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Quality of Reporting of Meta-analyses (QUOROM) flow diagram. ANP indicates atrial natriuretic; BNP, B-type natriuretic peptide; CNP, C-type natriuretic peptide; HF, heart failure; RCT, randomized controlled trial.
Graphic Jump Location
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All-cause mortality meta-analysis of individual trials. Fixed-effects model (χ2 = 3.75; P = .59). CI indicates confidence interval.
Funnel plot of individual trials (filled circles) contributing to all-cause mortality meta-analysis. RR indicates relative risk.
Fixed-effects models. A, All-cause hospitalization meta-analysis of individual trials (χ2 = 0.78; P = .68); B, survival free of any hospitalization meta-analysis of individual trials (χ2 = 0.00; P = .98). CI indicates confidence interval. The size of squares reflects weighting for each study. The diamonds indicate the overall results, with the middle being the RR and the outer tips reflecting the 95% CIs around the result.
Patients having medical treatment adjustment. A, Percentage of patients having doses of medication increased; B, percentage change of patients reaching target dose. ACE indicates angiotensin-converting enzyme; BNP, B-type natriuretic peptide.
Patient Characteristics in Included Trials
EF, %a
HT, %
DM, %
Renal Function (Cr or CCr)a
Type of NH Use
Method of Assay: NH
Baseline BNP-NT-BNPc
Troughton et al21
CCr ,1.0 (0.7)d
CCr,0.9 (0.7)d
NT-pro-BNP
NT-pro-BNP, 1844
Beck-da-Silva et al22
Cr <200e
Triage, Biosite Incf
BNP, 502
Esteban et al23
Similar in both groups
STARS-BNP24
Cr, 97 (40)e
Imm, Biosite Incf
TIME-CHF25
Cr, 1.32 (0.45)g
BATTLESCARRED26
CCr, 57h
NT-pro-BNP, NT-pro-BNP, 2012
PRIMA27
Cr,121i
SIGNAL-HF28
Male >800Female >1000e
Treatment Group Targets in Included Trials
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, β-blocker; BNP, B-type natriuretic peptide; BP, blood pressure; FC, functional class; HF, heart failure; HR, heart rate; NA, not available; NT-pro-BNP, pro-BNP split by a protease enzyme into BNP and N-terminal pro-BNP; PE, physical examination. See Table 1 footnote for study name abbreviations.
aHeart failure score based on Framingham data for a diagnosis of HF with major criteria each scoring 1 point and minor criteria each scoring 0.5 point.
Sensitivity Analysis of the Effect of BNP-Guided Medical Therapy on All-Cause Mortality and All-Cause Hospitalization
Abbreviations: BNP, B-type natriuretic peptides; CI, confidence interval; RR, relative risk. See Table 1 footnote for study name abbreviations.
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Troughton RWFrampton CMYandle TGEspiner EANicholls MGRichards AM Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet 2000;355 (9210) 1126- 1130PubMedGoogle ScholarCrossref
Beck-da-Silva Lde Bold AFraser MWilliams KHaddad H BNP-guided therapy not better than expert's clinical assessment for beta-blocker titration in patients with heart failure. Congest Heart Fail 2005;11 (5) 248- 253PubMedGoogle ScholarCrossref
Esteban FAnguita MCastillo J et al. BNP levels-guided therapy for heart failure: a comparative study against usual clinical monitoring: ESC 2006. Eur Heart J Suppl 2006; ((suppl)) 1416Google Scholar
Jourdain PJondeau GFunck F et al. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study. J Am Coll Cardiol 2007;49 (16) 1733- 1739PubMedGoogle ScholarCrossref
Pfisterer MBuser PRickli H et al. TIME-CHF Investigators, BNP-guided vs symptom-guided heart failure therapy: the Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) randomized trial. JAMA 2009;301 (4) 383- 392PubMedGoogle ScholarCrossref
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PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart failure morbidity And mortality Study. Paper presented as a late-breaking clinical trial at: Annual Scientific Meeting of American College of Cardiology March 29, 2009 Orlando, Florida
SIGNAL-HF Study. Paper presented as a late-breaking clinical trial at the European Heart Failure Association Annual Meeting June 1, 2009 Nice, France
Lainchbury JGTroughton RWFrampton CM et al. NTproBNP-guided drug treatment for chronic heart failure: design and methods in the "BATTLESCARRED" trial. Eur J Heart Fail 2006;8 (5) 532- 538PubMedGoogle ScholarCrossref
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Porapakkham P, Porapakkham P, Zimmet H, Billah B, Krum H. B-Type Natriuretic Peptide–Guided Heart Failure Therapy: A Meta-analysis. Arch Intern Med. 2010;170(6):507–514. doi:10.1001/archinternmed.2010.35
B-Type Natriuretic Peptide–Guided Heart Failure Therapy: A Meta-analysis
Pramote Porapakkham, MD; Pornwalee Porapakkham, MD; Hendrik Zimmet, MD; et al Baki Billah, PhD; Henry Krum, MD, PhD
Author Affiliations Article Information
Author Affiliations: Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia.
Arch Intern Med. 2010;170(6):507-514. doi:10.1001/archinternmed.2010.35
Background The use of plasma levels of B-type natriuretic peptides (BNPs) to guide treatment of patients with chronic heart failure (HF) has been investigated in a number of randomized controlled trials (RCTs). However, the benefits of this treatment approach have been uncertain. We therefore performed a meta-analysis to examine the overall effect of BNP-guided drug therapy on cardiovascular outcomes in patients with chronic HF.
Methods We identified RCTs by systematic search of manuscripts, abstracts, and databases. Eligible RCTs were those that enrolled more than 20 patients and involved comparison of BNP-guided drug therapy vs usual clinical care of the patient with chronic HF in an outpatient setting.
Results Eight RCTs with a total of 1726 patients and with a mean duration of 16 months (range, 3-24 months) were included in the meta-analysis. Overall, there was a significantly lower risk of all-cause mortality (relative risk [RR], 0.76; 95% confidence interval [CI], 0.63-0.91; P = .003) in the BNP-guided therapy group compared with the control group. In the subgroup of patients younger than 75 years, all-cause mortality was also significantly lower in the BNP-guided group (RR, 0.52; 95% CI, 0.33-0.82; P = .005). However, there was no reduction in mortality with BNP-guided therapy in patients 75 years or older (RR, 0.94; 95% CI, 0.71-1.25; P = .70). The risk of all-cause hospitalization and survival free of any hospitalization was not significantly different between groups (RR, 0.82; 95% CI, 0.64-1.05; P = .12 and RR, 1.07; 95% CI, 0.85-1.34; P = .58, respectively). The additional percentage of patients achieving target doses of angiotensin-converting enzyme inhibitors and β-blockers during the course of these trials averaged 21% and 22% in the BNP group and 11.7% and 12.5% in the control group, respectively.
Conclusions B-type natriuretic peptide–guided therapy reduces all-cause mortality in patients with chronic HF compared with usual clinical care, especially in patients younger than 75 years. A component of this survival benefit may be due to increased use of agents proven to decrease mortality in chronic HF. However, there does not seem to be a reduction in all-cause hospitalization or an increase in survival free of hospitalization using this approach.
Heart failure (HF) is a leading cause of death, hospitalization, and rehospitalization worldwide.1 Despite advances in the treatment of HF, including use of drugs, devices, and heart transplantation, the condition remains associated with substantial morbidity and mortality. A likely contributor is inadequate dose titration of HF medications2 such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-adrenergic blockers, and spironolactone, all of which have been shown to improve outcomes and are recommended by international guidelines.3,4
B-type natriuretic peptide (BNP) is a neurohormone secreted predominantly from the ventricle of the heart in response to intracardiac volume loading.5B-type natriuretic peptide functions as a counterregulatory hormone to angiotensin II, norepinephrine, and endothelin, having vasodilatorary and diuretic effects.5 The precursor of BNP is pro-BNP, stored in secretory granules in myocytes. Pro-BNP is split by a protease enzyme into BNP and N-terminal pro-BNP (NT-pro-BNP). Compared with BNP, NT-pro-BNP is a longer peptide sequence than BNP (76 vs 32 amino acids) and has a longer half-life (60-120 minutes vs 15-20 minutes).6 Both BNP and NT-pro-BNP plasma concentration have been shown to be useful in the diagnosis of acute decompensated HF.7 In addition, these peptides can be used as prognostic indicators in prediction of mortality and clinical outcome in patients with chronic HF. Specifically, lower plasma BNP levels are predictive of a reduced likelihood of future major cardiovascular events.8,9
B-type natriuretic peptide plasma concentrations can be reduced considerably in patients with acute decompensated HF after aggressive treatment with ACE inhibitors,10 ARBs,11 and aldosterone antagonists.12 B-type natriuretic peptide plasma levels also fall following long-term treatment with β-adrenergic blockers, although levels may increase temporarily in the short term.13 Titration of ACE inhibitors or β-blockers after comprehensive treatment resulting in further reduction of BNP levels may reflect a reverse remodeling process on the ventricle of the heart.14 Thus, lowering of BNP plasma levels by use of proven HF medications represents a putative therapeutic target (BNP-guided therapy).
