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Home / Courses / Herbal Safety Lesson
Herbal & Supplemental Safety
In the first section of the course, we will go over some background information on herbal and dietary supplements and how the gained popularity in the U.S.
Next, topics and questions regarding herbs and dietary supplement regulations within the United States are discussed, as well as basic safety knowledge on regulatory requirements, cautions, potential adverse effects, and herb-drug interaction.
Herbal & Dietary Supplements Gain Popularity
It was in the late 1960s when a lot of Americans began changing their feelings towards their own health and recovering from illness. Instead of tackling illness once it started, the focus of health started to revolve around disease prevention. People started to discover the therapeutic benefits of herbs and plants, and by the turn of the 21st century, United States medicinal herb sales totaled about $4 billion a year (Castleman, 2009).
Several trends caused a renewed interest in herbal remedies. For one, there was a new excitement for alternative healing arts such as Ayurveda medicine, naturopathy, Chinese medicine such as acupuncture, and Qi gong exercises. These healing arts especially make great use out of healing herbs and supplements.
Popularity of self-care and education regarding health also helped the herbal and dietary supplement industry increase its business. While mainstream Western medicine may lead the pack in scientific research and lead to great break-throughs in medicine, more often than not some feel modern medicine to be impersonal and costly.
Additionally, disdain for pharmaceutical drugs and their side effects have caused consumers to be pro-active in their search for remedies to their ailments that come with more "pros" than they do "cons".
We also see increase awareness in regards to the environment, climate change, and protection of tropical rainforest. Because of more notoriety of these issues, we see people becoming more concerned of how climate change and destruction of rainforests affect the plants, some of which are herbal medicines and many of which have not been screened for potential medicinal use (Castleman, 2009).
On an interesting side note, the National Cancer Institute and government agencies around the world have launched testing programs, hoping to find therapeutic components of the plants in these areas threatened with destruction (Castleman, 2009).
Furthermore, the educational system increased acceptance of alternative medicine after the 1980s (Castleman, 2009), and currently several prominently known schools such as John Hopkins University, Harvard University, and more now offer programs for degrees in alternative medicine.
To begin, licensing of health practices occurs on the state level. According to the American Herbalists Guide (AHG), there is currently "no licensing or certification for herbalists in any state that precludes the rights of anyone to use, dispense, or recommend herbs. However, naturopathic and acupuncturist licensing laws include clauses and define natural remedies and specifically herbal remedies within the scope of licensed practice. Besides a membership to the AHG, non-licensed credentials can be provided by the NCCAOM through the Diplomate in Chinese Herbology.
The First Amendment of the Constitution protects the right to free speech when providing information to clients related to their health (AHG, 2015). Medical practice is regulated on the state level, and any licensed Chiropractor recommending herbal supplements to their patients should keep abreast of the state statues in which they practice. When dispensing herbs to any patient, it is important to describe the herbal supplement as an aide that may assist in improving their condition or needs.
Herbs should not be described as diagnostic, preventive, treating, or that they cure disease indefinitely because using this language may violate the Food and Drug Administration (FDA) and Federal Trade Commission (FTC) regulations regarding product claims, especially since in that context the herbal remedy can be considered an unapproved drug (AHG, 2015). If dispensing herbs to patients be clear and transparent in the description of use and have them sign an Informed Consent and Disclosure document that puts in writing everything you discussed with them regarding the use of the herb.
The FDA
The FDA or Food & Drug Administration was established in 1928 but was limited in their authority and somewhat lax about their drug safety standards. After an antibiotic concoction of sulfanilamide killed 107 people because it contained a harmful ingredient, Congress passed the Food, Drug, and Cosmetic Act, which lead to the very first United States Drug regulations.
It was around 1960s when the FDA decided to implement higher drug safety standards after witnessing the effects of approximately 10,000 European babies born with phocomelia, a condition characterized by the shortening or absence of limbs. These birth defects were the side effect of the over-the-counter sleeping aide, Thalidomide.
Thalidomide was marketed as sleeping aide and sedative in the post-war era, entering the German market in 1957, when sleeplessness among the population was quite common.
Additionally, thalidomide was the only non-barbiturate sedative known at the time, which made the drug very popular. After the success of thalidomide in the European market, the drug company hosting the drug petitioned it to the FDA in 1960 to be allowed in the United States market.
In short, the drug was never licensed for production and distribution within the United States; it was however distributed as samples to physicians, to give to their patients to try. The physicians would then document the results of the drug on their patient. Since there were no guidelines to govern clinical trials of new drugs at the time, this was typically how the drugs were tested with little consent or knowledge on behalf of the patient. Thalidomide did impact a small amount of Americans (Botwin Raphael, 2014).
Aside from the drugs apparent sedative effects, an Australian obstetrician noticed that it had positive effects for alleviating the morning sickness associated with pregnancy, and began recommending the drug for this off label purpose. The additional recommendation for Thalidomide unfortunately became a trend worldwide, ultimately leading to devastating birth defects for newborns.
From this point on ward, the FDA began stepping in to the drug manufacturing and regulating process, creating the strict oversight and quality control we see today.
The Dietary Supplement Health & Education (DSHEA) Act of 1994
The Dietary Supplement Health and Education Act of 1994 (DSHEA) is a piece of legislation that regulates the manufacturing of dietary supplements, herbs, and it defines supplements as foods, not drugs.
The reason being for this is to ensure high quality, natural food-supplements, and in addition to side step the drug approval process, which can be very costly. If supplements were categorized as drugs, chances are many of them would fall off the market due to the expense of getting them through new drug approval (Alliance, 2016). The DSHEA only defines permissible labeling claims and places the responsibility on the Food and Drug Administration to show that a product may be inconsumable. It also outlines safety requirements for new dietary ingredients (Alliance, 2016).
The DSHEA describes supplements as "vitamins, minerals, herbs, botanicals, amino acids, substances such as enzymes, organ tissues, glandulars, metabolites, extracts, concentrates, that may be found in forms such as tablets, capsules, soft gels, liquids, or powders." Herb Labeling requirements include – statement of identity, net quantity of contents, directions for use, other ingredients in descending order of predominance and by common name or proprietary blend (AHG, 2015).
Often times people may relate the word "herb" or "supplement" to "good", "natural", and/or "healthy", but this is not always the case. Herbs are defined as dietary supplements, which enable the manufacturers to produce, sell, and market herbs without first demonstrating safety and efficacy, as is mandatory for pharmaceutical drugs (Bent, 2008).
While the FDA does not provide as strict regulation to the supplement industry as it does the drug industry, it still controls two important aspects of the supplement market. One being good manufacturing practices, and two, product labeling.
There are many herbs that provide us with positive effects but there are others that can be quite harmful to the body if taken in excess, such as ephedra (ephedra may induce hypertension, restlessness, tremors, or tachycardia) as one extreme example.
Ephedra is a derivative of the ma huang herb. In this case, according to Jack Miller, a licensed acupuncturist and President of Pacific College of Oriental Medicine, "If one of the dozens of chemical compounds found in any herb is isolated, concentrated and then used as a drug, there is definitely an increased possibility of toxicity and negative effects. This is compounded when the herb is used for conditions not traditionally indicated" (Miller, 2014).
Due to the contraindications surrounding ephedra and several reports from individuals taking ephedra, in 2004 the Food and Drug Administration (FDA) banned the sale of ephedra dietary supplements because of the adverse reactions people were reporting.
The supplement industry was doing very well by selling the weight loss products containing ephedra and challenged the FDA's ban. One year after the ban, a federal judge in Utah stated that the FDA had not proven that low doses of ephedra are harmful, and thus "struck down" the FDA's action (Kilham, 2013). However, the case was taken to the 10th U.S. Circuit Court of Appeals, which reversed the action of the Utah judge and reinstated that ephedra is still illegal in certain quantities.
This ban is still in effect today and carries over into the realm of professional sports. For example, if a professional athlete tests positive for ephedra, this could disqualify them from competing/playing their respective sport professionally (Kilham, 2013). Adverse effects of ephedra are anxiety, irritability, tachycardia and potential nausea to name a few.
Due to the adverse reactions and incidents reported from ephedra usage, some of these including death, the FDA stepped in and issued a ban against ephedra (FDA, 2004). One source reports that the supplement was linked to 155 deaths (MSN, 2004).
Herbal Supplement & Drug Interactions
While certain supplements can enhance and protect components of our health, there are cases where the effects of supplements may be the opposite.
Some herbal supplements can have interactions with prescription drugs, over-the-counter medications, or interfere with cancer interventions such as chemotherapy.
It is important to be aware of the risk factors associated with combining prescription medications with herbal and dietary supplements. Herbal supplements such as echinacea, St. John's Wort, calcium, ginko biloba, and several others may cause harmful side effects if used in conjunction with certain medications.
A recent study published in the International Journal of Clinical Practice, discovered that herbal and dietary supplements sometimes caused reactions in the body because the supplements may alter the pharmacokinetics of the prescription medications (Ernst, 2012). Pharmacokinetics meaning how the drug is absorbed, it's distribution, it's metabolization, and its elimination within the body (Garcia 2012) (Ernst, 2012).
Researchers studied 213 different herbal and botanical supplements, evaluating their interaction with 509 prescription medications. They found nearly 900 adverse reactions resulting from those interactions (Garcia, 2012) (Ernst, 2012).
The study found that herbal supplements like ginkgo and echinacea were more likely to have an adverse interaction with prescription medications than vitamins, amino acids or minerals such as iron or calcium, the study found (Garcia, 2012) (Ernst, 2012).
