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Home » Hospital Medicine: Past, Present, and Future
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Hospital Medicine: Past, Present, and Future
Cholera Cases: Past, Present, and Future
Trauma Reports Supplement - ED Thoracotomy Revisited: A Complete Reassessment of its Past, Present, and Future
Using Etonogestrel Implants and LNG-IUDs Past FDA-approved Duration
Authors: Shaun D. Frost, MD, Assistant Clinical Professor of Medicine, Hershey Medical College, Penn State University, Director, Non-teaching Inpatient Services, Division of Medicine, Staff, Section of Hospital Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio; Franklin A. Michota, MD, Assistant Professor of Clinical Medicine, The Ohio State University College of Medicine, Assistant Clinical Professor of Medicine, Hershey Medical College, Penn State University, Associate Director, Internal Medicine Residency Program and Head, Section of Hospital Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio.
Editor's Note—Over the past decade, American medicine has witnessed a revolution in health care delivery that arguably rivals any preceding it in our society. Adopting a model of care popular for decades in other countries such as Great Britain and Canada, the United States has largely shifted to a hospitalist-based mode of inpatient care delivery since the mid 1990s. Affecting virtually every aspect of our health care system, the stunning growth and rapid integration of hospital-based medicine has affected the practice of both medicine and surgery by significantly modifying the delivery of inpatient, outpatient, and subacute care. Conservative estimates suggest there are currently 7000 to 8000 hospitalists practicing in the United States with a projected workforce of approximately 20,000 physicians.1 The present demand for hospitalists is greater than the supply, evidenced by the large number of classified advertisements for hospital medicine physicians currently appearing in American medical journals.
Criticism of the movement has centered on the purposeful interruption in the continuity of care created by an intentional "handing-off" of patient responsibility from primary care provider to hospitalist. Although concern for adverse patient outcomes and dissatisfaction has been frequently cited, research critically analyzing the hospitalist movement has not substantiated these fears. Critics have also claimed that hospitalist-based care is purely a cost and resource saving strategy motivated by a managed care environment. Although the promise of hospitalist cost efficiency (now confirmed by substantial literature) has undeniably aided growth of the movement, the true catalyst lies in the hearts of hospitalists themselves who are motivated by the same altruistic patient centered factors that lead all physicians to their chosen career paths.
This article details the history of hospitalists in the United States by defining the practice of hospital medicine, and reviewing the evidence extolling its virtues. Although hospital medicine appears here to stay, work must still be done to address a number of current and future issues facing hospitalists and the health care community embracing them.
Drivers of Change Toward Hospitalist-Based Care Delivery
The establishment of a hospitalist system of care by the Park Nicollet Clinic is widely regarded as one of the first large-scale experiments in hospital medicine in the United States. Driven primarily by physician dissatisfaction with the uncertainty of night call and the challenges of getting through the post call day, general internists and family practitioners at the Minnesota multispecialty physician practice created a successful hospitalist service in 1994.2 Wachter's subsequent 1996 report of this and similar experiences represent the first description of the emerging role of hospitalists in the American health care system.3 In addition to physician dissatisfaction with traditional models of inpatient care delivery, Wachter cited the growth of managed care and its emphasis on efficiency as an important driver of the hospital medicine movement. According to Wachter, hospital-based care would flourish because of favorable effects on lowering cost and enhancing quality. These effects would beneficially affect the delivery of both hospital and outpatient care, and would thus maximize value in all health care systems.3 Other drivers of the remarkable growth of hospital medicine are presented in Table 1. These drivers have been stimulated by a number of factors that have altered the current landscape of hospital care. A change in surgical practice leading to more outpatient procedures has decreased the number of surgical admissions.4 This, combined with an increasing number of emergency department (ED) medical admissions resulting from a rise in ED use by uninsured patients,4,5 has shifted the inpatient majority from surgical to medical patients thus creating the need for more inpatient medical services. Advances in technology and the aging of the population have led to an increasing complexity of acute illness among hospitalized patients that has challenged physicians' clinical expertise and hospital availability. In addition, trainee education considerations, a desire to remedy hospital system flaws, and a sincere interest in the provision of acute care among physicians choosing hospital medicine careers have stimulated the hospital medicine movement.
Defining the Hospitalist
The hospitalist was initially defined as "a physician who spends at least 25% of his or her professional time serving as the physician of record for inpatients, during which time he or she accepts hand-offs' of hospitalized patients from primary care providers, returning the patients to their primary care providers at the time of hospital discharge."6 Others have more simplistically defined hospitalists as physicians who devote much of their professional time and focus to the care of hospitalized patients.7,8 While a minimum time commitment may be difficult to quantify, the concept of a "hand-off" is an essential element defining the practice of hospital medicine. It is the referral or patient care "hand-off" from the primary care physician that distinguishes a hospitalist from the historical "house doctor" who is available for emergencies when the physician of record is not on sight, yet does not participate in decisions regarding the overall hospital management plan.
Relevant to defining today's hospitalist is an analysis of the core competencies necessary to provide efficient, high-quality hospital care (see Table 2).9 This skill set may be learned by physicians of many training backgrounds. General internal medicine practitioners, who make up 83% of the workforce,10 dominate current hospital medicine practice. Other physicians working as hospitalists include general pediatricians, family practitioners, pulmonary and critical care specialists, and infectious disease specialists. Among the skills necessary to practice hospital medicine, communication is of key importance. The potential for "information drop" sacrificing quality patient care is significant and may occur on multiple levels. Hospitalists must be proactive in seeking information of historical importance at the time of patient admission from primary care physicians, families, and outside medical institutions. Hospitalists must communicate timely with consultants, primary care providers, nurses, case managers, social workers, and family members regarding patient progress and changes in status. Special skill in discussing end-of-life issues and communication of emotionally sensitive information is mandatory. Finally, hospitalists must succinctly summarize and detail the course and outcomes of a patient's hospitalization, and timely transmit this information to primary care providers, nursing home and rehabilitation facility physicians, and subspecialty consultants to ensure a seamless transition of care from the hospital.
Table 2. Defining the Hospitalist:
Core Competencies for the Inpatient Physician
Finally, consideration of the typical roles assumed by hospitalists (see Table 3) is useful in defining hospital medicine practice. Patient care responsibilities generally include more than serving as physician of record on primary general medical service admissions. Most hospitalists also perform medical consultations, and many comanage postsurgical patients, provide medical intensive care, staff observation or clinical decision units, and supervise rehabilitation in post-acute care facilities. Beyond patient care, hospitalists perform important administrative and hospital support functions. Survey data from the Society of Hospital Medicine indicate that 73% of hospitalists spend an average of 299 hours annually performing nonpatient care work.4 These activities combined with the various clinical settings in which they practice, mandate that hospitalists be skilled in the art of multitasking. Wilson and Kislingbury have commented "after mastering multitasking, efficiency demands that hospitalists go the next step beyond to simul-tasking, the ability to coordinate and complete multiple tasks simultaneously. Admits, discharges, continuity visits, consults, procedures, and ER evaluations, often needing to be done at the same time, creates the conundrum of competing, congruent, contemporaneous care processes."4 Figure 1 presents a typical day in the life of a hospitalist illustrating the need to multi- and simul-task.
Roles of the Inpatient Physician
Figure 1. A Day in the Life of a Hospitalist
Benefits of Hospital Medicine
Initial growth of American hospital medicine was founded only on the promise of benefits. However, the past decade has witnessed the publication of several investigations presenting evidence suggesting a number of positive outcomes directly related to the implementation of hospitalist systems of care (see Table 4).8,11-13 Wachter recently reviewed 19 published studies regarding the effect of hospitalist programs on financial and clinical outcomes.8 An average 13.4% decrease in hospital costs and 16.6% decrease in hospital length of stay were reported, with significant benefits in these 2 measures noted by 15 of the 19 studies. Additional beneficial outcomes were only variably reported, with these data being interpreted by Wachter as "insufficient to support an unqualified statement that hospitalists improve quality." Most of the investigations reviewed found no significant change (positive or negative) in quality measures directly attributable to hospitalist systems. Wachter's conclusion was that the hospitalist model "appears to have achieved its minimum goal of improving efficiency without adverse effects on quality, teaching, or patient satisfaction." The potential savings to be had by this improved efficiency could result in a reduction in inpatient costs by approximately $2.4 billion per year.8
Table 4. Evidence Documented Benefits
of Hospitalist Systems of Care
Current and Future Challenges
The future of hospital medicine is promising. The field has grown rapidly with an estimated current workforce of 7000-800014 and a projected future workforce of 10,000-30,000 physicians,1 which is comparable in size with the field of cardiology.15 In Massachusetts, 39 hospitalist programs now manage 42% of the 1.8 million medical inpatient days in the state.16 Hospitalists are represented by their own professional organization, the Society of Hospital Medicine (SHM), formerly known as the National Association of Inpatient Physicians. SHM has witnessed an explosion in membership, growing from approximately 450 members after its first year of existence in 1999 to 4000 members today (A. Musial, written communication, June 2003). This is larger than many other medical organizations, including the Society of General Internal Medicine. Recent survey data indicate hospitalists find their jobs appealing, intellectually stimulating, well paying, and conducive to a balanced lifestyle.17,18
But the work is not yet done. As hospital medicine appears here to stay, it is no longer necessary for hospitalists to justify their existence. Questions to address now pertain to organizational, financial, ethical, educational, and clinical issues that arise from a major change in the organization of health care delivery.8 Current and future challenges to hospital medicine and the health care system embracing it include the following:
More proof of improvement
Hospital medicine must continue to improve upon realized successes. Although the existing data appear robust, further studies on cost savings are indicated. Such studies might focus on issues such as the shifting of cost from the hospital to other settings (ie, extended care facilities or the outpatient arena), the cost of care to health insurers, the cost of hiring hospitalists, the effect of hospitalists on institutional budgets, and monetary and other costs to patients' families.19 Additional and ongoing trials should confirm preliminary data and observations suggesting quality improvement. Further decreases in length of stay may yet be recognized,4 and better studies regarding the effect of hospitalists on patient and physician satisfaction are needed. Satisfaction assessment should also be expanded to the direct study of inpatient subspecialists, nurses, ancillary staff, trainees, and families.
The increasing presence of hospitalists at academic medical centers will assist in defining a new research agenda that expands beyond the study of the hospitalist model itself. Academic hospitalists are now investigating critical inpatient issues such as patient safety, preventing nosocomial infections, end-of-life care, and hospital quality measurement.8 It is expected that in the future, hospitalists will devote increasing time to clinical trials, patient-centered research, and genetic epidemiology.8
Maturation of individual hospitalist groups
Major current and future challenges to individual groups of hospital medicine physicians include creating sustainable job descriptions and ensuring financial viability. Much has been written about the potential for the hospitalist to burn out. This is clearly a legitimate concern given the acuity of patient illnesses, need to provide 24-hour-a-day care, and the multi- and simul-tasking demanded by restricting one's scope of practice to the hospital. Recent reports suggest that 13% of hospitalists consider themselves burned out, with an additional 25% indicating levels of physical, emotional, and mental exhaustion placing them at risk for burn out.17 A common approach to maintaining job sustainability is to create job descriptions that provide the opportunity to intermittently escape from the high-pressure hospital atmosphere. Many hospitalists, for example, regularly engage in limited out-patient care activities, provide out-patient preoperative medical consultations, supervise residents in out-patient clinics, provide rehabilitative care in subacute nursing facilities, and staff emergency department clinical decision units.