This hypothesis has been investigated in a number of prospective randomized controlled trials (RCTs). To date, however, the therapeutic benefit of this approach remains uncertain. In particular, individual studies have generally been underpowered in the evaluation of the impact of BNP-guided therapy on major cardiovascular and mortal events. In addition, the ability of individual studies to ascertain reasons by which BNP-guided therapy may influence such outcomes is also limited. Furthermore, there has been some variability in the findings reported in these studies. The aim of the present study was therefore to assess the potential clinical benefits of BNP-guided therapy in chronic HF, by performing a meta-analysis of RCTs comparing BNP-guided treatment and usual clinical care.
Data sources and searches
Clinical RCTs were identified via MEDLINE (source, PubMed, 1966 to December 2008), EMBASE (1974 to December 2008), the Cochrane Controlled Clinical Trials Register Database (through December 2008), and the ClinicalTrials.gov Web site (through December 2008). Each search query included the keywords and corresponding MeSH terms for brain natriuretic peptide, pro-brain natriuretic peptide, heart failure, and therapy. Manual reference checking of the bibliographies of all retrieved articles was also performed. To identify studies reported only at scientific meetings, searches were undertaken both manually and electronically of the abstracts of annual scientific sessions of the American Heart Association (2005-2008), the European Society of Cardiology (2005-2009), the American College of Cardiology (2005-2009), the European Heart Failure Society, and the Heart Failure Society of America (through 2009). Eligibility assessment and data abstraction were both performed independently in an unblinded15 standardized manner by 2 reviewers (P.P. and P.P.)
Only prospective RCTs conducted in outpatients with a history of HF were considered for inclusion in this meta-analysis. An RCT was defined according to the National Library of Medicine.16 Trials with a total of 20 or fewer patients17 or with end points that were reported only in a single study18,19 were excluded.
Data extraction and quality assessment
All qualifying studies were assessed for patient characteristics as well as for adjustment of medications in both the clinical usual care and BNP-guided groups. Clinical outcomes assessed included all-cause mortality, all-cause hospitalization, survival free of any hospitalization, mortality in patients younger than 75 years or 75 years or older, number of days alive outside of hospital, and additional percentage of patients prescribed adjusted HF medication (diuretics, aldactone, β-blockers, and ACE inhibitors or ARBs), and whether target doses of ACE inhibitors and β-blockers were achieved during the study. We were unable to assess hospitalization for HF owing to differences between studies in the method of reporting used (ie, number of hospitalization events vs number of patients hospitalized).
Data synthesis and analysis
Results were pooled with Stata statistical software (version 10; StataCorp, Cary, North Carolina) using the Mantel-Haenszel fixed-effects model. In the Mantel-Haenszel model, we used Stata software to calculate a weighting for every study in accordance with the number of events that occurred in every study to form an average overall outcome statistic and 95% confidence interval (CI). Heterogeneity among studies was analyzed by χ2 and sensitivity analyses were performed to determine the influence of individual trials on the results. Statistical significance was set at the .05 level for both χ2 test for heterogeneity and z-test for relative risk (RR).
Detailed search steps are summarized in a flowchart illustrating the mechanisms of exclusion for certain studies (Figure 1) in accordance with the Quality of Reporting of Meta-analyses (QUOROM) recommendations.20 We initially identified 1020 potentially relevant articles. Sixteen articles were considered to be of interest and were retrieved for detailed evaluation. Eight articles that did not meet our criteria were excluded, and the remaining 8 studies were included in the meta-analysis.
Qualitative findings
Eight trials, with a total of 1726 patients, met the specified criteria for meta-analysis. Trials included were those by Troughton et al,21 Beck-da-Silva et al,22 Esteban et al,23 the Systolic Heart Failure Treatment Supported by BNP (STARS-BNP) study,24 the TIME-CHF study (Trial of Intensified vs standard Medical therapy in Elderly Patients with Congestive Heart Failure),25 the BATTLESCARRED study (NT-pro-BNP-AssisTed Treatment to LEssen Serial CARdiac REadmissions and Death),26 the PRIMA study27 (PRo-brain-natriuretic peptide guided therapy of chronic heart failure to IMprove heart failure morbidity And mortality) and the SIGNAL-HF study.28
Patient characteristics in these trials are summarized in Table 1. The studies varied in terms of number of patients, duration of the intervention, and primary end points. In studies where all-cause mortality or all-cause hospitalization was not the primary end point, they were included as secondary end points. The total number of patients in each study ranged from 41 to 499, and the duration of follow-up time varied from 3 to 24 months (mean duration, 17 months). All studies were performed in patients with New York Heart Association (NYHA) class II or greater and left ventricular ejection fraction less than 50%. The participants' ages ranged from 18 to 85 years. Most were men, with the exception of the study by Beck-da-Silva et al,22 in which the percentage of males was around 35% in each group. Three studies, including those by Beck-da-Silva et al22 and Esteban et al23 and the STARS-BNP study,24 used the BNP level as a monitor to guide medication doses in the intervention group, whereas the other 4 studies (Troughton et al,21 the BATTLESCARRED study,26 the TIME-CHF study,25 the PRIMA study,27 and the SIGNAL-HF study28) used NT-pro-BNP levels.
Target plasma BNP or NT-pro-BNP level in the intervention group and clinical aims in the control group of each trial are summarized in Table 2. In the BATTLESCARRED study,29 there were 3 study arms: hormone-guided care, intensive clinical care, and usual care. "Usual care" in this trial involved no adjustment of medication or further contact with the research team other than an enquiry after 3 months to document medications, adverse events, readmissions to hospital, and death. Consequently, this group was not used in the subsequent meta-analysis. The intensive clinical care group was similar to the clinical usual care groups of the other trials used in this meta-analysis and thus was used as such. In the TIME-CHF study,25 the authors reported the overall survival outcomes instead of all-cause mortality. We therefore used these data to calculate all-cause mortality for the purpose of our analysis. Only 2 studies, the TIME-CHF study25 and BATTLESCARRED studies,26 presented data according to age group (<75 years or ≥75 years). One-year all-cause mortality data in patients younger than 75 years or 75 years or older from the BATTLESCARRED26 trial were used, because insufficient data were available at the 2-year time point. The STARS-BNP study24 and the PRIMA study27 reported the numbers of patients whose doses of the HF medication were up-titrated during the studies, and only the STARS-BNP24 and TIME-CHF25 studies provided details of the percentages of patients achieving the target dose of medications proven to decrease morbidity and mortality.
Quantitative findings
The risk of all-cause mortality was significantly lower in the neurohormonal (BNP)-guided treatment group (RR, 0.76; 95% CI, 0.63-0.91; P = .003) (Figure 2) compared with the clinical-guided treatment group. This effect was dominated by the TIME-CHF study,25 which contributed 49.6% of the weight. There was no significant heterogeneity between the trials (heterogeneity χ27 of 3.81; P = .80). Funnel plot analysis suggested that there was little in the way of publication bias in this result (Figure 3).
A subgroup analysis was performed in the TIME-CHF25 and BATTLESCARRED26 studies, which provided data on patients younger than 75 years or 75 years or older. All-cause mortality was significantly lower in younger patients treated with BNP-guided therapy (RR, 0.52; 95% CI, 0.33-0.82; P = .005) than in those in the clinical guided group with a heterogeneity χ21 of 0.57 (P = .45). In contrast, all-cause mortality of those 75 years or older was not significantly different between groups (RR, 0.94; 95% CI, 0.71-1.25; P = .70 [heterogeneity χ21 of 1.14; P = .29]).
Three studies21,22,24 provided data on all-cause hospitalization. There was no significant difference seen in the BNP-guided therapy group on all-cause hospitalization vs clinical guidance (RR, 0.82; 95% CI, 0.64-1.05; P = .12) (Figure 4A), with a heterogeneity χ22 of 0.78 (P = .68). For this end point, the effect was dominated by the STARS-BNP study24 with around 80.4% of the weight.
