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3-year-old Pennsylvania boy contracts rare illness from tick bite
By Chris Oberholtz
After a diagnosis of meningoencephalitis and proper IVIG treatment, there would be light at the end of the tunnel in Johnny's road to recovery. (Jamie Simoson)
Fifteen minutes.
That's all it took to transmit a rare, dangerous and debilitating tick-borne disease that seriously sickened an energetic, witty and generally healthy 3-year-old Pennsylvania boy.
Jamie Simoson's motherly intuition pushed her to seek further medical treatment for something her youngest son's pediatrician assured her was a virus that needed to run its course. However, it was something she later learned required weeks of medical care and came with the possibility of lifelong effects.
The bite that changed everything
Jonny Simoson was swimming in a neighbor's pool on June 15 when his mom noticed a small speck on his right shoulder blade. It was a tick smaller than a pen point.
"It was not embedded. It was not engorged. I easily removed it with a pair of tweezers, and it was still alive," Simoson said. "He didn't necessarily have any marks on his back shoulder until a few days later; there was just a tiny red bump. That was it."
The tick shown above that bit Johnny was smaller than a pen point. (Jamie Simoson)
About two weeks later, Jonny's daycare called saying he was not feeling well.
"He was mopey, had no appetite, and the fact that he was complaining about a headache was not normal for a 3-year-old," Simoson said.
Just that morning, his mom said he had been eating breakfast, playing with water guns and having the time of his life.
His symptoms got worse over the next two days. After a visit to the pediatrician, Johnny was sent home with some supportive medicines. He woke up that night with a fever.
"We called the doctor the very next morning, and I said he's sleeping a lot and that's really not like him," Simoson said.
After a second visit to the doctor, she took her son to the ER as his fever spiked above 104 degrees. He also showed no reaction to a Tylenol suppository, which was abnormal for a typically rambunctious boy.
TICK SEASON IS IN FULL SWING
Johnny spent 12 days in the hospital undergoing multiple tests. He tested positive for Powassan virus, a rare and dangerous tick-borne disease. (Jamie Simoson)
Days in the hospital turned to weeks. Elevated white blood cell counts swelled to 30,000. He was unusually drowsy and showed no signs of perking up after IV fluids.
"We were terrified that we might not be coming home with our child."
— Jamie Simoson, Johnny's mother
A spinal tap found that he had increased neutrophils – a type of white blood cell that acts as the immune system's first responders – in his cord fluid. He was treated for bacterial and viral meningitis until doctors ruled them out.
Johnny was transferred to a specialty children's hospital, where he spent four days in the pediatric intensive care unit undergoing a coronary CT scan to rule out a brain bleed, an abscess or mass. All of those were ruled out.
"Things got really scary at that point," Simoson said. "It was so frustrating searching for an answer. We were terrified that we might not be coming home with our child."
However, after an MRI, neurologists were able to diagnose him with meningoencephalitis – an infection of both the brain and the thin tissue that surrounds it. After a night of intravenous immunoglobulin, a treatment for patients with antibody deficiencies, there were signs of hope.
Johnny is recovering at home but still has some noticeable left-side deficiencies. (Jamie Simoson)
Simoson believes that IVIG made all the difference for her son.
"Within 15 hours of his first dose, I heard 'Mommy, is that pepperoni pizza?'" she recalled.
In reality, it was simply a tissue box. To Johnny, however, it looked like a pizza box, and that's all the kid wanted – a slice of pie.
"So we started asking him questions to try to gauge his cognitive ability at this point," Simoson said.
After almost five full days of unresponsiveness, her son was alert and talking.
"It was amazing. That was the first time since the whole situation started that my husband and I both just completely broke down," she said with confidence, finally knowing that their little boy would be headed home soon.
NEW REASON TO FEAR TICKS: EXTREME FOOD ALLERGY POSSIBLE FROM SINGLE BITE
Jonny Simoson is one of the most energetic 3-year-olds you will meet, his mother said. As the youngest of three in the family, his mom and dad joke that if he were first, he'd be an only child. (Jamie Simoson)
There was light at the end of the tunnel for Johnny, but the toll of isolation was devastating.
"Isolation is hard on a toddler," Simoson said. "He started having ICU delirium and by the time he was allowed out of isolation, he did not want to go back to the room."
His parents had to teach him how to eat and drink again, as well as how to sit up and speak clearly.
"We had discussed inpatient rehabilitation with PT/OT, but found that the paperwork would delay our discharge by up to three more days," Simoson said.
They agreed that taking him home and searching for outpatient services was acceptable.
"We knew coming home was going to be hard," Simoson said. "He's active and doesn't understand his limitations. We were so excited to get out of the hospital but so scared of what happens next."
After 12 days, Johnny was finally discharged.
"Johnny was still not walking, and his balance was poor," Simoson said. "We knew we had a ton of work to do but were up for the challenge."
A rare virus
Three days after he was discharged, Simoson said, Johnny tested positive for Powassan virus – a rare and dangerous tick-borne disease.
According to the Centers for Disease Control and Prevention, human Powassan virus infections have been found in the U.S., Canada, and Russia. In the U.S., cases of Powassan have been reported primarily in the northeastern states and the Great Lakes region. These cases occur primarily in the late spring, early summer and mid-fall when ticks are most active.
There have only been 178 reported cases in the U.S. since 2011.
Simoson said her son is recovering but still has some noticeable left-side deficiencies. She has started a Facebook page, so other's can follow his journey.
"He appears to have regressed a bit cognitively, but we are optimistic that his resilience will see him through," she said.
THESE ARE THE PESTS THAT BUG YOU EACH SEASON
The Simoson family lives in Harveys Lake, Pennsylvania, a borough in Luzerne County. (Jamie Simoson)
Simoson is now urging others to prevent tick bites and advocate for their children.
"You are the only one who knows them and what is normal for them, and if you don't feel right about it, advocate for them," she said. "Don't feel like you're questioning someone. That's your job."
Simoson is also urging people to donate blood. Her son had five doses of IVIG, a blood product, over the course of his hospital stay. With each dose, she said doctors saw consistent improvements.
"We are confident, it can't be proven, but we know deep down that IVIG was the turning point for Johnny, and if we can do anything to help someone else get that treatment quickly, that's really our goal," she said.
Get the latest updates on this story at FOXWeather.com.


OSLO (Reuters) - Norwegian bank DNB (DNB.OL) does not have sufficient systems in place to combat money laundering, the country's Financial Supervisory Authority (FSA) said on Friday.
"Compliance with anti money laundering in the business division remains insufficient," the watchdog wrote in a letter to DNB published on the FSA's website which followed an audit by the regulator.
"The FSA expects management and the board to ensure that this work is prioritized," it said.
A DNB spokesman said the bank gives high priority to fighting economic crime, while adding that the FSA audit had not uncovered any concrete examples of money laundering taking place.
The letter was first reported by business daily Dagens Naeringsliv.


