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Bannon Testimony has DOJ Spooked, with Department Pushing to Silence Media Magnate
Cowards.
While some Democrats have applauded the boldness of the select committee investigating January 6th, there are undercurrents of concern about the group's actions beginning to surface.
For starters, their willingness to call some of the right wing media's most potent orators to the witness stand, where they will almost certainly befuddle and obliterate those who seek to do harm to their reputations.
In other words: Subpoenaing Roger Stone, Alex Jones, and Steve Bannon is likely an exampled of the committee biting off more than they can realistically chew.
It seems as though the Department of Justice agrees with this assessment, and they are taking action to prevent the Democrats on the committee from embarrassing themselves.
Prosecutors have accused former President Donald Trump's ex-adviser Steve Bannon of attempting to try his criminal case through the media instead of in court and have asked a judge to limit what Bannon can release publicly throughout the case, according to a new filing in DC District Court.
Bannon is trying to convince a judge not to bar him and his lawyers from sharing documents he receives from the Justice Department with the public before his trial.
The DOJ prosecutors said in the filing Sunday some of those records must stay private while the case is pending, because they include internal communications between congressional staffers and notes of FBI interviews with witnesses who could testify against Bannon at trial.
The DOJ would rather work in darkness.
"Allowing the defendant to publicly disseminate reports of witness statements will have the collateral effect of witness tampering because it will expose witnesses to public commentary on their potential testimony before trial and allow a witness to review summaries of other witnesses' statements recounting the same event or events," the prosecutors wrote on Sunday.
The move reeks of cowardice on behalf of the Biden administration, and flies in the face of transparency and understanding.
Media Hysteria over Omicron Variant? | Schaftlein Report
Tiananmen Square 'Simpsons' Episode Goes Missing in Hong Kong
As the January 6th committee continues down a blatantly partisan path that is unlikely to bring the country together in any meaningful way, there are fears that their actions could spark a great deal of animosity within this powder keg of a nation.
We are as divided as we ever have been, or at least in the last 150 years, and every political motion must be true and just. Otherwise, we can consider it fuel for whatever trouble appears to be looming just over the horizon.
The January 6th committee and the Democrats supporting it, being under the microscope as they are, must be particularly careful not to deal in rumors, hyperbole, or propaganda. They have at least one hand firmly on the rudder of this nation for the time being, and any hard, jerking motions could send us all figuratively to the floor.
That's why the latest speculation regarding their investigation is so mindlessly dangerous.
Senate Democrats believe there is a good chance the Department of Justice will prosecute former President Trump for trying to overturn the results of the 2020 election and inciting the Jan. 6, 2021, attack on the Capitol, which would have major political reverberations ahead of the 2024 presidential election.
Democratic lawmakers say they don't have any inside information on what might happen and describe Attorney General Merrick Garland as someone who would make sure to run any investigation strictly "by the book."
The narrative was even bolder than that:
Sen. Richard Blumenthal (D-Conn.) said "clearly what [Trump] did" in the days leading up and the day of the Jan. 6 attack on Congress "falls in the ambit of what's being investigated and perhaps is criminal."
Sen. Tim Kaine (D-Va.) said it's up to the prosecutors at the Justice Department whether to charge Trump, though he believes that the former president's actions on and before Jan. 6 likely violate federal law.
"They have all of the evidence at their disposal," he said.
Kaine believes federal prosecutors are looking seriously at charges against Trump, although he doesn't have any inside information about what they may be working on.
"My intuition is that they are" looking carefully at whether Trump broke the law, he said. "My sense is they're looking [at] everything in a diligent way and they haven't made a decision."
"I believe there are federal statutes that are very much implicated" by Trump's efforts to overturn President Biden's victory in the 2020 election, Kaine added.
As the January 6th committee continues down a blatantly partisan path that is unlikely to bring the country together in any meaningful way, there are fears that their actions could spark a great deal of animosity within this powder keg of a nation. We are as divided as we ever have been, or at least in the last 150 years, and every political motion must be true and just. Otherwise, we can consider it fuel for whatever trouble appears to be looming just over the horizon. The January 6th committee and the Democrats supporting it, being under the microscope as they are, must be particularly careful not to deal in rumors, hyperbole, or propaganda. They have at least one hand firmly on the rudder of this nation for the time being, and any hard, jerking motions could send us all figuratively to the floor. That's why the latest speculation regarding their investigation is so mindlessly dangerous. Senate Democrats believe there is a good chance the Department of Justice will prosecute former President Trump for trying to overturn the results of the 2020 election and inciting the Jan. 6, 2021, attack on the Capitol, which would have major political reverberations ahead of the 2024 presidential election. Democratic lawmakers say they don't have any inside information on what might happen and describe Attorney General Merrick Garland as someone who would make sure to run any investigation strictly "by the book." The narrative was even bolder than that: Sen. Richard Blumenthal (D-Conn.) said "clearly what [Trump] did" in the days leading up and the day of the Jan. 6 attack on Congress "falls in the ambit of what's being investigated and perhaps is criminal." Sen. Tim Kaine (D-Va.) said it's up to the prosecutors at the Justice Department whether to charge Trump, though he…


There are more than 150 Clifford titles.129 million copies are in print.Many of his stories are translated into 13 languages.
The Clifford Series.The Witch Series.A Tiny FamilyNo Dogs AllowedThe Cat and the Bird in the Hat.
Clifford got his iconic red color when Norman Bridwell was drawing him for the first time he had a bottle of bright red paint on his desk and decided it would make Clifford more fun for kids.
Norman Bridwell named the main charachter after his daughter, Emily Elizabeth.
Norman Bridwell's idea for Clifford stemed from his childhood disire to have a dog as big as a pony.
Norman Bridwell orginally wanted to name Clifford, Tiny. After the disaproval of his wife, he allowed her to name the dog after her imaginary childhood friend.


I was so in love with the flute that I couldn't contain myself; I played with such joy, I talked about everything flute with so much enthusiasm, and then….I wrote about my musical life, too. I expressed struggles with my teacher, the hilarious antics of my students, what it was like to perform a concert in a prison, and the incredulous experience of watching James Galway record a CD with the London Symphony. I wrote from my heart.
We don't have many "pleasure" books in the flute community — the kind that inspire, uplift, and are infused with love, spirit, and joy. A Flute in My Refrigerator is one of the few, and it speaks to adult amateurs, flute teachers, students, and professionals. I'm honored that Flute Specialists chose a few excerpts to share in its newsletter.
My 13-year-old flute student, Eric, asks if he can come and use my tuner for a science project due the next day. When Eric arrives, I give him my tuner and leave him to his own devices. A short while later I get thirsty and go to the kitchen to get some juice. There on the refrigerator shelf, carefully nestled on top of a folded towel, are the three parts of Eric's flute.
Life is full of surprises-small ones, like a flute chilling among eggs and milk cartons, and large ones, like my life in music, which also began as something of an experiment and grew into two life-affirming careers. Teaching flute was the first.