Survival free of any hospitalization was reported in 2 trials. There was a nonsignificant difference in survival free of any hospitalization between the 2 groups (RR, 1.07; 95% CI, 0.85-1.34; P = .58) (Figure 4B), with a heterogeneity of χ21 0.00 (P = .98). This was predominated by the TIME-CHF study,25 with approximately 81.6% of the weight.
Number of days alive and not hospitalized
The STARBRITE18 and PRIMA27 studies provided data on the number of days that patients were alive and not hospitalized. The number of days they were alive and not hospitalized was higher in the BNP-guided group than in the clinical control group, but the difference was not significant in both studies (mean [SD], 85 [12.1] days vs 80.4 [20.6] days in the STARBRITE study18 and 685 days vs 664 days in the PRIMA study27). Unfortunately, we are unable to perform a formal meta-analysis of this outcome because of differences in the presentation of data.
The STARS-BNP24 and PRIMA27 studies presented the percentages of patients having medical treatment adjustment during the study period. Patients in the BNP-guided group had doses of their HF medication adjusted more than those in the clinical care group (Figure 5A; 75% vs 58% in diuretics, 13.4% vs 8.2% in aldactone, 49.6% vs 30.9% in ACE inhibitors or ARBs, and 51.1% vs 41.6% in β-blockers).
The mean percentage of patients reaching their target dose of ACE inhibitors and β-blockers during the study were calculated from the STARS-BNP24 and TIME-CHF studies.25 Approximately double the number of patients in the BNP-guided therapy group had their doses up-titrated and reached their target level of ACE inhibitors and β-blockers compared with the clinical usual care group (Figure 5B) (21.% and 22.0% in the BNP group vs 11.7% and 12.5% in the usual care group, respectively).
Other parameters
Change of functional class, quality-of-life (QOL), and left ventricular (LV) ejection fraction (LVEF) could not be meta-analyzed. In terms of functional class, the TIME-CHF25 and STARS-BNP24 studies showed improvement in both groups; however, Beck-da-Silva et al22 and Esteban et al23 found no change. The TIME-CHF25 study reported a significant improvement in both the BNP and control groups on QOL, particularly during the first 12 months, but the difference between the 2 groups was not significant. However, statistical improvement in QOL in the BNP-guided therapy group (P = .03) was observed in the study by Beck-da-Silva et al22 (P = .03). Troughton et al21 and Beck-da-Silva et al22 found significant improvement in LVEF in both treatment groups but no significant difference between the 2 groups (P = .23 and P = .40, respectively).
We performed sensitivity analysis to determine the effect of plausible changes in assumptions on the association between BNP-guided therapy and all-cause mortality (Table 3). With the exclusion of the TIME-CHF study,25 the point estimate changed to become nonsignificant (P = .052; RR, 0.76; 95% CI, 0.58-1.00). All-cause mortality significance was not affected by exclusion of the other individual trials, including the PRIMA study.27 Therefore, only the TIME-CHF study25 among studies evaluated had a major impact on the point estimate of the pooled data.
Sensitivity analysis was also performed for the end point of all-cause hospitalization (Table 3). The point estimates for all-cause hospitalization were stable under a range of assumptions, and although studies favored BNP-guided therapy, significance was not achieved under any scenario.
We performed a meta-analysis of clinical RCTs of BNP-guided therapy in the outpatient treatment of HF. We found that using this approach can decrease all-cause mortality of these patients significantly compared with usual clinical care, particularly in patients younger than 75 years. The number of days that patients were alive and not hospitalized was also significantly higher in the BNP-guided group; nevertheless, all-cause hospitalization and survival free of hospitalization between the 2 groups were not significantly different.
One case report30 and 1 case series31 of 76 patients with LV dysfunction showed promising results regarding the potential clinical benefits of measuring the plasma BNP level to guide the treatment. Larger studies18,19,21,24 using BNP monitoring in the treatment of patients with chronic HF suggested the effectiveness of this approach, with demonstrable improvements in clinical outcomes, including rates of death and rehospitalization. However, subsequent RCTs of this therapy, including those used in this meta-analysis, have found variable results. The overall findings of our study suggest that BNP-guided treatment reduces all-cause mortality in patients with chronic HF. This observation is supported by a recently published evaluation32 that included some (but not all) of the studies used in the present meta-analysis.
We found that the mortality benefit observed with BNP-guided therapy was restricted primarily to those patients in a younger age group (<75 years). In general, these patients have high mortality rates despite use of proven medications and/or devices. Use of ACE inhibitors,33 β-blockers,34 and spironolactone35 reduce morbidity and mortality in patients with chronic HF. As a result of treatment using BNP-guided modification, it was shown that there is an increase in prescribing of these HF medications (spironolactone, ACE inhibitors, and β-blockers) compared with clinically guided treatment. Specifically, the percentage of patients achieving their target dose of ACE inhibitors and β-blockers in the BNP-guided group were increased to approximately 2-fold higher than those in the control group. Therefore, mechanisms underlying decreased mortality in the BNP-guided therapy group could relate to the higher percentage of patients achieving the target dose of drugs with proven prognostic efficacy. Alternatively, there may be other, as-yet unidentified factors contributing to the mortality benefit.
The BATTLESCARRED26 and TIME-CHF25 studies showed that the group of patients younger than 75 years derived considerable clinical benefit from BNP-guided therapy, including decreased all-cause mortality. In contrast, in the older age group (≥75 years), the mortality benefit was not substantive. The reason for this is uncertain. Older patients may have more comorbid diseases, including hypertension, chronic kidney disease, diabetes mellitus, and dysrhythmia, that make them less able tolerate target doses of medication than those in younger age group. They may also be less responsive to these therapies. In the TIME-CHF study,25 patients in the older age group had a mean age of 82 years (compared with 69 years in the younger group) and had more prevalent comorbidities (eg, hypertension [77% vs 61%], atrial fibrillation [36% vs 26.7%], and kidney disease [62% vs 44%]), and more were classified as having NYHA functional class III disease (80% vs 65%). The TIME-CHF25 study also suggested that the less severe the comorbidities, the more favorable the effects of NT-pro-BNP–guided therapy. Older patients are also more likely to have noncardiovascular diseases such as cancers36 and chronic lung37 and liver diseases.38 Thus, these may contribute to mortality in patients of advanced age, and BNP-guided therapy would not alter these outcomes.
The optimal target level of BNP to which therapy should be guided is difficult to decide on. Confounding effects include age, sex, and weight; BNP levels are higher in females and those of advanced age.39,40 Furthermore, too aggressive a reduction in BNP levels by up-titration of diuretics, ACE inhibitors, and β-blockers may potentially result in worsening rather than improvement in clinical outcomes, especially in elderly individuals, by causing hypotension and worsening renal failure.
Rates of all-cause hospitalization and survival free of hospitalization were not significantly different between the 2 study groups (Figure 4). However, there was a trend toward lower risk of all-cause hospitalization and more survival free of any hospitalization in this group. This may be explained in part by the contribution of non–HF events on which BNP-guided therapy would not have an impact. Unfortunately, we could not calculate the impact on HF hospitalization owing to a lack of data.
A major limitation of this evaluation of BNP-guided therapy is that we were not able to meta-analyze some key clinical end points on which this approach may have a beneficial impact. In particular, hospitalization for HF is one such end point, where BNP-guided therapy and accompanying intensification of use of standard HF pharmacological therapies should theoretically have a favorable impact on this outcome.
We identified 3 ongoing trials of BNP-guided therapy: the NorthStar study,41 the PROTECT trial,42 and the EXIMPROVE CHF trial.43 The NorthStar study41 is a clinical RCT conducted in Denmark and involving 720 patients with follow-up for 30 months, in which there were 3 arms: treatment in general practice, a standard follow-up program in an HF clinic, and follow-up with plasma NT-pro-BNP levels monitored in an HF clinic. The PROTECT trial42 is an RCT in Massachusetts General Hospital, Boston, that includes 300 patients with follow-up for 1 year. There are 2 arms: standard of care and NT-pro-BNP–guided groups. The EXIMPROVE CHF (Improvement of patients with Chronic Heart Failure Using NT-pro-BNP) study43 is an RCT in St Michael's Hospital, Toronto, Ontario, Canada, using NT-pro-BNP–guided care, with follow-up for 2 years.
Based on the findings of the present meta-analysis, future studies will require a larger number of patients and careful matching of age, sex, and other key clinical variables to definitively address the true effectiveness of BNP-guided treatment in the treatment of chronic HF. Prospective evaluation of relevant study end points for which BNP-guided therapy may be expected to have a beneficial impact on outcomes (eg, hospitalization for HF) would also be of great importance.