Many of the complications included heart problems, chest and abdominal pains, and headaches. Patients taking medications for issues involving the cardiovascular system and central nervous system were more likely to experience adverse events (Garcia, 2012) (Ernst, 2012).
In addition, more common side effects presented themselves as gastrointestinal issues from taking prescription drugs and supplements, accounting for 16% of the cases. Neurological complications can also occur, and according to the study accounted for 15% of the cases (Garcia, 2012) (Ernst, 2012).
Prescription drugs to be on the look out for in your patients: aspirin, insulin, warfarin, ticlopidine, and diogoxin (Garcia, 2012). These drugs had the greatest amount of adverse interactions and the herbal supplements flaxseed, echinacea and yohimbe had the greatest amount of side effects (Garcia, 2012).
Scientists say the findings are the "tip of the iceberg," of much needed research in this area and are also calling for more government control over the use of such herbal and dietary supplements. Researchers also stress the dangers of combining prescription medications with herbal remedies and dietary supplements (Garcia, 2012).
Another source mentions a study from the Journal of Parenteral and Enteral Nutrition, where the researchers found that most herbal supplements exert little to no benefit in the body, with the exception of omega-3s and Vitamin D, which have been proven to be effective (Jackson, 2012).
Vitamin K & Coumadin/Warfarin
Coumadin, the prescription blood thinner (anticoagulant) used to prevent blood clotting, can have a reduced effectiveness from taking Vitamin K. So why and how does Vitamin K reduces the effectiveness of Coumadin?
Well, for starters, vitamin K is used by the body to initiate clotting factors in the blood, to stop the body from loosing too much blood during an injury.
Individuals who have heart disease may use Coumadin to prevent blood from clotting in blood vessels, veins, and arteries, especially if they are already narrowed. As we know, if blood cannot easily pass through these vessels, stroke may occur. Coumadin will help thin the blood, especially in these areas.
Since vitamin K has the opposite effects (initiating coagulation), this could negatively impact the effects of Coumadin has on the patients' blood.
St. John's Wort vs. Prescription Birth Control and Anti-depressants.
Today, the herb is touted for its anti-depressant effects. According to a systematic review published in 2005, St. John's Wort can be helpful in the treatment of mild to moderate depression (Murlow, 2005). For individuals coping with severe depression, two separate studies published in 2001 and 2002 revealed St. John's Wort to be ineffective.
This herb contains an important compound called hypericin, the primary source of its anti-depressant effects. Additionally, St. John's Wort contains antiviral compounds and immune-boosting chemicals called flavonoids, making it beneficial against viral, bacterial, and fungal infections (Castleman, 2009).
In regards to treating depression, it appears that St. John's Wort has some affect on mood by increasing the level of neurotransmitters serotonin, norepinephrine, in addition to levels of dopamine, GABA, and L-glutamate. Compared to other anti-depressants, this herb has a wide spectrum of action. The potent ingredient is the chemical called hypericin, which has a similar mechanism of action to common anti-depressants like Prozac and Zoloft (Schneider, 2006).
St. John's Wort, a popularly used herb in the treatment of minor depression, can promote the breakdown of prescription birth control and antidepressants, which in turn, reduces their effectiveness. Because herbal supplements are not subject to the same testing or the same post-marketing watch as the FDA approved pharmaceutical drugs are, these interactions are often unknown (ABC, 2011).
St. John's Wort is an interactive herbal product, and has been shown to interfere with numerous drugs metabolized by the cytochrome P-450 liver enzyme system, including protease inhibitors (commonly used in HIV patients), chemotherapeutic agents, and oral contraceptives (Basch, 2003).
The active compound, hypericin, found within St John's Wort, is highly active in a broad range of viral infections, including influenza, herpes, polio, hepatitis C, and HIV. It can additionally combat several types of bacteria. In 1988, research at the Weizmann Institute in Israel and New York University discovered that hypericin has dramatic activity against HIV.
This in turn sent many people to stores to purchase St. John's wort, and some have reported beneficial effects from taking the herb, one of them being improved immune function.
In the late 1990s, protease inhibitors entered the medical scene as powerful AIDS drugs. The hype around St. John's wort slowly started to wear down. Interestingly enough, individuals who take protease inhibitors should not use St. John's Wort because the herb interferes with the actions of these drugs (Castleman, 2009).
Consumption of St. John's Wort has caused AIDS patients to lose control of their HIV because the herb caused an interaction, which eliminated their anti-viral drugs within the body too quickly, states Dr. Raymond Woosley, MD, and PhD. Dr. Woosley also mentions that 40% of patients do not tell their physicians that they are taking herbals, even when asked, and most patients are not asked this important question.
Additionally, St John's wort has caused individuals to reject transplanted organs because it interferes with cyclosporins, drugs used to control organ transplant rejection.
Some side effects of St. John's wort can include GI upset, dry mouth, constipation, dizziness, and restlessness. Individuals with bipolar disorder should not consume St. John's Wort because it may induce mania (Schneider, 2006). If the individual is already on anti-depressant drugs such as SSRI's, this herb should not be taken in conjunction.
Please be advised that interactions with St. John's wort and HIV drugs, oral contraceptives, cyclosporine (to control organ transplant rejection) digoxin, theophylline, anticonvulsants, and triptans (drugs to treat migraine symptoms) may occur (Schneider, 2006).
For some individuals, glucosamine oral supplements or injections may be a great choice to help increase joint strength and reduce joint related pain. However for some individuals it may not be the most appropriate choice.
Glucosamine supplementation is typically contraindicated if the individual has shellfish allergies, diabetes, bleeding disorders, or is pregnant or planning to become pregnant, to name a few.
The reason why it is recommended that individuals with shellfish allergies not take glucosamine is because this product comes from shellfish such as shrimp and crab. Shellfish contain glucosamine sulfate, which typically causes the allergic reaction such as throat swelling, diarrhea, contact uticaria, and others.
It is worth mentioning however, that there are conflicting sources in regards to what component of shellfish contain the allergy inducing protein. One source states that glucosamine is produced from the shells of shrimp, lobster and crab, while it is actually the meat of the shellfish that causes the allergic reaction. In contrast, a research article published in 1984 states that it is the shell that causes the swelling and redness (Nagano, 1984).
However there are some manufacturers of glucosamine supplements on the market that offer a product with reduce levels of the shellfish allergen that may cause the allergic reaction. When suggesting dietary supplements to patients, such as glucosamine, it is highly recommended to ask if they have any allergies prior to taking this supplement.
Additionally, those with iodine allergies should avoid glucosamine.
For individuals who have diabetes, supplementing with glucosamine for joint pain may not be the best idea.
Glucosamine is a sugar that utilizes a few glucose processing pathways. The pathway it is processed through is called the "Hexosamine Biosynthetic Pathway", which takes part in glucose control AND the development of insulin resistance – the hallmark cause of type 2 diabetes (Love, 2005). Additionally, glucosamine is used in laboratory settings to induce insulin resistance to help study the condition of diabetes, and how to treat it with drugs.
Animal studies have also concluded that glucosamine interferes with the liver's ability to regulate glucose production, the intake of the glucose from surrounding tissue, and the production of insulin in pancreatic beta cells.
In a person with diabetes, the amount of insulin needed to regulate blood sugar levels in the body is insufficient. With this lack of needed insulin, glucose is not absorbed the right way, and we see too high or too low levels of sugar circulating in the blood.
In conclusion, a research study published in 2007 by the American Journal of the Medical Sciences found that individuals taking 1500mg of glucosamine per day for 6 weeks, who already have poor insulin sensitivity, will increase their risk for diabetes if they supplement with glucosamine (Pham, 2007).
Therefore, glucosamine supplementation is not the best option for individuals overweight or at risk for diabetes.
The Benefits of Certain Dietary & Herbal Supplements
Omega-3s & Healthy Joints
While Omega-3 fatty acids or EPA/DHAs are excellent for a wide variety of health components, we will highlight to areas where omega-3 supplementation, or simply consuming it regularly within the diet, can be particularly beneficial.
First are omega-3 EPA/DHA's uses for joint lubrication and bodily function. Secondly are its applications in improving and stabilizing mood. As we will find out, omega-3 EPA/DHA can be very helpful for individuals coping with depression or mood disorders, and the research says so.
For joints and other inflamed tissues, omega-3s have the ability to reduce wear and tear in these specific areas, and all other areas of the body. Joints, as we know, need lubrication to move and function effectively, and omega-3s are excellent in treating sore joints because they help keep protect the area and keep it smooth for motion.
Inflammation can be a common cause of joint and arthritic pain. Luckily, omega-3s exert their influence directly in the cell membrane. Inside the cell membrane are enzymes called COX.
This next step is important: In an effort to protect the membrane and vital nutrients inside each cell, the Cox enzymes inside the membrane biochemically convert the omega-3 EPA/DHA into potent anti-inflammatories to protect the cell from excess inflammatory chemicals. These chemicals are called cytokines, which bring on the inflammation that lead to wear and tear in the body.
In these cell membranes, we also find omega-6 fatty acids, or arachidonic acid. Omega-6 fatty acids in excessive amounts within the body can be pro-inflammatory.
However as long as omega-3 and omega-6 fatty acids are in balanced amounts, the cell can protect itself with inflammation that actually helps the body, such as fighting off foreign germs that get you sick, but leaving the healthy cells alone.
Now, when we consume a high fat, high sugar, high carbohydrate meal with few omega-3s and ample amounts of omega-6s, the blood and cell membranes are swarmed with omega-6 fatty acids; not a good thing.