I never aspired to be a musician. I am amused and amazed that I ended up becoming one. And then I began to write as a way to share my love for music. I am endlessly grateful, because these aspects of myself have brought me boundless joy, rich friendships, exciting adventures, and fabulous opportunities. Many of them are here in this collection of articles I wrote between 1992 and 2010. Reading them now, I appreciate more than ever how teaching and writing about music led me to experiences that proved to be wider and deeper than anything I had dreamed in my childhood imaginings.
This summer, so many of my students participated in flute and music activities that I decided to invite them out for ice cream, just before school got underway, so they could share their experiences with each other. Last Sunday evening, we met at The Inside Scoop, a small place not far form the university campus at the center of town.
Each student told a little about what they did over the summer - touring Europe as principal flute of a national band, attending Jeanne Baxtresser's Summer Masterclass, going to a band camp, and so on. I was especially pleased that two of my new students joined us, and they shared as well.
I had said that they could bring flutes and play before eating, so as not to get sugar on the pads. The owner of the place was happy to allow us to play our flutes. However, no one was "in the mood." So, we got our treat: "The Kitchen Sink." Fifteen scoops of ice cream, six toppings, fudge sauce - a decadent indulgence. You get the picture.
They had no trouble scarfing it down while talking flute talk (a conversation that was not directed by me). Who won what competition, who plays too sharp in band class, what pieces they were going to play for recital, and so on. They were really into flutes! The exception was the youngest, who was mostly into discovering what toppings he could find at the bottom of his bowl.
Then, after they ate, they decided to play. Fine with me. I did ask them to go rinse their mouths with water first. Every one of them got up, right there in the noisy ice cream parlor and played a piece of music.
They are such hams. The other customers in the shop paid us no attention, and we paid them no attention. The kids got a big kick out of it, saying they'd never played in an ice cream place before, that it was really "cool." We heard everything from a quarter note rendition of Beethoven's Ode to Joy to the Burton Sonatina.
We were there for over two hours before they called their chauffeurs (moms or dads) to pick them up. They had fun, and I did, too.
Finding my niche as a musician has been the most important and difficult part of my musical journey. Memorizing the minor scales into the fourth octave and acquiring a fast double tongue technique were easy compared to the challenges I encountered during my quest to find my true musical self.
The dictionary defines a niche as "a shallow recess in a wall." Imagine the ruins of an ancient building, with big stone bricks and small hollowed-out spaces. In my mind's eye I see an ancient woman stashing her corn kernels in one niche and maybe her bone sewing needles in another.
Another definition of a niche is "a position in life to which a person is well suited." Since childhood, I've loved playing the flute. I was good at it, but I never aspired to be a professional musician. From the time I was 12, I had a deep desire to teach blind children, and after earning my Master's in Special Education I taught visually impaired children for 13 years. I kept playing my flute but felt confused about making music. I didn't know where I fit in or what my niche looked like. I couldn't understand why others younger than I were so much more competent, and I often felt shame about my playing. I didn't want anyone to hear me.
One day, as if by accident - although I believe that nothing is truly an accident - I came across Stephanie Judy's book, Making Music for the Joy of It. That book changed my life, and I don't say that about many books. For the first time, I had a name for what I was: amateur musician. And I learned that being an amateur wasn't a lesser form of being a professional. Being an amateur musician is something good and wonderful, a source of pride in its own right.
Our task as amateurs is not "to play music perfectly but to love it deeply," Stephanie wrote, so I started looking for my niche.
Writing is my most recent niche. I never aspired to be a writer, but I was so excited about flute playing that I wanted to talk about it all the time. Writing became another medium. My articles are published all over the world, and I write for and help manage the FLUTE List online discussion group.
Remember that wall filled with many niches? Claim one - or several - for your own. If the niche you want isn't available, you can create it.
People often say that I've done a good service for the community by hosting the musicales. I'm happy to serve the community, but truthfully, I started them for myself. I wanted a performance venue, and I created it.
Other people have found different niches. One of my adult students loves chamber music. Although she's a full-time physician and mother of two teenagers, she finds time to play in groups several evenings a week. Some folks want to play alone on the beach, just for the seagulls. Other enjoy performing for senior citizens in retirement communities or coaching children in schools. Many find joy in a flute choir or a village band or orchestra. Myriad niches exist for those who make music.
Ask yourself these questions: Why are you making music? What really makes your soul sing with joy? And, most importantly, what would you do if you knew you couldn't fail?
For an amateur, there is no failure. Just do what you love. Think about amateur tennis players. They reserve a court, knock around a few balls, and keep score. Someone wins, someone loses, and they all leave feeling great. They don't have the same form as the players at Wimbledon, nor do achieve the same ball speed or score. They play because they enjoy it. And that's how it can be for amateur musicians.
With the emphasis on giving, there is no need for fear. Imagine that a friend makes you a beautiful piece of pottery, although the sides are a little lopsided and the glaze isn't quite even. Wouldn't you receive that pot and cherish it within the context of the love in which it was made and given?
That's how people will receive your music if you give it with love.
I implore you not to go near the land of "Should." Don't think about what your parents want you to do or what your teacher thinks you should do. Don't imagine how you should play as compared with someone else.
Exposing your heart can be scary, but it's human. Trust your heart, because that is where your power is.
Claim your musicality. Empower yourself to use your music to radiate love and caring. The world is in serious trouble, and music has the power to transcend our differences and create vibrations of change. You have the power to make that happen.
I ask you not to underestimate that power of the beauty of your playing. You may be sitting in one little niche in a huge wall, but if it's your special niche, the one to which you're well suited, you can light up the whole world.
Helen Spielman has been an inspiring voice in the field of performance anxiety and flute teaching for three decades, teaching countless musicians to take the excellence they produce in a relaxed practice room to the high-stakes arena of auditions, recitals, and pressure-cooker orchestras. She had guided musicians who, ready to quit their careers, regain their original love of music and return to the stage with joy.
Helen Spielman has taught at international conventions, prestigious music conservatories, music festivals, and private studios in Africa, Europe, Central America, and around the US. She was appointed a Fulbright Senior Specialist in 2010, and is a Distinguished Honorary Member of Sigma Alpha Iota, the international music fraternity.
Helen lives in Chapel Hill, NC with her husband. Please visit PerformConfidently.com.


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Moderated Poster Session III: Pediatrics/Voiding Dysfunction
Blood product utilization pattern in pediatric renal transplantation: A single-institution analysis
Rakan I. Odeh,Frank J. Penna, Naimet K. Naoum, Teresa Skelton, Armando J. Lorenzo, Walid A. Farhat, Martin A. Koyle
The Hospital for Sick Children, Toronto, ON, Canada
Background: In renal transplantation (RT), there is an inherent lack of evi-dence-based guidelines to direct the amount and need of cross-matching blood products for surgery. Due to the inherent added costs, limited avail-ability of blood products and potential waste if not used, we aimed to evaluate our practice to identify factors that can lead to standardized policy for blood product utilization in RT.