In summary, the present study demonstrates that BNP-guided therapy can significantly lower all-cause mortality rate in patients with chronic HF compared with those receiving usual clinical care, particularly in patients younger than 75 years but not in those of advanced age. However, this approach does not seem to either reduce all-cause hospitalization or increase survival free of hospitalization.
Correspondence: Henry Krum, MD, PhD, Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria 3004, Australia (henry.krum@med.monash.edu.au).
Accepted for Publication: October 8, 2009.
Author Contributions:Study concept and design: Zimmet and Krum. Acquisition of data: Pornwalee Porapakkam. Analysis and interpretation of data: Pramote Porapakkam, Zimmet, Billah, and Krum. Drafting of the manuscript: Pramote Porapakkam, Pornwalee Porapakkam, and Krum. Critical revision of the manuscript for important intellectual content: Zimmet, Billah, and Krum. Statistical analysis: Billah. Administrative, technical, and material support: Pramote Porapakkam, Pornwalee Porapakkam, and Zimmet. Study supervision: Zimmet and Krum.
Financial Disclosure: None reported.
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So, who on earth doesn't make mistakes?
WHY do we make mistakes in the first place?
How do we move on from our mistakes?
Is there another way when it comes to mistakes?
What is Google saying about the word mistake?
What is the reliable English dictionary telling us?
Where does this word come from?
An act of judgement that is misguided or wrong. (1)
Concise Oxford English Dictionary
Something which is not correct; an inaccuracy.
An act of judgement that is mis-guided or wrong.
Wrongly identify someone or something as. (2)
1. something that you have not done correctly, or something you say or think that is not correct.
a. something that you say or write in a way that is not correct.
2. something you do that you later wish you had not done, because it causes a lot of problems. (3)
Collins English Dictionary
1. an error or blunder in action, opinion or judgement
2. a misconception or misunderstanding
3. misunderstand; misinterpret
4. to take (for), interpret (as), or confuse (with)
5. to choose badly or incorrectly
6. to make a mistake in action, opinion, judgement, etc. (4)
Origin of the word Mistake
Early 14 century – "to commit an offense;"
Late 14 century – "to misunderstand, misinterpret"
From a Scandinavian source such as Old Norse mistake "take in error, miscarry"
From mis– "wrongly" (see mis-(1)) + taka "take"
Related: Mistook; mistaking. (5)
Do we get all these definitions for one word?
Is this making sense to us all about the word Mistake?
Do we truly and deeply understand it now?
Are we any wiser and better informed now after reading this?
Where is the marker of what is correct and what is not?
Who actually defines when we make a mistake?
Who are we choosing to listen to and why?
Whose opinion matters to us and who do we value?
How many of us feel our heart thumping at the thought of a mistake?
How many of us feel a constriction in our heart because of a mistake?
How many of us feel our blood pressure rising when we make a mistake?
How many of us feel internal pressure at the very thought of a mistake?
How many of us are aware our chest area feels hard and tight?
How many of us notice a change in our breathing after a mistake?
How many of us tread on eggshells to avoid making a mistake?
How many of us keep thinking we are going to make a mistake?
How many of us avoid life because we are scared of making a mistake?
How many of us know that feeling when we override and it turns into a big fat ugly mistake?
How many of us can almost see ourselves making a mistake before it even happens?
How many of us always say "I knew that was going to happen" like we know the mistake before it even happens?
How many of us have got into the habit of making mistakes?
How many of us mess up with mistakes all the time and hate it?
How many of us have a life-long pattern of always making mistakes?
How many of us want to shut off from the world when we make a mistake?
How many of us go into a moment of madness just because of a mistake?
How many of us go off spinning in thoughts when we make a mistake?
How many of us are dis-honest when it comes to our mistakes?
How many of us have become mini masters at lying about our mistakes?
How many of us squirm at the thought of others finding out about our mistakes?
How many of us are scared and can't face the world in case they know about our mistakes?
How many of us avoid eye contact because we know, they know about our mistake?
How many of us feel shame around the mistakes in our lives?
How many of us have a cover up story about our past mistakes?
How many of us brag about our great life but hide from our mistakes?
How many of us try and hide our dodgy past which was full of mistakes?
How many of us work our butt off to cover up the mistakes we made?
How many of us hate being reminded by others of our past mistakes?
How many of us are a pay check away if we make a mistake in our job?
How many of us are paranoid as a mistake in our job could mean a life?
How many of us make mistakes with money and never get over it?
How many of us have cost our company big bucks with our mistake?
How many of us make tiny mistakes but in our head they are huge?
How many of us keep repeating the ugly thoughts about our mistakes?
How many of us beat ourselves up because of our mistakes?
How many of us just can't get over the fact we make mistakes?
How many of us have a mood drop soon as we recall a mistake?
How many of us feel sad even thinking about a mistake from our past?
How many of us feel depressed because of our mistakes?
How many of us start having nightmares because of our mistakes?
How many of us go for the munchies when we make a mistake?
How many of us just want to stuff our feelings down when we know we have made a mistake but cannot own up to it?
How many of us know how to justify when we make a mistake?
How many of us get frustrated because we keep messing up?
How many of us get so angry with others when we know it's our mistake?
How many of us just point the finger and blame others for our mistakes?
How many of us are ok to let someone else take the hit for our mistake?
How many of us make sure we are right when we make a mistake?
How many of us are up front and transparent about our mistakes?
How many of us find it hard to own up to our mistakes?
How many of us deny to kingdom come that we made a mistake?
How many of us pace the floor to find a way out of the mistake we just made?
How many of us run for the hills after making a mistake?
How many of us avoid people when we know there is a mistake to deal with?
How many of us phone a friend to talk ourselves out of the mistake we just made?
How many of us run away from our lives in the hope the mistakes will go away?
How many of us duck and dive but never own up to our mistakes?
How many of us want to lash out at others because of mistakes?
How many of us become aggressive when it comes to our mistakes?
How many of us get super angry at others who make a mistake?
How many of us feel bitter and resentfull about other people's mistakes?
How many of us make mistakes with relationships but say nothing?
How many of us want to fix our terrible mistakes in our relationships?
How many of us keep going backwards when it comes to mistakes?
How many of us forget something and don't see it as a mistake?
How many of us think mistakes mean the end of our perfect life?
How many of us make crazy mistakes when we drink alcohol?
How many of us know our drug taking is a big mistake?
How many of us can say that smoking cigarettes was our worst mistake?
How many of us are deeply hurt from our past mistakes?
How many of us live in our own prison inside our heart, for making a terrible mistake?
How many of us give ourselves a life sentence, never to recover because we made some bad mistakes years ago?
How many of us write ourselves off like it's a wasted life just because of our mistakes?
How many of us live our lives in regret because of our past mistakes?
How many of us give up on life because of one or two mistakes?
How many of us take our mistakes to our grave?
How many of us try and laugh it off but deep down our mistakes are hurting us?
How many of us are embarrassed when we think about the mistakes we have made and keep making?
How many of us just want to talk and talk about our mistakes?
How many of us just shrug it off and keep repeating those ill mistakes?
How many of us make the effort so we don't repeat the same mistakes?
How many of us put our hands up and own up to our mistakes?
How many of us are willing to take full Responsibility for our mistakes?
WHY do we struggle to move on from our mistakes?
WHY do we keep making mistakes over and over again?
WHY do we judge others when they make mistakes?
WHY do we get the judge and jury out on us for making a mistake?
WHY do we find it hard to Accept our mistakes as mis-takes?
WHY do some of us never get over our mistakes?
WHY do we give ourselves a hard time with mistakes?
WHY do we spend years dwelling on our mistakes?
WHY do we spend years in regret because of our mistakes?
WHY do we find it easy to allow our kids to make mistakes?
WHY do we have understanding when our children make a mistake?
What if mistakes are a way for us to learn?
What if there was another way to see our mistakes?
What if mistakes can be corrected with new choices?
In other words, a Take 2 on anything that is not Truth?
What if a mis-take can be corrected with a re-take?
ill choice = mis-take
new choice = re-take
repeated new choices = another way
consistent new choices = a new imprint going forward
living a life of new choices = erasing the past mistakes
What if we can learn from our mistakes by making new choices going forward?
Example – late night, more late nights, wake up feeling awefull.
Sleeping aids, trying this and that – nothing working.
Alcohol, eating late, partying and social media = poor sleep quality.