Another challenge to hospitalist groups is addressing the fact that hospital medicine is not a lucrative business. Individual programs must devise creative methods to maintain financial viability. A hospitalist group consisting of 3 physicians, 1 case manager, and 1 administrative assistant will have a typical annual operating cost in excess of $500,000.4 Revenues collected from inpatient care activities alone generally equal only 60-80% of a hospitalist's salary.20 The reasons for this are multifactorial, and not unique to the United States. Canadian officials for example have stated "at our hospital we charge more for parking than physicians can make caring for (unassigned) patients."21 One logical solution is to expect those components of a system benefiting from a hospital model of care to "subsidize" the budget deficit.20 This seems reasonable if hospitalists save inpatient costs, create the ability to maximize outpatient productivity, and perform critical hospital administrative and institutional support duties that historically have not been financially rewarded.
Training emphasizing the core competencies outlined in Table 2 is essential to developing a competent hospital medicine work force. Existing traditional training programs may be inadequate. A survey of members of the National Association of Inpatient Physicians found that practicing hospitalists believe their residency training experiences were deficient in a number of core competencies including perioperative consultation, geriatrics, communication skills, end-of-life care, continuum of care, and systems issues.22 To augment education in these areas, existing training programs will need to be restructured or additional training opportunities offered. To this end, special residency tracks and fellowships in hospital medicine have been established at a number of training facilities in the United States.23 The SHM is also actively developing continuing medical education materials for hospitalists currently in practice, and sponsors an annual national meeting and 4 annual regional meetings. Many local SHM chapters also sponsor regular educational activities.24 A future challenge to medical training will be to incorporate hospital-focused curriculum that does not compromise the ambulatory education necessary for maintaining hospitalists' competencies in understanding the scope of outpatient practice.
Specialty designation
Whether hospital medicine constitutes a new specialty is an important question. Specialty designation would almost certainly lead to separate board certification and could result in greater system changes such as requirements for added credentials to obtain privileges to practice in the hospital. Traditional medical specialties have been organized according to organ system (ie, cardiology, gastroenterology, dermatology), patient population (ie, pediatrics, geriatrics, obstetrics), and procedural/technological competencies (ie, anesthesiology, radiology, surgery). Recent precedent for organizing a specialty based on practice location, such as that seen in hospital medicine, has been set by critical care and emergency medicine.25 Criteria required by the American Board of Internal Medicine for a discipline to receive specialty certification are presented in Table 5.25 While developments such as the recent publication of a hospital medicine text book,26 a growing original literature foundation, and the establishment of fellowship training programs would meet many of these criteria, hospital medicine has yet to completely satisfy all of the requirements for medical specialty certification.
Requirements for Certification
as a Medical Specialty
Declining popularity of primary care
Interest among medical students in pursuing primary care careers is declining.27 Since 1998, 17% fewer American medical school graduates have matched to categorical, primary care, and medicine-pediatrics internal medicine training programs.28 In 2003, primary care internal medicine residencies saw a 6% decrease in enrollment, while family practice experienced a 12% drop resulting in a 6-year loss of 44%.28 The reasons for this are likely multifactorial, but the potential effect of hospital medicine on the training of future generalist physicians should be considered.
Some claim that the "playing field and the opportunity to influence medical trainees toward primary care fields is far from level," citing that the majority of residency education occurs in the hospital where the clinic experience is often resented because it is "wedged into a ward month wherever it can fit."27 Addressing this concern as it relates to the training of hospitalists is necessary, but unfortunately there are no simple answers. Separate tracks for residents interested in hospital or primary care internal medicine is a potential solution, yet could also be detrimental to the goal of recruiting internal medicine trainees. Weissler, for example, has commented that the splitting of internal medicine training into ambulatory or hospitalist tracks could drive trainees interested in stressing continuity of care to family practice.29 Whatever the solution, internal medicine must seemingly find one, as Weissler further cautions that other specialties might assume the role of formal hospitalist training if internal medicine does not.29
However, to advocate that internal medicine be the sole provider of hospitalist training opportunities is controversial. Collaboration on the training of hospitalists by internal medicine and family practice has been suggested30 and may serve as a means to ensure that family practitioners have access to hospital medicine careers. Observation of the increasingly common stipulation that applicants for hospitalist jobs be board certified in internal medicine has led to a concern that family practice trained physicians will not be allowed to compete for these positions.30 Ensuring access to the provision of hospital care by family practitioners may be essential to recruiting new family practice trainees. An inability to follow care into the hospital has been viewed as a significant interruption in patient contact that may lead to the deterioration of the family practice paradigm of comprehensive, lifelong continuity of care.31
Hospital medicine is currently revolutionizing the delivery of health care in the United States. Initial fears of adverse outcomes related to the rapid adoption of hospitalist-based care appear to be unfounded. Research has seemingly justified hospital medicine as a rational means of enhancing health care value. Ongoing research will explore recent literature suggesting that hospital medicine systems decrease morbidity and mortality, improve satisfaction, and enhance the education of medical students and residents. The initial concern that "the presumed brave new world of the hospitalist may be another case of the emperor's new clothes"7 seems irrelevant today, for even initial skeptics of the hospital medicine movement have since truly seen the cloth on its loom. (For more information, see case study.)
1. Lurie J, et al. The potential size of the hospitalist workforce in the United States. Am J Med. 1999;106:441-445.
2. Freeses R. The Park Nicollet experience in establishing a Hospitalist system. Ann Intern Med. 1999;130(4S):350-354.
3. Wachter R, Goldman L. The emerging role of "Hospitalists" in the American health care system. N Engl J Med. 1996;335: 514-517.
4. Clinical Advisory Board. Second generation hospitalist programs. Strategies for securing program returns. 2002, The Advisory Board Company, Washington, DC.
5. McCaig L, Burt C. National hospital ambulatory medical care survey: 2001 emergency department summary. Available at: www.cdc.gov/nchs/data/ad/ad335.pdf. Accessed June 9, 2003.
6. Wachter R. An introduction to the hospitalist model. Ann Intern Med. 1999;130:338-342.
7. Goldmann D. The hospitalist movement in the United States: What does it mean for internists? Ann Intern Med. 1999;130: 326-327.
8. Wachter R, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
9. Whitcomb W, Nelson J. The role of hospitalists in medical education. Am J Med. 1999;107:305-309.
10. National Association of Inpatient Physicians 2002 Hospitalist Productivity and Compensation Survey, Available at: www.hospitalmedicine.org/presentation/default.asp. Accessed June 9, 2003.
11. Auerbach, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
12. Meltzer D, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: Results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
13. Tenner, et al. Improved survival with hospitalists in a pediatric intensive care unit. Crit Care Med. 2003;31:847-852.
14. Society of Hospital Medicine. Available at: www.hospitalmedicine.org/presentation/default.asp. Accessed June 9, 2003.
15. Wachter R. Debunking the myths about the hospitalist movement. Am J Med. 2000;108:672-673.
16. Miller J. The hospitalist movement: The quiet revolution in healthcare. Health Leaders News. Jan. 8, 2003.
17. Hoff, et al. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161:851-858.
18. Lindenauer P, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343-349.
19. Showstack J, et al. Evaluating the impact of hospitalists. Ann Intern Med. 1999;130(4Pt 2):376-381.
20. Bellet P, Wachter R. The hospitalist movement and the implications for the care of hospitalized children. Pediatrics. 1999;103: 473-477.
21. Sullivan P. Enter the hospitalist: New type of patient creating a new type of specialist. CMAJ. 2000;162:1345-1346.
22. Plauth W, et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111: 247-254.
23. Kripalani S. Hospitalist fellowships on the rise. The Hospitalist. 2001;5(6):9.
24. Kettering L. Evolution of a local NAIP chapter: Organizational pearls from grassroots hospitalists. The Hospitalist. 2002;6(3): 15-17.
25. Kelley, M. The hospitalist: A new medical specialty? Ann Intern Med. 1999;130(4S):373-375.
26. Hospital Medicine. Wachter R, Goldman L, Hollander H, eds. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.
27. O'Connell P, Wright S. Declining interest in primary care careers. J Gen Intern Med. 2003;18:230-231.
28. Maguire P. In this year's match, internal medicine continues to lose U.S. graduates. ACP Observer. 2003;23:1-4.
29. Weissler J. The hospitalist movement: caution lights flashing at the crossroads. Am J Med. 1999;107:409-413.
30. Jimbo, M. Advantages and limitations of the hospitalist movement. JAMA. 2002;287:2073-2076.
31. McConaghy J. The emerging role of hospitalists—Will family physicians continue to practice hospital medicine? J Am Board Fam Pract. 1998;11:324-326.
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Can we exchange our dong now at .47 cents exo?
Posted by galpearl NatDania.com dong at .47 cents says Exo.
Dwight: IMHO until the currency exchange Dealers change their rates your Dong shall exchange at what they will pay you for it ! Other wise they would go broke real fast !
Im guessing, because It is nowehere yet to be seen on any PUBLIC viewing website links.....private only trading platforms you have to belong too.
Former Assistant Treasury Secretary, Dr. Paul Craig Roberts, says, "Gold and the dollar are in a fight to the death." Dr. Roberts explains, "The Fed, in order to save a handful of banks too big to fail that are the mindless deregulation of the 21st century, the Fed has had to create a tremendous number of new dollars.
The United States has never experienced anything like the creation of new money it has issued from quantitative easing, which is now multi-years old.
Because the dollar has been the world reserve currency since the end of WWII, countries all over earth have huge stocks of dollars. It's not just countries or central banks, but companies and individuals.
As people view their holdings, an enormous supply of dollars in light of this extraordinary printing of new money by the Fed, they get nervous.
EXOGEN April 12, 2014 ZIMBABWE HAS TONS OF NATURAL RESOURCES TO BACK THEIR CURRENCY.
ALSO THE DONG IS NOW TRADING AT 47 CENTS IF YOU KNOW HOW TO ADJUST YOUR NETDAMIA SETTINGS. PEOPLE ARE LOOKING AT THE WRONG SCREENS.
Army guy : Who told you that Dong is now trading at $.47? Are we suppose to believe that while it's still showing to be worthless?
The CBI is taking measures to protect its money abroad by distributing its funds into a number of different banks.....this comes as a result of the US ceasing their protective measures for Iraqi funds on May 22, 2014.
The CBI plans to purchase more gold in the coming months....we had kind of heard that already.....what I'm struggling to understand is how the World Gold Council can say that with 65.8 tons of gold that Iraq is third among the forty largest gold holders of the world...."in the formal sector"....whatever that means....behind Denmark and ahead of Pakistan.....that "formal sector" thing must be the kicker.....on a side note, I thought we had seen where they now owned like 90 tons of gold.
Zlynn: ...Zim dollar notes were printed in October and November 2013, a senior official at Fidelity Printers and Refineries said. They were all high-denomination notes, with the biggest being $10-million."
The Zim currency advised to purchase here and other sites was the 100 trillion dollar banknote printed in 2008. This currency series was made obsolete in 2008. Based on this article, since I have the 100 trillion banknotes, I have the wrong currency to exchange.
[tlm724] wanna see what they did ?
[tlm724] Bank for International Settlements enjoys immunity high and offers free high investment and Aymanh this opportunity, but central banks into confidence BAGHDAD / obelisk: Central Bank of Iraq announced that he Light Bank for International Settlements in Basel to increase investments has announced his agreement to invest another billion dollars for this year.
PRESS RELEASE: THE RETURN OF THE ZIMBABWE DOLLAR......."THE MONEY PRESSES ARE COMING ON"
Africa Return of the Zim dollar?
Facing serious funding problems, the Zimbabwean government may switch on the money presses again.
Welcome To Friday Night News Time With Millionday!
[millionday] Prime Minister Nuri al-Maliki, said Friday that the change will end the quota system to complete what we started with, despite attempts by some to obstruct the process of state-building, and in the detection of possession of a list of projects that disrupted the "foreign agendas", described it as comes to excite people on the government.
Maliki said in an official ceremony for the coalition of state law, which was held in the city sports in Basra and attended "Tomorrow's Press," "We want to change the ending of quotas to complete what we started with, despite attempts by some in the blocking state-building process," noting that "the approaching election saga will be the Account those who sold and bought between Iraq and stop the prey. "
WASHINGTON, April 11 (Reuters) - Finance chiefs from around the globe on Friday gave the United States until year-end to ratify long-delayed reforms to the International Monetary Fund and threatened to move forward without it if it fails to do so.
Shade wrote on April 11th, 2014, 1:03 am: IMO unlikely before elections.
Anyone, having researched, worked through a currency reform/s... would, state same... All, 3 factors... directly related, too...and, have... a direct impact on the success or failure of the process..
the conference's own economic study international economic changes and their impact on the financial system in a federal Iraq with the participation of 120 specialists from universities in different Iraqi conference included throwing about 20 academic research dealt with axes economic and financial important at the level of Iraq and the Kurdistan region.