Methods: Retrospective chart review of patients who underwent pediatric RT over a 10-year period at our institution was performed. Variables ana-lyzed included: patient age, weight, pre- and postoperative hemoglobin (Hb), donor source (deceased- or living-donor), estimated allograft size by ultrasound, mean intra-operative blood loss (EBL), erythropoietin, number of units transfused per case, cross-matched/transfusion (C:T) ratio, overall transfusion rate, type of dialysis and the total cost of unused cross matched units.
Results: RT was performed in 188 patients during the study period. Males represented 59.5% (n=112) and females, 40.5% (n=76). Of these, 54% (103/188) received blood transfusions. The total number of units cross-matched was 455 (2.3 units/patient). Average EBL was 212 mL, and C:T ratio was 2.6:1. Univariate analysis of factors predictive of the need for intra-operative blood transfusion demonstrated the following statistically significant parameters:preoperative Hb , age, weight, and EBL. Multivariate analysis showed EBL as the only factor predictive of the need for intra-operative blood transfusion. Total estimated cost of unused cross-matched units was $22 282 CAD.
Conclusions: At our center, the number of unused cross matched units in pediatric renal transplantation represents a considerable waste of limited resources. EBL is the only factor predictive of intra-operative transfusion. More efficient institutional policies with regard to blood cross-matching in RT are in progress.
Cost-effectiveness of a multidisciplinary stone clinic in a tertiary care children's hospital
Jessica M. Ming, Elizabeth Harvey, Darius J. Bagli, Roberto I. Lopes, Megan A. Saunders, Walid A. Farhat, Joana Dos Santos
Background: Here, we assess the cost-effectiveness of a multidisciplinary clinic for children with urinary stones. With rising healthcare costs, the primary goals of the clinic were to decrease unnecessary visits, duplicate imaging and costs, while optimizing quality of care.
Methods: Since October 2012, children with complex stone disease, previ-ously treated in urology and/or nephrology clinics, were seen at a triannual pediatric combined stone clinic. Patients attended one appointment in which they were seen by both nephrology and urology teams, allowing for both medical and surgical needs to be assessed simultaneously. A total of 79 patients have been evaluated since the clinic began. We compared the number and cost of imaging studies, emergency room visits and stone surgeries performed before and after the initial evaluation of each patient. All patients also received satisfaction surveys in clinic or the mail.
Results: Median age at diagnosis of all clinic patients was 72 months (range 5‒185). Of the 79 patients, 32 were seen at least twice in the combined clinic. Prior to the combined clinic, 27 of these patients were followed mul-tiple times in either a urology or nephrology clinic and numbers and costs of the above interventions in this subgroup were compared. Underlying metabolic disease was identified in 17 (63%) patients, including idiopathic hypercalciuria (25.9%), cystinuria (18.6%), nephrocalcinosis (11.1%), and primary hyperoxaluria (7.4%). There was no significant difference in the number per year (1.97 vs. 1.6; p 0.13) or cost (591.2 vs. 496.2; p=0.16) of the ultrasounds performed before and after the clinic intervention. The number per year (0.29 vs. 0.1; p<0.001) and cost (59.2 vs. 8.9; p<0.001) of emergency room visits significantly decreased after being evaluated in clinic. There was also a significant difference in the number per year (0.38 vs. 0.20; p=0.016), and cost (482.4 vs. 89.3; p=0.003) of surgeries related to stone disease. After correction for followup time of two years, the results remained significant. Twenty four survey responses were returned. Seventy five percent of families believed the clinic was time saving and 79% agreed that the information given was consistent between the teams and they had a better understanding of their child's condition.
Conclusions: We believe this combined clinic may be beneficial for those patients requiring long term management of nephrolithiasis to decrease overall healthcare costs. Although a small sample size, the number of emer-gency room visits and stone related operations were significantly decreased after the initial combined clinic intervention. Longer-term data will need to be collected to see if the positive findings continue.
Feasibility and efficiency of pediatric outpatient cystoscopy: A step out of the operating room
Frank J. Penna, Abby Varghese, Katharine Williams, Hissan Butt, Martin A. Koyle, Armando J. Lorenzo
Background: Awake cystoscopy is routinely performed in the adult ambula-tory setting, while pediatric cystoscopy is most commonly performed in the operating room (OR), particularly in younger children. Cystoscopy in the OR necessitates additional anesthetic risk to the child, is time-consuming, and expensive. We hypothesized that selective cystoscopy in the ambula-tory setting is feasible and results in higher satisfaction and lower costs.
Methods: All older children and adolescents requiring cystoscopy at our institution within a one-year period (2014‒2015) were offered the option of in-clinic vs. OR cystoscopy for diagnosis, stent removal or intravesical botulinum toxin injection. Parameters such as age, gender, procedure time, and total clinic time, were reviewed. The patients were administered a survey assessing their level of satisfaction with the experience and their preference for scheduling future outpatient procedures, if indicated.
Results: Thirty children underwent cystoscopy in the outpatient setting. The mean age was 12 years, with 18 male and 12 female patients. Anxiolytic medication was requested by 87% of the patients. The mean procedure time was 22 minutes and mean total clinic time was 131 minutes, as compared to 240 minutes (the mean in-hospital time for cystoscopy in the OR). The mean cost was $217 (CAD), compared to the estimated cost of cystoscopy in the OR ($1016 CAD). Over 95% of patients either strongly preferred or preferred the procedure in the ambulatory setting.
Conclusions: Outpatient cystoscopy in children is safe and feasible and translates to improvements in patient satisfaction and overall efficiency and
availability, while minimizing costs. This option should be considered and offered to older children and adolescents.
Impact of email and media communication on emergency room visits post-hypospadias repair
Michael Chua1, Megan Saunders1, Paul Bowlin2, Jessica Ming1, Roberto Iglesias Lopes1, Walid Farhat1, Joana Dos Santos1
¹The Hospital for Sick Children, Toronto, ON, Canada; ²Children's Mercy Hospital, Kansas, KS, USA
Background: Advances in communication technology are shaping our medical practice; herein, we aim to evaluate the effect of email com-munication with application of smart phone photography on emergency room (ER) visits post-hypospadias repair.
Methods: This prospective cohort study included patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented to email communication with smart phone photography and Group B declined. Reason for ER visits within 30 days postoperatively was assessed by another physician for an objective evaluation. The
rea-son was categorized as: unnecessary ER visits (defined as postoperative wound check with no intervention needed); indicated ER visits (defined as ER visits that required intervention or visits unrelated to hypospadias surgery). Chi square test and T test were used for statistical analysis. Relative risk and corresponding 95% confidence interval were also cal-culated. Statistical significance set at p<0.05.