New choices = asking Questions WHY
WHY alcohol is needed in the first place?
WHY are we on social media every night and all day long?
WHY can't we say NO to the party binge weekend?
WHY are we eating so late at night when our belly hurts?
Could it be possible our lifestyle choices are a mistake?
Could it be possible we can make a new choice?
Could it be possible we can make more new choices?
Could it be possible this new way of living can erase our past mistakes?
What if we have a different perspective if we do make a mistake?
What if our attitude changes towards self and others when it comes to making mistakes?
What if we could nominate our mis-takes first?
What if we had the tools to not bash and beat ourselves up every time we made a mistake?
What if there is no room for self-bashing if we re-imprint with new choices?
What if there is no space for nonsense thoughts about how bad we are because of our mistakes, as we have replaced our life with Responsibility?
In other words, take Responsibility by admitting we made a mistake.
What if a life of Responsibility stamps out the hard time we give ourselves when we do make a mistake?
What if something inside us shifts the moment we admit we made a mistake?
What if we can feel the tension release just by saying we made a mistake?
What if our blood pressure and stress levels go down, just because we have nominated our mistake?
What if we could accept that we have made mistakes and it is time to learn?
What if we gave ourselves the true compassion we do for our children, when we make a mistake?
What if mistakes are the way we humans learn?
What if learning from our mistakes is evolving us?
What if we can move on from our old mistakes?
What if we can choose again and ensure we do not walk the road of irresponsibility?
What if our past mistakes can be erased by the way we choose to live now?
In other words, making a commitment to life in all areas to take Responsibility for all our choices.
What if there was another way that works?
Could it be that Simple?
(1) (n.d). Google. Retrieved July 20, 2017 from
https://www.google.co.uk/search?q=mistakes+meaning&oq=mistakes&aqs=chrome.3.69i57j0l5.5513j0j7&sourceid=chrome&ie=UTF-8
(2) Concise Oxford English Dictionary – Twelfth Edition. Oxford University Press. 2011
(3) (n.d). Macmillan Dictionary. Retrieved July 20, 2017 from
http://www.macmillandictionary.com/dictionary/british/mistake_1
(4) (n.d). Collins English Dictionary. Retrieved July 20, 2017 from
https://www.collinsdictionary.com/dictionary/english/mistake
(5) (n.d). Online Etymology Dictionary. Retrieved July 20, 2017 from
http://www.etymonline.com/index.php?term=mistake
Ken Elmer
I have learned so much from all the mistakes I have made in my life. I know that making mistakes is the best way to learn. Yet after 66 years of making mistakes, I sometimes still react like I have done something wrong.
When I was learning to walk, I made many "mistakes" yet I did not judge myself. So when did I start to feel that making mistakes was bad?
It was when I started to feel that I had to do what other people wanted. And if I could not do what they wanted, I started to believe I had done something wrong.
In order to do this I had to ignore what myself was telling me was true.
So when I feel I have done something wrong is that me remembering the moment that I gave on myself to do what another person wanted?
Is it possible that that is the only thing I have ever done that is truly wrong?
Jo Elmer
Your last sentence brings tears to my eyes Ken because I can feel that the biggest mis-take I have made (and repeated), which has brought me the most harm has been just that; 'giving up on myself to do what others wanted'.
Jenifer Swallow
"I can choose again" – wow, that's huge.
It shifts the focus entirely to how we are going to move forward with the learning.
What life-changing thought: that we can re-write our past choices with our choices from this point.
Once you've considered that, it's hard to be mad at yourself or indulge in shame or guilt or whatever. The only thing is 'what's next?' and 'can I be consistent with that?'.
Focusing on our mistakes can be a great way to avoid listening to the message that the "mistake" is presenting to us.
Mistakes can be an opportunity to stop and ask why did this happen?
Understanding that everything happens for a reason, can help us go deeper, and not get caught up in the idea that mistakes are bad.
This concept can help us look at what is happening in the world and not just react to all the increasing levels of illness, disease and violence in the world.
What is happening in our world is a huge message that something is not working. It is time to wake up, take responsibility for the world we have created, get together and ask real questions about what is going on.
That is what this website is all about. Thank you Simple Living Global for presenting another way to be in the world.
This way has turned my life around. I am now inspired to do what ever is needed of me, to support humanity to return to the amazingness that we all are.
There is nothing in this world that has squashed me and kept me down as effectively as the consistent berating, denigrating, self bashing I have done over what I perceived as "mistakes" or there being something wrong with me…
Simple Living Global most definitely has shown me another way to be and live.
Because I am stuck with me for better or worse, learning to be a supportive and compassionate friend to myself instead of the abusive one has turned my life around.
Simple Living Global helped me see 'mistakes' as simply mis-takes and opportunities to recognize a behavior or pattern I do not like (do not want to keep as part of my life) and has empowered me to simply do a re-take.
I can now say, from experience, that this is true responsibility and it is transformative.
If mistakes are part of our education as human beings – isn't it important to get honest about how we perceive and handle these never ending lessons?
My old way destroyed me on a regular basis and this new way rebuilds me in the way I choose to go forward; this is evolution.
Ruth Ketnor
I used to beat myself up big time for making mistakes and reading your 'how many of us' list could tick a fair few.
In recent years I have been choosing to take responsibility for my choices, to build a loving relationship with, and foundation for, myself and with this accept myself for who I truly am. In doing this the self bashing has stopped, I am now able to see my mistakes as a point of learning and that I have a choice to erase the past by re imprinting with new choices, this allows me to stay with the joy I feel and not make a big thing out of my mistakes or let them take over my life.
Shevon Simon
I used to beat myself up so much when I made a mistake, it was my default behaviour, there was no other option.
All the things the author described would be what I'd experience –
Spinning with negative thoughts
Avoiding people
Wanting to run and hide from the world
Bashing myself for years after a mistake
but recently I've noticed that the negativity is not as intense or sometimes is not even there.
So what has changed?
There's been a shift in my attitude towards myself. Instead of feeling like a bad person I now accept myself more and really appreciate who I am and the beauty that I bring to the world and others.
I also know that I am not perfect and that I will make mistakes. By accepting all of this and feeling it within me, my default position is now a sense of understanding and acceptance when I make a mistake rather than a bashing. I actually feel it physically in my body where my heart opens up and relaxes whereas before it used to jump and go crazy at the thought of even making a mistake.
With this I am so much more understanding and accepting of others when they make a mistake. As I am not bashing myself, I am not bashing them either. This makes me much easier to be around.
This blog makes the profound point that life is full of 'lessons' and how we handle them is what matters.
Berating one's self is a night and day difference from simply taking note of a choice that is not what we want, learning from it so we can go forward in responsibility.
I used to replay my 'mistakes' compulsively (some haunted me for years), especially the ones which brought on embarrassing moments for me, seemingly just to make myself feel bad…
I had little understanding of why I did things I did not like or why I would torture myself with it thereafter let alone how to go forward differently; instead of learning I was crushing myself…
Simple Living Global – Back to Basics supported me to learn from 'mistakes' by simply putting my understanding hat on (self-compassion) and making a new choice; this melts my self blame and is entirely self empowering; this alone has changed my life.
Jane Keep
Great and much needed conversation about mistakes.
Its interesting how we can for the most part feel heavy and be hard on ourselves when we make a so called mistake – but what if there is no such thing as a mistake? And only a learning as you say a learning. How else can we learn unless we try and test things, and we realise we could things another way.
I know a wise mentor who once pulled me up as I was in the doldrums about making a mistake and feeling I was in the wrong. She said that I was making myself a victim of it and using it to bash myself – when all I needed to do was 'cut myself some slack', observe/reflect on what had happened, feel my part in it (where was I responsible) and then have another go. Since then I have had a go at so many things some of which I know could have been different or better but I try not to look at them as right or wrong or mistakes. After all – if I have never experienced something and I give it a go and I realise that I could do it differently next time – how else would I learn? given I had never experienced it in the first place how could I be hard on myself for something I had to learn by experiencing?
I love how this blog brings the clarity of how making mistakes is our way to learn, so we don't have to live in the wake of our choices for months, years or lifetimes, but see them for just that.. a moment of learning, then make different choices that evolve us from this, during which cancel out the previous ones.
It takes the stress and angst out of making decisions/choices as there are always many more to make.. and learn from, whether they are mistakes or not.
I spent many years beating myself up when I made mistakes. I ended up in a cycle of repeating them and IGNORING the fact all I needed to do was move on and ACCEPT that it happened. Fast forward to present day and the author of this blog has really helped me to understand that by taking RESPONSIBILTY for my choices and making a COMMITMENT to LIFE my pattern of repeating the same MISTAKES grinds to a halt.