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Although wills are frequently used as a directive for monetary and health affairs, there could be variations to each paper, or use of numerous other documents, that are utilized depending upon situational factors. Employing elder law attorneys to prepare these papers is an invaluable service, which guarantees clients that their desires and instructions shall be followed on the occasion that they are not able to make choices on their own. When it comes to elder law, lawyers have the understanding and experience to prepare the suitable files and papers to keep you, your loved ones and your possessions protected.
Senior citizen financial abuse cases are where financial predators utilize unnecessary control and coercion to take personal residence and financial assets from senior citizens who have lessened mental capacity. The criminals can be anybody, but are usually members of the family, caretakers or pals who have the most access to the elder and are least likely to be challenged by outsiders.
An elder law lawyer might likewise be required in any of the following cases, disputes concerning Medicaid, assisting with financial management and health-care decisions, administration and management of trusts and estates and long-term care planning for assisted living home. They may act as estate organizers, tax consultants, accounting professionals, client's advocate and even social workers. Whatever the scenario, you would want to get your loved one an elder law lawyer to take care of his/her interests in advanced age.
The probate procedure allows a decedent's estate to be dispersed to loved ones after death. With the proper use of trusts and wills, the probate process might not be essential. Nevertheless, if no prior estate planning was achieved, then it may be required to use the probate court in order to finish the release of properties.
Retirement home abuse or mistreatment of an assisted living home patient typically arises from insufficient staffing where there are too many residents and not enough nursing assistants. In some cases, this is a conscious policy on the part of the nursing home who puts corporate revenue ahead of client care. Thankfully, there are numerous legal remedies readily available to stop these wrongful acts and to compensate the senior victim for injuries suffered.
When an elderly person is no longer able to make sound monetary and healthcare choices and no other options are readily available, then a demand can be presented to the court to establish a conservatorship and designate somebody to have the legal authority to make such choices. This is an involved process but offers a solution to assist an elderly person who can no longer secure their affairs.
There are numerous firms that concentrate on elder law issues. The best senior lawyers belong to at least one of these organizations in order to take advantage of the many benefits of membership, including advocacy and research meetings. On the regional level, ask if the law firm is an active member of the area Agency on Aging or any equivalent groups.
If an attorney frequently does lectures or has speaking engagements on numerous issues dealing with those 65 or older or is a legal representative hired to inform others through the Bar Association, you can be sure she or he has an in-depth understanding of any concerns facing the senior population. Search for Beloit Ohio elder law lawyers who regularly teach others about elder issues, estate planning, senior abuse, proficiency issues, and health-care problems.