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The Open Nursing Journal
Information Retrieval – Swedish Specialist Student Nurses` Strategies for Finding Clinical Evidence
Cathrin Madsen-Rihlert, Kerstin Nilsson, Margareta Warrèn Stomber*
Sahlgrenska Academy at University of Gothenburg, Institute of Health and Care Sciences, P.O. Box 457, SE 405 30 Gothenburg, Sweden
The care that intra-operative nurses perform has to be based on scientific knowledge. It is therefore vitally important that they have access to different databases and the Internet, as well as knowledge of the search procedure to find evidence for best practice. This means that specialist nurses should be proficient in the search procedure, interpretation of data, and implementation of available knowledge.
The aim of this study was therefore to highlight the search strategies of specialist student nurses for finding scientific knowledge with regard to specific clinical issues. An additional aim was to assess their ability to critically evaluate scientific articles.
The participants, n 16, all students enrolled in a university programme for specialist nursing in anaesthesia care, were required to find support for six questions, by using scientific knowledge databases. The tasks that required support are related to their future profession and were divided into three main areas: pre-, intra-, and post-operative care. Two distinct questions for each main area had to be answered. The data was analysed quantitatively using manifest content analysis as a basis.
This study reveals that the student nurses mostly used the CINAHL and PubMed databases to search for answers related to the areas in focus. The keywords the participants used differed between the individuals and were applied more frequently than MESH terms. In addition, the critical evaluation of articles of scientific value that were found was not optimal. The study demonstrated that most of the participants were unable to complete all the required tasks. With regard to the initial questions, all 16 participants provided answers, while only eight student nurses completed the final questions.
The specialist student nurses in this study used the databases Chinal and PubMed to find scientific knowledge with the help of MESH-terms and keywords. Further research is needed to understand how education of the specialist student nurses should be carried out, in order to optimise their search strategies and critical evaluation of scientific articles.
Keywords: Information retrieval, search strategies, nurses.
Publisher Id: TONURSJ-6-47
PMCID: PMC3349943
Electronic publication date: 2/5/2012
© Madsen-Rihlert et al.; Licensee Bentham Open.
* Address correspondence to this author at the Sahlgrenska Academy at University of Gothenburg, Institute of Health and Care Sciences, P.O. Box 457, SE 405 30 Gothenburg, Sweden; Tel: + 46 31 7866026; E-mail: margareta.warren.stomberg@gu.se
17-12-2011 Original Manuscript Information Retrieval – Swedish Specialist Student Nurses` Strategies for Finding Clinical Evidence
In today's intra-operative care, nurses must base their nursing competence on scientific knowledge. The development of knowledge in the field of nursing anaesthesia has increased rapidly during the last decades, both with regard to the development of medical technology and the relational individual care and treatment. Furthermore, patients receiving anaesthesia today are often older people with multiple diseases. All these developments thus require updated individual solutions. Nurse anaesthetists must therefore apply actual knowledge to different aspects of their work. Such knowledge can be readily accessed on available research databases or more general search engines on the Internet, making it easier to find solutions to problems [1 Verhoeven F, Steehouder MF, Hendrix RM, van Gemert-Pijnen JE. Factors affecting health care workers' adoption of a website with infection control guidelines Int J Med Inform 2009; 78(10 ): 663-78.
[http://dx.doi.org/10.1016/j.ijmedinf.2009.06.001] [PMID: 19577956] ].
In health care, the use of computers to manage health care duties and to find knowledge on the Internet has increased substantially since the 1990s [2 Estabrooks CA, O'Leary KA, Ricker KL, Humphrey CK. The Internet and access to evidence: how are nurses positioned? J Adv Nurs 2003; 42(1 ): 73-81.
[http://dx.doi.org/10.1046/j.1365-2648.2003.02581.x] [PMID: 12641814] ]. For this reason, computer-based clinical decision-support programmes and best practice guidelines for evidence-based practice (EBP) are being developed to support clinical physicians and nurses in their daily work. In 2009, 73% of the population in the USA, 60% in Australia, and 50% in Europe used the Internet for this purpose [3 Younger P. Internet-based information-seeking behaviour amongst doctors and nurses a short review of the literature Health Info Libr J 2010; 27(1 ): 2-10.
[http://dx.doi.org/10.1111/j.1471-1842.2010.00883.x] [PMID: 20402799] ]. It is also common for patients themselves to seek medical information about their symptoms on the Web [4 Chou WY, Liu B, Post S, Hesse B. Health-related Internet use among cancer survivors: data from the Health Information National Trends Survey 2003-2008 J Cancer Surviv 2011; 5(3 ): 263-70 .
[http://dx.doi.org/10.1007/s11764-011-0179-5] [PMID: 21505861] , 5 van Uden-Kraan CF, Drossaert CH, Taal E, et al. Health-related Internet use by patients with somatic diseases frequency of use and characteristics of users Inform Health Soc Care 2009; 34(1 ): 18-29.
[http://dx.doi.org/10.1080/17538150902773272] [PMID: 19306196] ]. Despite these increases in the use of computers and the Internet, the limited availability of improved access to these facilities in the workplace has been found to be a barrier when it comes to the adoption of new technology [6 Garrett P, Brown CA, Hart-Hester S, et al. Identifying barriers to the adoption of new technology in rural hospitals a case report.Perspectives in Health Information Management/AHIMA J AHIMA 2006; 3: 9.]. It has been revealed that nurses in the USA do not have the necessary skills to integrate research into clinical practice. They do not understand or value research and receive little or no training in search strategies on scientific knowledge databases [7 Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice Am J Nurs 2005; 105(9 ): 40-51.
[http://dx.doi.org/10.1097/00000446-200509000-00025] [PMID: 16138038] ]. The use of Internet-based searches for knowledge by physicians increases the quality of clinical problem solving [7 Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice Am J Nurs 2005; 105(9 ): 40-51.
[http://dx.doi.org/10.1097/00000446-200509000-00025] [PMID: 16138038] , 8 Westbrook JI, Coiera EW, Gosling AS. Do online information retrieval systems help experienced clinicians answer clinical questions? J Am Med Inform Assoc JAMIA 2005; 12(3 ): 315-21.
[http://dx.doi.org/10.1197/jamia.M1717] [PMID: 15684126] [PMCID: PMC1090463] ]. Physicians making complicated diagnoses could also be given valuable support by using general search engines such as Google [9 Tang H, Ng JH. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study BMJ 2006; 333(7579 ): 1143-5.
[http://dx.doi.org/10.1136/bmj.39003.640567.AE] [PMID: 17098763] [PMCID: PMC1676146] ]. However, contradictory results were found in a review from 1995-2009 which indicated that there were no differences between the doctors and nurses who used the Internet to search for knowledge and the participants who did not [3 Younger P. Internet-based information-seeking behaviour amongst doctors and nurses a short review of the literature Health Info Libr J 2010; 27(1 ): 2-10.
[http://dx.doi.org/10.1111/j.1471-1842.2010.00883.x] [PMID: 20402799] ]. Nurses predominately rely on tacit knowledge, both when searching for evidence and when evaluating a treatment outcome [1 Verhoeven F, Steehouder MF, Hendrix RM, van Gemert-Pijnen JE. Factors affecting health care workers' adoption of a website with infection control guidelines Int J Med Inform 2009; 78(10 ): 663-78.
[http://dx.doi.org/10.1016/j.ijmedinf.2009.06.001] [PMID: 19577956] ]. In spite of the expressed positive attitudes of nurses regarding scientific nursing knowledge, the use of research results is impaired by different barriers among nurses, for example, insufficient power to change practice, difficulty understanding statistical analyses, and perceived isolation from knowledgeable colleagues with whom to discuss the findings [10 Chang HC, Russell C, Jones MK. Implementing evidence-based practice in Taiwanese nursing homes: attitudes and perceived barriers and facilitators J Gerontol Nurs 2010; 36(1 ): 41-8.
[http://dx.doi.org/10.3928/00989134-20091204-04] [PMID: 20047246] ]. Another barrier identified with regard to using databases on the Internet is limited experience in using the online library [3 Younger P. Internet-based information-seeking behaviour amongst doctors and nurses a short review of the literature Health Info Libr J 2010; 27(1 ): 2-10.
[http://dx.doi.org/10.1111/j.1471-1842.2010.00883.x] [PMID: 20402799] ]. In Sweden, barriers to research utilisation in nursing have been investigated; they include the lack of clear, realistic goals for nursing work focused on evidence-based care [11 Kajermo KN, Unden M, Gardulf A, et al. Predictors of nurses' perceptions of barriers to research utilization J Nurs Manag 2008; 16(3 ): 305-14.
[http://dx.doi.org/10.1111/j.1365-2834.2007.00770.x] [PMID: 18324990] ], the research-related skills of nurses [12 Kajermo KN, Nordstrom G, Krusebrant A, Bjorvell H. Perceptions of research utilization comparisons between health care professionals nursing students and a reference group of nurse clinicians J Adv Nurs 2000; 31(1 ): 99-109.
[http://dx.doi.org/10.1046/j.1365-2648.2000.01255.x] [PMID: 10632798] ], and the fact that relevant literature has not been gathered in one place [13 Bostrom AM, Kajermo KN, Nordstrom G, Wallin L. Barriers to research utilization and research use among registered nurses working in the care of older people: does the barriers scale discriminate between research users and non-research users on perceptions of barriers? Implement Sci 2008; 3: 24.
[http://dx.doi.org/10.1186/1748-5908-3-24] [PMID: 18452603] [PMCID: PMC2405784] ]. To cover the limited research utilisation in clinical practice, nursing educators improved their teaching with regard to generic skills, in accordance with the Higher Education Ordinance in Sweden [14Swedish National Agency for Higher Education; Higher education ordiance. Available from URL: http: //www.hsv.se/lawsandregulations.4.5161b99123700c42b07ffe3904.html [Cited: 12 December 2011];]. One example is using problem-based learning to integrate theory and practice during clinical education [15 Ehrenberg AC, Haggblom M. Problem-based learning in clinical nursing education: integrating theory and practice Nurse Educ Pract 2007; 7(2 ): 67-74.
[http://dx.doi.org/10.1016/j.nepr.2006.04.005] [PMID: 17689426] ].
Extended efforts have been made to fill the gap between theory, research, and practice in Sweden, by developing guidelines for clinical education. In another Swedish study, it was illustrated that assisting student nurses in integrating the theory of nursing into practice was crucial [16 Jerlock M, Falk K, Severinsson E. Academic nursing education guidelines: tool for bridging the gap between theory research and practice Nurs Health Sci 2003; 5(3 ): 219-8.
[http://dx.doi.org/10.1046/j.1442-2018.2003.00156.x] [PMID: 12877723] ]. To support research utilisation, an organisational learning culture which involves knowledge, skills, feelings, attitudes, and beliefs needs to be developed in the workplace [17 Matthew-Maich N, Ploeg J, Jack S, Dobbins M. Transformative learning and research utilization in nursing practice: a missing link? Worldviews Evid Based Nurs 2010; 7(1 ): 25-35.
[http://dx.doi.org/10.1111/j.1741-6787.2009.00172.x] [PMID: 19804587] ]. There are advantages in developing a learning culture at work, an increase in the standard of care, improved patient treatment outcomes, as well as progress in the continuation of professional development [18 Tolson D, McAloon M, Hotchkiss R, Schofield I. Progressing evidence-based practice: an effective nursing model? J Adv Nurs 2005; 50(2 ): 124-33.
[http://dx.doi.org/10.1111/j.1365-2648.2005.03371.x] [PMID: 15788076] ]. The resources available on the Internet are a dynamic, well-established way of seeking information, but domain knowledge is a prerequisite for achieving good knowledge acquisition. A well-defined question has an impact on the ability to successfully find knowledge from the internet [19 Portney LG, Watkins MP. Foundations of clinical research : applications to practice Upper Saddle River. NJ: Pearson Prentice Hall 2009.]. It has been found that student nurses are limited in their ability to find answers to their clinical nursing questions. However, whether the students lacked the skills to search the relevant databases and literature, or whether there really were no answers to the clinical questions, was not made apparent in the study [20 Dawley K, Bloch JR, Suplee PD, McKeever A, Scherzer G. Using a pedagogical approach to integrate evidence-based teaching in an undergraduate women's health course Worldviews Evid based Nurs 2011; 8(2 ): 116-23.
[http://dx.doi.org/10.1111/j.1741-6787.2010.00210.x] [PMID: 21155969] ].
The quality of the information found via general search engines does not include any guarantees that reinforce claims relating to the above-mentioned knowledge and skills [6 Garrett P, Brown CA, Hart-Hester S, et al. Identifying barriers to the adoption of new technology in rural hospitals a case report.Perspectives in Health Information Management/AHIMA J AHIMA 2006; 3: 9., 21 Kuiper E, Volman M, Terwel J. Integrating critical Web skills and content knowledge: development and evaluation of a 5th grade educational program Comput Human Behav 2008; 24(3 ): 666-92.
[http://dx.doi.org/10.1016/j.chb.2007.01.022] , 22 Parker VA, Miyake Geron S. Cultural competence in nursing homes issues and implications for education Gerontol Geriatr Educ 2007; 28(2 ): 37-54.
[http://dx.doi.org/10.1300/J021v28n02_04] [PMID: 18032190] ]. Furthermore, the quality of scientific nursing journals also varies [23 Holleman G, Poot E, Mintjes-de Groot J, van Achterberg T. The relevance of team characteristics and team directed strategies in the implementation of nursing innovations: a literature review Int J Nurs Stud 2009; 46(9): 1256-64.
[http://dx.doi.org/10.1016/j.ijnurstu.2009.01.005] [PMID: 19371873] ], which means that nurses require a particular level of domain knowledge and knowledge of critical evaluation, in order to review articles related to nursing and medical databases on the Internet. They also need technical search skills, that is, how to apply the search process and knowledge of the appropriate databases [20 Dawley K, Bloch JR, Suplee PD, McKeever A, Scherzer G. Using a pedagogical approach to integrate evidence-based teaching in an undergraduate women's health course Worldviews Evid based Nurs 2011; 8(2 ): 116-23.
Very few articles have been found in the literature review that investigate the way nurses search for information and evidence relating to clinical practice, that is, whether a single search word is used or whether MESH terms (Medical Subject Headings) are employed [3 Younger P. Internet-based information-seeking behaviour amongst doctors and nurses a short review of the literature Health Info Libr J 2010; 27(1 ): 2-10.
[http://dx.doi.org/10.1111/j.1471-1842.2010.00883.x] [PMID: 20402799] ]. Similarly, the number of studies investigating the critical evaluation of retrieved articles is also small. Furthermore, the way students in specialist nursing programmes in Sweden use the available resources on the Internet to find relevant scientific knowledge has not been investigated.
The aim of this study was therefore to highlight the search strategies that specialist student nurses use to find scientific knowledge about specific clinical issues. An additional aim was to assess their ability to critically evaluate scientific articles.
The student nurses were required to answer the following research questions:
To what degree are the participants successful in finding scientific knowledge for given clinical issues?
To what extent do the participants evaluate?
the scientific merit of articles
the search strategies used?
A descriptive, cross-sectional design was used for this study. In order to complete the research tasks, a questionnaire with six different questions was developed. The participants, students enrolled in the Specialist Nursing Programme, had to seek answers to these questions in scientific databases available on the Internet. The issues in focus are related to their future profession and were divided into three main areas: pre-, intra-, and post-operative care.
In this small-scale study, the issues relating to pre-surgical care were made clear to the participants and focused on six areas: 1) the nurse anaesthetist's professional role when giving the patients pre-surgical information before the day of surgery, 2) the nurse anaesthetist's field of responsibility when preparing the patient for anaesthesia. The intra-operative issues focused on 3) the kind of operations generally performed on the day of surgery and 4) the nurse anaesthetist's intra-operative responsibility. Issues related to post-operative care were 5) post-operative symptoms, especially pain, and 6) the nurse anaesthetist's post-operative responsibility to prevent and relieve pain. The participants were also asked to indicate the databases, keywords, and MESH terms used, the number of articles found, and to assess the scientific value of the articles. The questions were based on earlier research focusing on nurses' anaesthesia procedures in peri-operative nursing [24 Segerdahl M, Warrén Stomberg M, Rawal N, Brattwall M, Jakobsson J. Clinical practice and routines for day surgery in Sweden: results from a nation-wide survey Acta Anaesthesiol Scand 2008; 52(1 ): 117-24.