I see mistakes not as burden anymore but it shows me when something is OFF and gives me the space to deal with it rather than beat myself up. We are human and making mistakes is all part of our learning.
Who I was 6 years ago is not who I am today and that really makes me APPRECIATE how far I have come. If we put the base ball bat down just for a minute would the world not Feel a better place.
I made what seemed to me a bit of a whopper of a mistake recently, in an area of life I had not experienced so didn't handle it as well as felt I could. When I realised what had happened I felt a little flat afterwards but then saw it for the learning it offered me and got over it.. and sure enough soon after another opportunity was there from a different direction for me to have another go. How profoundly simple this was when I took responsibility for my part in what took place, saw it for what it was and let it go.. it turned out not to be such a whopper after all. Sure beats giving myself a hard time and letting it affect how I am and my life from then onwards, which is what I used to do.
Bina Pattel
Who doesn't make mistakes and who doesn't give themselves a hard time?
I know as a kid it would bother me so much that I could not let go and had zero understanding of why or how I could erase that.
As an adult, I made some big mistakes with money and lived in so much regret that I could not get over it for over a decade. Once I got a clear and thorough understanding from a wise man called Serge Benhayon, things started to slowly change.
Living a life of True Consistency is a life of True Responsibility. So those words stayed stuck to my fridge door for about 4 years and then it became my normal.
I done the formula in this blog about re-take and the new choices business and that was it. Today I claim that I live a life that is very consistent when it comes to taking Responsibility and that includes all areas of my life and not just money. No perfection ever needed and forever a student learning and learning.
I cannot erase my ugly past mistakes but I sure can re-imprint the new choices and simply stamp out what did happen. It feels deeply empowering and it holds a quality that is hard to put into words. What I can say is that not a single moment is now lived in regret about what happened as how I live today is totally the opposite and living irresponsibly is just not on my radar and never will be. That means the end of regret.
To not live with regret feels like a huge energetic millstone that we so easily carry around with us has been removed. What is left.. a lightness, acceptance and the ability to move on.. evolve.
When we live a life afraid of making a mistake, it totally limits our experiences in life.
If we are afraid of making a mistake we are totally in our head.
Our bodies have a natural ability, that knows what it can do and not do. It loves to be on the edge, where it is learning all the time. Just watch a young child learning to walk.
Being at this edge in all that we do, almost forces us to be in our bodies. Forces us to be present. If we start thinking, outside of what we are doing, it almost guarantees we will be fearful because we are not with ourselves.
Simple Living Global's Back to Basics program has supported me to stay with myself in all that I do. This has lowered my stress levels, reduced my body tension, allowed me to have better focus in my life. It has turned my life around. I am now committed to whatever is asked of me to support humanity, understanding that when I am with myself I can not make a mistake.
Yesterday my 6 year old lost a bag of food shopping he was carrying. I asked him 'what would you say to me if I had done this?'. He paused and said "I would ask you 'what is the lesson?'.
It seems to me kids have a natural wisdom about 'mis-takes'. Perhaps we all have it and just need to tune back into what we have forgotten.
I like how you bring the Why Questions into making new choices. Asking myself why gives me a deeper understanding of why I made the mistake, I can see where I have made similar choices that have led to mistakes.. see the likening thread running through them so I don't need to repeat them over and over. I then can make different ones.. ones that support me. I love the simplicity of it.
Even with all the illness, disease, war, and unease in the world, we are just continuing doing what we have been doing, not considering that maybe we have made a mistake.
When a young child is growing up, it is constantly re-evaluating what is happening in its life. If it is not working it will naturally do something different untill it finds something that works. It is not afraid of making mistakes.
So how much suffering will it take to for the human race to do something different? Why are we so afraid of change?
With support from Simple Living Global, I have dealt with many of my issues in life that I feel have limited my ability to move on in my life. I now am open to do what ever it takes, make as many mistakes I have to, to support humanity to get back on track.
If we are not making mistakes then we are not evolving.
Just staying in our comfort zone. Afraid to live life.
Being afraid of making mistakes can be a way of avoiding taking responsibility for our lives. An excuse. And it actually is very boring.
The key is to find your own edge in life. To be open to things that evolve you but not pushing beyond what you are able to deal with lovingly.
When you can stay at this edge, life is amazing.
So be like a young child, go for it, because mistakes are not wrong, just messages that guide us in life.
Tim Bowyer
Top blog Simple Living Global and I specifically like this line – "What if our past mistakes can be erased by the way we choose to live now?"
This is a great way of looking at our so called mistakes of the past as it gives us permission to move forward and to not beat ourselves up.
I'm sure every one of us has made mistakes in their lives, I know I have, but are they really 'mistakes'?
Is it possible that a mistake isn't a mistake if we learn from it and don't do it again?
Is it possible that a mistake isn't a mistake if we don't beat ourselves up with it and allow it to hold us back?
We are all on a journey of learning and there will be times when we make the wrong choice.
The way we deal with those wrong choices will determine whether they are mistakes or not.
What does it take to admit that we have made a mistake, and realize it is time to stop and truly ask what is going on?
The first time l tasted beer l spit it out, it tasted awful, my body knew it was poison. Yet eventually l ignored the message and starting drinking beer and even convinced myself l liked it.
It took 30 years to finally get it, that alcohol was slowly killing me.
Humans are considered the most intelligent species on earth. (A good question to ponder on is who came up with this fact?)
And we continue to believe this even with all the crazy things we do to our bodies and the earth.
The human race is basically in huge denial of the fact that something is wrong with the way we are living. This website is exposing this fact.
We are able to live so dishonestly because we have numbed ourselves with all the distractions in the world, so we do not have to feel what is really going on.
It is time to stop and ask ourselves is this the world we want?
Why have we allowed our world to get to the point where our true quality of life is rapidly declining, and we are ignoring that fact?
Simple Living Global is not only exposing all this rot, it is presenting a way of living that can support us to come up answers to these problems, a way to access a level of intelligence that humans have always had but have chosen to forget.
It has worked for me. I am committed to living this way and I have much more awareness of what is going on in the world and feel the responsibility l have to do whatever l can to get us back on track.
Yes Tim, it makes so much sense to treat mistakes as just a learning.
It has taken me a while to get past the belief that mistakes are bad. Understanding that it is ridiculous to think you could live life perfectly, was helpful.
And observing a young child when it is growing up, it has no concept of mistakes until someone judges.
When we feel judged it totally limits our ability to experience life objectively. We start to develop doubt in ourselves.
When we think we made a mistake, we are giving our power away. Do other people really know what is true for me?
My youngest recently explained that he would like to learn to read by making his own mistakes.
He says he doesn't like being 'corrected all the time at school' because it feels bad and stops him figuring it out by himself.
He then read a sentence, mixed up the 'b' with the 'd' and fell about laughing because his mistake was really funny and helped him learn which is the 'b' and which is the 'd', without any input and with a whole heap of joy.
Mistakes are okay to make, something I would never admitted a few years ago. If I made a mistake in the past I would spend many a night lying awake worrying about it. Fast forward to present day, when I do make a mistake I look at why it happened, learn from it and move forward.
Society does not give you permission to make mistakes as we are often judged when we do. What I do know is making mistakes is all part of growing and it does not have to consume you. A great blog!
What is it about us that hates making mistakes and Why have we become masters at focusing on those mistakes, more than all the great things we have done?
It is like appreciation is not even on our radar.
As adults we tend to beat ourselves up consistently and have constant dialogues in our head about our mistakes and do our best to not mess up again and when we do, we repeat giving ourselves a hard time.
I recently was leading a team and there were just so many lessons to learn and making mistakes had to be part of that learning. We all messed up and ugly as it was coming out the other end, I realise how much wiser I am today and doing my best to not go back on old ground and dig it up, but move on with the wisdom in my backpack.
I wonder if our kids were raised with the understanding and truth that this blog is presenting, would they grow up as adults not fearing, avoiding or thinking mistakes were a big deal?
It is high time we brought this type of learning into education, as it would be a game changer for us humans who have these ingrained habits like never getting over our mistakes and torturing ourselves in our heads for what we have done wrong.
It really retards us and serves no one.
We can feel devastated when we make mistakes, but what if, as this blog suggests mistakes are there for us to learn?
That is most certainly a different approach.
What if without mistakes we would never be able to grow?
Could making mistakes be an important and inevitable part of life that none of us can avoid?
If so, this really takes the pressure off trying to be perfect!