Remember those important COX enzymes that are used inside the cell membrane to convert the good omega-3 EPA/DHA into anti-inflammatories? Well now, those COX enzymes are stolen by the harmful omega-6 fatty acids for their own use, converted into PRO-inflammatories, and not enough are left for use by the omega-3s.
Hence, the result you get is an imbalance of the fatty acids, with a surplus of the pro-inflammatory omega-6s; painful or achy joints included.
In 2012, a systematic review was conducted exploring the effects of marine n-3 polyunsaturated fatty acids (or in other words, omega-3s), on immune functions for their effects and clinical outcomes on rheumatoid arthritis.
In conclusion, the study indicated that the types of omega-3s found in seafood and fish oil may be modestly helpful in alleviating some of the symptoms of rheumatoid arthritis (Miles, 2012).
After reviewing results of the study, researchers also noted that many of the participants explained that when taking the fish oil, their morning stiffness was brief, and less joint swelling in pain, which in turn lowered their need for anti-inflammatory drugs to control their symptoms (Miles, 2012).
Omega-3s & Depression
In one recent study, brain researchers found that omega-3 EPA/DHA helps to improve the effectiveness of anti-depressant drugs by helping the serotonin molecules fit better into the receptor sites on brain cell membranes.
In one study, 60 patients with a diagnosed major depressive disorder were dividied into three groups. Group 1 received 1000mg of EPA fish oil daily, group 2 received, 20 mg of Prozac daily, and the 3rd group received a combination of the two (1000mg of EPA fish oil and the Prozac).
The results presented that the combination of Prozac plus EPA was more effective than either of them alone. The results of those who received EPA alone compared with the group who received Prozac alone showed that both are equally effective, but the fish oil takers suffered no side effects.
Other studies show clear benefits of omega-3 fish oil for depression and bipolar disorder were impeccably convincing that the American Psychiatric Association now recommends a dosage greater than 1000mg per day of EPA/DHA fish oil in addition to appropriate psychotropic drugs to treat certain mood disorders.
Another research study conducted on seventy six young adults and adolescents ages 13-25 years old, with early mood disorders, were given doses of 700 mg of EPA and 480 mg of DHA. This group was compared with a placebo group, and the conclusion of the study was that the group given the EPA and DHA supplement showed fewer depressive symptoms and a slower progression of psychoses.
In conclusion research studies have shown that the dosage for beneficial results for mood disorders is 1000-6000 mg (1-6 grams) of EPA per day, with most studies finding positive results at 2000 mg (2 grams) of EPA per day.
Therefore we can conclude that while omega-3s can be great for improving joint swelling and pain, and they are also excellent for stabilizing mood.
Comfrey is a herb that has popular uses as a topical application for easing joint & back pain and also has uses in promoting wound healing. Interestingly enough, this herb has roots in uses dating back to the 1st century A.D., where the Greek physician Dioscorides began prescribing comfrey tea internally for respiratory and gastrointestinal problems. Additional uses for comfrey around this era and after it included fever, gout, hemorrhoids, gangrene, diarrhea, dysentery, and menstrual problems, to name a few.
By the mid 1990s herbalists ceased to recommend comfrey for internal uses because of its potential to cause liver damage. Pyrrolizidine alkaloids, or PAs, are a chemical within the comfrey herb that, in high concentrations, can cause serious liver damage. There have been several human cases of poisoning that were reported after long-term usage of comfrey (Castleman, 2009).
One of comfreys popular uses is topically for the treatment of arthritis or joint & back pain. While comfrey does contain a toxic chemical, only small amounts of this herb used topically can be absorbed through the skin. Transdermal comfrey is not digested, and therefore poses no hazard to the liver.
It is important to note that tests by the FDA researchers have proven that PA content of comfrey varies greatly, and the root of the herb, most often used by those in herbal medicine, contains the highest concentrations. While there has been some claims that PA chemicals are not water soluble, and therefor consumption of comfrey tea is safe and free of PAs, has not been similar to the FDAs research (Castleman, 2009). FDA scientists have identified PAs in comfrey tea as well, indicating comfrey tea unsafe for ingestion due to the potential harmful effects it can have on the liver.
According to one study conducted by German researchers, 220 individuals with painful arthritis of the knee were given either a placebo ointment or a comfrey cream (2 grams, three times per day). After 3 weeks, the comfrey cream provided significantly greater pain relief. At the end of the trial, a reduction of pain by 58.0% was recorded for the comfrey group versus 14.1% for the placebo group.
The results of this study ultimately conclude that Kytta-Salbe comfrey root ointment can be effective for the treatment of osteoarthritis of the knee. The researchers identified that pain was reduced, mobility of the knee was improved, and quality of life was increased (Grube, 2007).
The authors of the study mention that because the comfrey root ointment was significantly superior to the placebo medication with regard to all the parameters, the study identifies the therapeutic efficacy of the comfrey root ointment in the treatment of painful osteoarthritis of the knee (Minigh, 2017).
A separate group of German scientists gave a placebo or comfrey ointment to 142 men with sprained ankles. Yet again, scientists discovered significantly greater pain relief in the group given the comfrey ointment (Castleman, 2009).
Additional therapeutic uses for comfrey lie in it's ability to help protect skin and promote the growth of new skin cells. The chemical comfrey contains that allows this herb to have such positive wound healing effects is called allantoin. Some studies show that the herb also helps reduce inflammation in compliments to it's wound healing abilities.
According to the FDA, allantoin is safe in concentrations up to 2%, and is regulated by the FDA when used in skin preparations (CFR, 2016). Allantoin can be found in several over the counter products for dry skin, diaper rash or radiation therapy.
Arnica is another popular herbal supplement that finds its uses in injuries, muscle soreness, and pain, and is typically prescribed by homeopaths. Developed by Germany physician Samuel Hahnemann in the 1830s, homeopathy was very controversial because it used micro-doses of medicines to treat certain ailments. Under the scrutiny of modern pharmacology, they insist that these treatments are so dilute they could not possibly exert any effect.
However, the majority of studies show benefit for this herb, and in homeopathic doses, it can be safe and inexpensive (Castleman, 2009).
For muscle soreness, Norwegian researchers evaluated the effects of runners in Oslo marathons in 1990 and 1995. There was a total of 82 runners in the trial, and half were either given arnica or a placebo. Five pill starting the evening prior to the races and then morning and evening of the race day, including 3 days after. In conclusion, the arnica group reported less muscle soreness than the placebo group (Bruset, 2003).
Furthermore, muscle soreness immediately after the marathon run was lower in the Arnica group than in the placebo group (P = 0.04). Cell damage measured by enzymes was similar in the Arnica and the placebo group (Bruset, 2003).
According to a study published in 2007 by Swedish researchers, topical arnica gel was found to be equally as effective as NSAIDS in reducing osteoarthritic pain of the hand.
In the study, researchers looked at 204 participants from 20 Swiss clinics who had osteoarthritis of the fingers and hands. Half of the participants were given topical arnica gel, the other half was given topical ibuprofen (5%). This was given 3 times per day for three weeks, and study participants left a 4 centimeter gel strip on the arthritic joint for an hour before washing hands.
Upon conclusion of the study, those who used the arnica jell reported 26.6% less pain compared to the 23.9% of the NSAID group. Topical gels, such as an arnica ointment, may be a preferred alternative to individuals wanting to avoid the internal side effects of taking NSAIDs (Castleman, 2009).
Please be advised that it is unsafe to ingest arnica plant material because it is poisonous. High doses of the plant may cause vomiting, nausea, gastrointestinal upset, or potential coma, cardiac arrest, or death. Pregnant or nursing women should also be advised to not consume arnica. Additionally, depending on the individual, arnica may cause allergic reactions or side effects. In the case of homeopathic dosages, where consumption of arnica is too minimal to cause issues, any current medications the patient is on should be evaluated as problematic herb-drug interactions may occur (Castleman, 2009).
Evaluate Patient History & Current Medications
Prior to recommending a herb or supplement to a patient, obtain a list of medications they are currently taking and evaluate if it would still be beneficial for the patient to supplement with the herb or dietary supplement in question.
Does the patient have diabetes? Are they pregnant or planning on becoming pregnant? Is the patient on any blood thinning medications? Do they have severe allergies? If yes, what are they? And so-on and so forth.
If the patient wants to do further research on the herbal supplement that is recommended, provide them with reliable sources to do so.
Stop Herbal Supplements Prior to Surgery
If you aware your patient is taking herbal or dietary supplements and they have an up-coming surgery, it would be best to recommend them to stop taking the herb or supplement at least 2 weeks prior to the surgery date, OR to at the very least, encourage your patient to inform their physician of any herbal or supplemental products they are currently on, prior to surgery.
For safety precautions, the operating physician may recommend that the patient discontinue the herbal/supplemental product further in advance.
While it is important to be aware if the patient is taking herbal/dietary supplements, this should also be communicated transparently to the doctor. This is important and especially pertinent if the patient is taking anticoagulant herbal products. Some anticoagulant herbal products include evening primrose oil, garlic, ginger, turmeric, and white willow (Castleman, 2009).
According to a research study conducted in 2008 by the Journal of General Internal Medicine, lead by Stephen Bent, the results showed that there is limited scientific evidence to establish safety and efficacy of most herbal products. More funding for research, changes in herbal regulation, and increased scientific evidence are needed to prove these products as an efficient alternative to standard medical therapies (Bent, 2008).
It is therefore the duty of providers to be aware of the research in regards to herbal & dietary supplements, to also be aware of the patients' medical history and background when recommending health supplements.