Results: Over a 14-month period, 96 patients underwent hypospadias repair (Group A 81, Group B 15). Patients in Group A were significantly younger than patients in Group B (Group A median 11 months [IQR 9‒17] vs. Group B median 15 months [IQR 9‒23, respectively], p<0.001). The number of ER visits for wound check not requiring intervention was significantly lower in Group A than in Group B (3 [4%] vs. 4 [27%], respectively [RR 0.14; p=0.005; 95% CI 0.035‒0.56). A higher number of ER visits requiring intervention was noted in Group A compared with Group B.
Conclusions: Email communication with the use of smartphone pho-tography significantly reduced the number of unnecessary ER visits for postoperative wound.
P38. Table 1. Summary of baseline characteristics of study groups
Consented Declined P value
Number 81 15
Average pictures sent 6.8 (5%) 0
≥2 60 (74%)
≥10 34 (42%)
Age in months, mean (standard deviation) 16.3 (15.4) 32 (46.4)
Median (interquartile range) 11 (9–17) 15 (9–23)
None 76 (93.8%) 13 (86.7%)
Yes 5 (6.2%) 2 (13.3%)
Concomitant inguinal surgery
Yes 3 (3.7%) 1 (6.7%)
Hypospadias classification
Distal 47 (58%) 13 (86.7%)
Midshaft 13 (16%) 0 (0%)
Proximal 21 (26%) 2 (13.3%)
Hypospadias repair type
Single stage 62 (76.5%) 14 (93.3%)
First stage 12 (14.8%) 0 (0%)
Second stage 7 (8.6%) 1 (6.7%)
P38. Table 2. Emergency room (ER) return analysis of study groups
Consented Declined P value Relative risk (95% confidence interval)
ER return for consult 15 (18.5%) 6 (40%) 0.05 0.46 (0.21–1.0)
ER return reason
Wound check 3 (4%) 4 (27%) 0.005 0.14 (0.035–0.56)
Non-related/medical reason 3 (4%) 2(13%) 0.14 0.28 (0.05–1.52)
Indicated (excessive bleeding/
catheter issues) 9 (11%) 0 (0%) 0.36 3.7 (0.23–60.54)
Improving the management of bladder and bowel dysfunction in children
Joana Dos Santos, Rebecca Rockman, Niraj Mistry, Roberto I. Lopes, Walid A. Farhat, Martin A. Koyle
Background: Bladder and bowel dysfunction (BBD) is very common, but underdiagnosed in children, resulting in significant complications and family distress. The majority of BBD cases improve with basic bladder retraining and constipation treatment. We are seeing increasing numbers of children with BBD in urology practice. As a result, the excessive num-ber of referrals to the surgical specialist led to delays in care. We aim to decrease the number of BBD urology visits and wait times by 50% over six months, by optimizing strategies to empower pediatricians to manage BBD in the community. Objectives: 1) Identify which barriers pediatricians may have in preventing care of such conditions via online questionnaires; 2) assess the impact on care from a pediatric elimina-tion network in which children with BBD who are referred to urology in a single quaternary center are re-referred to a network of community pediatricians (closer to home) with support of the urology division (Fig. 1).
Methods: After quality management approval, an online survey was distributed; 54 community pediatricians have answered to date. In the elimination network, the Dysfunctional Voiding Score System and Bristol stool chart are being completed at zero, three, and six months, and an anonymous satisfaction survey is offered to families at every visit. Results from multiple community pediatric offices and a urology clinic in a single quaternary center will be compared.
Results: 83% (45/54) of respondents were primarily office-based or com-bined office-hospital practice. BBD was diagnosed at least five times per month by 42.5% (23/54) of pediatricians; 55.5% (30/54) refer up to four patients per month to urology or gastroenterology. BBD management with polyethylene glycol 3350 and dietary changes was recommended by at least 89.1%; however, the use of a voiding diary was only done by
45.6%. Increased fluid intake was recommended by 60%, and bladder retraining strategies was recommended by 73.9%. 50.9% of pediatricians considered treatment failure to be the lack of improvement before six months of adequate management. Most pediatricians requested additional educational initiatives for healthcare practitioners and parents.
Conclusions: Our preliminary data suggests that constipation is ade-quately managed by community pediatricians, however, improvement in strategies surrounding bladder retraining is needed. Once data from the elimination network is analyzed, we will be able to compare outcomes from community pediatricians and urology. Educational initiatives are recommended for improvement of the management of BBD in children.
Operating room utilization in a tertiary care, free-standing pediatric hospital: Current practices and improvements
Jessica M. Ming, Michael E. Chua, Megan A. Saunders, Melyssa Stoute, Vannessa Chin, Martin A. Koyle
Background: Operating room (OR) hours are a valuable resource for hospitals and can be very limited due to a variety of factors, including: appropriate scheduling and allocation of case times, efficiency of turn-over, and the preset culture of each individual facility. Multiple attempts have been made to identify optimal utilization in the OR with variable success and mostly in the adult setting. Here, we characterize the operat-ing room efficiency and utilization of four pediatric urologists in a free standing children's hospital with the aim to identify points of potential improvement for increased throughput and team satisfaction.
Methods: We prospectively, after QI committee approval, collected data over a six-week time period of the four pediatric urologists operating collectively for 10 full OR days per week. This included: scheduled time per OR case, time in and out of the room, turnover, induction to incision start, surgery time, incision end to extubation, and extubation to time out of room. For any delays or alterations to the schedule, we identi-fied cause for delay or change and recorded the reason. OR efficiency ([sum of operative time/sum of case time including turnover] x100) and utilization ([sum of time OR occupied by patient/ sum of block time] x 100) was calculated per day.
Results: Overall, times were recorded for 129 patients. For the four sur-geons, overall mean OR efficiency ranged from 38‒44%. The overall mean OR utilization for each surgeon ranged from 63‒75%. There were 45 late starts (35%) identified with the majority of cases being due to the prior case going over time scheduled. This subsequently created an expected domino effect for the remaining cases in the day. All first start cases were on time (in the room within five minutes of 8:00 am start). The second most common reason was due to a delay in receiving a PACU bed, requiring time waiting in the operating room (46% of cases). The mean wait time was five minutes overall with range of 2‒15 minutes. Patient factors such as NPO violations did not have a major impact on schedule delays, but did lead to cancellations.
Conclusions: We have identified the overall utilization and efficiency of OR time among pediatric urologists operating in a free-standing academic children's hospital. Important factors contributing to our late starts was appropriate booking times and delay of transporting the patient to the PACU. Current efforts to improve the flow of patient care in the operat-ing room are in effect.
Optimal length of followup for the detection of an unsuccessful pediatric pyeloplasty: A single-center experience
Utsav K. Bansal, Pankaj Dangle, Heidi Stephany, Asad Durrani, Glenn Cannon, Francis Schneck, Michael Ost
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Background: There are no standard guidelines on ideal followup and imaging post-pediatric pyeloplasty. Our goal was to assess the optimal length of followup for patients undergoing both open and minimally invasive pyeloplasties to ensure detection of a recurrent obstruction in timely manner.
