeks after fertilization. In his announcement, Perry said he'd call lawmakers back as many times as it would take to pass the measure, which was subject to a contentious hearing into the night. In the last week, Perry was criticized for mocking Democratic state Sen. Wendy Davis, thrust into national prominence for her hours-long filibuster to block the abortion bill.
Root writes:
Perry has 18 months left in his current term, so he'll still have a huge political megaphone, appointment power and the ability to call a 30-day special session on any topic at any time. No one watching politics in Texas will be surprised if Perry makes full use of his authority and then some during his remaining time in office.
Friends and allies say Perry is energized by the abortion battle that propelled filibustering Democratic Sen. Wendy Davis of Fort Worth to stardom and temporarily derailed legislation that would ban abortions after 20 weeks and dramatically tighten standards on the facilities that provide them.
Perry came under fire for his criticism of Davis — for making it personal by saying that her compelling biography would never have been written had her mother taken a different path and not had a baby. But the controversy over the remarks and the legislation has helped Perry garner attention for his cause just as it has for Davis.
During an appearance on the weekend TV show Fox News Sunday, Perry said his comments about Davis were "meant to be a compliment." He also said the disruptions by people in the gallery during the abortion debate amounted to "mob rule," and predicted the GOP-dominated Legislature would soon send him a bill to tighten abortion regulations.
NPR's Liz Halloran found the day's events to be a signal that Perry "clearly wants another shot at his party's nomination."
Perry's 2012 chances faded after poor debate performances, most famously forgetting the last in a list of three federal agencies he would eliminate if elected as president. The "oops" moment defined his bid, but he did not drop out of the race until late January. When exiting, he endorsed Newt Gingrich.
On Monday, Perry told supporters gathered for the announcement that his decade-long tenure has been an "improbable journey" and said with emotion in his voice that "each day has been an honor."
Dan Balz dubs it the opening of "a new chapter" for Lone Star State politics. He writes in the Washington Post:
With Bush in political retirement and Perry exiting the governor's office, a new generation of Republicans looking to put their stamp on the party in Texas will begin to assert their influence.
One of them is U.S. Sen. Ted Cruz, who was elected just last year and has become a favorite of conservatives with his sharp-tongued pronouncements. Cruz has been mentioned as a potential 2016 presidential candidate, which could put him on a collision course with Perry and others for the support of the party's most conservative wing.
Standing in line to seek the governor's mansion and the mantle of top dog in Texas? Attorney General Greg Abbott and state GOP chairman Tom Pauken.
Here's a profile of Abbott's under-the-radar abilities, also written by Root.
Balz is keeping an eye on George P. Bush, a grandson and nephew of former presidents and son of former Florida governor Jeb Bush, who he notes is "beginning his political career by seeking the office of Texas land commissioner."
With Democrats hungry to break into the Lone Star State and a wide-open field, expect a Texas-sized contest in the months to come.
Watch Perry's statement in full here or below:
- The New York Times' Mark Mazzetti and Matthew Rosenberg reported Monday that Mr. Obama is "giving serious consideration" to speeding up the withdrawal of U.S. forces from Afghanistan because he is "increasingly frustrated" by President Hamid Karzai.
- House Speaker John Boehner, R-Ohio, blamed Senate Democrats and the president for allowing the interest rates on student loans to double at the beginning of this month, saying, "The House has done its job."
- Boehner also insisted again Monday that border security enhancements must be "in place" before a legalization process for the undocumented immigrants included in legislation can begin.
- Politico noticed Rep. Paul Ryan and Sen. Ron Johnson, both of Wisconsin, pulled together a small group of their fellow Republicans to talk about the need to pass a comprehensive immigration bill.
- And the Service Employees International Union is running these Spanish-language radio ads urging 10 House Republicans to back a bill.
- PolitiFact comes up with the top five falsehoods in the immigration debate.
- Teresa Heinz Kerry's condition was upgraded to "fair," and someone close to the Kerry family said it was a possible seizure that sent her to the hosptial over the weekend.
- Robert Pear examines Kathleen Sebelius' role as the "No. 1 public advocate" for health care.
- The Associated Press reports the White House said Monday that the federal budget deficit for the current fiscal year will shrink to $759 billion, more than $200 billion less than the last prediction.
- Maine Republican Party Chairman Richard Cebra resigned last week after six months on the job, surprising Pine Tree State Republicans, Abby Livingston reports for Roll Call.
- In New Jersey's special senate election, Democratic Rep. Frank Pallone has earned the endorsement of the family of the late Sen. Frank Lautenberg. The Lautenberg relatives did not say very nice things about Pallone's rival, Newark Mayor Cory Booker.
- Virginia Gov. Bob McDonnell hired former Vice President Dick Cheney's criminal lawyer from the Valerie Plame affair, the Richmond Times-Dispatch reported. And the Washington Post has the latest on the executive chef.
- Chris Cillizza has a newsflash: Congress is old.