It is recommended to take into account the following before assigning any patient on a herbal supplement regime: list of current medications, previous reactions to herbs taken, history of depression/anxiety, any heart conditions, and any other medical conditions.
Case Study – Mislabeled Herb Causes Renal Failure
In one case study published in the Journal of Alternative and Complementary Medicine in 1998, a herb called Aristolochia fangchi was mislabeled as Stephania tetrandra.
The mislabeled Stephania tetranda was used in a weight loss program for 100 patients, and the misnamed herb ultimately caused the development of renal disease in these patients. The journal article titled "Misuse of herbal remedies: the case of an outbreak of terminal renal failure in Belgium (Chinese herbs nephropathy", ultimately expresses the need for tighter control on Chinese herbs (Vanherweghem, 1998).
In 2009, a woman from Missouri filed a cause of malpractice against a medical doctor and Traditional Chinese Medicine (TCM) provider for prescribing herbs that caused her to suffer kidney failure. The herbs contained aristolochic acid, a naturally occurring toxin, and when consumed can cause permanent kidney failure or cancer of the urinary tract. The FDA issues a strong warning for consumers to avoid this herb (medicinenet.com). Since the provider failed to warn her of the herbs alleged side effects, she argued that this fell below the standard of care.
Several incidents of aristolochic acid-related nephropathy have been reported elsewhere in recent years. "Since using a complementary and alternative therapy invariably deviates from the standard of care, physicians cannot undertake a responsible, measured integration of such therapies in clinical practice without risking malpractice exposure," states Michael H. Cohen, a Newport Beach, California, attorney who specializes in alternative medicine law (Heller, 2009).
Several articles from previous years have also expressed concern in mercury, arsenic, lead and other highly toxic compounds in Chinese herbal formulas. But if inspected, the vast majority of Chinese herbal formulas are safe, effective and free of contaminants. An analysis of the California FDB (Food and Drug Branch) report shows that the problem of contamination in Chinese patent formulas is far less widespread than portrayed in previous reports.
The mission of the California FDB is to "improve the health of all California residents by assuring that foods, drugs, medical devices and certain other consumer products are safe and are not adulterated, misbranded nor falsely advertised; and that drugs and medical devices are effective" (California Department of Public Health).
It is still advised to get all herbal supplements from a reputable source that has standards in checking the formulas for naturally occurring contaminants and potentially deliberates adulteration of herbal formula (Puertas, 2015).
Unfortunately, the true frequency of side effects for most herbs is not known because most have not been tested in large clinical trials and because surveillance systems are much less extensive than those in place for pharmaceutical products. A 2001 review conducted by the Office of the Inspector General concluded that surveillance systems designed to detect adverse reactions to herbs are inadequate and probably detect less than 1% of all events (HHS, 2001).
Expert commentary in published articles from 2002 proposed a variety of helpful and worth while suggestions to change the regulation of herbs that could improve the safety and appropriate uses of these products (Lewis, 2002) (Marcus, 2002).
The expert suggestions include:
(1) Requiring manufacturers to register with the FDA
(2) Mandating safety tests similar to those required for over-the-counter drugs
(3) Requiring all health claims to be supported by data approved by the FDA
(4) Ensuring that product labels provide an accurate list of all ingredients (Bent, 2008).
There is limited rigorous scientific evidence and research studies conducted on the topic to establish the safety and effectiveness of most herbal products (Bent, 2008). According to the article, of the top 10 herbs, only five of them (ginkgo, garlic, St. John's wort, soy, and kava) have scientific evidence suggesting efficacy (Bent, 2008).
However if the individual investigating consuming the herb has concerns over safety regarding herb-drug interactions, they may elect against it. Additionally the decision to take a herb may hinge on the recommendation of the patients primary care doctor. Weighing in the consideration of other medical therapies that the doctor presents as more effective than herbs, (due to lack of research indicating efficacy) may hinder the decision to use herbal products.
(2015). Legal and Regulatory FAQs. American Herbalists Guild (AHG): An Association of Herbal Practitioners.
Bent, S. (June 2008). Herbal Medicine in the United States
Review of Efficacy, Safety, and Regulation. Journal of General Internal Medicine. Doi: 10.1007/s11606-008-0632-y
Vanherweghem, LJ. (1998). Misuse of herbal remedies: the case of an outbreak of terminal renal failure in Belgium (Chinese herbs nephropathy). Journal of Alternative and Complimentary Medicine. 4(1):9-13.
Puertas, L. (2015). The Truth about Contamination in Chinese Patent Medicines. Acupuncture.com: Gateway to the Chinese Medcine, Health and Wellness.
Miller, J. (2014). Ma Huang Herb Misused and Abused. Pacific College of Oriental Medicine.
Heller, M. (2009). Chinese Medicine Doctor Sued over 'Dangerous' Herbs. On Point News.
Alliance for Natural Health USA. (2016). Dietary Supplement Health and Education Act (DSHEA).
Jackson, I. (2012). Dietary Supplements carry Potential Risks and Provide Little Benefit: Report.
Ernst, E. (2012), Interactions between drugs and supplements: the tip of an iceberg?. International Journal of Clinical Practice, 66: 1019–1020. doi: 10.1111/ijcp.12007
Dietary Supplements with Prescription Drugs May Cause Complications. (October 31, 2012). M. Garcia.
Dietary Supplements Carry potential risks and provide little benefit: Report. (October 18, 2012). I. Jackson.
Flemmer, M., Marik, P.E., Do dietary supplements have beneficial health effects in industrialized nations. What is the evidence? Journal of Parenteral and Enteral Nutrition JPEN. March 2012 36 no. 2 159-168. Published online before print January 24, 2012, doi:10.1177/0148607111416485
Alere Staff. (2016). Spinach, Vitamin K and Warfarin. PTINR.com
NIH. (2011). Dietary Supplements: What you need to know.
Woo, C. K., & Bahna, S. L. (2011). Not all shellfish "allergy" is allergy! Clinical and Translational Allergy, 1, 3. http://doi.org/10.1186/2045-7022-1-3
Allergic contact urticaria caused by raw prawns and shrimps: three cases. Nagano T, Kanao K, Sugai T. J Allergy Clin Immunol. 1984 Oct; 74(4 Pt 1):489-93.
Glucosamine Sulfate Safety and Side Effects. (2017). RX List.com.
What is Coumadin? – Important information. (2017). Drugs.
St John's wort: a systematic review of adverse effects and drug interactions for the consultation psychiatrist. Hammerness P, Basch E, Ulbricht C, Barrette EP, Foppa I, Basch S, Bent S, Boon H, Ernst E, Natural Standard Research Collaboration.
Psychosomatics. 2003 Jul-Aug; 44(4):271-82.
St John's wort for depression–an overview and meta-analysis of randomised clinical trials.
Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D
BMJ. 1996 Aug 3; 313(7052):253-8.
Schneider, E.L., Hirschman, L.A. (2006). What your doctor hasn't told you and the health store clerk doesn't know – The truth about alternative treatments and what works.
Pham T, Cornea A, Blick KE, Jenkins A and Scofield HR. Oral glucosamine in doses used to treat osteoarthritis worsens insulin resistance. The American Journal of the Medical Sciences 2007; 333(6):333-339.
St. John's Wort may block the effects of the pill. ABC News.
Castleman, M. (2009). The new healing herbs. The essential guide to more than 125 of natures most potent herbal remedies.
Love DC, Hanover JA. The Hexosamine Signaling Pathway: Deciphering the "O-GlcNAc Code". Science Strike 2005; 312: 13
France de Bravo, B., Weerasingh G.R. (2015). Glucosamine supplements: Good for joints but possibly risky for diabetes.
Sears, J., Sears, W. (2012). The Omega-3 Effect.
Miles EA, Calder, PC. (2012). Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis.
NIH. (2015). 7 Things To Know About Omega-3 Fatty Acids.
Castleman, M. (2009). The new healing herbs.
Kilham, C. (2013). Ephedra: A Beneficial and controversial herb.
Botwin Raphael, M., Cronin, E. (2014). Born without arms or legs: The secret legacy of thalidomide.
Carias, E., Samaras, A.T., Fintel, B. (2009). The thalidomide tragedy: lessons for drug safety and regulation.
All the Americans will pull together… The Federal Government's Evolving Role in Dealing with Disaster: Thalidomide Drug Crisis 1960s. Emory Libraries & Information Technology.
Minigh, J. (2017). Comfrey Root Ointment Reduces Pain in Patients with Knee Osteoarthritis.
Grube B, Grunwald J, Krug L, Staiger C. Efficacy of a comfrey root (Symphyti offic, radix) extract ointment in the treatment of patients with painful osteoarthritis of the knee: results of a double-blind, randomised, bicenter, place-bocontrolled trial. Phytomed. 2007;14( 1):2-10.
CFR. (2016). Code of Federal Regulations Title 21. Title 21 – Food & Drugs, Chapter I – Food and Drug Administration.
Bruset, S. Tveiten D. (2003). Effect of Arnica D30 in marathon runners. Pooled results from two double-blind placebo controlled studies.
Arnica soothes osteoarthritis pain in hands. Rheumatology International: 2007; Vol. 27, No. 6, 585-91.
FDA. (2004). FDA Issues Regulation Prohibiting Sale of Dietary Supplements Containing Ephedrine Alkaloids and Reiterates Its Advice That Consumers Stop Using These Products.
NBC. (2004). Nationwide ban on ephedra goes into effect.
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A friend recently told me that she got teary eyed watching an advertisement for a coffee brand. Safe to say she doesn't generally get emotional about caffeine. It was the music in the background that triggered the response. She could just about make out the feint beat of "stand by me" by the Ben E. King and this was the song that played while she and her husband had their first dance. Their wedding day was a couple of years ago, but the mere suggestion of that song makes her heart race and her eyes fill. This anecdote says it all really.