The participants were trained by the librarian (3 x 45 minutes) in information retrieval a week before data was collected for the study. They also received instruction regarding the different search strategies that can be used to find knowledge in databases and general search engines on the Internet. MESH terms and key words were introduced. MESH terms comprise vocabulary developed by the U.S National Library of Medicine indexing articles for PubMed (http://www.ncbi.nlm.nih.gov/mesh), while keywords are commonly search words or phrases that describe content in an article and are used as search terms in both databases and other search engines. Evidence-based care was also a subject the students had studied on the course before data collection. Each participant answered the questionnaire individually, without communicating with other participants or teachers. During the data collection, each one had access to a computer and the Internet, the library's available databases were on hand, and they had four hours to complete the questionnaire.
The participants, that is, the 16 students enrolled in a one-year Specialist Anaesthesia Nursing Programme, were all registered nurses with at least one year work experience. The study was conducted during the first term of the two-term educational programme. All the participants gave their informed consent. In accordance with the Declaration of Helsinki [25World Medical Association.Declaration of Helsinki. Ethical principles for medical research involving human subjects Nurs Ethics 2002; 9(1 ): 105-9.
[http://dx.doi.org/10.1191/0969733002ne486xx] [PMID: 16010903] ], the students were informed about the purpose of the study and the confidentiality of the results. No ethical permission was sought, as Swedish legislation [26The Swedish statute book The act of ethical trail of research concerning humans [In Swedish] Stockholm Ministry of Education and Research 2003; 460.] does not require consent for this kind of research. Furthermore, each questionnaire was coded with a number to ensure confidentiality of the participants' identity. None of the students refrained from participating in the study, the result of which was not included in the course examination.
The data was analysed using manifest content analysis [27 Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philadelphia:: Wolters Kluwer Health/Lippincott Williams & Wilkins 2012., 28 Krippendorff K. Content analysis: an introduction to its methodology. 2nd ed. Thousand Oaks, Calif: Sage 2004.] and the content was subsequently quantified. The first step involved reading all the data to obtain a sense of the whole manifest content. This was followed by the content of the six issues in focus for the study and the additional questions being grouped into categories. A phase involving the condensation of the search words and MESH terms continued to elucidate the content. Inspired by Polit and Beck [27 Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philadelphia:: Wolters Kluwer Health/Lippincott Williams & Wilkins 2012.], the students were requested to judge the scientific value of the articles on the basis of the following questions: 1) Was the chosen method appropriate? 2) Was the selection of participants well described? 3) Was the analysis logical? All the data was entered into a computerised database and processed using the Statistical Package for the Social Sciences (SPSS version 18.0).
The sixteen participants responded to a various number of the six issues in focus (presented under method) and their answers were collated both in text and in three tables. Firstly, the response rates are presented in Table 1 and illustrate the number of participants who responded to the individual questions, and whether they referred to one or more articles. The table also lists the databases that dominate the issues. The response rate to questions 1-6, the number of relevant articles found and the databases used are presented in Table 1. The keywords and MESH terms used in the search process are indicated in Table 2, while the critical analysis of the articles found is described in Table 3. Finally, the number of students who completed the task is included in a summary.
Response Rate for Each Question, Number of Articles Found and Databases Used
Keywords and MESH Terms Used
Evaluation of the Articles
Table 1 reveals that the response rate gradually decreased from the first to the last question; being 8/16 for the last one. Similarly, the number of participants who did not answer the last question gradually increased to 71 of 96 possible answers for the last question. In addition, the number of articles found to support the findings that were requested gradually decreased in a similar way.
The participants made a total of 74 searches and in the study their strategy was to use the CINAHL database for the searches. Consequently, CINAHL was used 56 times, PubMed 16 times, while Medline was employed on two occasions. Table 2 presents a list of the search terms, such as keywords and MESH terms, employed.
As Table 2 indicates, similarities in MESH terms and keywords were used as strategies to find scientific articles. Both MESH terms and keywords were used at the same time. Keywords were sometimes used more frequently than MESH terms, 67/54 respectively. Depending on the question, the search paths varied, but the dominant MESH term was ambulatory surgery and even the keyword "ambulatory surgery" was used in four of the six issues in focus.
Table 3 shows that the critical evaluation of the articles found was not completed by all the participants. Several answers were missing. Half of the participants (8/16) answered all the questions. Nevertheless, the critical evaluation showed that a clear majority of participants considered that the articles were appropriate in terms of methodology, sampling, and analysis. The assessments of a few participants were critical of the findings. Only one participant answered "no" to the question of whether the method was appropriately described and three answered "no" to whether the participants were well described. Two participants were critical of the logical analysis.
A summary of the number of participants who completed the whole task allocated reveals that eight of the 16 students succeeded.
The results show a progressive decrease in the responses to the questions, which may be due to many reasons. One could be the time factor, as four hours was allocated for answering the questions. This time limit was estimated by the authors and determined as being sufficient. Based on the response rate, it could be discussed whether more time should have been allotted to allow all the participants to complete the task or whether the specialist nursing students' lack of experience in searching for scientific articles was the reason for the low completion rate. It is surprising that the students' newly completed training in searching for scientific articles did not improve the findings to a greater extent.
In this study, there were six well-delineated questions, based on the fact that Portney and Watkins [19 Portney LG, Watkins MP. Foundations of clinical research : applications to practice Upper Saddle River. NJ: Pearson Prentice Hall 2009.] emphasise the importance of limiting issues as a means of guiding participants. This may also have influenced the students in the sense that peri-operative care is a new area for which they may not have the required domain knowledge necessary for finding the appropriate keywords [22 Parker VA, Miyake Geron S. Cultural competence in nursing homes issues and implications for education Gerontol Geriatr Educ 2007; 28(2 ): 37-54.
[http://dx.doi.org/10.1300/J021v28n02_04] [PMID: 18032190] ]. However, the fact that all the participants had a three-year university nursing education which included training in searching for scientific articles argues against this hypothesis. In addition, all the participants have worked as nurses, which mean they should be familiar with searching for scientific articles. Nevertheless, previous studies have shown that clinically active nurses reveal a lack of time and experience with regard to searching for scientific knowledge [29 Pravikoff DS, Pierce ST, Tanner A. Evidence-based practice readiness study supported by academy nursing informatics expert panel Nurs Outlook 2005; 53(1 ): 49-50.
[http://dx.doi.org/10.1016/j.outlook.2004.11.002] [PMID: 15761401] ]. Instead, nurses prefer to work as they were taught during training. Any corresponding results for Swedish conditions have not been found. However, the results of the study, which reveal weaknesses in the participants' skills in terms of information retrieval, can be interpreted as an indication that the corresponding conditions also apply in Sweden [12 Kajermo KN, Nordstrom G, Krusebrant A, Bjorvell H. Perceptions of research utilization comparisons between health care professionals nursing students and a reference group of nurse clinicians J Adv Nurs 2000; 31(1 ): 99-109.
[http://dx.doi.org/10.1046/j.1365-2648.2000.01255.x] [PMID: 10632798] , 13 Bostrom AM, Kajermo KN, Nordstrom G, Wallin L. Barriers to research utilization and research use among registered nurses working in the care of older people: does the barriers scale discriminate between research users and non-research users on perceptions of barriers? Implement Sci 2008; 3: 24.
[http://dx.doi.org/10.1186/1748-5908-3-24] [PMID: 18452603] [PMCID: PMC2405784] ]. On the other hand, results indicate that doctors rapidly obtain information by making more extensive use of the Internet [9 Tang H, Ng JH. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study BMJ 2006; 333(7579 ): 1143-5.
[http://dx.doi.org/10.1136/bmj.39003.640567.AE] [PMID: 17098763] [PMCID: PMC1676146] ]. It is possible that there are deficiencies in the education content/structure with regard to giving aspiring nurses the tools to search for knowledge. This could, in turn, indicate a need to intensify training in information retrieval in nursing education. There is a pre-existing perception that specialist students have the skills needed to seek strategies for scientific knowledge. Nevertheless, previous studies show that these skills vary widely and that the age of students could have an impact [30 Profetto-McGrath J, Smith KB, Hugo K, Taylor M, El-Hajj H. Clinical nurse specialists' use of evidence in practice: a pilot study Worldviews Evid Based Nurs 2007; 4(2 ): 86-96.
[http://dx.doi.org/10.1111/j.1741-6787.2007.00086.x] [PMID: 17553109] ], even if availability and use of the Internet has increased dramatically since 1990 [2 Estabrooks CA, O'Leary KA, Ricker KL, Humphrey CK. The Internet and access to evidence: how are nurses positioned? J Adv Nurs 2003; 42(1 ): 73-81.
[http://dx.doi.org/10.1046/j.1365-2648.2003.02581.x] [PMID: 12641814] ]. This study demonstrates that registered nurses participating in specialist education have not fully internalised this technology. The study shows that most of the participants answered questions with the support of only one article, while only a few referred to a maximum of two articles. The time factor may have played a crucial role regarding the number of articles found to ensure a reliable answer to the question. On the other hand, nurses in their everyday work can hardly be expected to have more time to search for information, which raises a question about the kind of validated evidence on which the care is based.
The databases most frequently used were (mainly) CINAHL and to some extent PubMed. The dominance of these databases may be due to the training in information retrieval that was given prior to the implementation of the study, which emphasises search strategies in the CINAHL and PubMed databases. However, these databases are also extremely relevant with regard to finding answers to questions and are frequently used by professionals in the health care sector when they search for information. One participant used the Medline database, which can perhaps be explained by that person's past experience in using this database. Since the participants mostly used CINAHL and PubMed, it may guarantee that they have learned to employ secure sources on which to base their practice. However, there are other search strategies, such as Google and Google Scholar, which can provide information. None of the participants used these general sources, which may be due to the fact that they require more knowledge in order to critically evaluate the scientific value.
Large individual variations, as well as similarities, in the use of MESH terms were revealed, which may be explained by the issue in focus and by the participants' ability to search for information. English keywords were clearly dominant. The questions focused on issues related to patients undergoing surgery. Ambulatory surgery was the MESH term used most frequently in questions 1-3 and 6. One explanation for the variation in the search words could be that the Swedish term "day surgery" has several international counterparts, such as day surgery, day care surgery, ambulatory surgery, office-based surgery, and outpatient procedure [29 Pravikoff DS, Pierce ST, Tanner A. Evidence-based practice readiness study supported by academy nursing informatics expert panel Nurs Outlook 2005; 53(1 ): 49-50.
[http://dx.doi.org/10.1016/j.outlook.2004.11.002] [PMID: 15761401] ]. The results show that, to some extent, the participants had the ability to customise the keywords to match the question and delimit the area of inquiry. Question number 4 focused on the anaesthesia nurses, with regard to their responsibilities, and the MESH term nurse anaesthetist dominated, which resulted in only 10/16 participants answering the question. Perhaps the most appropriate MESH term was not used. In the search for support relating to a patient's post-operative pain, keywords such as post-operative pain and nurse's role were used, resulting in 9/16 not answering the question.
When there is insufficient domain-specific knowledge, it can be useful to initially "Google" for information about one diagnosis to provide the foundation for subject-specific search terms that can facilitate further inquiries in specific databases [9 Tang H, Ng JH. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study BMJ 2006; 333(7579 ): 1143-5.
[http://dx.doi.org/10.1136/bmj.39003.640567.AE] [PMID: 17098763] [PMCID: PMC1676146] ]. The study result did not provide any indication that the participants took advantage of this alternative strategy.
EBP is the core of care and medicine and focuses on the Swedish description of the skills of anaesthesia nurses, and the description of skills for registered nurses with a graduate diploma in specialist nursing specifies this anaesthesia care [31Description of registered nurses' competencies With graduate diploma in specialist nursing anaesthesia care [In Swedish] 2008.]. It is surprising that the participants did not critically evaluate the scientific value of the articles. Gerjets and Hellenthal-Schorr [32 Gerjets P, Hellenthal-Schorr T. Competent information search in the World Wide Web: development and evaluation of a web training for pupils Comput Human Behav 2008; 24(3 ): 693-715.] show that the query being investigated must be sufficiently well defined to be answered and the reader must have the necessary knowledge in order to examine the result critically. To assess whether the participants' knowledge enabled them to interpret the scientific value of the articles they found, they were required to evaluate the method used for each article, the sample selection, and whether the analysis was logical. The internal response rate was extremely low and most of the respondents that answered the questions evaluated the articles as scientifically well written. In all, only six assessments of the scientific value of the articles found regarded them as non-optimal. This could be due to the participants not having the necessary competence to methodologically evaluate the scientific relevance, as described by [23 Holleman G, Poot E, Mintjes-de Groot J, van Achterberg T. The relevance of team characteristics and team directed strategies in the implementation of nursing innovations: a literature review Int J Nurs Stud 2009; 46(9): 1256-64.
[http://dx.doi.org/10.1016/j.ijnurstu.2009.01.005] [PMID: 19371873] ] who argued for the improbability of all the articles being optimal in scientific terms. Based on this result, it is obvious that the assessment of the scientific value was not optimal in this study.
This study had several limitations. Firstly, the population was small and therefore we cannot make any generalisation of the study. In addition, we did not know the extent to which the participants were experienced in searching for scientific knowledge. The participants had just begun to study a new topic about which they were asked to search for information. Consequently, their knowledge with regard to defining the subject could have been limited. All of these factors may have affected the result. Otherwise, they had all recently participated in a course on data-based search procedures and since they were registered nurses they should also have been accustomed to searching for scientific knowledge. The relevance of the content of the articles in relation to the six questions has not been evaluated in this study.
Implications for Improvements in Education
The results underline the necessity for the education of Swedish specialist student nurses to intensify the training in search strategies and critical evaluation of the results found. A critical approach to routines in clinical practice must be internalised.
This study shows that most of the participants did not optimally complete the required task, despite recent training in how to find scientific knowledge and despite the fact that the participants were registered nurses. The CINAHL and PubMed databases were primarily used to search for the issues in question. Furthermore, the keywords differed between individuals and were used more frequently than MESH terms, and the critical evaluation of the scientific value of the articles was not optimal. In conclusion, further research is needed to understand how education of the specialist nursing students should be performed to optimise their search strategies and critical evaluation of scientific articles.
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redpajama_set_name: RedPajamaCommonCrawl