Compact dimensions, angry styling and technologies straight out of the World Rally Championship is a recipe that still sounds amazing.
We're both skeptical and hopeful about reports that Subaru's planning a new supermini hot hatch to enter in the World Rally Championship.
The 2003 World Rally Champion returns for just one race in Rally Spain next month.
British rally car driver Kris Meeke was fired from Citroen .
The Safari was dropped from the WRC in 2002, but Jean Todt wants to bring it back.
The Lego Speed Champions Ford Fiesta WRC could be the perfect gift.


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Seattle Arena
Seattle Arena Group reiterates new offer to city; street vacation dependent on NBA or NHL team
Letter to Seattle mayor and city council offers simple, clear terms for new arena agreement
By Matt Tucker@TuckeratSR Dec 8, 2016, 2:18pm PST
Share All sharing options for: Seattle Arena Group reiterates new offer to city; street vacation dependent on NBA or NHL team
The proposed street vacation for the Seattle Arena project would be contingent on the acquisition of either an NBA or NHL team the project group clarified in a letter to Seattle mayor Ed Murray, the city council, and King County executive Dow Constantine on Thursday.
The letter is sent to formalize the new offer from the group for consideration by the city. It also states they will be submitting their new street vacation application soon.
To allay concerns of some council members expressed during last May's vote that denied the conditional street vacation for the project, the group — comprised of hedge fund manager Chris Hansen, former Sonics executive Wally Walker, local retail scions Pete and Erik Nordstrom, and newly minted member (and Seattle Seahawks starting quarterback) Russell Wilson — made clear that if the street vacation were granted on a conditional basis, they would agree that it could not be finalized unless a team were acquired to begin construction of the arena in the SoDo district.
More important, this would open the possibility of either an NBA or an NHL franchise being the catalyst to start the project. Under the Memorandum of Understanding signed by the city, county, and private group in October 2012 to explore the arena project, an "NHL-first" option was not available.
With this condition in place, the group stresses that a conditional street vacation for the SoDo project would not interrupt the Request For Proposal process the city expects to open in January 2017 to explore potential renovation of KeyArena as an arena solution. They argue that, alongside the RFP, the vacation "puts the city in the best possible position to take advantage of franchise opportunities that could become available."
One of the two groups that has publicly expressed interest in a potential renovation, Tim Leiweke's Oak View Group, just hired former Seahawks and UW executive Lance Lopes to handle their bid, the Seattle Times reports. The Times also reveals they've hired ICON Venue Group to head the redesign proposal.
Following up on a letter the Seattle Arena group sent to city leaders on October 25, 2016, their new proposal would tear up the existing MOU. Investment in the project would become fully private and the proposed public contribution and tax framework to pay it off would cease to exist.
The design plans submitted and approved by the city's design board, as well as the package of public benefits offered for the street vacation vetted and recommended by both the design commission and the Department of Transportation, will remain the same. That includes regrading of both Massachusetts and Holgate streets, the limited access alleyway that can be used by the Seattle Mariners for their games, and the pedestrian bridge on Holgate to safely cross the railway tracks, amongst other things.
The group agrees that any money they pay for the two-block section of Occidental Ave South vacated by the city should be directed specifically to the Lander Street Overpass project to aid in freight mobility improvement. They will add some additional improvements as part of their public benefits package for the new street vacation application.
The group also agrees to maintain the event scheduling agreements worked out with the Seahawks, Sounders, and Mariners ahead of the previous street vacation vote. They also reiterate their commitment to fair labor agreements and working with minority- and women-owned and operated businesses.
In exchange, they formally ask for a waiver of the city's admission taxes on the new arena to match similar exemptions for both CenturyLink Field and Safeco Field. They also seek an adjustment to the city's Business and Occupational Tax for national broadcast media.
In a commentary on the arena group's website, Russell Wilson adds his thoughts about approving the street vacation:
Approving the conditional street vacation makes the Arena shovel-ready, and sends a loud message to the NBA and NHL that Seattle is ready and eager for teams. That we want our Sonics back to accompany the Storm, and a hockey team to pick up where the Seattle Metropolitans left off nearly a century ago. All we need is for the Seattle City Council to make this one last nod of approval.
Read the letter in full below:
Seattle Arena Group

redpajama_set_name: RedPajamaCommonCrawl


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Technical Manager Geotechnical A Technical Manager is required to oversee the Geotechnical...
Star Leadership Academy, Salford would be a 750-place secondary school. Credit: Ares Landscape Architects
Julia Hatmaker
Plans for the 62,000 sq ft Star Leadership Academy, Salford will be voted on at the 20 January city council planning meeting. The application has been recommended for approval by planning officers.
If signed off, Wates Construction will build the two-storey secondary school on six acres to the west of Longshaw Drive. The brownfield site was formerly the home of Hulton High, which was demolished in 2009. The site has been vacant since.
Capable of teaching 750 students, the school is part of the government's Free Schools Programme.
Free schools are funded by the government but are not controlled by the local authority. Star Academies, which runs 19 secondary schools across the country, will operate the new building.
Around 100 staff would work at the Star Leadership Academy, Salford. Credit: Ares Landscape Architects
Wates Construction North West regional director Dave Saville described how the brownfield site fit into the Wates ethos.
"Regenerating communities is hugely important to Wates and we feel this secondary school provides the perfect opportunity for Little Hulton by providing much-needed places for local children, on a site that has been undeveloped for years, and with sustainable family homes also planned for this site," Saville said.
"It gives us great pride to be supporting Star Academies, the Department for Education and Salford City Council in reviving this site and improving the lives of local people."
The 62,000 sq ft school would sit off Longshaw Drive. Credit: Ares Landscape Architects
As part of the plans, the school would have a hard-court multi-use games area, all-weather pitch, and sports facilities. There would also be an 88-space car park with five accessible spaces and six electric vehicle charging ones. Additionally, there would be parking bays for two school minibuses and three motorcycles. The school would have covered cycle storage for 48 bicycles.
Sheppard Robson designed the school. The project team includes Avison Young as the planning consultant and Ares Landscape Architects.
Star Leadership Academy, Salford is one of six schools Wates has been contracted to build for the Department for Education.
Want to learn more about Star Leadership Academy? The application's reference number with Salford City Council is 21/78560/FUL.


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Horror StoriesQuestions to AskMaking an ImpressionInternship GoalsGeneral
r/cscareerquestions - Summer 2018 Intern Horror Stories?
https://www.reddit.com/r/cscareerquestions/comments/9esiit/summer_2018_intern_horror_stories/
17 Intern Horror Stories That Will Make You Want To Quit Your Job
https://www.buzzfeed.com/tahliapritchard/real-life-intern-nightmares
Internship Horror Stories (and How to Avoid Them)
https://www.themuse.com/advice/internship-horror-stories-and-how-to-avoid-them
10 Intern Horror Stories You Won't Believe
https://www.hercampus.com/money-career/10-intern-horror-stories-you-wont-believe
5 Questions to Ask Your Boss on the Last Day of Your Internship
https://studybreaks.com/college/internship-3/
7 Questions to Ask Your Boss Before Your Internship Ends
https://www.hercampus.com/money-career/7-questions-ask-your-boss-your-internship-ends
Making an Impression
10 Ways to Stand Out at Your Internship
https://www.fastweb.com/career-planning/articles/ten-ways-to-stand-out-at-your-internship
Ask the intern: How to make a lasting impression at your internship
https://www.theinterngroup.com/our-blog/make-a-lasting-impression-at-your-internship/
Former eBay executive shares her 15 tips to impress your boss at an internship
https://www.usatoday.com/story/life/allthemoms/2018/06/20/tips-impress-your-boss-your-internship/718202002/
Internship Goals
A Learned Skill: Top 7 Goal Setting Tips for Interns
https://internsdc.com/internship-tips/7-goal-setting-tips-interns/
Goals That You Should Have During an Internship
https://careertrend.com/goals-should-during-internship-5641.html
5 Goals to Make at Your Internship - The College Juice
https://www.thecollegejuice.com/2017/06/5-goals-make-internship/
Examples of Internship Goals - OpenView Labs
https://labs.openviewpartners.com/examples-of-internship-goals/
How to Develop Goals for Your Internship
https://www.thebalancecareers.com/developing-internship-goals-1986643
10 Tips to Make the Most of an Internship | Columbia CCE
https://www.careereducation.columbia.edu/resources/10-tips-make-most-internship
10 Ways to Get the Most From Your Internship | Indeed.com
https://www.indeed.com/career-advice/starting-new-job/how-to-get-the-most-from-your-internship
6 Ways to Make the Most of Your Internship
https://hbr.org/2016/07/6-ways-to-make-the-most-of-your-internship
How to Make Your Internship More Than an Entry on Your Resume
https://www.thebalancecareers.com/how-to-get-the-most-out-of-your-internship-4157867