So how important is the first dance at a wedding? Well, the dancing itself is probably the least important thing. I've personally seen everything from ballroom dancing and waltzing right down to Irish Dancing and a hip hop dance routine. What is important is the sentiment. You see, so much of a wedding is about inclusion. It's about sharing a personal and poignant experience with those you love the most. You want everybody to be comfortable. You want to ensure that everyone enjoys the food, the music and the atmosphere. But the first dance? It's about just you two. Apart from the ritual element of the wedding ceremony (at the alter or otherwise) this may be the only other moment that is specifically for you and your new spouse. The spotlight is on you and the person you have just married. It's a couple of minutes to lock eyes, stand close and connect. To celebrate what has actually just happened. You've just taken the biggest step in your journey of love. You have united in marriage in front of your family and friends.
The timing of the first dance is quite appropriate too. The ceremony is over, the meal has been enjoyed the you have just about fixed your make-up after the beautifully emotional speeches. The first dance is an opportunity to focus on the couple once again and take it right back to basics. It's a chance to watch and appreciate a special moment between the couple who have just promised a life of love together. It's an opportunity to have a glimpse at where it all began. To where the story once started. It started with just two people and here we can appreciate the simplicity and magnificence of them sharing a dance together surrounded by those who love them most.
For some couples choosing a first dance song couldn't be easier. They may have always had "their song" and it is the obvious choice. It may be so obvious that their friends and family know in advance too. It could be a song that they notoriously dance to on a night out or share on social media.
For others it takes a little more consideration and it can feel a bit pressurising to find THE perfect song for their big day. Let's face it, the first dance happens once and once only.
Rather than making it a stressful task, many people have great success when they simply keep their ears open in the lead up to their wedding. The wedding planning stage might be eighteen months and for that eighteen months they make a list of songs that speak to them. They may have heard the song on the radio, at another function or come across it on a TV show or ad. If a song speaks to you and evokes an emotional response then it's probably going to be a contender. Especially if the emotion is connected to your partner and the relationship and life you share.
For others the song is a tribute to a time, person or experience they may have shared with their other half. It seems fitting to play it and experience it in the presence of their loved ones.
The important thing to remember when choosing a first dance song is that you make the rules. It doesn't have to be a slow song. It doesn't have to be a ballad and it absolutely doesn't have to be a song that the wedding party will recognise. If you want to head bang to Metallica then you should absolutely do that. If you want to quietly slow dance to 'My Heart Will Go On' then you should do that proudly too. 2018 has seen a rise in weddings using songs from The Greatest Showman as their first dance.
At the end of the day(or start of the night) it is your song choice. Pick the song that whenever you or anyone else hears it, you and they know that it was the song you had your first dance to on your wedding day. In essence, IT'S YOUR SONG.

redpajama_set_name: RedPajamaCommonCrawl


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The Geneva Conventions and their Additional Protocols
Jonathan Crowe
Centre for Professional Legal Education
International humanitarian law (IHL) can be defined as the body of international law governing the conduct of armed conflict. It protects those not, or no longer, taking part in the hostilities and limits the means and methods of warfare. The four Geneva Conventions of 1949 (GCs) and their Additional Protocols of 1977 and 2005 (APs) are the central international treaties regulating IHL. These documents, in conjunction with customary IHL, establish a rule, applicable in both international and non-international armed conflicts, whereby States must not only respect IHL, but also ensure respect for IHL. This requirement is stated explicitly in Common Article 1 (CA1) of the GCs. The contributors to this volume consider the ways in which the requirement to ensure respect for IHL confers States with legal obligations in specific domains of conduct. This chapter sets the scene for those discussions by considering the historical development and key principles of IHL, focusing particularly on the GCs and APs. The chapter thereby aims to provide the necessary framework for understanding the significance of the other contributions in this volume.
Ensuring Respect for International Humanitarian Law
Eve Massingham, Annabel McConnachie
https://doi.org/10.4324/9780429197628-2
10.4324/9780429197628-2
Fingerprint Dive into the research topics of 'The Geneva Conventions and their Additional Protocols'. Together they form a unique fingerprint.
Additional Protocol Social Sciences
International Humanitarian Law Social Sciences
respect Social Sciences
Armed Conflict Social Sciences
applicable rules Social Sciences
Legal obligations Social Sciences
international agreement Social Sciences
historical development Social Sciences
Crowe, J. (2020). The Geneva Conventions and their Additional Protocols. In E. Massingham, & A. McConnachie (Eds.), Ensuring Respect for International Humanitarian Law Routledge. https://doi.org/10.4324/9780429197628-2
Crowe, Jonathan. / The Geneva Conventions and their Additional Protocols. Ensuring Respect for International Humanitarian Law. editor / Eve Massingham ; Annabel McConnachie. Routledge, 2020.
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Fancy running 2.4km on National Stadium's world-class Mondo Super X track surface?
Be it for pleasure or a challenge to your friends or family, ActiveSG welcomes everyone for this rare opportunity.
Now it's the chance to do so to clock your personal best!
IMPORTANT NOTE: Proper running footwear is mandatory. No spikes or cleats allowed.
Participants must be able to run 2.4km in under 20 minutes. Any runner who takes longer than this will be disqualified and prevented from finishing the ActiveSG 2.4km Red Run.
Participants will receive the race pack (number bib and running chip) at the reporting desk with their proof of identification (NRIC) on race day. Reporting time is 1 hour before flag-off.
Participant must be an ActiveSG member. Non-members are welcome to participate, but will not be eligible to win prizes.
Registration deadline is extended to 26 April 2016 11:59pm.
No baggage deposit services are available. ActiveSG or its agents shall not be liable for any other loss or inconvenience caused.
ActiveSG will contact the participants from time to time via emails. The race confirmation notice sent to the email address registered with ActiveSG shall be deemed as received by the Participant.
Results will be announced on www.myactivesg.com. Winners will be notified via emails.
Proper running shoes must be used at all times. Failure to do so, he/ she will be disqualified and no refunds will be allowed.
Participants must put on the number bib and running chip at all times. He/ she will not be allowed to participate in the race without the number bib and running chip.
Participants are responsible to ensure that they are allocated the correct number bib and the running chip is in good condition.
Participants will be disqualified if he/ she fails to report 5 minutes before the flag-off time.
Participants must select and register for ONE (1) wave only. Multiple registrations will not be allowed. Any participants registered for more than ONE (1) wave, he/ she will not be allowed to participate in subsequent waves and no refunds will be allowed.
Participants are not allowed to transfer or withdraw their registration. No refunds will be allowed.
ActiveSG reserves the right to modify, cancel or postpone the ActiveSG 2.4km Red Run at any time without prior notice to the Participants. If there is a cancellation or postponement, there shall be no refund of registration fees and ActiveSG shall not be liable for any other loss or inconvenience caused.
ActiveSG reserves the right to disallow any participant deemed physically incapable of continuing with the race to prevent him/ her from causing greater harm and injury to himself/ herself.
ActiveSG's decision is final and there will be no appeal to the results allowed.


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Club sponsors & supporters
Club Championships 2018
DEC 2011: WINTER COACHING HUGE SUCCESS!
We are delighted to announce that Bishopbriggs Tennis Club's 2011 Winter Coaching was a huge success. 30 players took part in the sessions and the club would like to congratulate every single person who took part in the session for their effort, attitude and progress during the coaching block. The club would also like to thank the coaches, parents and Kirkintilloch Leisure Centre for supporting this event. Work is underway planning a coaching block for the spring time! (Pictures of the sessions can be found in club photos)
DEC 2011: RONAN MCVEY WINS JUNIOR PLAYER OF MONTH AWARD!
Congratulations to Ronan McVey who was awarded the Junior Player of the Month Award for his effort, perfect attendance and progress at Bishopbriggs' Winter Coaching.
DEC 2011: TOTAL RACQUET SPORTS DONATES MINI-RED TENNIS COURT LINES!
A BIG thank you to Total Racquet Sports for donating a set of mini-red court lines. Will really help us to get off to a fantastic start - the support is very much appreciated!
NOV 2011: CLUB RECEIVES £250 FUNDING FROM ROSS & LIDDELL!
Bishopbriggs Tennis Club would like to thank Ross & Liddell for generously donating £250 to the club to help with the renovation of the clubhouse kitchen. Alex Liddell of Ross & Liddell came down to the club to present us with the cheque on Saturday 19th November.
NOV 2011: AGM
Scott McLean was elected to continue as president for 2012 with Sean Gallacher elected as vice-president.
At the AGM the club lowered the minimum age limit for membership to allow a mini-tennis programme to be run for the first time. The constitution was amended such that all children under 8 who are of primary school age shall be eligible for a mini-membership.
Bishopbriggs Tennis Clubs Annual General Meeting will take place on Sunday the 6th of Nov at 7.30pm in Cadder Church South Hall. All senior members are invited to attend. (This includes seniors on a family membership)
SEPT 2011: BISHOPBRIGGS HOLDS FIRST MINI-RED COACHING SESSIONS
Bishopbriggs Tennis Club and new coach Allwyn Crawford held taster sessions on Sunday 11th & 18th September for local children. These sessions included the first mini-red (5-8 year olds) tennis session to be held at the club. A special thank you to all those who were able to attend. Pictures of the session can be found in the Club Photos section.