Methods: A retrospective chart review identified 279 patients (<18 years old) who underwent pyeloplasty for ureteropelvic junction obstruction between April 2002 and December 2014. Ultrasound was obtained every 3‒4 months for the first year following pyeloplasty and thereafter at the discretion of the treating physician. Patient characteristics including symp-toms and imaging were reviewed.
Results: Of the 279 patients, 71% were male (mean age of 52 months) and mean followup of 27.4 months. Of these 279 patients, 73% were followed up to three years. Fifteen patients (5.4%) had a recurrent obstruc-tion. Among the failures, 80% were diagnosed and underwent success-ful redo-pyeloplasty within three years. The six infants with recurrence (40% of all unsuccessful surgeries) were detected and diagnosed within three years of the initial surgery. Patients undergoing a minimally inva-sive procedure were less likely to be followed for more than three years compared to an open procedure (p<0.001). Patients with severe hydro-nephrosis preoperatively were followed longer and this was statistically significant in a univariate analysis (p=0.036). Age at time of surgery and type of surgical approach (p<0.01) were significant predictors of length of followup in a negative binomial regression, which accounts for maximal length of followup.
Conclusions: Based on the results, a minimum of three years of followup is necessary to detect the majority of recurrent obstructions. Among those who require a secondary pyeloplasty, younger patients with severe hydro-nephrosis are at an increased risk of recurrence.
Prognostic factors of chronic kidney disease in patients with posterior urethral valves
Monica Salgado, Yann Chaussy, Pierre-Alain Hueber, Anne-Marie Houle, Diego Barrieras, Julie Franc-Guimond
CHU Sainte-Justine, Montreal, QC, Canada
Background: Posterior urethral valves (PUV) is the most common cause of congenital bladder outlet obstruction and chronic kidney disease (CKD) in the male pediatric population. The aim of this study is to determine the prognostic value of nadir creatinine during the first year of life and all other potential factors that might increase the likelihood of developing CKD in patients with this condition.
Methods: Hospital records of all patients with PUV were reviewed from 1980‒2010. Abnormal kidney function was defined as CKD Stage 2 or higher (National Kidney Foundation). Patients were divided in two groups based on GFR at latest followup. Receiver operating characteristic (ROC) curve, univariate and multivariate analysis were conducted in order to identify independent prognostic factors for CKD. Statistical significance was defined as a p<0.05.
Results: A total of 114 PUV patients satisfied our inclusion criteria. At diagnosis, the mean age was three years. Among them, 32.5% were diagnosed antenatally, 23.7% before one year of life and 43.9% after. The mean followup period was eight years (SD±4.6). An abnormal kidney function was found in 18.4% patients, among them 4.38% reached end-stage renal disease (ESRD). Mean of Nadir creatinine at first year of life in patients who developed CKD was 54.75 µmol/l vs. 27.95 µmol/l for patients with normal renal function. Levels of nadir creatinine during the first year of life >30 µmol/L were found to be a cutoff point for determine future prognosis (ROC curve, AUC=0.94; p<0.001) with a sensibility of 95%, specificity of 32%. Diagnosis before one year of age, elevated nadir creatinine at first year of life, bilateral hydronephrosis, recurrent UTIs, and loss of corticomedullary differentiation were significant predictors of renal outcome on univariate analysis.
Conclusions: PUV disease can lead to deleterious effects on renal func-tion. Nadir creatinine during the first year of life was the only indepen-dent predictor of CKD on multivariate analysis. As a predictive factor for future CDK, we found a much lower threshold than previously reported in the literature. In addition, age at diagnosis, presence of urinary tract infection, and radiological findings on ultrasound represent important prognostic factors that should be taken into consideration in order to optimize patient management.
Radiation exposure in children with posterior urethral valvesduring the first year of life: A necessity or an avoidable oversight?
Frank J. Penna, Rakan I. Odeh, Hissan Butt, Armando J. Lorenzo, Walid A. Farhat, Darius J. Bägli, Martin A. Koyle
Background: Although the long-term risks of radiation exposure remain unknown, it has been estimated that cumulative exposure increases the long-term risk of malignancy. Posterior urethral valves (PUV) is one of the most common causes of chronic kidney disease in children. While certain imaging studies are necessary to adequately diagnose and treat the critically ill child, we hypothesized that some of these studies, which carry radiation exposure, may be avoidable, particularly in the critical first year of life.
Methods: A retrospective, single-institution review of all children born with a diagnosis of PUV over a 10-year period (2003‒2013) was per-formed. Patients were stratified into three groups at two different time periods (one month and one year of age) based on creatinine (Cr) range and mean total radiation exposure from all imaging studies performed during the first year of life was estimated for each group: Group I (20‒50 umol/L), Group II (50‒100 umol/L), and Group III (>100 umol/L).
Results: Fifty-three children were included in the study. The mean gesta-tional age was 36.6±1.9 weeks and the mean birth weight was 3.0±0.3 kg. All of the children except for three had a documented history of antenatal hydronephrosis, with seven having a history of oligohydramnios. The majority of the children were treated with endoscopic valve ablation; only three had vesicostomy creation. Table 1 summarizes the mean Cr and radiation exposure/patient by Group. Fig. 1 demonstrates the significant shift in Groups based on Cr at one month vs. one year.
Short-stay pediatric pyeloplasty: A pilot project
Martin A. Koyle, Armando Lorenzo, Darius Bagli, Walid Farhat The Hospital for Sick Children, Toronto, ON, Canada.
Background: Healthcare costs continue to escalate, and this has incentiv-ized hospitals and healthcare workers to increase value by maintaining and/or increasing quality and safety, while reducing wastes and costs. A surgical short stay (SSS) unit was introduced to our facility, where cases were identified by each surgical service, where potentially, length of stay (LOS) could be reduced to <24 hours. Pyeloplasty was the procedure chosen as the pilot case for analysis in this unit by pediatric urology. The primary objective was to assess adverse outcomes (AOs) associated with reduced LOS by examining readmissions and emergency room (ER) visits.
Methods: During the inaugural period of this pilot project, September 23‒November 15, 2014, 149 total patients passed through the SSS. The records of these patients were reviewed to document those who under-went pyeloplasty and measure LOS compared to historic controls and report any adverse events.
Results: Pyeloplasty represented the fourth most common indication for SSS admission, 7/149 (9%) of patients, equal to that of appendec-tomy. In 2013‒2014, 54 pyeloplasties were performed with mean LOS of 1.61±1.69 days compared to 0.89±0.41 days in the SSS group. No patients in the SSS were readmitted. However, a single child was evalu-ated and treevalu-ated in the ER for a febrile urinary tract infection, >48 hours after discharge. All eight services who used SSS felt that the pilot was of benefit, although other than pyeloplasty, in the majority of other pro-cedures, LOS did not demonstrate a trend to decrease. Of 44% (n=60) of families who completed feedback by returning a survey, satisfaction with the SSS unit surpassed that of pre-pilot patients in eight categories.