Welcome to the main entrance of the Virtual Structural Engineer. In the Structural Engineering area the "visual" factor is very important. Photos, diagrams and maps play an important role in the understanding of a matter. In this page, some cases which are related with the civil engineering works are presented via photos. Resources are divided into sections shown to the left. Choose the topic of your interest.
Currently the Virtual Structural Engineer Section includes 88 resources in 6 categories.


Many are willing to pay the price and go under the knife to fix their insecurities, including Paula Blades. She chose breast augmentation. Then, after years of severe mystery illnesses, it turns out the very thing she needed to feel good about herself was killing her.
Down a quiet Gilbertsville road, you'll find Paula Blade's home.
"We live on a little farm. I love animals," Paula said.
The lawn is manicured. Inside, her home is tastefully decorated, every detail thought out. Growing up, Paula had less control over her appearance.
"I actually had this little Skipper Barbie doll growing up, and you could twist her arm and her chest would expand," Paula said. "So my cousins, they would try to, they would, like, try to twist my arm trying to get them to grow."
Paula laughs about it now, but the teasing harbored insecurities about her chest size. She was determined to have a breast augmentation. She even asked her parents for one when she graduated high school. They said no, but in 1992, at 20 years old, Paula was capable of making the decision on her own. She did her research and chose saline breast implants.
"Was told they were totally safe, would last me a lifetime," Paula said. "If they did rupture, it's no big deal."
The implants had a valve, like many on the market. They are placed into the breast deflated, then a syringe is used to fill the implant with saline through the valve.
Even in the beginning, there was trouble. Two years after her surgery, she went back under the knife to fix the look of the implants. They looked wavy under her skin.
"I started getting like chronic sinusitis and different infections —bronchitis, things of that nature that wouldn't go away," Paula explained. "I got these sores all over my upper torso that wouldn't heal."
"Severe chronic sinusitis and running a temperature every day. My white blood cell count was increased," she recalled.
"Just one thing after another," Paula said. "It seemed like it never ever was going to end."
"I was to the point where I was planning my funeral. I knew I was gonna' die," Paula said.
"She was like me. She had the same symptoms, everything, and I was just like 'Oh my gosh, that's me,'" Paula said.
"The next week I was in Atlanta, met with her on a Wednesday," Paula said. "She's like 'Honey, I know what's wrong with you.'"
"Most doctors have never heard of this disease, so they don't know anything about it," said Kolb. "I think most doctors right now that are internal medicine, neurology, family practice and plastic surgery have patients in their practice that are diagnosed with you know, MS, lupus, other auto-immune diseases and fibromyalgia, that are curable. Curable, if they had explant, anti-fungals, treatment of co-infections.
"She probably wouldn't have lived very much longer had she not had some intervention in her health," Dr. Kolb explained.
"Specifically, you have to have the entire scar capsule removed. Not just the implant," Kolb said.
The implants were then sent to Dr. Pierre Blais with Innoval Failure Analysis in Ottawa, Canada, for further testing. That testing found "the valve capping mechanism…faulty", the "filling fluid grossly contaminated" and indication of "aspergilli-related entities," —mold.
"It can do all sorts of things in the body," said Kolb.
Kolb also discovered silicone from the shell of her saline implant had leaked, collecting in certain areas of her body.
Anne Ziegenhorn and Paula talked with a British radio station about their stories the day we interviewed them. Anne's from Florida, but she knows exactly what Paula's been through.
"After going through what I've gone through —hundreds and thousands of dollars in medical bills, I've lost my career. It was taxing on our marriage," Anne said, explaining the toll her illness has taken on her life.
To read Anne's blog concerning her health issues related to her breast implants, click here.
The two each thought they were alone, then found each other. Kolb performed explants on both women.
"She saved our lives," Anne said of Dr. Kolb.
Now, they plan to spread the word.
"If I had known some of these symptoms to look for then, I would have thought 'Hey, it's my breast implants, and I need to get them out,'" Paula said.
Life is better for Paula. Her health has improved, although she does have long-term neurological damage. She says she can accept that, because she's alive.
"Does it all look a little different to you now?" I asked her of her life.
"Oh yeah. Yeah," Paula answered. "Life's totally, my outlook on life's totally changed."
"I'm just happy to be here."
Paula and Anne have consulted with an attorney to see if there are legal options available to them. They've also started a group called The Implant Truth Survivors Committee, with the goal of connecting women who have this condition and providing funds to women who do not have the finances to pay for an explant procedure. To learn more, click here.
Kolb, meanwhile, says women need to be informed about all the possible side effects and complications of any cosmetic procedure, short and long term.
"In general, most patients don't become ill before eight to 15 years," Kolb said.
She also urges women to consider where they live. If you live in a climate that is humid and moldy, you may be more susceptible to this condition. In that case, saline implants may not be the best option for you.
As far as finances, Kolb says women need to make sure they are financially prepared to not only pay for the surgery, but upkeep on the implants. She told me silicone implants, for example, need to be changed out every eight years. Others can last longer. Beyond the upkeep, make sure you can pay for an explant or emergency surgery to fix them if something goes wrong.
To learn more about Kolb, click here. To see more about her book, "The Naked Truth About Breast Implants," click here.