SEPT 2011: CLUB CHAMPIONSHIPS WINNERS
Congratulations to our club championship winners: Greg Marlow (Gents' singles), Rebecca Cox (Ladies' singles), Sean Gallagher & Greg (Gents' doubles) Marlow Rebecca Cox & Denise (Ladies' doubles). Mixed doubles TBC (postponed due to weather)
AUG 2011: LADIES 1st TEAM WINS LEAGUE
Congratulations to Bishopbriggs Ladies' 1st team who won their West of Scotland Division 4 league section in 2011.


Welcome to Forsayth State School. We are a small rural school situated approximately 480km inland from Cairns, in the Etheridge Shire.
Forsayth State School is a multi-age Prep to Year 7 school with all students learning in the one classroom. Students are well supported by a passionate and dedicated team of staff, including a teaching principal, itinerant teacher, full-time teachers' aide and administration officer.
The school is part of the active after school communities program, engaging the students in one afternoon of sporting activities each week. We also have a school chaplain who visits our school once a week to assist and support teaching and learning activities.
Forsayth is situated in a safe and caring community that provides a wonderful support network for the school and its students.
Swimming lessons are on every Friday for this term.
Forsayth School will be having a break up party on 5/12/2018.


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AHI's Prosky on Skilled Nursing Optimism, M&A Strategies
By Maggie Flynn | August 26, 2018
Danny Prosky, one of the co-founders of American Healthcare Investors, Inc., has spent more than 20 years in the field of health care real estate investment — and he remains upbeat about the future of skilled nursing.
Skilled Nursing News spoke to Prosky about the state of skilled nursing industry in his capacity as managing director at American Healthcare Investors, which along with Griffin Capital Corporation is a co-sponsor of the Griffin-American Healthcare REITs. In addition to his role as managing director at AHI, Prosky currently serves as president and COO of Griffin-American Healthcare REIT IV, Inc. and as the president, COO and director of Griffin-American Healthcare REIT III.
Prosky began work in the health care real estate investment trust (REIT) space in 1992 as an accountant for American Health Properties, which was acquired by HCP (NYSE: HCP) in 1999. He remained with HCP through 2006, and then joined Triple Net Properties, which merged with Grubb & Ellis Company. In 2011, he left to found American Healthcare Investors with Jeff Hanson and and Mathieu Streiff.
How do the Griffin-American REITs assess skilled nursing properties?
I would say first of all, we still like the skilled nursing space. We still feel it is the low-cost provider for patients who need that level of care, and we think it will continue to grow.
I think what we look for has changed a little bit over the past 25 years. We look for probably initial higher cash-flow-to-rent coverage than we used to get in the past. We used to be okay with 1.4x to 1.5x cash flow to rent coverage. Now we look for coverage north of that.
We look for operators that have the ability to move up the acuity chain to improve their quality mix. We look for operators who have good market presence, good size of scale within their markets, as well as good quality outcomes, which I think is more important now than ever.
What do AHI and the Griffin-American REITs look for in a SNF acquisition? What do you consider in a portfolio?
We certainly prefer to buy portfolios as opposed to single assets. We typically have them in master lease structures where the leases will be cross-defaulted and cross-collateralized across the portfolio. That gives us an additional layer of protection in case there's an issue at one of the facilities.
We're not typically a one-off buyer. And I think if you look at the deals we've announced recently, those are certainly portfolio deals.
What are some of the issues would cause you to walk away from a portfolio?
We've avoided deals many, many times. Certainly if someone is facing regulatory issues, that is going to affect our willingness to move forward on a transaction. If we see that occupancy and cash flow is dropping, that's probably not going to help as far as moving forward on closing a deal.
We certainly like to see folks that are improving their market share as opposed to losing out [on] market share. But if you don't have good outcomes and good market share in your markets, it's going to be tough when you're negotiating for Medicare Advantage, etc. It puts you in a weak position.
We typically offer on about 10% of what we see. The last two years we've looked at north of $20 billion of assets each year, and we've submitted offers on less than 10% of that. We're certainly an income buyer; we're not a value-add buyer, so we're looking for stabilized assets that are well-leased and have good strong rent coverage.
Has the profile of the sellers you work with altered in the years you've been doing this?
I don't think tremendously. When I look at the deals we're doing now, compared with what we did 10, 20 years ago, they're not that dissimilar. I would say sale-leasebacks are pretty common, sometimes we'll do a transaction that's under lease and we'll just assume the leases.
But keep in mind, we're portfolio buyers. I think maybe for the folks that are doing more one-off transactions, I think you probably see more changes there as opposed to the portfolio buyers who are really just buying stabilized assets and then leasing them back to the seller. I think for the one-off buyer, things have changed. It's gotten harder for the smaller one-off facilities to survive or thrive, and I think you've seen some of them capitulate in a sense and sell out to larger operators. But that's not really what we buy.
What do you look for in terms of skilled nursing operators, especially given that, as one executive recently said, skilled nursing "is truly an operating business environment?"
There's no question that's true. This is an operating business, first and foremost. You can buy fantastic real estate in great locations, but if your operator is not good, they're not going to do well there.
We look at the strength of the operator and their ability to cover the rent. That's the first thing we look at before we look at the quality, the location of the real estate, etc. Because if the operator can't operate profitably, it doesn't matter how nice the real estate is; it's going to give us a problem at some point.
We look for operators that have shown consistent ability to adapt and to thrive. Any time there's a change in the payment paradigm [and] they've been able to adapt and adjust and thrive, those are the kind of folks that we like to work with. It's typically the folks that have got better facilities better outcomes and better market concentration. I'd say those things were always important, but they're more important now than they've ever been.
From an investment perspective, what are some of the biggest misconceptions about skilled nursing?
Many people are very concerned about the fact that there's significant government reimbursement, right? Medicare, Medicaid are going to be a significant percentage of the revenues that you're going to see within a skilled nursing facility. Of course, those of us who've been in the industry for a while can think back to periods of time when there's been adjustments to those reimbursements and it's had a negative effect on the operators.
I think the better operators have been able to adjust. I think that there's a limit to how much can be cut, and I think a lot of the good providers that we're working with are moving up the acuity chain and they're taking more private insurance and Medicare patients as opposed to Medicaid patients as they've done in the past. That's how they've adjusted; they've taken higher-acuity, shorter length-of-stay patients, and that's how they've done well.
What are some of the greatest risks of the space, and some of the greatest rewards?
I'd say the biggest risk is that they are heavily reliant on where there's government reimbursement, Medicare Advantage. It's unlike many other businesses, where costs go up [and] you can raise your rates. It's harder to do that within skilled nursing. Your rates are oftentimes set by a third party and you kind of have to adhere to those rates You can adjust your mix, there's things you can do. But you don't have the flexibility to just raise your rates. That's always been an issue with skilled nursing, and remains one.
I think from the other side, from a demographic perspective, I think skilled nursing facilities are well-positioned as far as increasing demand for their services. I think there's a lot of consolidation in the space. I think there's a lot of opportunities there.
Have we hit bottom in terms of occupancy for SNFs?
I think that's probably true. I don't necessarily expect skilled nursing occupancy to rebound by 5% over the next few years, but I think we've seen the bottom.
What's been driving the flurry of portfolio deals in recent months?
You've had some of the REITs culling their portfolios, and I think if you look at a lot of the transactions, they've been REITs selling a leased asset to another buyer.
I think you've seen a lot of people — maybe smaller portfolios, or even onesie, twosie-type deals — look at the environment and what's going on and say, "Hey, this is a tough business, and it's getting tougher. I don't have pricing power in my market, so I'm going to sell to someone who does."
The changes in reimbursement, the shorter length of stay, I think has driven a lot of that. You either need to adjust or sell out. I think without doing either one of those, it's going to be tough.
Anything else you'd like to note?
Those folks working within the industry are more bullish than those working outside the industry, is what it feels like to me. If you look at our operators, even the REITs themselves, when you talk to them in private, they're more bullish on the space than when they're out there publicly. I think those within the industry feel good about it long-term.
American Healthcare Investors, Griffin-American Healthcare REIT III, Griffin-American Healthcare REIT IV


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JJ Redick says Allen Iverson once played live basketball in practice wearing socks
Author Alejandro Torres
Anyone born after the year 1995 probably does not know much about Allen Iverson, but it was truly magical for those who had a chance to follow the best days of his career. Iverson was the first small player since Isaiah Thomas to dominate the league, and he took the NBA by storm with a magnificent crossover move on prime Michael Jordan. In the years after, Iverson continued to use his otherworldly physical gifts to be a threat on both ends of the basketball court, turning the Philadelphia 76ers into a contender for the first time in over fifteen years.
Stories of Iverson's athletic gifts are well-documented. From his time playing football in high school to his successful careers in prep and college hoops, A.I. was cat-quick with long arms and as agile of a human being one has ever seen. JJ Redick had Kyle Korver on his podcast, and the two talked about their experiences playing with Iverson, to which Korver recalled how The Answer helped a young shooter find his way.
"If you couldn't shoot it, Allen wasn't passing you the ball. So when I came in he always had his arm around me, telling me to shoot it."
Kyle Korver, The Old Man and the Three
Allen was an underrated leader because while he may have been so supportive of teammates like Korver, he didn't always seem to be the most interested in things like practice. Who could ever forget the famous "we talking about practice" line from the press conference or the many altercations he had with head coach Larry Brown? Apparently, JJ Redick had another story to add, which not many people were aware of.
"We had training camp one day and Allen came in rather tardy… (laughs) Then he played for the first how many minutes of live basketball, wearing just his socks."