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We are a highly ambitious education investment company whose current portfolio includes Myddelton College in Denbigh and Adcote School for Girls near Shrewsbury. Our plans over the next five years are for rapid expansion, and we are seeking somebody looking for a long term position to join us.
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North West London Jewish Day School, Brondesbury, London NW6
180 Willesden Lane, Brondesbury, London NW6 7PP
10 simple reasons to choose North West London Jewish Day School
State primary school (academy converter) and nursery in Brondesbury.
Jewish faith school.
Small school with an average of one class per year.
10 better reasons to choose North West London Jewish Day School
One of the best state primary schools in Brondesbury and one of the 3 best independent or state primaries within 1 mile. Every year places in Reception are oversubscribed (first preference).
In the top 15% of schools in the country for attainment in Year 6 SATS exams, over the last 4 years. Pupils go on to one of 15 secondary schools, JFS accounting for 50% of leavers. 30% go on to academically selective state and independent schools.
A modern Orthodox and Zionist school. The secular (Chol) curriculum is guided by the National Curriculum. Jewish Studies curriculum (Kodesh) is distinct from the secular curriculum and accounts for 30% of the school day.
School curriculum also includes PSHE, Modern Hebrew. There are a small number of academic clubs.
School offers over 10 different sports. Representative teams in major sports from Year 3.
Art and music are taught as discrete subjects to all pupils. DT, drama, dance integrated into other subjects. Choir. Over 5 different visual and performing arts clubs per year group per term.
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Naima Jewish Preparatory School (1.4 miles); St Margaret's School, Juniors (1.7 miles); Southbank International School, Hampstead (1.7 miles).
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text:
When Father's Become Caregivers
Wendy Bronfin
In his book Bonfire of the Vanities, Tom Wolfe writes, "Sherman made the terrible discovery that men make about their fathers sooner or later… that the man before him was not an aging father but a boy, a boy much like himself, a boy who grew up and had a child of his own and, as best he could, out of a sense of duty and, perhaps love, adopted a role called Being a Father so that his child would have something mythical and infinitely important: a Protector, who would keep a lid on all the chaotic and catastrophic possibilities of life."
On Father's Day, families come together to celebrate multiple generations of beloved fathers in our lives. Far too many families have been affected by the catastrophic reality of Alzheimer's disease, dementia, and cognitive decline. While we celebrate, we need also to reflect on how these terrible diseases have affected our dads, husbands, or spouses, either as patients or as caregivers.
More and more men are caring for their wives and other loved ones battling dementia. While almost 75% of family caregivers are women, the number of caregivers who are men has doubled recently, a proportion that continues to grow. Women are more likely to develop Alzheimer's than men, meaning that fathers are increasingly needed to serve as caregivers for their aging spouses, a fact that is only exacerbated by the decision that many want to make to age-at-home.
He adopted a role called Being a Father so that his child would have something mythical and infinitely important: a Protector.
For many men, adopting a role as caregiver can mean a pretty big transition from a life previously focused on profession and other activities outside the home. "Men often start from a very different place than women as they transition to caregiver roles," says Beth Kallmyer, vice president of care and support at the Alzheimer's Association in Chicago. Even with a desire to provide care, some men may need help learning how to cook healthy meals and others may need support with bathing and dressing loved ones. The new challenges they face may also underscore the need to hire home health aides.
Living with cognitive decline is stressful, not only for the patient but for the caregiver as well. In fact, caregivers have a significantly increased risk of stress, fatigue, depression, and other health complications. The National Alliance for Caregiving and other organizations like HFC strive to educate the public about the needs of caregivers, and provide valuable resources and support groups for them.
Family caregiving is challenging and persistent. None of us ever dreamed of having that job. It's hard work, emotionally and physically. When a father takes on the responsibility of managing the household and all the medical and emotional needs of their loved one's daily care, he is often at risk of burnout. While our fathers strived to be our protectors as we grew up, for many of us, this Father's Day, we need to do our part to protect them, too.
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One of the things that I have learned over the last 5 years, with my child battling cancer, my marriage ending, my cousin dying and my new journey as a coach is that imperfect action is better than perfect inaction. I have also learned to really love and accept who I am and how I want to engage in the world.
It is so easy to get stuck in a place where you feel that you can't act until everything is in place – I'll get life insurance when I lose 20lbs, I'll resign my job when I have X-many dollars in my bank account, I'll start learning the guitar when I have more time, I'll break up with my lover when I find someone else…. While we all know that it's good and important to plan for the future, you also have to live in the right now. Because this moment, this moment is your life.
I have usually been pretty good at acting in ways that recognize that my life right now is important and worth living. Actions, which are big – major decisions, like emigrating from the UK, having children, buying or selling my home – have, generally not been difficult for me to commit to completing. What has taken more time to evolve into, is the realization that sometimes you need to act before you feel ready to act: the concept of imperfect action.
The more I have worked on myself, the more I realized that the brakes holding me back here were around this notion of imperfect action. What if, by acting too soon, before I really felt ready, I was not following the path of right action: that is, would I perhaps be harming someone, or myself? I aim to act with compassion, so if I hurt someone or myself, it was not intentional, so, I worked hard to let this one go.
Then, there is the element of imperfect action that relates to speech and what I struggled with more, was the ability to speak what I felt needed to be spoken. Could I speak to the person, at the moment it needed to be said? I would procrastinate. When my marriage ended, people I knew and loved died or suffered immensely I realized that this could not continue. There was no way that I was going to continue to live this way.
So, I looked at myself. Whenever a situation came up where I felt compelled to talk to someone about something – maybe something that would be considered hurtful, or upsetting, but that I felt needed saying or doing – I realized that I wasn't acting out of a place of fear. Fear that I would be rejected or the recipient of anger or confusion.
But, as one of my mentors recently said to me – you have a gift: you help people, and what you need to do is get over your fears and become obsessed with how you can help people, and ultimately that requires that you speak and act. However, remember to keep yourself safe and nourished and not to give everything away. This was a reality for me recently: I had a friendship for many years which I ended when I realized that everything was always on her terms and, when I reached out to her with terrible and sad news, she didn't even acknowledge it. So, I let her go.
As I approach my 40th birthday (10 days), and enter Chapter 2 of my life, I have committed to this path: I don't want superficial, how's-the-weather kinds of conversations anymore. I want more. I want deep, intense, satisfying exchanges with those who cross my path and those who are firmly embedded in my life. I want to be challenged and to challenge. I want to support and know where and when I can reach out for support. These exchanges result in growth and deep satisfying relationships, which, let's face it, is the basis for a life well lived.
That's how I have chosen to live my life going forward. It's how I have chosen to engage with the people around me – truthfully, deeply, mindfully and with acceptance – of myself, of my fears and ultimately for the love I have for myself and those I engage with on this journey.
1)	Reflect, before you act & speak: is this a good time, a good place, what are the clearest & kindest words?
Copyright Tamsin Astor, YogaBrained LLC, 2016.