- Former Rep. Bobby Schilling, a Republican, is looking at Democratic Rep. Cheri Bustos for a rematch in hopes of winning back his old seat in Illinois.
- Appointed Sen. Tim Scott, R-S.C., delivered his maiden speech Monday, and admitted he failed civics in ninth grade.
- The rapper-turned-activist best known as Mos Def demonstrates on video what it's like to be force fed in an effort to draw attention to the hunger strike among prisoners in the detention center at Guantanamo Bay, Cuba. Warning: it's hard to watch.
- A truly awesome Slate piece for true fans of "The Wire."
- Relive the 1990s this fall — Pearl Jam is going on tour.
- A lifelong Cleveland Browns fan who passed away July 4 has made a final request of the ill-fated franchise. According to his obituary in the Columbus Dispatch, Scott Entsminger "respectfully requests six Cleveland Browns pall bearers so the Browns can let him down one last time."
- On Tuesday, Wednesday and Thursday, Christina is guest-hosting again for Kojo Nnamdi on WAMU 88.5 in Washington D.C. Tune in.
NEWSHOUR: #notjustaTVshow
- Health producer Sarah Clune delivers the real reasons behind public smoking bans.
- Don't miss the detailed reporting from Ray Suarez and Dan Sagalyn of our Foreign Affairs beat about China stealing proprietary data from American companies.
- We examined the Canadian train wreck and updated the investigation into the Asiana Airlines flight that crashed over the weekend.
- You can watch the National Transportation Safety Board's press conference here.
Latest Qpac Poll on #njsen Booker 52, Pallone 10, Holt 8, Oliver 3 among Ds; for Rs, Lonegan 62, Eck 5.
— Herb Jackson (@record_dc) July 9, 2013
A place of honor for the cwsoftballgame trophy in the House Press Gallery. Cc @rollcallabby,… http://t.co/hSUB5CFZnh
— Kasie Hunt (@kasie) July 8, 2013
This student loan debate fight is becoming a Repub vs Dem battle of who can get the most interns to stand behind them at a press conference.
— Ginger Gibson (@GingerGibson) July 8, 2013
If Rick Perry announces he is going to coach West Dillon next season, I am going to lose it.
— The Fix (@TheFix) July 8, 2013
Rick Perry announces he's going to run for New York Comptroller.
— delrayser (@delrayser) July 8, 2013
Most Republican members of the US Senate are now figuring out a way to sell Ted Cruz on a run for Texas governor.
— Glenn Thrush (@GlennThrush) July 8, 2013
.@bonjovi and I reunited in his hometown of Sayreville to walk the streets & talk to residents hit hard by Sandy. pic.twitter.com/8TpfJrhD65
— Governor Christie (@GovChristie) July 8, 2013
Dear Outlook, please stop autocorrecting "Spitzer" to "Spritzer." #thanks.
— Kasie Hunt (@kasie) July 8, 2013
overheard in the press scrum awaiting Eliot Spitzer at Union Square: "it's been less than 6 hours and I'm already sick of this whole thing"
— Dan Hirschhorn (@DanHirschhorn) July 8, 2013
Spitzer says "only voters will tell me" whether "five years of reflection" is enough
— maggie haberman (@maggiepolitico) July 8, 2013
Welcome to my Twitter account – AY
— The Duke of York (@TheDukeOfYork) July 8, 2013
Terence Burlij and Simone Pathe contributed to this report.
For more political coverage, visit our politics page.
Sign up here to receive the Morning Line in your inbox every morning.
Questions or comments? Email Christina Bellantoni at cbellantoni-at-newshour-dot-org.
Follow the politics team on Twitter:
Follow @cbellantoni
Follow @burlij
Follow @kpolantz
Follow @elizsummers
Follow @tiffanymullon
Follow @meenaganesan
Follow @ljspbs


text:
HustleThis action-packed drama is full of humour and intrigue. Hustle follows the fortunes of a gang of five expert con artists let loose on the streets of London. They are specialists in the ways of the grifter and all are keen to liberate cash from the amoral and undeserving.
Visit the Hustle website
|Episode Description
Pacific Time
|More Hustle on IDAHO (PT)
|No upcoming shows in database


text:
Work History
DevOps Automation Architecture, Coding & Mentoring
- Virtual Environments: AWS, Docker, VirtualBox.
- Tools: PowerShell, CloudFormation, AWS CodeDeploy, S3, Stash (git), Jira, YAML, In-House Orchestration Tooling, Jenkins (Windows & Linux), Gitlab CE.
- Level 3 Escalation Debugging and Engineering for Windows, Linux and Cloud Native Applications and Automation.
- Windows Image Template AMI CI Automation that uses one code base but works in straight PowerShell and under Jenkins CI to build 5 different Windows Server images (2012 R2 GUI and Core, 2016 GUI, Core and Container Host) including over 50 automated QA Pester tests.
- Standardized tooling for Windows domain joining that provides consistent, error managed, version immutable code to be used by multiple application teams across all multi-tenant cloud migration efforts.