Conclusions: Pediatric pyeloplasty patients can be discharged safely with LOS <24 hours, from a unit where the culture is focused on SSS. Based on our early experience, there is the potential for reducing costs because of reduced LOS. We have agreed to expand our inclusion criteria to include other common surgical procedures involving the ureter and bladder (e.g., reimplants). It has been our observation that if cases selected for SSS unit are performed as the first case of the day, particularly in infants, they invariably are ready to be discharged that evening with the proper nursing support and family/patient education. Family and surgeon acceptance is superb. Selection bias likely influences LOS, as all patients chosen had open pyeloplasty performed and were <2 years.
The fate of postoperative perinephric fluid collections within one month of pediatric renal transplantation: Etiology and therapeutic interventions
Frank J. Penna, Armando J. Lorenzo, Walid A. Farhat, Martin A. Koyle The Hospital for Sick Children, Toronto, ON, Canada
Background: Postoperative perinephric fluid collections are common after pediatric renal transplantation (RT), and may be caused by clinical enti-ties such as urinoma, hematoma, and lymphocele. These collections are usually monitored with serial ultrasounds. Size, etiology, extrinsic ure-teral obstruction, and/or the presence of symptoms dictate management. We hypothesized that these fluid collections rarely require intervention and gain little benefit from close followup with imaging in the presence of stable clinical status (asymptomatic with stable renal function) and absence of hydronephrosis.
Methods: Retrospective review was performed of all children who under-went pediatric RT at our institution within the last five years (2010‒2014) and monitored at least one month postoperatively. Perinephric fluid col-lections on postoperative renal ultrasounds were measured in three axes and correlated with clinical parameters and symptomatology. Indicated interventions including image-guided drainage and surgery were captured.
Results: One hundred three children underwent RT (59 deceased and 44 living-related donor) over this period, at a mean age of 10.6±5.4 years. Only 37 patients (36%) had no perinephric collections on ultrasound at two weeks postoperatively. Sixty-six patients (64%) had fluid collec-tions, 14 of which underwent intervention: nine lymphoceles (8.7%), three infected hematomas (2.9%), and two urinomas (1.9%). Four patients with lymphoceles underwent laparoscopic marsupialization after failed drainage and/or sclerotherapy. The average fluid collection volume was 169 cm3; 618 cm3 in the intervention group compared to 46 cm3 in those observed.
Conclusions: Perinephric fluid collections are common after pediatric renal transplantation, the majority of which do not require intervention. Larger volume fluid collections were associated with intervention and are usually secondary to lymphoceles.
Trends in renal extirpative surgery: A single-institution experience over 10 years
Rakan I. Odeh, Frank J. Penna, Naimet K. Naoum, Ibraheem Abu Azzawayed, Walid A. Farhat, Armando J. Lorenzo, Darius J. Bägli, Martin A. Koyle
Background: Renal extirpative surgery (RES) for benign and malignant conditions may be performed as total or partial nephrectomy, accom-plished in an open (O) or laparoscopic (L) fashion. We set out to trend RES at a large, free-standing children's hospital and hypothesized that the trend of surgical intervention for benign conditions would demonstrate a decrease over the course of the study, primarily due to a paradigm shift in the management of benign congenital urological conditions, particularly duplex systems.
Methods: A retrospective chart review was performed on all patients who underwent RES at a large pediatric referral center over a 10-year period (2005‒2014). Parameters evaluated included: diagnosis, surgical approach (O vs. L, total vs. partial), mean age, operative time, estimated blood loss (EBL), and complications.
Results: Of the 292 patients evaluated, 30 patients were excluded who either underwent transplant nephrectomy or were lost to followup. Of the 262 patients included, 60.7% had benign conditions, with over half (52.4%) being approached laparoscopically. Over the time course of the study, the trend of surgical intervention for benign conditions decreased significantly (15.7‒6.3%; p=0.0003). Partial nephrectomy for benign condi-tions, particularly duplex systems also decreased significantly (28.6‒4.76%; p=0.009). Conversely, malignant conditions represented 39.3% of patients, with 22.3% of these patients being treated laparoscopically. The trend of surgical intervention for malignant conditions demonstrated a steady increase over the time course of the study (3.9‒18.4%; p=0.06).
Conclusions: Over the period of the study, the trend of extirapative surgery for benign disease has decreased significantly, particularly duplex systems and multicystic dysplastic kidneys. Conversely, the trend for malignant conditions increased steadily over the same time period. Despite initial
P44. Table 1. Patient radiation exposure parameters during the first year of life
enthusiasm, the trend for laparoscopic approaches for all conditions has remained flat.
Consistent and durable improvements in quality of life with long-term onabotulinum toxin A treatment in patients with overactive bladder
Benjamin Brucker1, Victor Nitti2, Sidney Radomski3, Angelo Gousse4, Marcus Drake5, Albert Kaufmann6, Andrew Magyar7, JP Nicandro8, David Ginsberg9
1New York University Langone Medical Center, New York, NY, USA; 2New York University, New York, NY, USA; 3University of Toronto, Toronto, ON, Canada; 4Bladder Health and Reconstructive Urology Institute, Miami, FL, USA; 5Bristol Urological Institute, Bristol, UK; 6Kliniken Maria Hilf GmbH, Mönchengladbach, Germany; 7Allergan plc, Bridgewater, NJ, USA; 8Allergan plc, Irvine, CA, USA; 9USC Institute of Urology, Los Angeles, CA, USA
Background: Overactive bladder (OAB) is a chronic condition that can cause significant burden and have a negative effect on patients' daily lives. There is a need to offer patients with OAB who are inadequately managed by an anticholingergic alternative therapies that are effective and improve quality of life (QOL) over the long-term. A long-term extension study involving patients with OAB and urinary incontinence (UI) who were inadequately managed by an anticholinergic (ACH) demonstrated that onabotulinum toxin A 100U provides consistent, long-term improve-ment of OAB symptoms. Here we evaluated the long-term effects of onabotulinum toxin A 100U on QOL in this extension study.
Methods: Eligible patients who completed either of two phase 3 trials could enter a three-year extension study to receive onabotulinum toxin A treatment "as needed" for control of symptoms. Results are reported for up to six treatments. Assessments included change from baseline in Incontinence-QOL (I-QOL) total score and proportions of patients who achieved/exceeded the minimally important difference (MID) in I-QOL score (+10 points) after each treatment. Consistency of response over repeat treatments was evaluated by determining whether patients achieved ≥MID after the first treatment, and then analyzing the proportion who achieved ≥MID for all subsequent treatments.
Results: Of 829 patients enrolled, discontinuations due to lack of effi-cacy/adverse events were 5.7%/5.1%. After onabotulinum toxin A treat-ments 1‒6, QOL improvements were consistently maintained at 2‒3X MID across treatment cycles, with most patients achieving ≥MID (range 65.2‒76.1%). 72.9% of patients who achieved ≥MID after treatment 1 maintained I-QOL improvements ≥MID in all subsequent treatments. Over one-third (38.3%) of patients not achieving ≥MID after treatment 1 achieved improvements ≥MID in all subsequent treatments. No new safety signals were observed.