JJ Redick, The Old Man and the Three
Allen was an amazing athlete, but to play basketball against NBA players and likely dominating in just your socks is incredible. This is a testament to Allen's quickness and agility. He was so light on his feet that he could scrimmage in just his socks.
"Allen would also beat everyone in the mile run, running the last lap backwards. It's just ridiculous."
The Answer may have retired with zero rings, but he was undoubtedly one of the biggest basketball icons of his generation. Kobe might have won more rings, but Iverson got kids to start wearing arm sleeves, ankle socks, and baggy shorts because of how his style of play captivated the hearts and minds of young basketball fans. Iverson was one of the greatest of all time, as he had the mystique of these types of instances in the same way that Jordan, Bird, and Kobe did. If you still have doubts about Iverson's immense talents, try playing a game of basketball the way he does, in just your socks.
Allen Iverson (117) JJ Redick (44) Kyle Korver (8)
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3 Questions with ex-Wharton Dean J.J. Cutler
Adcoms Speak
For two plus years, the name J.J. Cutler was synonymous with admission to the third leg of the elite "H/S/W" triumvirate that every MBA applicant dreams of. First as Director of Admissions & Financial Aid, beginning in early 2009, and then as Deputy Vice Dean, until August 2011, Cutler presided over both Wharton's admissions and career services functions, an unusual dual role, where he evaluated over 7,000 applications and innovated the elite MBA admissions process. Before admissions Cutler was himself a Wharton MBA, leading an impactful strategic marketing career with Johnson & Johnson and Aramark, which he returned to after Wharton as Executive Vice President. Today, Cutler is Sector Leader of executive search firm Korn Ferry's Futurestep recruitment process outsourcing arm. Cutler graciously agreed to answer three quick questions for this blog:
1. What are you proudest of about your tenure as Wharton's admissions director?
"Two things come to mind: (1) we were the first top tier business school to achieve 40% women in the full time program. Many similar schools had gotten the percentage into the 30s and now many schools are pushing to get to 50%. But at the time, we were the first to put a stake in the ground and work hard to achieve that number. It's an important issue and Business Schools need to take a leadership role. (2) we redesigned our evaluation process, particularly around the interview. Our research proved that 1:1 interviews conducted by many different interviewers around the world weren't an effective evaluation tool. They help 2 individuals determine if they have a good interpersonal connection, but they aren't an effective way to make admissions decisions. And they provided a very uneven, inconsistent experience for the applicant. So we did a lot of research to build a new method using team-based discussions. It is better for the applicant and better for the school."
2. What surprised you most during your directorship?
"The sheer diversity and complexity and strength of the applicant pool was completely overwhelming to me. Such incredible talent in our work doing such interesting things and with so much potential. It is very humbling and requires incredible agility, intellectual curiosity, empathy, and an open mind at all times."
3. What advice would you give to someone weighing an offer to become an elite business school's admissions director?
"Take time to recharge. Take time to reflect. Build a great team. Over-communicate. Find people you trust and who think differently from you and go to them before you make any big decision and get their perspective."
Thank you, J.J.
Kellogg MBA's New Admissions Team


Okie dokie, artichokie, it's Friday (woo!) and as promised, here is part two of my Life in Color collection review. Like part one, this post features three gorgeous shades (and a bonus link to a 7th!) from Emerald & Ash.
Let's get down to business. As per usual, the descriptions come directly from the maker.
The snozzberries taste like...blurpurple jelly. Wait no, that can't be right. Anywho, our version of Snozzberries is a purple jelly that is filled with color shifting square glitter and some purple and red holo micro glitters. Goes on in two to three coats depending on your application. Can also be put over a base color if that tickles your fancy. A top coat is recommended to give the polish a smooth look.
Charlie & The Chocolate Factory is one of my favourite movies EVER and I tend to use the phrase this polish is inspired by quite often, so how could I help but love it? Plus, it's blurple which I'm fairly certain is the best colour name ever (grellow, you don't hold a candle!). The formula on this was fantastic and the perfect amount of glitter applied to the nail with every stroke (how amazing is the tiny red glitter?). Shown here is two coats and one coat of Gelous.
I love sunshowers. The sun glittering off the rain drops just makes it seem so much more magical. The flakies in this polish are so pretty - they glint and glimmer when they hit the sun and the grey base is so delicate and elegant. Shown here is two coats and one coat of top coat.
Once upon a time we found an ottoman that had beautiful bright colors and it needed to come home with us. It also needed to be made into a polish. After many trials and errors it decided to be a fun, festive glitter topper. Because it said so. And so, Confusion with a K was born. A glitter topper full of neon pink, neon green, metallic navy blue, grey and white glitters of all sizes. It wants to go on top of ALL of your polishes and maybe even be sandwiched between them as well. You're good to go with one to two coats, depending on how glitter-hungry you are!
This glitter topper is where Emerald & Ash's thicker base really comes in handy. I did not have to fish for a single piece of glitter! See those large pink hexes? Yep, they just willingly came out on the brush. Glitter application like this makes my life so much easier and less frustrating. Plus, these colours are amazing and perfect and I love them. :) Shown here is one coat over China Glaze Def Defying and one coat of Gelous.
Bonus link: Ashley and I were chatting one day and she mentioned that she thought my custom, Stubble Jumper, would be the perfect addition to a new collection she was planning. Of course, I was flattered and said yes right away. The thought that people like something I had a hand in creating just tickles me. Spread the prairie love, people!
I was also sent a 3ml bottle of the July oil of the month, Fresh Cut Grass, which is a scent I already love. I had kind of... badgered? nicely? Ashley about a grass scent. :) And you already know how I feel about their cuticle oils.
All Emerald & Ash lacquers are 5-Free and are not tested on animals.
The people who make the polish are always better at describing it than I am so, as usual, polish descriptions are taken directly from Emerald & Ash.
Who doesn't like magic bananas!? We sure love them around here, especially when used as an exclamation! It's a phrase used so much around here that we had to make this yellow and green all flakie polish that has a hint of gun metal flakies - you know...for those bruises that pop up on your bananas, no matter how magical they are. This can easily be a full coverage flakie in 2-3 coats, but you can always uses it as a topper if that tickles your fancy.
Now is where I admit to being an incompetent nail blogger. I need practice applying flakie polish. Polish with flakies in it? Sure, I've worn those. Pure flakies? A polish literally packed to the brim with flakies? Nope. I think I rushed my coats which resulted in some dragging and bunching at the tips (you can particularly see this on my index finger). All you need is some patience and you will be handsomely rewarded. The flakies in this are so pretty and the final result is simple yet complex. Shown here is two coats and one coat of top coat.
You say tomato and I say...this tomato based polish looks amazing with flakies that throw off a red and gold shimmer while trapped in a sheer red jelly base. Can be worn to full coverage in 2-3 coats, depending on your application or it can be placed over your favorite reds to add a quick punch of fun!
Another polish that highlights how poorly I applied it. :/ As with Magic Bananas, this flakie packed polish just requires an extra bit of patience with the application.
You know, if asked, I will always say that red is never my go to colour and yet, it plays so nicely with my skin tone. This one in particular is gorgeous! The gold with the red not only plays perfectly off the tomato theme, but it's a great fall transition colour. Again, I used two coats and one coat of top coat.
An eye-searing bright neon leaning coral crelly that hits you with a dose of scattered holo, just in case you already haven't been blinded. Due to the nature of neon pigments this will dry to a semi-matte look. Leave it as is or gloss it up with a top coat, your choice! You can always layer it over a base coat of white polish to make the color pop even more! Without a base color you can get full coverage in 2-3 coats.
Good lord, I love this polish. Neon coral with scattered holo?! Be still my heart. The formula on this one was amazing! With careful application I only needed two coats and one coat of top coat for this stunner. This is one of my favourites from the entire collection!
So, there are the first three. What do you think so far? Definitely full of colour, right? Stay tuned - I will have the final three up later this week.
Exciting news, guys! Tia (of Iced Lacquer) and I are teaming up to create a podcast!
Nail Newscast was Tia's brainchild and is something she's been thinking about for a while. She and I connected over our love of WingDust polish and she was kind enough to approach me about being a co-host! Awesome, right?! I have to admit, in the very beginning I was *thisclose* to saying no. "I'm awkward and strange and try too hard to be funny," I thought. "My voice sounds weird in recordings," I thought. And then I said to myself, "self, WTF are you thinking? Say yes! It will be awesome and fun and what's the worst that could happen? So you push yourself out of your comfort zone. Isn't that a good thing?" So, yes it was.
Tia and I have had fun brainstorming and Skyping and coming up with lists of people we'd love to interview. We've tried to get over our inherent introvert and just put out a quality product.
I hope you are as excited about this as we are and I sincerely hope that you tune in every Wednesday for the latest in the nail polish world.
We are Nail Newscast. We are a team of nail polish bloggers who wanted to create a podcast all about nail polish. Our team currently includes Tia from Iced Lacquer and Courtney from Swatcher, Polish-Ranger.
The Nail Newscast podcast is all about upcoming nail polish collections, sales, trends, interviews with indie polish makers and other bloggers, and general nail polish news.
Why did we make this?
A nail polish podcast is definitely something that doesn't exist yet. We felt like there is definitely a lot of great content out there that people are interested in, we're just putting it in a new format that's easy to listen to!
As of right now we are planning to release our first episode on Wednesday, August 6th.
For now we'll be hosting each episode on our Soundcloud account. We will also have an embedded player for each episode on this blog as well as an RSS feed you can subscribe to. Feel free to follow us on Facebook, Twitter, and Instagram, and Bloglovin for additional content and updates!