- Technology and skills advocacy for PowerShell and Windows Automation to application teams.
- Scrum Master for multiple, simultaneous agile DevOps projects.
- Site reliability engineering (SRE) and DevOps automation for internal SCM as a Service based on a private, highly available GitLab CE implementation on AWS Linux containers, ECS, EFS (AWS PaaS file system) and ProgreSQL PaaS.
- Architect / Scrum master / developer for OS Platforms to provided shared, value-added OS images for use by all teams deploying software to the Infor multi-tenant cloud. Includes: Windows Server 2012 R2 / 2016 Full & Core, Amazon Linux, CentOS and Ubuntu.
DevOps Automation Architecture, Coding & Mentoring
- Hypervisors: AWS, VirtualBox, HyperV, Dev Workstations on Real Hardware.
- Tools: Packer, Chef/Ruby, PowerShell/DSC, Packer, TeamCity, Octopus, Visual Studio, Chocolatey, NuGet, Nexus Repository, ProGet Repository, AWS EC2, VPC.
- Automation of developer workstation environment using advanced Chocolatey NuGet packages so that identical automation could be shared to build CI servers and developer workstations and production end nodes with any of PowerShell, Packer or Chef. Reduction of Dev workstation build from 9 manual hours to 1 and 2 days of waiting for environment to 1 hour.
- Initiated, designed, prototyped and deployed shared NuGet services via self-hosted Nexus Repository server deployed in AWS - including support for secure package transfer via SSL, Chocolatey and CI NuGet packages, secure internet egress for global sharing of proprietary packages. Contribution of packages back to open source community. Enabled automated builds in any AWS VPC, Virtual Box or real hardware anywhere on the planet. Configured TeamCity to push and pull packages from repository. Full proof of concept on ProGet as part of requirements gathering. Proof of concept stood up for Nexus on both Windows and Linux.
- Design prototyping and deployment of secure AWS segregated environments for deploying Continuous Delivery automation services into production environment using AWS security best practices. Leveraged AWS Accounts, VPCs, VPC Peering, Subnets, AWS Security Groups (Extensive), AWS Security Policies, AWS Security Roles, VPN configuration and Network ACLs as appropriate. Use of visualops.io for rapid scenario testing. Implementation of Least Privilege Security Built-in, Monitoring Built-In, Backup, Self-Service, Multifactor Authentication (MFA) for IAM and VPN.
- Maintained and refactored Packer build configuration to streamline around packaging, allow selection of builds from on packer config file, better credential security and ensure proper operation via scripted kick-off or under TeamCity pipeline. Created least-privilege role for TeamCity to accomplish Packer builds with least-privileges which are assigned to an instance role (no credentials storage).
- Maintenance of TeamCity infrastructure automation builds including AWS orchestration from TeamCity.
- Updated monitoring scripts for Windows (abandoned by Amazon). Enhanced to submit metrics for all existing disks (rather than having know what disks are present) and created a Chocolatey NuGet package to automatically deploy and schedule disk metrics collection. One command line and the machine starts submitting disk utilitzation metrics.
- To foster a knowledge sharing community among Devs, Ops and Engineering:
- Conducted Lunch and Learns sessions,
- Initiated use of yammer and actively posted to information groups,
- Initial setup of team intranet website including recordings of Lunch and Learn sessions and how to section.
- Initiated creation of reusable, re-settable VM test templates for devs and operations along with getting started instructions on team site and along side VM images. Images created for Windows 8.1, 10, Server 2012 R2, Server 2016 TP5 w/ Containers, Nano Server TP5 w/ Containers, CentOS Linux 7 w/ Docker Containers.
- Troubleshooting of production systems for performance, advisement on application design and auditing of security best practices.
- Full participation in all aspects of Agile management of our team's work, including sprint planning, sprint demos, sprint retrospectives, sprint tracking (in Rally Dev).
- Experimentation and learning on Windows Containers, Nano Server, Server 2016 and Docker Containers on Linux.
- All work done as a member of a distributed team.
- Achieved AWS Certified Solutions Architect Associate.
Chocolatey NuGet Essentials for Automation Pros
- Decide and outline content coverage - including instruction design principles.
- Create slides and demos and recorded and edited training videos.
- Researched technology domain for NuGet and Chocolatey.
- Creation of assessment questions.
- Course Link: https://www.pluralsight.com/courses/chocolatey-nuget-automation-pros
On an as needed basis, I provide brainstorming and perspectives to Qompat's Executive team in several focus areas:
- Application of Lean Startup (Agile for building businesses) principles to new products and market possibilities.
- Business Model Strategy - application of principles of lean build-out, running lean, problem/solution fit and product/market fit and lean canvas to new business ideas.
- Micro-road mapping of technical strategy for enabling a lean startup to scale with growth - identifying sufficiently viable implementation of technology solutions while also identifying possible next level implementations and what triggers (pain levels) should be considered due justification for moving to the next level.