sweet smile melts my heart.
heaven each time we kiss.
Thank you voice of my heart.
And know when I'm not.
And know that I am.
And know that I can be for him.
And know that I can be.
And know I can be for him.
than sitting here, waiting for later.
I cannot live without you here.
that I'll stand with you, no matter the foe.
I end peacefully, as tears flow.
and only you can stop my pain.
But one thing got taken away from me.
And if you do it tends to be broken.
Just how much he loved me.
I don't think I'll ever stop loving him.
To deal with my pain.
Should I be your friend again after what you have done?
Do I want to take you back?
if thats all you give?
So then why do I still feel this?
I know you feel some pain.
Doubt as much as me thought.
Even if it was hard.
I can't change what's happened.
I can only move forward in life.
Even if it means without you.
All I have is this pain and memories and this stupid love.
Once it was easy to block feelings.
But you broke one thing.
No ones ever reached this far.
I hope you happy with yourself.
It's easier to hate people than love.
But funny enough I still love you.
Cry until I feel nothing.
Only makes me cry more.
For I am not the same person anymore.
No one can reach me now.
It is my only friend now.
All is quiet and I welcome this new life.
I want you to know, that I've always loved you.
Since the day we met, I loved you.
Even when we fought, I loved you.
Being with you was amazing and I'll never regret it.
Making love to you was mind blowing, and I'll always remember it.
You cared for everything I did.
You saw all the emotions I hid.
You deserve everything you dream of and more.
One day your wounds will heal that are now so sore.
Everywhere you go, and everything you do.
There is a spot in my heart that you hold.
My affection for you, you'll never fully know.
If I never see you again, it will kill a part of my soul.
But I'm thankful for the precious time we stole.
2006-09-23 [gods2armys]: *PETS [Raikcoes]* your a predy dragon with fur. can i keep you and use you as my shag rug ?
2006-10-11 [just another gothic person]: how do i put a poem up on this kind of stuff for every one to read?
2006-10-17 [Raikcoes]: how are we all today?
2006-10-18 [Raikcoes]: lmao lmao./...you need to share hun!!!
2007-08-03 [Hereby Deleted]: have i put mine in the right place? sorry for the inconvenience.