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The EDF Group launches the construction of Neart na Gaoithe 450 MW offshore wind farm along with new Irish partner, ESB
GlobeNewswire November 28, 2019
The EDF Group is announcing the construction of the Scottish Neart na Gaoithe (NnG) offshore wind farm project and the new partnership with the Irish electricity company ESB which is taking a 50% stake in the project. The 450 MW NnG project confirms a wider commitment to renewables in the United Kingdom where EDF already has a strong footprint.
Neart na Gaoithe1 will consist of 54 turbines and will be located in the North Sea approximately, 15km off the coast of Fife in south-east Scotland. When fully operational, the NnG offshore wind farm will generate the equivalent electricity to power over 375,000 households each year, which corresponds to 4% of Scotland's electricity consumption. This fully consented offshore wind project has a 15 year Contract for Difference (CfD) at £114.39/MWh in 2012 pound sterling, and grid connection agreements in place.
With all of the financial agreements now in place, EDF Renewables is launching full construction of the project and can announce some of the tier one contractors. These include:
- Siemens Gamesa Renewable Energy (SGRE) is the wind turbine generators supplier. It will provide the 8 MW turbine model ;
- Saipem is the turbine foundations supplier and installer ;
- GE Renewable Energy Grid Solutions will carry out the supply the two electrical substations, plus electrical design work ;
- Prysmian SRL will supply and install the export cables, both offshore and onshore ;
-Deme Offshore has won the contract for engineering, procuring, constructing and installing the inter-turbines cables with offshore installation;
- Fred Olsen Windcarrier will be delivering the transportation and installation of the turbines with offshore installation.
Construction of components is now underway, offshore construction will start in June 2020 and full commissioning will be complete in 2023.
NnG will contribute to the local Scottish economy providing new jobs and manufacturing opportunities. Some foundations jackets will be built by the Scottish engineering firm BiFab. The wind turbine generators will be assembled at the Port of Dundee. Eyemouth Harbour has been selected as preferred supplier to operate and service the wind farm over its 25-years lifetime. More precisely, this activity will create around 50 permanent jobs, located nearby the wind farm.
EDF Renewables is also announcing its partnership with the leading Irish energy company ESB that is taking a 50% stake in the project. This operation will result in the consolidation of the project by equity method. ESB operates across the electricity market on the island of Ireland, from generation, through transmission and distribution to the supply of customers with an expanding presence across Great Britain. In 2017, ESB opened an office in Scotland and is spearheading further development of renewable energy projects, in particular onshore and offshore wind.
The EDF Group, via its subsidiary EDF Renewables, is a significant global player in the offshore wind market with a 5 GW portfolio of projects under operations and development, including 103 MW of offshore wind farms already operational in the United Kingdom (Teesside with 62MW and Blyth with 41,5MW both in north-east England).
In total, the Group currently operates more than 13 GW of gross wind and solar capacity around the world, including nearly 1 GW in the United Kingdom, and in addition of the 23 GW of hydroelectricity. The NnG project is consistent with the CAP 2030 strategy which aims to double EDF's renewable energy globally between 2015 and 2030 increasing to 50 GW.
Bruno Bensasson, EDF Group's Senior Executive Vice President, Renewable Energies and Chairman and CEO of EDF Renewables said: "These are two major milestones achieved by EDF Renewables demonstrating our strong capabilities in developing large offshore projects. We are pleased to get work underway with our new partner ESB and all Scottish companies and stakeholders involved. The 450 MW NnG project will play an important role in de-carbonising the UK electricity system."
Simone Rossi, CEO of EDF Energy added: "The UK has committed to achieving Net Zero emissions by 2050 and the UN's latest emissions gap report underlines the need for urgent action. NNG is our largest offshore windfarm in the UK to date. We are determined to play our part in reducing the country's carbon emissions, while also generating jobs and economic opportunities for communities."
Pat O'Doherty, Chief Executive of ESB said: "Our 50 percent stake in Neart na Gaoithe fits entirely with ESB's Brighter Future strategy to build a balanced low carbon generation portfolio of scale. Offshore wind is one of the main technologies underpinning the clean electricity systems that will power our societies into the future. This investment in the Neart na Gaoithe project builds on significant ESB involvement in offshore wind off the Irish coast as ESB develops its experience to assist Ireland deliver its Climate Action Plan. We look forward to pooling our expertise with EDF Renewables in delivering this major project."
This press release is certified. Its authenticity can be checked on medias.edf.com
About EDF
A key player in energy transition, the EDF Group is an integrated electricity company, active in all areas of the business: generation, transmission, distribution, energy supply and trading, energy services. A global leader in low-carbon energies, the Group has developed a diversified generation mix based on nuclear power, hydropower, new renewable energies and thermal energy. The Group is involved in supplying energy and services to approximately 39.8 million customers(1), 29.7million of which are in France. It generated consolidated sales of €69 billion in 2018. EDF is listed on the Paris Stock Exchange.
(1)The customers were counted at the end of 2018 per delivery site; a customer can have two delivery points: one for electricity and another for gas
About Neart na Gaoithe (NnG)
NnG is a key UK offshore wind farm project and, with up to £1.8billion invested in its infrastructure, will have a major positive impact on the Scottish economy.
NnG is located off the east coast of Scotland, 15.5 km off the Fife coast and covers an area of approximately 105 km2. This project also benefits from a wind regime among the best in the world.
EDF Renewables acquired NnG in 2018. The project is fully consented and was awarded a Contract for Difference (CfD) by the Low Carbon Contracts Company in February 2015. The CfD, which was awarded under a highly competitive tendering process, gives the wind farm an inflation-linked strike price for the electricity it produces for a period of fifteen years.
About EDF Renewables
EDF Renewables is a leading international player in renewable energies, with gross installed capacity of 12.5 GW worldwide. Its development is mainly focused on wind and solar photovoltaic power. EDF Renewables operates mostly in Europe and North America but is continuing to grow by moving into promising emerging regions such as Brazil, China, India, South Africa and the Middle East. The company has strong positions in offshore wind power, but also in other areas of the renewable energies industry such distributed energy and energy storage. EDF Renewables develops, builds, operates and maintains renewable energies projects, both for itself and for third parties. Most of its international subsidiaries bear the EDF Renewables brand. EDF Renewables is the EDF Group subsidiary specialising in developing solar and wind power.
For more information, visit: www.edf-renewables.com
Follow us on LinkedIn and on Twitter @EDF_RE in French and @EDF_Renewables in English.
About EDF Renewables in the UK
EDF Renewables in the UK is bringing down costs for consumers and bringing significant benefits for communities.
With our operating portfolio of 36 wind farms and battery storage unit (almost 1GW) we are providing some of the much needed new affordable, low carbon electricity to the UK.
Work is well underway on the 450 MW Neart Na Gaoithe offshore wind farm project which is in the Firth of Forth and we've extended our Edinburgh office to accommodate around 60 new team members. We have more than 1 GW of renewables projects in planning and development and half of those are consented. We also have offices in Rainton Bridge near Durham and in London.
EDF Renewables is a joint venture between EDF Renouvelables and EDF Energy.
Find our more at www.edf-re.uk
ESB operates across the electricity market on the island of Ireland: from generation, through transmission and distribution to the supply of customers with an expanding presence across Great Britain. In 2017 ESB opened an office in Glasgow to spearhead further development of renewables, in particular onshore and offshore wind, across Scotland. ESB is the owner of the distribution and transmission networks in the Republic of Ireland (via ESB Networks) and Northern Ireland (via Northern Ireland Electricity Networks Ltd). In 2017, the company had a 42% share of generation in the all-island market (via Generation and Wholesale Markets) and a 34% share of electricity supply in the all-island market (via Electric Ireland) with 1.4 million customer accounts.
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EDF SA
French societe anonyme
With a share capital of 1 525 484 813 euros
Registered lead office : 22-30, avenue de Wagram
www.edf.fr
Manon de Cassini-Hérail +33 (0) 1 40 90 48 22
Daniel Da Costa +33 (0) 1 40 90 22 26
Analysts and Investors: +33 (0) 1 40 42 40 38
1 Gaelic for 'strength of the wind'
PR_Neart na Gaoithe offshore wind farm_28.11.2019
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Dimensions: 38.5" x 12.5" x 12"
Refresh P240 HPDC Water Fountain by Zerica, designed in Italy! A stainless steel cased water dispenser that delivers continuous, refreshing cold water quickly where demand is high. Its exclusive and unique High Performance Direct Chill (HPDC) technology allows it to chill water in just 3 minutes from power-on. The 1/6 Hp PLUS compressor combined with its high power refrigeration system, at 450 Kcal/h, pushes output to reach the high capacity water supply of 60L/h and an energy consumption saving of 70%. Lower energy consumption, therefore a greater benefit to the planet without sacrificing performance.
This 3.2 foot(98 cm) water fountain is protected by a robust stainless or zinc-plated steel external casing that makes it tough, hard wearing and weather resistant. Fitted with the SAHARA CLIMA system and combined with its state-of-the-art manufacturing, these appliances are able to operate even in extremely severe external temperatures of up to 43°C(109°F). Simple and efficient, it is used in all models for customers requiring high performance and good overall efficiency at a lower cost compared to more advanced cooling systems.
The P240 Water Fountain's innovative system is a product of Zerica's intensive research that also covered materials selection with the aim of improving durability and hygiene levels. As a result, ZERICA started using a special type of copper which comes with a 30 year anti-corrosion guarantee(via drinking water). Clinical studies show that this copper is an excellent inhibitor of bacterial growth and in particular the deadly Legionella. Ecological, efficient, durable and also at the forefront in terms of hygiene, exclusive Refresh P240 HPDC is good for everyone.
Cools Water in 3 minutes.
New cooling system with silver particles with sanitizing and antibacterial properties.
Robust stainless or zinc-plated steel external casing for hard wearing and weather-resistance.
Easy Frontal Access for installation and maintenance.
Certified(DM 174/2004 - EC 1935/2004) food safe materials used for all components in contact with liquid.
Silver Turbo Clean - Evaporator "Zero Bacteria Risk" technology.
Frontal Water Filter Room Access.
* Data are subjected to change according to use and ambient conditions.
- 24 months Warranty on Cooling System.


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Phu Quoc Day Tours is an online booking platform managed and operated by Vietnam Package Travel. Phu Quoc Day Tours specializes in providing day trips and travel services in Phu Quoc island. Here is the source you can find anything you need regarding Phu Quoc Day Tours. We offer all kind of tours at any type of level service to match your demand, and yet, fulfill your desire about an amazing and memorable trip to Phu Quoc island. Each product we offer you is carefully selected or designed in order to give you good service. To be a local tour operator, we always keep the true value with real information and recommendation for your desire.