- Ideation contributor to design of dynamic equity program based on Slicing Pie.
- Cloud computing, design, product and vendor selection.
- DevOps models and implementation.
- Windows software deployment automation - historical market behavior and futures.
DevOps Automation Architecture and Coding
- Design and code DevOps infrastructure automation framework for SaaS solution server builds on Server 2008 R2 and 2012 R2 using desired state coding principles and approaches.
- Structured PowerShell Code: structured function libraries as includes and PS modules which follow PowerShell best practices for discoverability, self-documentation and advanced capabilities like pipelining.
- Architecture organizes installation artifacts into "Configuration Components" which are group into "Server Roles" that can be targeted at specific servers.
- Self-describing, self-specifying artifacts allow technicians to build installable components with no PowerShell coding.
- Remoting from TFS build server to automate end node builds.
- Lightweight framework code is easily extensible to accommodate new types of installation artifacts as new requirements are discovered.
- Artifacts can be specified in JSON which facilitates handover of configuration data from database systems.
- Automation framework includes comprehensive logging, error handling, remoting and best practices for discoverable functionality for developers who have to update or enhance it in the future.
DevOps Automation Architecture and Coding
- DevOps automation architecture supporting tiers, layers, artifacts and environments for single and multi-machine builds.
- Lightweight, serverless solution using Chocolatey Nuget, BoxStarter, PowerShell DSC and git.
- Full application stack install automation and configuration including PowerShell 5, SQL server, IIS setup and custom .NET software installation runs securely from web on machine to support distributed Dev / Test team.
- Broad platform support to work on Server 2012 R2 and Server 2008 R2 running on VirtualBox, VMWare, Hyper-V, Skytap and Azure.
- Design diagram in visuals section: http://www.darwinsanoy.com/visuals.html
- Creation of community packages for Chocolatey NuGet including SQL Express, SQL Management Studio, PowerShell 5, Nektra Spy Studio, Rohitab API Monitor and others that are visible on my on chocolatey profile: https://chocolatey.org/profiles/Darwin_CSIWindowscom.
Lead Automation Engineer: PowerShell Automation Framework / Function Library
- 5500 line PowerShell automation framework coded to run on 5 versions of Windows, running 2 versions of PowerShell, under 32-bit or 64-bit PowerShell, on 16,000 machines in 17 OS MUI languages.
- Replaced 2000 line legacy VBScript automation framework with significant enhancements.
- PowerShell comment based help for self-documentation and "dev mode" for discoverability by other automation engineers.
- More details and walkthrough video in portfolio: http://darwinsanoy.com/portfolio.html#Portfolio_PSHTemplate
- Architected approach to Office 2013 "Click To Run" deployment that respected ITIL disciplines, was fully compatible with SCCM content replication facilities and SCCM deployment & allowed for rapid rollback.
- Managed PowerShell deployment automation code to accommodate complex project requirements and fixes.
- Rigorous testing for very high level of quality when updating automation code actively being used by 14,000 machines.
- More details in portfolio: http://www.darwinsanoy.com/portfolio.html#Portfolio_Office2013.
- Used "Lean Engineering" principles to maximize flexibility for deployment via any mechanism (SCCM, GPO, Local Schedulers), minimize coding required to add "locations to encrypt" and simple data point collection via SCCM inventory for compliance reporting.
- Designed new solution to run in tandem with old one to allow easy piloting and minimize complexity for production deployment.
- Used scrum and sprints to gain agile SDLC benefits for project.
- Single package design specification on "Visuals" resume page: http://www.darwinsanoy.com/visuals.html
- Migrated over 50 deployment automation VBScripts to PowerShell deployment automation framework and served as level 3 advisor for other automation engineers doing the same.
- Improved company-wide PowerShell awareness, competency and adoption through monthly code share meetup, monthly coding clinic meetup, internal blogging on Yammer, curating shared resources, template publishing and by being an easily engaged one-on-one mentor.
- More details, including kick off meeting video, in portfolio: http://darwinsanoy.com/portfolio.html#Portfolio_Advocacy
- Details also in Windows IT Pro article: http://windowsitpro.com/powershell-scripting/be-powershell-champion
- Created and posted to Yammer group titled "DevOps: End to End Agility". Posted many free resources for technical staff and managers.
- Fostered cross team collaborative relationships with 7 other IT and business aligned teams.
- Implemented and administered scrum "lite" for 3 projects. I was the scrum master and entire development team, but applied sprints to managing stakeholder requirements and meetings.
- Created template collection set for even distribution of packages across all regions in 5%, 10%, 20% or 33% groupings which avoiding flooding network segments for large packages going to all machines - 4000 machines (25% of total) which needed to reach across a wide area network to access a distribution point.
- Analysis of benefits and limitations of SCCM 2012 "Application Objects" versus "Package Objects".
- Created automation to clean up old App-V packages.
- Created and deployed many packages to 18,000 SCCM end points.