As an Accredited Specialist in Family Law, with a Master of Laws focusing on family law and related matters, I have the expertise to deal with all issues which arise from the breakdown of relationships. I am dedicated to providing direct, pragmatic advice to my clients, with the aim to facilitate an early resolution to their matter, where possible.
Having previously worked in the Federal Circuit Court, and having had significant litigation experience in my practice, I am also well able to represent clients in contested Court proceedings, when necessary.
As an experienced practitioner I am sensitive to the stresses involved in family law disputes. I aim to enable clients to get on with their lives as quickly as possible, often engaging appropriate multidisciplinary experts and supports, such as clinical psychologists, both to support clients and their children, and to work towards a successful outcome for all involved.
I have more than ten years' experience in Family Law, having worked in the Federal Circuit Court as a Judge's Associate, prior to entering into private practice.
I have a thorough understanding of complex parenting and property disputes, inclusive of matters involving third parties, and the ability to work with practitioners from other legal specialties, where matters require this. I have expertise where one (or both) parties reside outside of Australia, and am happy to work with clients who reside overseas.
Property settlements (divorce and defacto), including complex matters involving corporate entities, trusts and self-managed superannuation funds.


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Jerry and Della Story
Description: Jerry and Della Story. When the post office moved from the Kit community to the town of Irving in 1904, Jerry Story served as temporary postmaster.
Partner: Irving Archives
PTA Officers, 1936
Description: PTA officers for the Irving public school system in 1936. Seated left to right: Mrs. F. N. Broach, Mrs. H. W. Simmons, Mrs. W. H. George, Mrs. Edgar Davis, Mrs. Ralph Barr, Mrs. Clyde Kirkpatrick, and Mrs. W. R. Duckworth; standing left to right: Mrs. A. C. Bolden, Mrs. R. L. Kirkpatrick, School Supt. A. S. Johnston, Mrs. Johnston, and Mrs. Ben Hurwitz.
Irving Train Depot
Description: Two men in front of the Irving train depot. The Chicago, Rock Island & Gulf Railway built this depot in 1904.
Hawks Chapel Methodist Church
Description: The Union Bower community was settled during the 1880s. It was located about north and east of the town site of Irving, which was founded in 1903. The Reverend W. E. Hawks of Dallas, who had been preaching in the Union Bower area since 1887, directed the building of a church in the community. In 1907, Hawks Chapel Methodist Church opened. In this photo, members of the congregation pose in front of the church.
Musicians in the Union Bower Community
Description: This group of musicians played for square dances in the Union Bower community. Dances were held in the fall and winter because the weather was too hot during the summer. Left to right are: Tom Owens, Earl Steele, Lillie Owens, and Tom Wright. Lloyd Smith called the square dances, but is not in the picture. Union Bower was a farming community on the eastern edge of the city of Irving. The community was established about 1880.
Lloyd Smith and Brother
Description: Lloyd and Bertie Smith, sons of William and Virginia Smith, area pioneers in the Union Bower community, c. 1894.
William Smith Home in Union Bower
Description: William Smith, area pioneer, built this house in the Union Bower community in 1888. It stood along what would become Maryland Street in Irving until it was torn down in the 1980s. Seen in this 1906 photo are L. G. Smith, Mr. and Mrs. J. T. Hood, Mrs. Mattie Smith, Bert Smith, Mrs. Jennie Smith, William Hood, and Frank and Charlie Voirin.
Couple in Union Bower
Description: An unidentified couple enjoys an afternoon in the Union Bower community, c. 1910. Union Bower was a farming community that today is part of eastern Irving.
Hezekiah and Elizabeth Story
Description: Hezekiah and Elizabeth Story. The Story family came from Illinois to the area that would later become Irving in 1855.
Hezekiah Story Family
Description: The Story family was one of the pioneer families to the region. Here Hezekiah Story is pictured with his family.
Model T Ford
Description: Model T Ford Pickup. In the vehicle are W. D. Lucas's sons Howard and Ray, c. 1915
Irving Student Body at the Water Tower
Description: The student body of the Irving Independent School District gathers at the water tower, which was in the middle of the intersection of Main and First streets (Irving Blvd.), to celebrate growing to a district of 500 students, c. 1915.
Doug Lucas Family in Surrey
Description: The Doug Lucas family in a surrey. Doug Lucas holds his daughter Lorene while his wife holds their son Howard.
Doug Lucas Store
Description: W. D. Lucas operated a general store on Irving's Main Street from 1906 until 1931. After changing locations twice, he settled in this two-story brick building in about 1920.
Brick School Building Being Torn Down
Description: The Irving Independent School District was established in 1909. The district built a three-story brick school building in 1913. The building, which came to be known as "Old Red," housed the entire student body for a number of years. It later became the elementary school and then the administration building. It was torn down in 1959.
Children in a Toy Car
Description: Howard and Lorene Lucas play in their early toy automobile, c. 1913. The children's father, Doug Lucas, ran a general merchandise store in Irving from 1906-1931.
Irving High School Football Team, 1924
Description: Irving High School football team, district champs, 1924. Back row: Vernon Thompkens, Lynn Harkey, Coach Fred Nance, Noel Toney, and Edwin Metker. Front row: Marshall "Bobby" Anderson, Harland Cunningham, Julius Toney, Eugene Grider, Ralph Plumber, J. L. Crosby, John Britain, and W. S. Fields, with water boy John Steele
[Photograph of People by Trinity River]
Description: Photograph of people on the bank of the Trinity River, surrounded with trees.
J. B. Howard House
Description: A lady standing on a porch at the Howard home at 318 Iowa (now O'Connor Rd.), believed to be Irving's oldest existing house, built in 1904.
Charles Schulze, Jr., and John Brown as Children
Description: Charles Schulze, Jr., and John Brown as children, c. 1915. Charles Schulze, Jr., was the nephew of town co-founder J. O. Schulze. John Brown was the son of the other town co-founder Otis Brown.
Mrs. Pierce's Jitney Service
Description: Before Irving received bus service, one of the ways to travel to downtown Dallas was on one of the local jitney services. Mrs. B. L. Pierce operated a jitney service from Irving to Dallas and back. Here she poses with some of her customers, c. 1915.
First St. Luke's Catholic Church
Description: First St. Luke's Catholic Church, built in 1904. Located on the corner of Second and Jefferson, this building was used until 1920. Several French families, many from the defunct La Reunion colony, founded the parish. A parish list from 1890 includes the names of DeHaes, Chassang, Beaufford, and Boinard. Prior to 1904, Masses were held in private homes and later moved to the Lively School House on Britain Street. The city founders donated the lot for this church.
C. P. Schulze, Sr., Otis Brown, and Fred Joffre in Schulze's Car
Description: C. P. Schulze, Sr., Otis Brown, and Fred Joffre (in back) sit in Schulze's new Hupmobile. The house in the background is Otis Brown's house on Iowa Street (today 327 S. O'Connor Road). Brown built the house in 1905.
W. D. Lucas Home at 127 Hastings Street
Description: Home of W. D. Lucas and family at 127 S. Hastings. The house was built in 1907. W. D. Lucas was the proprietor of a general merchandise store from 1906 until his death in 1931.
1950-1959 2 2 1940-1949 1 1 1930-1939 5 5 1920-1929 5 5 1910-1919 31 31 1900-1909 20 20 1890-1899 3 3 1880-1889 1 1
1882 1 1 1890 1 1 1894 1 1 1896 1 1 1902 1 1 1903 1 1 1904 5 5 1905 1 1 1906 8 8 1907 2 2 1908 2 2 1910 13 13 1911 2 2 1912 4 4 1913 1 1 1914 1 1 1915 7 7 1916 2 2 1919 1 1 1920 2 2 1922 1 1 1924 1 1 1929 1 1 1930 2 2 1931 1 1 1933 1 1 1936 1 1 1947 1 1 1950 1 1 1959 1 1
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Mild temperatures make fall the perfect time of year to conduct a thorough review of your commercial property. A few preventative maintenance steps can help you avoid unexpected repair costs that might become a bigger emergency in extreme winter weather.
1. Fully inspect the roof.
Your roof provides unparalleled protection to many of your systems and building infrastructure. Even small leaks can turn into major, costly issues if not promptly addressed. Ensure a professional roofer carefully inspects exposed surfaces and drainage systems, particularly if it's been a while since routine maintenance was last performed.
Ensure all your freeze protection systems are reliably and properly powered. Valves are often affected by the extreme heat of the Columbus summers, which can result in faulty operations and leaks when winter sets in. Go through each heated and chilled water system to pinpoint small problems before they become big ones.
3. Maintain the mechanical and plumbing systems.
Ensure freeze stats are set at correct temperatures and heating systems are properly operating. Have leaky valves, damaged actuators and linkages repaired. While tedious, an routine audit helps you locate and correct problems before an emergency occurs.
Even small breaches in insulation can lead to big problems, like high operating costs. Review each insulated system for damage or missing protection, and make necessary repairs. Consider the climate and exposure to the elements when determining the best level of insulation for your commercial property.
5. Don't set it and forget it!
Monitor how your commercial building responds to season changes over time. Consistent data collection enables you to identify when systems don't operate as intended. In winter months, for instance, your HVAC system might labor to bring the building to a comfortable temperature.
To minimize energy consumption, adjust the set-back temperature or identify over-performing heating elements.
Don't know where to start? DRK and Company in Columbus, OH, offers facility maintenance services to keep things running smoothly in your commercial property. We have been serving Columbus for more than 40 years with commercial property management. Preserve and improve the value of your real estate investment by contacting DRK and Company today at 614.540.2404.


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