text:
Q: How do I implement convenient logging without a Singleton? My current implementation, simplified:
#include <string>
#include <memory>

class Log
{
  public:
    ~Log() {
      // closing file-descriptors, etc...
    }
    static void LogMsg( const std::string& msg )
    {
      static std::unique_ptr<Log> g_singleton;
      if ( !g_singleton.get() )
        g_singleton.reset( new Log );
      g_singleton->logMsg( msg );
    }
  private:
    Log() { }
    void logMsg( const std::string& msg ) {
      // do work
    }
};

In general, I am satisfied with this implementation because:

*

*lazy instantiation means I don't pay unless I use it

*use of unique_ptr means automatic cleanup so valgrind is happy

*relatively simple, easy-to-understand implementation

However, the negatives are:

*

*singletons aren't conducive to unit-testing

*dissonance in the back of my mind for introducing a pseudo-global (a bit of a code smell)

So here are my questions directed towards those developers who are successful in exorcising all singletons from their C++ code:

*

*What kind of non-Singleton implementation do you use for application-wide logging?

*Is the interface as simple and accessible as a Log::LogMsg() call above?
I want to avoid passing a Log instance all over my code, if at all possible - note: I am asking because, I, too, want to exorcise all Singletons from my code if there is a good, reasonable alternative.

A: First: the use of std::unique_ptr is unnecessary:
void Log::LogMsg(std::string const& s) {
  static Log L;
  L.log(s);
}

Produces exactly the same lazy initialization and cleanup semantics without introducing all the syntax noise (and redundant test).
Now that is out of the way...
Your class is extremely simple. You might want to build a slightly more complicated version, typical requirements for log messages are:

*

*timestamp

*level

*file

*line

*function

*process name / thread id (if relevant)

on top of the message itself.
As such, it is perfectly conceivable to have several objects with different parameters:
// LogSink is a backend consuming preformatted messages
// there can be several different instances depending on where
// to send the data
class Logger {
public:
  Logger(Level l, LogSink& ls);

  void operator()(std::string const& message,
                  char const* function,
                  char const* file,
                  int line);

private:
  Level _level;
  LogSink& _sink;
};

And you usually wrap the access inside a macro for convenience:
#define LOG(Logger_, Message_)                  \
  Logger_(                                      \
    static_cast<std::ostringstream&>(           \
      std::ostringstream().flush() << Message_  \
    ).str(),                                    \
    __FUNCTION__,                               \
    __FILE__,                                   \
    __LINE__                                    \
  );

Now, we can create a simple verbose logger:
Logger& Debug() {
  static Logger logger(Level::Debug, Console);
  return logger;
}

#ifdef NDEBUG
#  define LOG_DEBUG(_) do {} while(0)
#else
#  define LOG_DEBUG(Message_) LOG(Debug(), Message_)
#endif

And use it conveniently:
int foo(int a, int b) {
  int result = a + b;

  LOG_DEBUG("a = " << a << ", b = " << b << " --> result = " << result)
  return result;
}

The purpose of this rant ? Not all that is a global need be unique. The uniqueness of Singletons is generally useless.
Note: if the bit of magic involving std::ostringstream scares you, this is normal, see this question

A: I'd go with the simple, pragmatic solution:
you want a solution that is globally accessible. For the most part, I try to avoid globals, but for loggers, let's face it, it's usually impractical.
So, we do need something to be globally accessible.
But, we don't want the additional "there can be only one" restriction that a singleton confers. Some of your unit tests might want to instantiate their own private logger. Others might want to replace the global logger, perhaps.
So make it a global. A plain old simple global variable.
This still doesn't fully solve the problem with unit testing, admittedly, but we can't always have everything we want. ;)
As pointed out in the comment, you need to consider the initialization order for globals, which, in C++, is partly undefined.
In my code, that is generally not a problem, because I rarely have more than one global (my logger), and I stick rigidly to a rule of never allowing globals to depend on each others.
But it's something you have to consider, at least.

A: I really like the following interface since it uses streaming. Of course you can add channels, time and thread information to it. Another possible extension is to use the __FILE__ and __LINE__ macros and add it as parameters to the constructor. You could even add a variadic template function if you do not like the stream syntax. If you want to store some configuration you could add them to some static variables.
#include <iostream>
#include <sstream>

class LogLine {
public:
    LogLine(std::ostream& out = std::cout) : m_Out(out) {}
    ~LogLine() {
        m_Stream << "\n";
        m_Out << m_Stream.rdbuf();
        m_Out.flush();
    }
    template <class T>
    LogLine& operator<<(const T& thing) { m_Stream << thing; return *this; }
private:
    std::stringstream m_Stream;
    std::ostream& m_Out;
    //static LogFilter...
};

int main(int argc, char *argv[])
{
    LogLine() << "LogLine " << 4 << " the win....";
    return 0;
}

A: // file ILoggerImpl.h

struct ILoggerImpl
{
    virtual ~ILoggerImpl() {}
    virtual void Info(std::string s) = 0;
    virtual void Warning(std::string s) = 0;
    virtual void Error(std::string s) = 0;
};

// file logger.h //
#include "ILoggerImpl.h"

class CLogger: public ILoggerImpl
{
public:
    CLogger():log(NULL) {  }

    //interface
    void Info(std::string s)  {if (NULL==log) return; log->Info(s); }
    void Warning(std::string s) {if (NULL==log) return; log->Warning(s); }
    void Error(std::string s) {if (NULL==log) return; log->Error(s); }

    //
    void BindImplementation(ILoggerImpl &ilog) { log = &ilog; }
    void UnbindImplementation(){ log = NULL; }

private:
    ILoggerImpl *log;
};

// file: loggers.h //

#include "logger.h"
extern CLogger Log1;
extern CLogger Log2;
extern CLogger Log3;
extern CLogger Log4;
extern CLogger LogB;

/// file: A.h //
#include "loggers.h"

class A
{

public:
    void foo()
    {
        Log1.Info("asdhoj");
        Log2.Info("asdhoj");
        Log3.Info("asdhoj");

    }
private:

};

/// file: B.h //
#include "loggers.h"

class B
{

public:
    void bar()
    {
        Log1.Info("asdhoj");
        Log2.Info("asdhoj");
        LogB.Info("asdhoj");
        a.foo();
    }

private:

    A a;
};

////// file: main.cpp  ////////////////

#include "loggers.h"
#include "A.h"
#include "B.h"
#include "fileloger.h"
#include "xmllogger.h"

CLogger Log1;
CLogger Log2;
CLogger Log3;
CLogger Log4;
CLogger LogB;

// client code

int main()
{
    std::unique_ptr<ILoggerImpl> filelog1(new CFileLogger("C:\\log1.txt"));
    Log1.BindImplementation(*filelog1.get());

    std::unique_ptr<ILoggerImpl> xmllogger2(new CXmlLogger("C:\\log2.xml"));
    Log2.BindImplementation(*xmllogger2.get());

    std::unique_ptr<ILoggerImpl> xmllogger3(new CXmlLogger("C:\\logB.xml"));
    LogB.BindImplementation(*xmllogger3.get());

    B b;
    b.bar();

    return 0;
};

// testing code
///////file: test.cpp /////////////////////////////////

#include "loggers.h"
CLogger Log1;
CLogger Log2;
CLogger Log3;
CLogger Log4;

int main()
{
    run_all_tests();
}

///////file: test_a.cpp /////////////////////////////////

#include "A.h"

TEST(test1)
{
    A a;
}

TEST(test2, A_logs_to_Log1_when_foo_is_called())
{
    A a;
    std::unique_ptr<ILoggerImpl> filelog1Mock(new CFileLoggerMock("C:\\log1.txt"));
    Log1.BindImplementation(*filelog1.get());
    EXPECT_CALL(filelog1Mock  Info...);

    a.foo();
    Log1.UnbindImplementation();
}

redpajama_set_name: RedPajamaStackExchange


We're used to seeing favorite restaurants close only to be replaced by banks or chain stores.
So when we heard that after 23 years, Sumi, the intimate French/Asian restaurant that's been one of our go-tos in the Castro, was closing, we were worried.
Until we got wind of Sumi Sushi, a slightly revamped and modernized version of the original, taking over the space and carrying the Sumi torch starting Monday.
Going back to its 80's roots as a sushi spot, Sumi is still small, still perfect as a date-night hideaway in an unconventional date-spot neighborhood, and still under the watchful eye of chef Sumi (at least until she embraces retirement).
Walking in, you'll feel as if you've entered a pagoda, with gold wood-lined walls and an exposed black-beam ceiling. Once you secure a spot at the new sushi bar, dive into the long list of specialties like bacon-wrapped scallops or the Spicy Girl Roll, or go for something a little more adventurous like the Sumi Maki (sea urchin spiked with wasabi). And if you're creative enough to dream up your own roll, the chefs will happily oblige.
The sake list is about twenty bottles deep, almost matching the number of seats.
Which is the kind of ratio we can get behind.


I have mentioned in prior blogs that the hardest part of infertility is being in the Orthodox Jewish world. While it is wonderful that we are thwarting Hitler through the birth of every Jewish baby, being left out is the toughest emotional challenge. No matter how small or large the shul is, even with the passage of time, the pain is still there. There is no escaping pregnant women or birth announcements. Recently I heard the announcement of the birth of a baby boy. I feel crappy for myself although I am happy for the family. I cried out to Hashem that the pain is becoming very unbearable. The burden and guilt associated with being the one with the fertility issue hurts to the very core of my neshama. Yet what can I do? I am powerless, at the mercy of Hashem's compassion and loving kindness.
I do not know what words of encouragement that I can offer to myself and others as I go through this pain which is a natural part of the process. I am learning a lot about myself through this very unpleasant journey across the valley of infertility. There are certain negative characteristics that have been instilled in me through my very super critical parents. As a child, I was compared to others. I also heard tons of negative comments about other people. As a result, it has been ingrained to view myself in the context of other people. As Rabbi Arush would say, we each have our individual soul correction to go through. I am having a tough time accepting the fact that infertility is part of my soul correction. The fact that other women have babies, or are pregnant, has no bearing on my present circumstance. The challenge is to accept my suffering with love and enuma, with the knowledge that soon this present situation will be over.
I have also heard that if we all were to lay down our packages, representing the very tests that Hashem has given us, and offered a choice of selecting a package that we could live with, we would pick the original package that was given to us.
As for the waiting and waiting until I get to travel to see my doctor for the next round of treatments, I must be patient and use this time to the best of my G-D given ability to grow. May the tears of pain that I weep today turn into tears of joy over the unfolding of Hashem's greatest miracle.
Recently a friend asked this very poignant question, 'What are you doing besides trying to get pregnant?" As someone struggling with infertility getting pregnant is constantly on my mind. I had to take a step back and analyze her question. What I am doing besides trying to get pregnant. Yes keeping busy does help. Recently we moved from one apartment complex to another so my energy has been occupied with moving. I also have been networking and looking for a job. Plus I have an idea for a new business. I also hang out at Starbucks with a friend of mine to chat and also to get work done. Another major development in my life is free counseling via a wonderful person. I have Puah to thank for for that.
Another question that I have been struggling with is how to deal with the pain associated with seeing other pregnant women and women with babies and toddlers? How do I get rid of the piercing pain that stabs my heart and hurts the very core of my neshama? There are no easy answers. We are in the month of Elul, a time for transformation. Hashem is also in the field so He is within reach to hear heartfelt prayers. The Hebrew verb for praying is "Hitpalel" which is a reflexive verb. Prayer in this context is a time for self-reflection.
After analyzing the source of my emotions at shul when I see a pregnant woman or a woman with a a baby/small children, I came to the realization that deep down inside I really do not believe that I could possibly get pregnant. What if I took a different perspective and applied emunah (faith) and I told myself that regardless I will be a mother whether through pregnancy or adoption? Would that change how I view pregnant women and women with babies and toddlers. Through the encouragement of my counselor, I am embarking on a journey of going to shul during kiddish and actually being around these very woman who unwittingly are a source of my pain. If I do not go through with this, then how can I possibly grow?
Remember the infertility support group that I was trying to initiate for childless Jewish couples? Well, it has been 3 days since I posted my announcement via the shul classifieds and the local community craigslist style email. No response yet. It is a small community so perhaps will take time to find a handful of couples. Sigh! I get so easily discouraged.
Remember the emotional rollercoaster? Well I am back on it. Today I went for a big ride up and down. The downward ride was very steep. I am feeling very left out of the mommy club. I was however good to myself and ate some chocolate ice cream.


Congratulations to World Journal on its 40th anniversary! What a milestone this is! For so many immigrants, the World Journal is their lifeline to the world. The news that World Journal provides helps immigrants stay connected with their old country, and understand what is happening in their new country, America, and within their local communities. Our family has a subscription to World Journal. It arrives every morning and my father reads it instead of the New York Times!


The app runs in the background of users' phones, using location data to monitor activities through the day.
The free app has been downloaded more than four million times for both iPhone and Android phones, according to the firm.
Many of the big technology firms are seeing money to be made from health technology. There is a range of fitness bands and smartwatches on the market already.
Apple is rumoured to be on the verge of launching its own smartwatch with fitness features and Google last month launched software for wearables.
But for Facebook, the purchase of a fitness app is likely to be all about new data which will allow it to better target adverts, thinks Alys Woodward, an analyst with research firm IDC.
"They want to know more stuff about what people do and where they are. This is useful information even if they don't tie it back to the individual," she said.
What is the meaning of "tie it back to the individual" in this context? I would appreciate your help if you could determine what the words "it" & "they" refer to when saying " This is useful information even if they don't tie it back to the individual"
In this case, the information is valuable to Facebook even if it isn't associated with a specific person. That is to say that they don't need to know the identity of the user to make use of the information.
They want to know more stuff about what people do and where they are. This is useful information even if they don't tie it back to the individual.
The idea behind the "back" motion of all this is that the company already knows who these people are, so this kind of data coming from things these people are wearing could be taken in the present or future and matched up with the file each person already has on record.
Monitoring user location and activity throughout the day, could provide a valuable set of data in the aggregate such as traffic patterns, popularity of businesses, etc.
This is key because knowing where someone is and who they are is a breach of privacy, but knowing where a bunch of people are without knowing any of their identities is not.