Conclusions: Consistent improvements in OAB symptoms after long-term treatment with onabotulinum toxin A corresponded with durable QOL improvements, with no new safety signals. Patients with clinically mean-ingful QOL improvements after treatment 1 had similar improvements in subsequent treatments, while lack of response to treatment 1 did not preclude positive response(s) in subsequent treatments. These results help set treatment expectations of patients and clinicians for onabotulinum toxin A and support persistence of its use over the long-term. Additional analyses may further characterize the long-term effects of treatment with onabotulinum toxin A in patients with OAB inadequately managed by an ACH.
Do postoperative urinary retention and urinary tract infections predict complications of mid-urethral slings?
Nahid Punjani1, Jennifer Wince-Ng2, Blayne Welk1
1Western University, London, ON, Canada; 2Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
Background: Mid-urethral slings (MUS) are the gold standard for treatment of stress urinary incontinence. Limited data exists regarding predictive factors for future mesh complications. Our study examines if postopera-tive urinary retention and urinary tract infection were predictors of future mesh complications requiring surgical intervention.
Methods: Administrative data in Ontario, Canada between 2002 and 2013, was used to identify all women who underwent a mesh-based MUS. The primary outcome was future transvaginal mesh complications including erosion, fistula, removal, or urethrolysis. The primary exposure was postoperative urinary retention (within 30 days of procedure) and secondary exposure was the number of postoperative serious urinary tract infections (requiring emergency room visit or hospital admission).
Results: A total of 59 556 women had a MUS, of which 1598 (2.7%) required reoperation for mesh complications. Of the 2025 women who presented to the emergency room or were admitted for postoperative urinary retention, 212 (10.5%) developed mesh complications. Of the 11 747 patients who had at least one postoperative urinary tract infec-tion, 366 (3.1%) patients developed mesh complications. Postoperative urinary retention was predictive of future reoperation (HR 3.33, 95% CI 2.86‒3.87). Postoperative urinary tract infections were also associ-ated with an increased risk for future complications (HR 1.15, 95% CI 1.13‒1.17).
Conclusions: Postoperative urinary retention and frequent urinary tract infections are associated with an increased risk of reoperation for MUS complications. These patients should be closely followed and appropri-ately investigated.
Increasing screening for overactive bladder and incontinence in at-risk patient population
Diane K. Newman1, Ruth Cohen Cooper2, Vandana Iyer2
¹University of Pennsylvania, Berwyn, PA, USA; ²Practicing Clinicians Exchange, Stamford, CT, USA
Background: Overactive bladder (OAB) and urinary incontinence (UI) remain underdiagnosed and undertreated, despite evidence-based guide-lines on assessment and treatment. Most patients are embarrassed to initi-ate conversations about UI and, since the prevalence of OAB increases with age, patients and clinicians often accept OAB as an inevitable part of aging. Diabetic and obese women are particularly at risk. Increasing numbers of these patients are being seen by advanced practice providers (APPs), nurse practitioners (NPs), and physician assistants (Pas). They have the opportunity to improve outcomes by consistently screening patients and increasing the use of strategies that promote patient adherence to treatment. To this end, the aim of this practice building activity was to increase APP communication techniques and use of guideline-based screening tools to improve diagnosis, treatment adherence, and long-term monitoring of OAB and UI within their practice.
Methods: In the initial (baseline) phase, APPs (NPs=39, PAs=15; total n=54) who see patients with OAB and UI were asked to review medical records of four patients with either type 2 diabetes (T2DM) and/or obesity and answer seven questions about their care in an online questionnaire. The APPs then received four educational email briefs reinforcing impor-tant aspects of optimal care for patients with OAB and UI, and were then asked to complete an action plan. In the final phase, APPs reviewed charts of four new patients with T2DM and/or obesity and answered the same questions to determine whether a change in performance occurred regarding practices involved in screening and management.
Conclusions: Clinical performance can be improved when clinicians participate in an educational format that requires them to assess their own practice patterns before and after an educational intervention. This activity led to significant improvements in practices related to OAB and UI screening, symptom evaluation, and long-term monitoring by targeting patients at increased risk for OAB and UI.
Network meta-analysis to assess the treatment effect of onabotulinum toxin A, mirabegron, and anticholinergics vs. placebo for overactive bladder
Benjamin Brucker1, Marcus Drake², David A. Ginsberg3, Christopher Chapple4, Rachael McCool5, Julie Glanville5, Kelly Fleetwood6, Daniel James6, Kristin Khalaf7, Victor W. Nitti8
1New York University Langone Medical Center, New York, NY, USA; 2Bristol Urological Institute, Bristol, UK; 3USC Institute of Urology, Los Angeles, CA, USA; 4The Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK; 5York Health Economics Consortium, University of York, York, UK; 6Quantics, Edinburgh, Scotland, UK; 7Xcenda, Palm Harbor, FL, USA; 8New York University, New York, NY, USA
Background: Pharmacotherapy is the second-line treatment for overac-tive bladder (OAB) after behavioral therapy, but there is a high discon-tinuation rate due to inadequate efficacy and/or intolerable side effects. Onabotulinum toxin A provides an additional treatment option for OAB in patients who are inadequately managed by an anticholinergic. This is the first comparison of the efficacy of all licensed doses of anticholiner-gics, mirabegron, and onabotulinum toxin A vs. placebo in adults with idiopathic overactive bladder using network meta-analysis (NMA) and meta-regression (NMR).
Methods: Electronic databases, review documents, guidelines, and web-sites were searched for randomized blinded trials of ≥2 weeks dura-tion comparing any dose of onabotulinum toxin A, mirabegron, or oral/ transdermal anticholinergics with each other or placebo. Networks were developed for outcomes of interest based on studies of similar quality of study methods, confounding factors, common treatment arms, and outcomes measured. Bayesian random effects NMA (for the outcome of 100% reduction in urinary incontinence episodes [UIE]) and NMR (for outcomes on changes from baseline in UIE, urgency episodes, and micturition frequency) models were used to synthesize results at Week 12. Safety outcomes were not compared due to differences in adverse event profiles.
Results: One hundred two trials were assessed. NMRs indicated that, after adjusting for differences in baseline severity between trials, all treatments were more efficacious than placebo. Patients who received onabotulinum toxin A (100U) had the greatest mean reductions in UIE (1.55 episodes/ day more than placebo [95% credible interval (CrI) 1.10, 2.01]), urgency (2.01 episodes/day more than placebo [CrI 1.48, 2.54]) and micturi-tion frequency (1.37 episodes/day more than placebo [CrI 1.03, 1.70]).
Onabotulinum toxin A patients also had the highest likelihood of achiev-ing 100% UIE reduction (OR 4.30 vs. placebo [CrI: 3.03, 6.23]).