- Compared and contrasted SCCM 2012 "Application model" objects with traditional SCCM "Package" objects for management and teammates.
- Packaging, customization, troubleshooting and best practice auditing of Windows Installer .MSI packages using InstallShield AdminStudio and InstEd.
- Use of Application Compatibility Toolkit (ACT) for shimming applications.
- Automation of MSI packages in PowerShell, VBS and .CMD/.BAT
- App-V sequencing and troubleshooting and deployment via SCCM 2007 and 2012.
- Automation of many setup.exe installers via command line switches for customization and silent installation.
- Successfully improved team collaboration and relationship with DEV team via DevOps collaborations.
- Reduced time required to support agile dev team from 30 hours to 7 hours.
- Aligned deployment automation with development team's adoption of "Agile" methodologies.
- Accelerated availability of VMs for DEV-Test cycle, partnered with scrum master to give access to deployment automation code and gain more testing of it in return.
- Repeated 98% success rate on overnight deployment of package to over 2000 customer service machines.
- Tool creation including: [a] recognizing the need, [b] coding and testing the solution, [c] promoting it's use, [d] creating built-in metrics to track used.
- Created utilities for: [a] Office 365 install log analysis, [b] procmon wizard to allow non-technical users to create procmon traces, [c] backend Lync IM account migration, [d] clean removal of Office 2007, [e] local/remote cleanup of temporary files, [f] links that allow globally distributed users to submit logs to a central location, [g] tool to show the list of installed software exactly as the PowerShell deployment automation framework sees it and export identifying information for any given software package, [h] script to open software center (for sending in user communications).
- Use of advanced tools for troubleshooting packaging and production problems, including: Procexp (Process Explorer) Procmon (Process Monitor), Rohitab API Monitor and Nektra Spy Studio.
- Leveraged in-depth understanding of windows registry, file system structures, WMI, WOW64 (64-bit Windows) and Windows process internals for deployment automation and troubleshoot production application problems.
- Leveraged knowledge of AD/GPO, DNS, networking, to troubleshoot packaging and application problems.
- Rigorous focus on evidence-based fact finding and log analysis led to discovering three independent paths by which a regular user could reboot production Citrix servers.
- Specific identification of the path by which a user could have unintentionally performed the server reboot.
- Follow up and immediate patch generation for SCCM failures that could be handled in automation code.
- More details in portfolio: http://www.darwinsanoy.com/portfolio.html#RootCause_ServerReboot.
- Improved work throughput implementing next level of Getting Things Done (GTD) using My Life Organized and toggl.com time tracking.
- Applied principles and tools of Agile, Lean and DevOps for my projects and work.
- Used highly visual slide deck to help IT managers understand how technical issues posed a risk to IT agility when considering virtualization of large / complex / plug-in rich applications. Leveraged visual single page designs and architectures to Examples in visuals section: http://www.darwinsanoy.com/visuals.html
Principle Consultant, Subject Matter Expert, Trainer
2001 to Present, CSI-Windows.com, DesktopEngineer.com.
- SME Speaking Engagements on Windows Automation and DevOps Topics
Future and Recent Engagements:
Modern Infrastructure Summit
- [2015-May] DevOps for Established Infrastructure: Help or Hype?
- [2015-July] Windows Packager Forecast: A DevOps Wind is Blowing
IT / DEV Connections (Windows IT Pro / Penton)
- [2015-Sept] Windows Packager Forecast: A DevOps Wind is Blowing
- [2015-Sept] Championing PowerShell: Creating Experts at Your Company
- [2014] Office 365 Pro Plus (Desktop Apps) Click to Run Enterprise Deployment Blueprints PortFolio: http://elearning.csi-windows.com/course/Office365ProplusClickToRunEntepriseBlueprints
European AppMangEvent (formerly "Packaging Event") (4 years and running)
- [2014] Office 365 Pro Plus Deployment In the Enterprise, Portfolio: http://elearning.csi-windows.com/courses/AppManagEvent2014
- [2014] Templating PowerShell for the Enterprise Desktop, Portfolio: http://elearning.csi-windows.com/courses/AppManagEvent2014
Full History: http://www.darwinsanoy.com/work.html#ConferenceSpeaking
- Authored eBook - Deploying and Supporting Applications on 64-bit Windows - See Amazon listing: http://www.amazon.com/Deploying-Supporting-Applications-64-bit-Windows-ebook/dp/B0098P9Z22
- Taught hundreds of students very technical classes. Class listing here: http://csi-windows.com/courses
- Instructional Design - built and revised course materials to conform to best practice for student learning.
- Entrepreneurship / Product Management - responding to the need for IT Pros to fortify their debugging and analysis skills, I built the CSI-Windows.com site, brand and courses.
- Application Packaging & Virtualization – Windows 7 / Windows Installer 5, InstallShield AdminStudio, Wise Package Studio, Orca, App-V Sequencer.
- Windows 7 Application Testing – VMware, Process Monitor, Process Explorer, AppVerifier, AppCompat, autoruns, DllRegView.