Yesterday in the car, I was explaining to my kids that I had left my phone on charge at home so I couldn't message Daddy. I hadn't thought I would need my phone.
My eldest son said 'learn the lesson'.
The lesson was 'feel don't think'.
'Just learn the lesson' – what great advice that is.
Thank you for this outstanding blog.
The question that the author poses – "what if mistakes are a way for us to learn?" – has struck me very forcibly.
I have spent so much time over the years beating myself up for mistakes, big and small. In the past, I rarely gave myself a break if I made a mistake. For many years, I had clearly forgotten that the only way I learnt to do anything as a child, including walking, talking and reading, was through a pursuing a virtuous cycle of attempts, mistakes and re-attempts.
I ask myself now, "why did I beat myself up so much for making mistakes?" There are a number of reasons, but the revelation I've just had in response to this question is startling to me: I chose to beat myself up because I did not want to take Responsibility.
Eventually, sooner or later, after making a mistake, I would have to take Responsibility and so I would make a new choice of thought, speech or behaviour.
But, all too frequently, the resistance to taking Responsibility for a particular event was so great that I chose to spend hours, days, and even years, telling myself I was stupid rather than make a choice to accept what had happened and look for the lesson.
I can see that I could have saved myself from so much misery over the years if I had been more willing to take immediate Responsibility for my mistakes but, all too often, I chose beating myself up and self-abuse instead. That doesn't make sense. But I did it. A lot.
When we take Responsibility for our mistakes everything always feels alot clearer.
When I make mistakes now, I own it, ponder on what I have learned and then move forward.
This is big for me as I spent most of my life trying to be the perfect person that making mistakes was a big no no.
A great blog to re-visit!
Thank you again for this tremendous blog.
In the past, in my mind, I equated mistakes with failure and I would do all I could to avoid failure because of a habit of perfectionism I had which was both nonsensical and debilitating.
So, in my life, this equivalence of mistakes with failure has resulted in me limiting myself immensely because I would all too often resist trying something new for fear of making mistakes.
Also, sadly, this fear I had of making mistakes, I know realise, contributed to the depression I felt at times because I would give up on something, an area of life, rather than make even more mistakes in an area where I perceived myself to be failing. And giving up on life, for me, has been a precursor to the state of depression.
Now, at this point in my life, I do understand that making mistakes is an element of the process of learning. I must admit, however, I still feel some discomfort at the thought of making mistakes and I have a little way to go to truly accepting myself making mistakes.
Having said all that, I find the author's take on mis-takes so very heartening.
I love it that, as the author says, we correct our mis-takes with our responsible re-takes. This is some true wisdom that would have been very useful to me when I was younger.
Thank you very much for this liberating and totally life enhancing blog.
I have just been pondering on how an increase in awareness and understanding can change how an event that one once considered to be a mistake feels.
I did not do well at university. I spent most of my time at university in a state of depression and I struggled academically.
I scraped through university and graduated with a 3rd Class Honours Degree. At the time, and for many years afterwards, I felt that getting a 3rd was the biggest mistake I'd ever made.
Having only a 3rd precluded me from most postgraduate courses and it affected my confidence when I entered the job market. I thought that I could not possibly get a decent job with only a 3rd, especially because the other applicants I would be competing against might have 2.1s or 1sts.
I gave myself a hard time for making the mistake of doing badly at university for years.
However, years later, the way I felt about this 'mistake' changed. As my understanding and awareness about myself and life has increased, I have come to realise that this seeming failure at university perhaps wasn't a mistake at all.
As crazy as it may sound to some, I feel that we are all born with a purpose to fulfill in life and I now feel that my life's purpose has never included academic success.
So, with the greater awareness and understanding I have developed over time, I have a new perspective on my experience at university and I no longer see graduating with a 3rd as a terrible mistake. It's simply an event which holds lessons that I can learn from.
Independent – 8 May 2019
A new research study has found that GPs are openly making mistakes because they are overtired, with the majority of doctors seeing more patients than they think is safe.
On average a GP is dealing with 41 patients per day despite 30 being a safe number.
50% said their workload that day was beyond safe levels and most said it represented a typical day.
As well as patient demand, there was a "workload dump" from secondary hospital care and this creates patient safety risks.
An example given was sending the blood test using the wrong patient details.
This GP raised safety concerns with governing bodies and was told to "shut up or my practice would be run over with a fine-toothed comb."
There is more but this gives us the main news story.
Our doctors in the community are unwell themselves and their job is to prescribe medicine for us but how can they if this is what is going on in our health system today.
We can blame government cutbacks, lack of funding (which has now become so boring to quote in the UK), patients coming in multi-symptomatic (which means more than one illness) and more and more getting sick, BUT blame will not change anything.
What if we all start to look at taking some Responsibility?
How many patients really do not need to bug the GP but they do because they can?
WHY are we as a country not united when it comes to the care of health professionals?
WHY do medical schools churn out doctors who have no clue about true self care?
We need to address the system that keeps us all moving in a direction that is failing.
The model of human life – how we are living – surely cannot be it if our GPs are making mistakes when we the general public expect them to be healthy and full of vitality. After all, they are the ones society has said can fix us, make us better by giving us the medicine or referring us on to the hospital for more tests.
How scary is it if we end up having the wrong name on a blood test and where could this end up if we do not make some serious and radical changes?
Is it time to question the very intelligence that puts ALL the focus on producing highly academic doctors but not on the value, importance and purpose of true self care and well-being which needs to be at the core of their teachings?
Things will get worse if nothing changes and we can expect more of these types of news stories.
The question is – what are we as individuals prepared to do or not do?
Can we really just sit back, accept it, have a moan and do nothing, or is there something we can do even if it is to start talking and having conversations about this type of news?
As this blog presents, we are not here on earth to be perfect but we can learn from our mistakes.
What will we learn from this news or do we need to have more mistakes before there will be any real change?


Off Topic (kinda): Do we have the Back To School organization tool for you!
August 11, 2016 by High Desert Frameworks!
Help the kids, family and mostly YOU get organized for the upcoming change!
Yep .. It's time to get ready for Back To School! What better way to stay organized and communicate important dates, times, events, school to do's and more than with your very own customized custom framed chalkboard frame and cork board!
Why text your kids when you can show your creative side and remind them with a post-it-note and pushpin!


text:
// Copyright (c) Samuel Cragg.
//
// Licensed under the MIT license. See LICENSE file in the project root for
// full license information.

namespace Crest.Host.Engine
{
    using System;
    using System.Threading.Tasks;
    using Crest.Abstractions;

    /// <summary>
    /// Allows the interception of specific status codes when sending a reply
    /// to a request.
    /// </summary>
    public abstract class StatusCodeHandler
    {
        private static readonly Task<IResponseData> NoResponse =
            Task.FromResult<IResponseData>(null);

        /// <summary>
        /// Gets the relative order this should be invoked in.
        /// </summary>
        /// <remarks>
        /// Lower numbers will be invoked before higher numbers (i.e. 100 will
        /// be executed before 200).
        /// </remarks>
        public abstract int Order { get; }

        /// <summary>
        /// Generates a response for 500 Internal Server Error.
        /// </summary>
        /// <param name="exception">The exception that caused the internal error.</param>
        /// <returns>
        /// A task that represents the asynchronous operation. The value of the
        /// <c>TResult</c> parameter contains the response to send.
        /// </returns>
        public virtual Task<IResponseData> InternalErrorAsync(Exception exception)
        {
            return NoResponse;
        }

        /// <summary>
        /// Generates a response for 204 No Content.
        /// </summary>
        /// <param name="request">The request to reply to.</param>
        /// <param name="converter">
        /// Allows the conversion to the requested content type.
        /// </param>
        /// <returns>
        /// A task that represents the asynchronous operation. The value of the
        /// <c>TResult</c> parameter contains the response to send.
        /// </returns>
        public virtual Task<IResponseData> NoContentAsync(IRequestData request, IContentConverter converter)
        {
            return NoResponse;
        }

        /// <summary>
        /// Generates a response for 406 Not Acceptable.
        /// </summary>
        /// <param name="request">The request to reply to.</param>
        /// <returns>
        /// A task that represents the asynchronous operation. The value of the
        /// <c>TResult</c> parameter contains the response to send.
        /// </returns>
        public virtual Task<IResponseData> NotAcceptableAsync(IRequestData request)
        {
            return NoResponse;
        }

        /// <summary>
        /// Generates a response for 404 Not Found.