It's Your Choice for Online Entertainment - or Is It?
It's Your Choice for Online Entertainment – or Is It?
When it comes to entertainment, there are an insane variety of options you can choose from. And most of them will cost you money, either in the form of fees you pay to consume them or as advertising you'll have to endure in the process. But not all forms of entertainment are created equal. Some of them, like real money online gaming, are not as well-seen by society than others. Millions of people around the world are restricted from accessing their games of choice, not allowed to play the slot machines vailable at All Jackpots, even if their land-based gaming industry thrives. Which is not fair, if you ask me.
Europe, as well as many other countries around the world, have chosen to regulate the online gambling industry. Residents of most European countries can play without restrictions at the All Jackpots Online Casino – provided they are of legal age (18 or older in most countries). Operators, in turn, are required to obtain a license to offer their services to the public. The above-mentioned All Jackpots Casino runs under a license issued by the MGA (Malta Gaming Authority), a very strict one that regulates player access, game fairness, security, privacy, and anti-money laundering measures, too. This offers All Jackpots players access to their favorite games on any device they might own, and peace of mind, too.
Some countries allow online gambling, but only for certain companies. In Canada, for example, state lotteries are the only companies that are allowed to offer real money online gambling services to their players. Unfortunately, not all Canadians can legally play at these gaming destinations – they are available to the residents of their own provinces only. And, since not all provinces' lotteries have decided to open their own online casinos, Canadians are still almost forced to rely on offshore operators to be able to play their favorite games.
In Australia, only sports betting is allowed over the internet – and the services can only be offered by companies based in the country. Thus, major international operations had no choice but to acquire Australian companies to be able to enter the market. When it comes to casino games, the laws are clear: it's forbidden to offer and promote online gambling services to Australians. But, as they like to play the pokies, Aussie players need to rely on offshore operators to get their fix.
In the US, there is no law that expressly forbids online casino games – but money transactions to and from real money gaming venues outside the country are restricted. There are just a handful of states that regulate online gambling – Delaware, Nevada, and New Jersey. Although there are several other states discussing the legalization of the industry, little to no progress was made in the area in the last five years.
Science has already had its say on online gambling years ago, stating that it's not as evil as its opponents would like it to sound. Still, the industry is in a regulatory limbo, balancing on the thin line that's known as the "gray zone". A comprehensive, global regulation of online gambling could allow people to choose their preferred form of online entertainment, at the operator of their choice, but it might harm some interests, which is possibly the explanation for the long debate over its viability.


text:
Centreville MP's sister detained after outburst in HOA
LocalMay 30, 2019May 30, 2019 at 3:43 am Royston Jones Jr.
Protester banned for remainder of HOA session
NASSAU, BAHAMAS – Parliamentary proceedings were abruptly suspended ahead of the highly-anticipated budget communication yesterday morning, when Centreville MP Reece Chipman's sister, Fontella, who was sitting in the gallery of the House of Assembly, made a loud outburst, screaming at parliamentarians, and hurling several elastic bands on the floor in protest.
One of the bands read: '#ChipmanStrong'.
The sudden outburst stunned onlookers and parliamentarians.
Authorities swiftly intervened and escorted the woman outside, but not before she issued condemning statements against the legislators, particularly two Cabinet ministers – Minister of Trade and Industry Brent Symonette and Minister of Tourism Dionisio D'Aguilar.
"This system that you think you have in place will be removed," she exclaimed.
"Yes, Mr. Symonette, you know it. Chipman's children deserves ski trips.
"Bahamian children deserve ski trips.
"And Mr. D'Aguilar, yes you're on Chipman land. Yes, you guys. Change the system."
She was detained at the Central Police Station and later released.
The Chipman family was celebrating the 100th year anniversary of the election to Parliament of their ancestor, H.N Chipman. Fontella wore a white shirt, which also read: '#ChipmanStrong'
Outside of Parliament, Reece Chipman told reporters he was surprised by the incident, but shares the views of his sister, and will make no apologies for her actions.
"I make no apologies for what she says because I believe in the same things she believes in, which is justice and righteousness within Parliament and without, and I think at this time, we have a lot of Bahamians [who] are frustrated with the way the system has not given them… a chance," Chipman said.
"You see, campaigning is one thing. When you come into the House of Assembly you see them playing politics with people within the [House of] Assembly. It's even worse.
"For me, I can appreciate her position. I make no apologies for what she said because I do agree, and appreciate exactly what she is saying, and sometimes it is very difficult when you are fighting a fight for the Bahamian people or for the people. It is very hard to take those sorts of stands, but thank God we have someone that will do it.
Chipman said the issue was not solely about the Chipmans, but about families in The Bahamas whose birthright have been "stolen" and "their stories re-written".
When the House returned, Speaker of the House Halson Moultrie said the woman's actions were "criminally motivated".
He ordered that she was "never to enter the precincts of this Parliament for the remainder of this session.
"My understanding is that she is now in police custody and so we will let the law enforcement officers and the courts take control on this matter from this point forward," he said.
Before the adjournment of the sitting, Moultrie readdressed the incident.
Quoting Rule 89 of House proceedings, Moultrie said when incidents on "unparliamentary behavior or disturbance by strangers" occur on the floor of the House, the camera is to remain on the chair to ensure to the offending incident is not broadcasted.
"The rules of the House suggest to the press that such broadcast of such incidents is prohibited and that same rule is repeated again in Rule 90, subsection 4," he said.
"I made mention of that because I that the incident this morning as a very, very serious breach of the security of the Commonwealth of The Bahamas, and such a breach should not be tolerated, whether it be by strangers or by members.
"Any act, in the chairs estimation, where a stranger would enter the precincts of the Parliament and toss objects onto the floor of the Parliament must be considered a very, very serious breach of the precincts of the Parliament and should be dealt with accordingly.
"At this time, the chair would reserve a decision, other than the decision already made, which was that the offending party is prohibited from entering the precincts of this Parliament for the remainder of this session."
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June is Brisbane's "winter", an ideal time to travel in Australia, with average day-time high temperatures around 20 degrees Celsius or 70 Fahrenheit. Take a few extra days and bring the family along to see the outback, the Great Barrier Reef, or lounge on one of the fabulous beaches along the Gold or Sunshine Coasts nearby!
All international visitors to Australia (the sole exception being citizens of Australia and New Zealand traveling on Australian and New Zealand passports) must obtain a visa in advance. You are urged to apply for a visa not later than six weeks prior to travel. Residents of many countries are eligible to apply for eVistor visa or Electronic Travel Authority visa online. Please check the Australian Government's Visa Finder tool for advice regarding your specific scenario.
Brisbane's international and domestic airport terminals are approximately 20 km north east of the Central Business District (CBD), a 15 to 20 minute drive. Visitors can reach the central business district by taxi, shuttle bus or train.
For more information about getting to and from the airport, please visit the Brisbane Airport website.
The taxi fare from the city centre is approximately AU$ 50 – 60 which includes a AU$ 3 fee for taxis departing from the airport. To calculate your fare please visit Black and White Cabs or Yellow Cabs.
Uber is a smartphone app that connects riders to drivers with the touch of a button. Download the Uber app, enter the promo code and hit request. Your driver will arrive within minutes to take you to your hotel or to the conference venue.
Ozscott Limousines is a Brisbane based company that runs a large fleet of corporate cars with pick ups and drop offs all over South East Queensland. Ozscott offers a flat charge of AU$ 55 for trips between the airport and Brisbane City. For further information and a full list of prices, please visit ozscott.com.au.
Buses connect the CBD and airport terminals. A single transfer starts from AU$ 16 with Coachtrans, which departs the airport terminals and Roma Street Transit Centre in the CBD every 30 minutes. All major city hotels are serviced on request.
Airtrain services run frequently from Brisbane Airport to the centre of Brisbane, and the express, air-conditioned journey takes only 20 minutes. The airport stations are located directly outside the domestic and international terminals and connect with 5 city stations covering 80% of downtown Brisbane.
For more information, please visit www.airtrain.com.au.
For information on Brisbane's public transport network, please visit TRANSLink or the Public Transport in Brisbane information page at www.visitbrisbane.com.au.