- Windows 7 Application Compatibility & Internals – Passed ACT/AppCompat ACF Exam, Completed ACT/AppCompat Partner Training, UAC, IEPM, UAC Virtualization, MSI 5, Integrity Levels.
- Cloud & Virtualization Technologies – VMWare Workstation, VMWare Server, App-V, Linux Server Virtualization, Linux in Rackspace Cloud, Azure Cloud and Skytap Cloud.
- Developed Many Advanced Scripts in .CMD/.BAT, VBScript (.VBS) and PowerShell (.PS1) – Expert in Windows Shell (.BAT/.CMD), VBScript and PowerShell including use of WMI, registry, permissions, file processing as well as creating templates and function libraries. Some examples are here: http://csi-windows.com/toolkit
- Operating Systems & Internals – Windows 7, Windows Vista, Windows XP, Windows Internals with a focus on application operations.
Practice Leader and Principle Consultant
1995 to 2001, CoreTech Consulting Group, Integrated Systems Consulting Group.
- Desktop Management Practice Leader - performed technical leadership, consultant career development, offerings formulation, vendor relationships, blogging and conference speaking.
- Sales Support - comprehensive sales support activities including proposals, presentations, statements of work, bidder's meetings, one-on-one sales calls, and formal large sales presentations.
- Career Mentoring – helped consultants in yearly career goals and guidance.
- SMS Architecture – creation of SMS architecture for global pharmaceutical. Technical requirements gathering, planning, engineering and documentation of architecture to be used by regional business divisions to ensure desktop management deployment was compliant and compatible globally.
- Lead Desktop Engineer - company wide deployment of Windows Desktop and server infrastructure. Proposed novel server acquisition strategy to facilitate desktop build servers. Provided technical leadership, oversight and primary engineering to the effort. Managed follow up development projects for utilities to support backend server migrations.
- Application Testing and Compatibility Lead – Led effort for large division of a manufacturing company to ensure all applications ran on new OS. Applied soft skills to keep application owners and developers engaged and moving forward. Finish in time for deployment and before any other company divisions.
Consulting Client History
- Air Products and Chemicals (> 16,000 Managed Nodes) - automation engineering team.
- Vanguard Group (3 onsite deliveries in PA) - Training on getting packaging processes ready for Windows 7.
- Morgan, Lewis & Bockius LLP - Trained global deskside support team of over 40 members via online delivery of troubleshooting course.
- Roche (2 onsite deliveries - Switzerland and IL) - Windows application packaging and automation and VBScript.
- Genentec (onsite San Francisco) - Windows application packaging and deployment automation onsite training.
- State Farm (> 100,000 Managed Nodes) - Windows application packaging and deployment automation onsite training.
- Chevron (> 100,000 Managed Nodes) - onsite delivery and online to Kazakhstan.
- Wyeth (now Pfizer) (> 100,000 Managed Nodes) - enterprise packaging technical architecture workshops.
- Microsoft - rewrite of SCCM custom internal remote client installer.
- GSK (> 50,000 Managed Nodes) - Packaging and deployment automation strategy workshops.
- GSK - SCCM Architecture.
- Heller Financial (> 10,000 Managed Nodes) - Desktop Lead for Global Deployment.
Education and Certification
Bachelors of Science Management Information Systems, Ambassador University, Texas.
Bachelors of Arts Liberal Studies, Ambassador University, Texas.
Current: Certified AWS Solutions Architect, MCSA
Past: MCSE, MCT
Bachelors of Arts Liberal Studies, Ambassador University, Texas.
Current: Certified AWS Solutions Architect, MCSA
Past: MCSE, MCT


text:
Loki has thrown his laptop out the window.
"You did save your manuscript somewhere else?"
"Of course I did, you imbecile! Haven't you heard of Dropbox?!" I do not answer. I do not know of this Dropped Box. But Loki continues. "I don't see what the POINT is though. I have nothing. NOTHING."
"You have thirty-thousand words, brother. That's more than half of a strong YA novel. You must keep writing."
"How can I when I don't know what to write?" He waves his arms in the air as he speaks.
Captain America runs into the room. "What happened? I heard -- " He sees the window and sighs. "Loki,"
"Oh don't you LOKI me," my brother says. "I am DONE. I thought I had the patience for this but I don't, and there's nothing you can do to change my mind!"
I roll my eyes. "Brother, you have writer's block. It's something we all struggle with."
"Yes, except most of us don't throw things when it hits." The Man of Iron says as he and the others enter the room. "Quite childish, wouldn't you say, Hulkie?"
Banner holds up his hands. "Hey, I didn't ask to be involved."
I approach Loki and place my hands on his shoulders. "Brother, we are trying to help you. But we can not help if you will not try."
Natasha places a different laptop on the table, and I hold my hand out toward it. Loki sits with a huff.
I lean over and whisper to him. "Do not be a child, brother, or you will only prove the Man of Iron correct."