        /// </summary>
        /// <param name="request">The request to reply to.</param>
        /// <param name="converter">
        /// Allows the conversion to the requested content type.
        /// </param>
        /// <returns>
        /// A task that represents the asynchronous operation. The value of the
        /// <c>TResult</c> parameter contains the response to send.
        /// </returns>
        public virtual Task<IResponseData> NotFoundAsync(IRequestData request, IContentConverter converter)
        {
            return NoResponse;
        }
    }
}

redpajama_set_name: RedPajamaGithub


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text:
Home SPORTS FIBA World Cup: Nigeria's D'Tigers overcome Cote d'Ivoire
FIBA World Cup: Nigeria's D'Tigers overcome Cote d'Ivoire
Nigeria's men national basketball team, D'Tigers, on Friday secured an 83-66 points win over Cote Cote d'Ivoire at the ongoing FIBA World Cup in China.
D'Tigers survived a late rally from the Ivorians to record their second win at the World Cup and also stay on course to pick an automatic ticket to the 2020 Olympics Games.
Friday's classification game started on an even note with both team trading baskets until Nigeria pulled away at 11-6 and then ending the first quarter 28-18 with a ten-point lead.
The Ivorians switched gear in the second quarter by going up 2 points at 30-32, but Nigeria quickly bounced back to take the lead with a 3 point shot from Ike Iroegbu to tie the game at 35-35 before pulling ahead to end the second quarter 37-35.
Nigeria won the first and third quarters while tying the 4th quarter 20-20 with Cote d'Ivoire winning the second quarter.
Nnamdi Vincent led all Nigerian scorers with 15 points while Cote d'Ivoire's Deon Thompson led all scorers with 19 points.
Nigeria and Cote d'Ivoire are familiar foes as during the final phase of the World Cup qualifiers, D'Tigers defeated the Elephants in Lagos 84-73 points before suffering an away 72-46 points defeat in Abidjan to hand the Ivorians a World Cup qualification lifeline.
Already, the Nigeria Basketball Federation, NBBF President, Musa Kida, said considering the financial implications of prosecuting the Olympics Qualification Tournament (OQT), it's important for the team to grab the only ticket on offer for Africa at the World Cup.
"Inviting players, camping them and playing the OQT will involve money which can be channeled to developing basketball back home. The boys are fully aware of what is at stake and the need to continue their winning run."
For D'Tigers to stand a chance of qualifying, they must win their games against Côte d'Ivoire (which they have done) and host- China to emerge as the highest placed team in Africa having enjoyed a better points deficit compared to the other four African teams.
D'Tigers
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Arinze Asuzu
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text:
GLBA and the California Privacy Act: Analyzing SB 1121's Change to the Financial Institution Carve-Out Provision
by the Privacy and Data Security Group
Less than three months after California passed the California Consumer Privacy Act of 2018 (CCPA), Governor Jerry Brown signed SB 1121 this week, making a number of technical and substantive changes to the law.
Of particular note: SB 1121 modifies the financial institution carve-out language in CCPA section 1798.145(e). While the change is a welcome development for entities subject to regulation under the Gramm-Leach-Bliley Act (GLBA), it does not grant full exemption from the CCPA. Therefore, GLBA-regulated entities that collect information online will need to analyze the CCPA's requirements and how they apply to a specific business.
The original carve-out language provided that:
"This title shall not apply to personal information collected, processed, sold, or disclosed pursuant to the federal Gramm-Leach-Bliley Act (Public Law 106-102), and implementing regulations, if it is in conflict with that law."
As we have previously discussed, that language raised a number of issues, such as what would constitute a "conflict" between the GLBA and the CCPA, and whether the language was even consistent with the GLBA insofar as personal information is not collected, processed, sold, or disclosed pursuant to the GLBA. The provision also failed to address the relationship between the CCPA and California's Financial Information Privacy Act.
The new language tries to resolve some of those issues, stating:
"This title shall not apply to personal information collected, processed, sold, or disclosed pursuant to the federal Gramm-Leach-Bliley Act (Public Law 106-102), and implementing regulations, or the California Financial Information Privacy Act … . This subdivision shall not apply to Section 1798.150."
The new language removes the phrase "if it is in conflict with that law," incorporates the California Financial Information Privacy Act, and adds a sentence providing that financial institutions are still subject to Section 1798.150. The preamble explains those changes as follows:
"The bill would also prohibit application of the act to personal information collected, processed, sold, or disclosed pursuant to a specified federal law relating to banks, brokerages, insurance companies, and credit reporting agencies, among others, and would also except application of the act to that information pursuant to the California Financial Information Privacy Act."
While the revised language is no doubt welcomed by GLBA-regulated entities, it should not be interpreted as a full exemption. Rather, GLBA entities will remain subject to the provisions and requirements of the CCPA if they engage in activities falling outside of the GLBA—which they almost certainly do.
By way of explanation, the GLBA regulates financial institutions' management of nonpublic personal information, which is defined in 15 U.S.C. § 6809 as personally identifiable financial information: 1) provided by a consumer to a financial institution; 2) resulting from any transaction with the consumer or any service performed for the consumer; or 3) otherwise obtained by the financial institution.
The CCPA defines "personal information" much more broadly to include "information that identifies, relates to, describes, is capable of being associated with, or could reasonably be linked, directly or indirectly, with a particular consumer or household." The CCPA identifies numerous examples such as online identifiers, Internet Protocol addresses, email addresses, browsing history, search history, geolocation data, and information regarding a consumer's interaction with a website or online application or advertisement. Notably, the CCPA's definition also includes any "inferences drawn" from any personal information that is used "to create a profile about a consumer reflecting the consumer's preferences, characteristics, psychological trends, predispositions, behavior, attitudes, intelligence, abilities, and aptitudes."
Therefore, to the extent that GLBA-regulated entities are using targeted online advertising, tracking web page visitors, and/or collecting geolocation data—to name a few examples—either through their web pages or apps, they will need to analyze the CCPA's requirements.
As for the new statutory language providing that "[t]his subdivision shall not apply to Section 1798.150," the impact of that sentence cannot be overstated.
Section 1798.150 sets forth a private right of action for consumers to seek statutory damages of not less than $100 and not greater than $750 "per consumer per incident or actual damages, whichever is greater" if the consumer's information "is subject to an unauthorized access, exfiltration, theft, or disclosure as a result of the business's violation of the duty to implement and maintain reasonable security procedures and practices." In other words, GLBA-regulated entities will still be subject to millions of dollars of potential damages if they experience a data breach.
Members of Ballard Spahr's Privacy and Data Security Group provide a full range of counseling, transactional, regulatory, investigative, and litigation services across industry sectors and help clients around the world identify, manage, and mitigate cyber risk. Our team of nearly 50 lawyers across the country includes investigators and advocates with deep experience in cyber-related internal and governmental investigations, regulatory compliance and enforcement matters, cyber-related crisis management, and civil and criminal litigation.
www.ballardspahr.com
(No claim to original U.S. government material.)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, including electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the author and publisher.
This alert is a periodic publication of Ballard Spahr LLP and is intended to notify recipients of new developments in the law. It should not be construed as legal advice or legal opinion on any specific facts or circumstances. The contents are intended for general informational purposes only, and you are urged to consult your own attorney concerning your situation and specific legal questions you have.
David M. Stauss
Kristen Poetzel
Malia K. Rogers
Privacy and Data Security


There are many different ways in the fashion industry to go about purchasing merchandise, between the networking that goes on and being the first to peek all the latest trends. Both current and upcoming trends can be found amongst the many attendees at Agenda Show. As an expanding styling brand it is imperative for us to attend conferences such as The Agenda Show. Numerous brands are under one roof and many opportunities arise to connect directly to the minds behind them all.
For our first time at the Agenda Show, we created behind the scenes content to show what a day as a buyer at an event like this really looks like. Buyers patrol the floor here at Agenda looking for the hottest trends and styles. Agenda gives Style Plug first account of the quality of clothes, in the midst of the mass display of clothes Style Plug curates items that grab the eyes of the fashion forward, and also those who are familiar with brand names such as Publish, FairPlay, G-Star Raw, DOPE, Elwood, and Civil Regime.


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Cannabis Community - 420 Singles - Marijuana Dating Site for the Cannabis community and all 420 friendly people.
Most importantly, it has become online dating computers and internet dating.
Collaborative filtering works by collecting the preferences of many people, and grouping them into sets of similar users.
The responses flooded in, confirming Tarr s suspicion that there was great demand for such a service among the newly liberated student population.
Every site now makes its own claims to intelligent or smart technologies underlying their service.