Deutsche Asset Management (Deutsche AM) today announced the acquisition of two logistics facilities located at 45 Fulton Drive, Derrimut in Melbourne; and 50-80 Southlink Street, Parkinson in Brisbane, for AUD 73.1 million from Propertylink, a listed Australian real estate investment trust (AREIT), in an off market transaction on behalf of a German institutional client.
The cold logistics facilities were purpose built and designed in 2010 for anchor tenant, Rand Transport, a leading service provider of refrigerated interstate transport and warehousing services in Australia. Comprising two single storey warehouses including administration offices and parking, the Derrimut site occupies over 34,000 square meters; and the Parkinson site over 30,000 square meters.
Both are well located within their respective markets, situated in key logistics locations favoured by leading logistic operators and distributors. They are well connected to local port, airport and railway stations in both Melbourne and Brisbane via major expressways and road networks. Nationally, Melbourne remains the manufacturing centre and distribution hub as home to Australia's largest port; whilst Brisbane has a growing industrial precinct.
The acquisitions follow on from the recent purchase of GLP Narita, a grade A modern logistics warehouse in Greater Tokyo, as Deutsche AM continues to increase its sector exposure to logistics in Asia Pacific.
Deutsche Asset Management's real estate investment business has been investing in real estate assets for more than 40 years. As part of the Alternatives platform, this business has more than 410 employees around the world and US$54.4 / €48.4 billion in assets under management as of September 30, 2016, and offers a diverse range of strategies and solutions across the risk/return and geographic spectrums, including core and value-added real estate, real estate securities, real estate debt and opportunistic real estate. To learn more about our real estate investment capabilities, go to www.deutscherealestate.com.
An investment in infrastructure involves a high degree of risk, including possible loss of principal amount invested, and is suitable only for sophisticated investors who can bear such losses. No assurance can be given that investment objectives will be achieved.
Past performance is not a guarantee of future results. Forecasts are based on assumptions, estimates, opinions and hypothetical models or analysis which may prove to be incorrect. Confidential. For Professional Client MiFID Directive 2004/39/EC Annex II) only. For institutional investors only.
With EUR 715 billion of assets under management (as of September 30, 2016), Deutsche Asset Management offers individuals and institutions traditional and alternative investments across all major asset classes.
¹ Deutsche Asset Management is the brand name of the Asset Management division of the Deutsche Bank Group. The respective legal entities offering products or services under the Deutsche Asset Management brand are specified in the respective contracts, sales materials and other product information documents.
In Australia issued by Deutsche Australia Limited (ABN 37 006 385 593) holder of an Australian Financial Services License. Deutsche Australia Limited is not an Authorised Deposit-taking Institution under the Banking Act 1959 nor regulated by APRA.
Deutsche Asset Management represents the asset management activities conducted by Deutsche Bank AG or any of its subsidiaries.


I have a RedHat Linux 6.1 Laptop. I successfully installed Oracle 11g in my laptop and configured the DB. Post Installation everything was working fine and I could open the EM console. After stopping the DB, I am not able to bring up the em console.


Senator Al Franken (D-Minn) introduced the End Congressional Stock Market Abuse Act of 2017 in response to recent Trump Administration confirmation hearings that surfaced allegations that a member of Congress may have obtained discounts or premiums in stock transactions. The Senator said in a press release that his bill (S. 350) would restrict the ability of members of Congress to obtain special pricing of securities in private offerings.
Closing an Exchange Act gap. The Franken bill would update Exchange Act Section 21A to prohibit members of Congress from buying or selling shares of covered securities that have price discounts or premiums. But a member of Congress could invoke an exception to the prohibition if he reasonably believes the discount or premium "was obtained in a manner generally available to the public."
For purposes of the bill, "covered security" includes securities registered on U.S. or overseas exchanges, plus synthetic interests that involve derivatives or short sales. "Price" refers to the national best offer or bid as defined in Rule 600 of the SEC's Regulation NMS.
Discounted shares. According to Sen. Franken, who is a member of the Senate Health Committee that vetted former Rep. Thomas Price, M.D. (R-Ga) before Price was confirmed as Secretary of Health and Human Services, Price may have received favorable pricing on at least one stock deal. Price, an orthopedic surgeon, was sworn-in nearly two weeks ago, and will play a key role in the Trump Administration's plan to repeal and replace the Affordable Care Act.
During his confirmation hearing, Senators raised questions about Price's $200,000 profit (a 400 percent return) on an investment Price was able to make in the Australian company Innate Immunotherapeutics. The senators said Price allegedly had participated in the transaction along with a small group of investors who received discounted offerings of shares.
In January, a group of Democratic and Independent Senators wrote to the SEC requesting an investigation of Price's stock deal, citing the Stop Trading on Congressional Knowledge (STOCK) Act of 2012; Rep. Louise Slaughter (D-NY) made a similar request. Senator Franken also had tried to delay Price's confirmation pending further investigation into Price's trades.


Even though 2018 has felt like 10 years packed into one, it's almost over. As everyone bids goodbye to the year that gave the world moth memes, endless amounts of political mishaps, three government shutdowns, and Lady Gaga's Enigma Las Vegas residency, it's time to think about what 2019 might look like. These memes about the "energy you're taking into 2019" are hilarious alternatives to New Year's resolutions — and they're sure to get you ready for the new year to come.
The "energy you're taking into 2019" meme — likely one of the last great memes of 2018, er, the first great meme of 2019 — encompasses tweets that declare a certain kind of "energy" that people plan on taking with them into the new year. You'll recall that 2018 saw the popularization of "big d*ck energy" thanks to Pete Davidson's excitement when he was with Ariana Grande, before they called off their engagement in October.
OK, back to happier thoughts of 2019 energy. The examples on Twitter range from serious commitments people are making to better themselves, like this tweet from rapper @ILoveMakonnen that reads, "In 2019 a new energy is with us so tap into it and be the better than before. Sending u that new energy now" to more lighthearted ones like this tweet from author Jessica Valenti, "I asked my eight year old if she had a crush on anyone and she said, 'no but pretty much everyone has a crush on me' and that's the energy I want to bring into 2019."
Here are some more 2019 energy memes that will get you ready for the new year.
Though 2018 was a wild ride for many people, there were some good moments you that can be used to channel positive energy into 2019. This year gave the world the remake of A Star is Born along with everyone's new, favorite song, "Shallow." Voter turnout at the Midterms was the highest in a century which led to a diverse Congress including 100 women in the House. Australia blessed the world with Knickers, the giant cow. Ariana Grande gave fans and non-fans alike "thank u, next" and forced everyone to re-frame their relationships with their exes. And in an effort to help you follow through on your "thank u, next" efforts, Instagram finally let you mute people without unfollowing.
So whatever energy you've decided to take into the New Year, you won't be alone. The world can feel like a volatile place at times but surprisingly, good content on the internet and memes like the "energy you're taking into 2019" can inspire everyone to look inward and take better care of themselves and others. Pick an energy (or a few) and use them to manifest the desires and intentions in the New Year. Happy 2019!


The federal budget has two practical purposes. One, the budget provides a financial record of federal revenue and expenditures. Two, the budget articulates the nation's priorities by allocating limited discretionary funds to various federal programs, such as funding for the National Science Foundation, U.S. Geological Survey, Environmental Protection Agency, and so forth.
Each spring, the Administration begins to work with federal agencies to prepare the budget requests for the following fiscal year. For example, federal agencies were working to develop their fiscal year (FY) 2019 budget during late 2017 to early 2018. The federal fiscal year runs from 1 October through 30 September.
The President sends a budget request to Congress each year on the first Monday of February. It is important to remember that the President's budget request is only a spending plan. It is not uncommon for Congress to make adjustments to a President's budget, particularly if the Congress and White House are controlled by different political parties with significant policy differences.
The congressional budget process begins with the receipt of the President's budget. Through the House and Senate Budget Committees, Congress determines the overall budget amount. Both chambers of Congress convene hearings to receive testimony from Administration officials, non-governmental policy experts, and other stakeholders. The outcome of these deliberations is a budget resolution (ultimately, a Concurrent Resolution when adopted by both chambers of Congress). Concurrent resolutions are non-binding (lack the force of law) and are not sent to the President.
Following adoption of the budget resolution, the appropriations process originates in the House Appropriations Committee. Subcommittees "mark-up" the 12 separate appropriations bills, each providing funds for specific federal departments and programs. Once approved by the Appropriations Committee, the appropriations legislation is sent to the full House of Representatives for consideration and subsequently the passed version is sent to the Senate. The process then repeats itself in the Senate, with the Senate Appropriations Committee drafting its own version of each of the 12 appropriations bills.
The House and Senate versions are rarely the same. Thus, a "conference" process is established in which leaders from both chambers work to reconcile differences in the legislation. Once a reconciled version of the legislation is approved by the House and Senate, the measure is sent to the President to be signed into law or vetoed.
The AIBS Public Policy Office (PPO) provides members of the biological sciences community with timely information about developments in the federal budget and appropriations process. Additionally, AIBS policy staff work to ensure that federal lawmakers understand how their actions relative to federal spending for scientific research impact biological sciences research and education. To this end, AIBS routinely provides formal and informal testimony to decision-makers in Congress and the Administration.


Country Oaks is a townhome community built in the early 1980s. Country Oaks is located in Aurora, Illinois south of Butterfield Road and west of N. Eola Road. There is one home for sale for $155,000. It is managed by Association Partners, Inc..
Country Oaks home sales for the month of March stayed the same in volume when compared to last year, while the median sale price stayed the same.


HF Virtual Book Tours invites you to Andrea Zuvich's The Stuart Vampire Launch Party on October 14, from Noon-2pm EST! There will be fabulous giveaways and prizes, Q&A, trivia, & more! We hope you'll join us & your fellow bibliophiles for some spookily bookish shenanigans!
Please join Andrea Zuvich as she tours with HF Virtual Book Tours for The Stuart Vampire, from October 13-24.