If there is one thing I refuse to do, it is to further boost Stark's ego. I thrust open Natasha's laptop, and she types in her password. I try to look as she does, but her fingers move too fast for me to catch even a letter. The screen opens to a word document. The cursor blinks.
"Type," Thor says.
A million different possible sentences run through my mind, but most of them involve killing the Avengers in gruesome, terrible ways and have nothing to do with my story (one even involves a toaster oven). I debate about incorporating them into Isaac's plot.
"You haven't moved," Captain Grandpa says.
"I'm thinking," I grunt.
"Well, that shouldn't take that long," Stark says.
I roll my eyes. Got to prove him wrong. Maybe... maybe... I think I've written Isaac into a tough spot.
Maybe Isaac needs someone to get him out of that. Maybe a side kick. An EVIL side kick. I glance at Natasha and decide that if I could create a character half as intimidating as her, I will have succeeded.
Enter Lorraine. So evil she can create a bomb from a toaster oven, a bobby pin, and some leftover mushroom marinara.
I type furiously. Stark raises his eyebrows with surprise, and I grin.
"Ah, so you've got a budding romance?" Stark says. I can see the anger building in Loki's eyes. "Never took you for that type, Loki. You know, you and I could go to-"
"That's enough, Stark," I cut in. He raises an eyebrow, which looks funny because, well, he's nearly a foot shorter than me.
"Can we please get back on track?" Banner asks. He has the most whiny voice I've ever heard. And I've heard a ton of voices.
"So what does this, ah, Lorraine girl do?" Hawkeye asks, always to the point.
"Can you not read, shortcake?" Loki asks. I snort and he cuts his gaze to me.
"Sorry," I mutter. I read over Loki's shoulder when he turns back to the screen.
Apparently Lorraine can do a lot of evil things. She sounds like a female version of Loki, which could be bad if every guy out there ran to her assistance.
"You can't keep saying 'Lorraine snapped' everytime she speaks. And it looks like she's speaking a whole lot of nothing," I say. Loki glares at me. I'm getting used to it. "Every word in the story needs to be essential to the story - in either building the world or moving the plot."
"We use that in our world as well, Captain. Speak only that which you must," Thor says. I nod.
"I do not like when you all agree on something," Loki says.
"We agree on lots of things," Natasha adds with a shrug.
"Yep." I cross my arms. "I could have argued that you didn't have writer's block before. But now that you're writing dialogue that's going nowhere, you've got it for sure."
Stark claps. "Thank you, Mr. Rogers, our genius."
I clench my fist. And of course, Banner starts droning on.
HULK: Writers' block isn't that difficult. I mean, you can just smash it, right? I'm not sure if Loki is playing Drama Queen (that title suits him, now I come to think of it) or if he's legitimately stuck. I sigh. I guess I'll give him the benefit of a doubt. Like I do.
It's tough being nice.
"Why don't you take a break, Loki?" I say. "Writers' block is simply a misnomer because the "block" implies one monolithic cause, when in reality --"
Captain America spins on his chair and holds up a hand. "Banner, please. English?"
"That is English," Stark says. "Best English I've heard all day, actually."
I cough politely. "Sorry. I'm just trying to say, writers' block is usually the cause of being stressed."
Loki looks bored.
"When you're, um, stressed..." Come to think of it, I feel kind of stressed right now. I wipe my sweaty palms on my purple pants. "The human brain shifts the control from the cerebral cortex to the limbic --"
"Woah! Green man!" Loki says. He smooths his helmet-thing, which I think makes him look like an antelope, but apparently he thinks is kingly. "I am not human. I am a god."
"I forgot," I mutter. "Puny."
"And," Loki goes on, his voice rising, "I'm not stressed! I'm not blocked! I am writing perfectly with no problems at all!"
"Denial," Stark and I say together. We share a half smile. Loki smoulders. The Captain rubs his temples.
"Maybe you need to talk through your block," Stark suggests, "but I wouldn't recommend Banner."
I feel bad. "Tony, about that elevator in Switzerland --"
Stark waves it away. "Don't worry. I don't mind telling it again. Besides, I probably started at the wrong place. It should have been back, before I took over Stark Industries --"
Oh great green eggs and ham. Help.
BLACK WIDOW: I roll my eyes and hold up a hand. "Stark. Enough. Your narcissism will get us nowhere. What Loki needs to do is think this through."
I walk over and lean toward his screen, ignoring the angry glare he gives me. "See, Loki, your problem is that this new love interest character has no personality outside of 'evil.'"
He snorts. "As if that isn't enough."
"It's not." Rogers jumps in. "Good character means chivalry, integrity, humilty, selflessnes..."
"Wrong again, Patriotpants." Stark interrupts. "We're not talking about the Boy Scouts here. That might be good moral character, but it doesn't mean every book needs to have it."
Rogers is about to answer back when Thor preempts him. "The Man of Iron is correct, brother. This character must be like you and I, not some blank, frosty beast."