My environmental ethics and ecology class had a huge final at the end of the semester. We were supposed to somehow impact our community in some way. I heard of a house that was torn down in the woods, which also had trails around, and thought it would be a good idea to build a recreational area. With the help of my teachers and classmates, we were able to clear out buckthorn and improve the trails with mulch. During the winter, I had to go to Prior Lake City Hall and speak with the council about the opportunity to build a park. After they agreed to the terms and the money that was provided, my connections with the DNR gave me the option to build a swing that over looks the lake and a picnic area that also over looks the lake. With countless hours and meetings about the arrangements of flowers and decorations, the person that lived in the house that was torn down has heard of the project I was doing and decided to donate five thousand dollars just for a butterfly garden. With that help and push of the donation, my group and I were able to plant around three thousand plants in one day. It is such a beautiful site, but it is not done yet. There are still some things that need touch ups for example, the main trail to the picnic area and swing needs stepping stones. The whole group of volunteers included my class, some friends that lived nearby and even boy scouts. I have always wanted to leave a mark on Earth and I had the opportunity to do so. Pike Lake in Prior Lake was not a place everyone has heard of, but now it is a very popular place to bird watch and just go for a walk.


text:
Q: How to organize web service in ASP .NET Web API This is a theoric question about how to organize web service.
Building a web service using ASP.NET Web API you can create a lot of controllers and web methods inside them. However, maintaining many controllers and methods in the same solution can be hard.
What are the criteria that shuold be used in order to choose to split a solution in two or more?
What advantages and disadvantages derives from using a single solution with many methods and controllers and the advantages and disadvantages of using many solutions ?

A: I guess first  question will be: what is the number are you talking about with "a lot of controllers"?
The main disadvantage I see when dealing with huge solution is load (CPU? RAM, Resharper caching). I do remember I had a solution of 54 project and it building takes over 3 minute. So we had to extract one small solution for development and full solution was loading only on integration of our part. (Well SSD probably helps here)
But also it is semantics. The best way on my opinion is making separation based on complete blocks for example you extract interface and then it implementation goes to another solution or project.


Fresh from a successful trip to the Dragons' Den, this gourmet delivery company brought their business to the MadeBrave studio. And we were IN!
This Scottish-born brand already had tongues wagging for all the right reasons – they'd gone from small start-up to next-big-thing in just a matter of months. And it's no wonder when you see the subscription boxes they sent out – full to the brim with food and drinks from artisan brands (editors note: nowadays they focus on beer, but back then they had gourmet nibbles galore!).
Our job was to capture their ethos of bringing boutique brands to the mouths of the many. We began by tasting some of the tantalising treats they sent out to members on a monthly basis (it's a tough job, but someone's got to do it!) and helping them get to the bottom of their business's reason for being.
With the brand foundations established, it was time to bring them to life. We created new designs for their delivery boxes to make the outside as exciting (well, almost as exciting) as what awaited on the inside. We also created campaign imagery that did justice to the premium quality of the contents, giving the wider world a flavour of what Flavourly is all about.


text:
David Bowie "Suffragette City" Song Analysis
Here's a song analysis of a classic. It's "Suffragette City" from David Bowie's seminal Rise And Fall of Ziggy Stardust and the Spiders From Mars album. I happen to know a bit about this record since I'm the co-author of the memoirs of Ken Scott, the co-producer and engineer of the record, called Abbey Road To Ziggy Stardust.
It's interesting to note that although Ziggy Stardust was a huge influence on American musicians at the time, it didn't actually sell that much in the US when it was first released. In fact, it was considered somewhat of a flop in the States, although a hit in the rest of world. It's also interesting that to this day, Ken can't fathom the impact that the record has had on us. He thinks the record is pretty good, but nothing special.
Ziggy Stardust was recorded at Trident Recording in London in 1972 before Bowie even had a record deal (he was being shopped at the time on the basis of an album he just finished - Hunky Dory). Although many consider this to be a concept record, it was like most albums are; just a group of songs, that in this case, seemed to have a common thread almost by accident (you'll have to read the book for the rest of the story).
Like all song analysis, we'll look at the song form, the arrangement, the sound and the production.
"Suffragette City" has a pretty simple song form that looks like this:
Intro, Verse, Chorus, Intro, Verse, Chorus, Solo, Chorus, Intro, Outro (C Section), Outro
The outros are a different song section which you can think of a section C, with the second outro being a reprise of the first. All in all, it's a simple song, but both interesting and energetic.
Like most great song arrangements, "Suffragette City" builds and breathes. The intro is big, with doubled guitars left and right, then gets smaller in the verse, then big again during the chorus, back down for the verse, etc. The song culminates with the loudest most energetic part in the dual outros.
The outros are interesting in that they take up a third of the song and are perfect examples of how to keep listener attention during a repeating part (in this case going back and forth between a 2 chord pattern). The lead and background vocals change every time the pattern is repeated (every 8 bars), and the synthesizer enters halfway through the outro section as an answer to the lead vocal.
The arrangement elements look like this:
* The Foundation: Bass and drums
* The Rhythm: Acoustic guitar strumming, 8th note piano
* The Pad: Synth and power chord guitars in the B section
* The Lead: Lead vocal, guitar solo, synthesizer line in intros
* The Fills: Background vocals, synthesizer
Although the popular conception is that Bowie played baritone sax on the intros, outros and choruses, the sound is actually an ARP 2600 synthesizer, programmed by Ken Scott and played by Mick Ronson. Bowie has taken credit for the "saxes" in a number of interviews, but it's unknown if he just didn't remember or was being coy about the part on purpose.
There are a lot of interesting sonic elements that make up "Suffragette City." First is Mick Ronson's guitar sound, which came as a result of a Les Paul into a wah wah pedal set at about half-way, into a Marshall Major. That's the classic Ronson sound.
The drums are interesting in the song as the snare is panned half-right and the kick half-left. This is because the song was recorded on 16 track, and the drum kit was frequently recorded either in stereo on two tracks, or with the kick or snare on one track and the rest of the drums on another, or some other combination. Regardless, the drums were recorded far differently from the way we do it today with each drum on it's own track, hence the odd panning.
The other interesting thing is how prominent the acoustic guitar is on the track, pushing the song along rhythmically, and almost serving in place of the cymbals. According to Ken, "I wasn't too into cymbals back then so I mixed them low."
Bowie's lead vocals are doubled throughout the song, going to a single vocal on the hook of the chorus ("I'm going to Suffragette City").
There's only a single EMT plate reverb on the entire mix, as that's all that Trident had at the time. You can hear it hang over a bit at the very tail end after the last chord of the song.
Also take note the legendary Trident piano pushing the song along in the chorus and panned to the right side. It was famous for its brightness, which was fantastic for rock or pop, but didn't work very well for classical music.
Like all records that Ken Scott has produced or co-produced (he produced Ziggy Stardust with Bowie), the production is typically excellent even though it was only his second stab at it (Hunky Dory being the first). The best thing about the song for me is the energy, which can be attributed to the number of takes by the band. David made it a point to never let the band go beyond 3 takes, and sometimes even two, so the players were always on the edge (this is with no rehearsal beforehand as well). Another interesting production fact is that according to Ken, almost all of the Bowie's vocals were done on the first take over the course of the 4 albums he did with him!
The background vocals (done by Bowie and Ronson) are interesting in that they move in the stereo spectrum, first starting on the left in the first verse, then changing to the right on the second and doing the same during the outro. All these little things add up to make the song both exciting and interesting, and as a result, a classic.
You can read more about Bowie and the Ziggy Stardust sessions in the upcoming Abbey Road to Ziggy Stardust book.
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Labels: Abbey Road To Ziggy Stardust, David Bowie, Ken Scott, song analysis, Trident, video, Ziggy Stardust
TY Bob, I actually found this eval very interesting
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Jess Haines, PhD, MHSc, RD is an Associate Professor of Applied Nutrition at the University of Guelph. Prior to her appointment at U of G, Dr. Haines was a faculty member at the Obesity Prevention Program in the Department of Population Medicine at Harvard Medical School.
She is the Associate Director of the Guelph Family Health Study, a family-based cohort study designed to identify early life risk factors of chronic disease and to test family-based strategies to support healthful behaviours early in life.
Dr. Haines is the Director of the Parent-Child Feeding Laboratory, funded through the Canadian Foundation for Innovation and the Ontario Ministry of Research and Innovation. The overarching goal of the laboratory research is to identify how parent-child feeding interactions influence children's eating behaviours.


Virtual Active Hike Series 6 welcomes you to experience the beauty of the Hawaiian islands, the lush trails of Taiwan, and Costa Rica's exotic jungles. You'll explore the caves and shores of Hawaii's Big Island, climb to breathtaking heights on Maui's Sliding Sands Trail, witness the awe-inspiring peaks and valleys of Kauai, discover the unique beauty of Taiwan, and trek the jungles deep in Costa Rica.
Note: these basic workouts includes environmental sounds only.


It has been far too long since The Crazy 8s Car & Social Club got together and rolled out in earnest! Well the wait is over as it's time for our next cruise to one of the best local car shows every year, the Motor4Toys car show on Sunday, December 2nd!
We'll meet up between 5:00 and 5:30am at our usual starting point, Peet's Coffee at 18973 Ventura Blvd in Tarzana. At 5:30, we'll head out to M4T at it's new location at Pierce College. After the show, at around 10:00am or so, we'll head out posse style over Topanga Canyon, with a stop at the Shell Station at 22295 Mulholland to meet up, and then on to Malibu for brunch!