"Thank you for that, brother." Loki glowers at him. "So, how do I fix it?"
I can't believe he's actually asking for help. I do my best to conceal my surprise as Clint answers. "Well, everything she says right now has to tell us something about her. What are her inner motives? Make her interesting."
Loki snorts, "But evil IS interesting."
I give a little nod. "Villains done right are interesting. But you have nothing INTERESTING about Lorraine. Sure, she has heck-a-million skills, but there's no drive or weakness to her skill. Why is she being evil? Is it revenge? Is it power? Everything needs a reason and a driving force." Seriously, can skulls get any thicker?
Stark has the nerve to speak again. "She's as perfect as my hair Antler man. Mess her up a bit."
"Fine." I don't like the glint in his eye. It's very...evil. Big surprise. "You want interesting? I'll give you interesting, Hobbit Boy."
Loki sets his fingers to the keyboard and begins to type away. Uh-oh. This can only go one direction, downhill. We sit in silence for a few minutes watching to Loki type away until Thor cuts in. "Ho brother! You're writing again! Why don't you read what you've got."
"Oh no, I couldn't. I'm too uninteresting for that." Loki hands the laptop to me. "Why don't you do the honors... Clint."
Warning bells are ringing like mad in my brain. I really don't like where this is going. But I take the laptop anyway and read:
"Lorraine paced menacingly in front of the prisoner. Ah, she was beautiful in all her evil glory. Her tall womanly figure wasn't hard to miss in the empty room. I watched from the shadows in the corner taking it all in. The prisoner cowed down as she leaned in close to his face.
"Are you ready to tell me yet?" She laughed, "Or would you like be to slice you?" In a split second, a knife is in her hand.
The man shook his head furiously. "Who are you? Why are you doing this? Please don't do this. I have a family at home."
Lorraine just laughed. "Therein lies the problem, Shortie. Can I call you shortie? Of course I can, these heels make you look up to me. The tables have finally turned to my favor."
"I don't understand."
"What? You don't remember? You don't remember your Sarah Bear?" A gasp slipped from the mans lips. He remembered.
"Yes, it's me. But your Sarah is long gone. I am Lorraine now. When you left me that day in the rain, I vowed no one would get the better of me again. And so I became a new person. A warrior. I am POWER. I should thank you for teaching me all the things I've learned in life. Never trust anyone, they'll just lead you astray. Won't they," she leaned in close and practically spat in his face, "Clinton?"
Clint? OH NO he didn't. I can just hear Loki's taunting voice in my head. Oh but I did. I already hated the guy, and this stupid book wasn't helping me. The only reason I stuck around was to keep my eye on the guy. Not to mention, I didn't exactly want to look like a fool. A growl rose in my throat.
Natasha put her hand on my arm. "Clint," she muttered a warning in her low breath. "Don't go there. Now is the not the time for anger."
I shook free of her grasp. "Oh I'm not angry. I don't need to be."
I walk over to Banner and thrust the laptop into his hands. "Bruce, would you smash this for me?"
"No laptop smashing," I said firmly. "Or any technology smashing at all. We do not smash."
Bruce gave me a look that plainly said he knew I was now just modifying House mottos from Game of Thrones but wasn't going to mention it unless I did, since the others would have a go at me for being unproductive in the time they thought I'd been working. To be fair, I'd read them first, and these guys liked reading. That was their thing.
That and this misguided attempt to get a decent novel out of Loki, which I really wasn't convinced by. I mean, hell, first drafts need work, but...
I realized that I was the focus of their attention (finally!) a few seconds later. The others were staring at me.
"Stark?" said Bruce. "Do you have anything useful to contribute?"
"Why, isn't my very presence stimulating enough?" I glanced at Loki. "Besides, ole Mischief seems to be getting on okay now. Back in the swing of it, as it were."
Cap frowned. "Is something wrong, Stark? You're normally raring to share your ideas. Today you're pretty quiet."
"I've shared all the opinion I've got," I said, irritable and unfriendly. "Loki's not a child. He can do this himself, and we can help in edits."
"You have the block too, Man of Iron!" said Thor triumphantly.
"Hang on a sec," I said. "I never said I was blocked."
"But you are, aren't you?" said Hawkeye with a look that suggested he wasn't that sorry.
"How is this now about me?"
"Seconded," said Loki. "How is this now about him?"
Cap shrugged. "Isn't it always?"


text:
Buy Item $4.99 Retail:
Save 17% ($1.00) $5.99
Add To Cart
In StockStock No: WW8765907
G.T. Luscombe Company Inc. / 2013 / Gift
Add To Cart
Add To Wishlist
4" x 5.5" flip book under half an inch thick is perfect for travel, slips easily into pockets and bags. 25 3.5" x 2.5" memory sheets post-its; 50 3.5" x 5" study notes; 25 each of five sticky arrow flags in orange, pink, yellow, green and blue.
|Format: Gift
Vendor: G.T. Luscombe Company Inc.
|Publication Date: 2013