Conclusions: This analysis suggests that onabotulinum toxin A 100U provides the greatest reduction in OAB symptoms and higher likelihood of being dry, relative to placebo, than all licensed doses of anticholinergics and mirabegron in the network. Additional studies should also evaluate the cost-effectiveness of onabotulinum toxin A vs. other OAB treatments.
The use of urodynamics in followup of neurogenic bladders treated with onabotulinum toxin A
Michelle Bergeron
CHU de Québec, Quebec City, QC, Canada
Background: Patients with neurologic disorders may suffer from detru-sor overactivity (NDO) or low bladder compliance, which can damage the upper urinary tract. Intradetrusor injections of onabotulinum toxin A (BoNTA) have recently emerged as a treatment for NDO. Urodynamics (UDS) are currently used at initial diagnosis and at regular intervals dur-ing followup to ascertain that the intravesical pressure remains within safe limits. However, with regards to the discomfort and risks associated with UDS, our objective was to assess if UDS done at regular intervals in the followup of neurogenic bladders treated with BoNTA had an impact on management.
Methods: We analyzed retrospectively the medical records of adult patients with neurologic disorders treated with intradetrusor injections of BoNTA for either detrusor overactivity or low bladder compliance at the Institut de réadaptation en déficience physique du Québec (IRDPQ). In our center, UDS were routinely done at baseline and then after every fifth set of injections.
Results: We identified 57 patients with a diagnosis of neurologic disorder. Each patient had between one and 19 sets of injections, with a mean number of 5.61 injections, and 1‒6 followup UDS representing a mean number of 2.09 UDS. Of the 119 followup UDS reviewed in our center, urologists took the decision to interrupt treatment in five cases (4.2%), which was eventually resumed, while three patients (2.5%), due to per-sistence of symptoms or high intravesical pressure, had their management changed to bladder augmentation. Two regimens were suspended and one was ended due to patient's preference.
Conclusions: Our study showed that UDS at pre-set intervals for fol-lowup of patients receiving BoNTA injections were rarely associated with modifications in the treatment course. Therefore, UDS should only be performed in cases where there is a change in the patient's symptoms or if the urologist suspects that the treatment response is suboptimal.
P50. Table 1. Summary of performance change for each of the 5 main patient questions
Questions % asking all 4 patients at initial phase % asking all 4 patients at final phase % increase P value
Ask patient about concerns about
bladder control problems? 57% 83% 45% <0.01
Document patient's bladder
complaints at every visit? 48% 72% 50% <0.01
Offer the patient a voiding diary? 24% 54% 125% <0.01
Discuss bladder symptoms at each
subsequent visit? 44% 78% 77% <0.01
Provide patient with material on behavioral and pharmacotherapeutic options?
Voiding symptoms, age, and BMI are driving factors in AUASS
Ilija Aleksic1, Charles Welliver1, Randy Sulaver2, Adam Whittington3, Brian Helfand3, Ömer Onur çakır4, James Griffith5, Kevin McVary2 1Albany Medical College, Albany, NY, USA; 2Southern Illinois University School of Medicine, Springfield, IL, USA; 3NorthShore University Health System, Evanston, IL, USA; 4Istanbul Bagcilar Research and Training Hospital, Istanbul, Turkey; 5Northwestern University, Chicago, IL, USA
Background: The AUA Symptom Score (AUASS) includes voiding (strain-ing, incomplete empty(strain-ing, intermittency, weak stream) and storage symp-toms (nocturia, urgency, frequency). To date, no comorbidity has been shown to have predictive value and no chief lower urinary tract symp-toms (LUTS) complaint (CLC) has been implicated as a driving factor in AUASS. Our objective is to determine influence of comorbidities, CLC, and treatment on AUASS.
Methods: Prospective evaluation of men with LUTS, completing AUASS and CLC survey at two consecutive visits. Collected comorbidities included: age, body mass index (BMI), hypogonadism, diabetes, hyper-lipidemia, hypertension, and smoking. Treatments included: anticholiner-gics, alpha blockers, 5-alpha-reductase inhibitors, and phosphodiesterase type 5 inhibitors.
Results: Predictors of AUASS are BMI and age (adjusted R2 7.5%) with each BMI and year of age yielding a score increase of 0.16 (SE 0.03; p<0.001) and 0.18 (SE 0.08; p<0.05), on stepwise regression. Straining as the CLC yielded the highest AUASS (ANOVA; Table 1A) of 17.0 (95% CI, 13.8‒20.1), significant vs. frequency, nocturia, multiple and no com-plaints (Tukey's test; p<0.05). No CLC yielded the lowest score, 6.76 (95% CI 5.68‒7.27), significant against all except intermittency (Table 1B).One-way ANOVA for AUASS change to CLC, the worst change was seen in patients with straining 3.5 (95% CI 1.06‒5.99) and incomplete emptying by 2.1 (95% CI 0.750‒3.416). Comparing AUASS change to treatment initiated, only anti-cholinergics demonstrated significant decrease in score (p<0.001) by 4.44 (95% CI 2.3‒6.6). Initiating finasteride or alpha-blocker yielded a decrease of 0.70 and 0.75. No new medication led to a decrease of 0.47 (95% CI 0.14‒0.80).
Related subjects : Voiding dysfunction Moderated Poster Session II: Reconstruction/Andrology Moderated Poster Session III: Pediatrics/Voiding Dysfunction Poster Session 2: Pediatrics / Trauma / Reconstruction Moderated Poster Session II: Pediatrics/Trauma/Reconstruction/Voiding Moderated Poster Session V: Oncology 2
Moderated Poster Session II: Pediatrics/Trauma/Reconstruction/Voiding
CUAJ ? September October 2015 ? Volume 9(9 10Suppl6) ? 2015 Canadian Urological Association S195 2015 NS AUA ABSTRACTS P13 Primary Urethroplasty for Idiopathic and Post traumatic Bulbar
Moderated Poster Session III: Oncology 1
CUAJ ? September October 2015 ? Volume 9(9 10Suppl6) ? 2015 Canadian Urological Association S205 2015 NS AUA ABSTRACTS2015 NS AUA ABSTRACTS P32 Pathologic Evaluation Of Non tumor Renal Tissue
Moderated Poster Session IV: Stones/Endourology/BPH/Infertility/General
CUAJ ? September October 2015 ? Volume 9(9 10Suppl6) ? 2015 Canadian Urological Association 2015 NS AUA ABSTRACTS S212 P49 Quality Of Care Of Uric Acid Stone Formers Single Center Review
Moderated Poster Session V: Oncology 2
CUAJ ? September October 2015 ? Volume 9(9 10Suppl6) ? 2015 Canadian Urological Association S219 2015 NS AUA ABSTRACTS2015 NS AUA ABSTRACTS P65 Budget Impact Model for the Utilization of
Moderated Poster Session 2: Pediatrics
CUAJ ? September October 2014 ? Volume 8(9 10Suppl6) ? 2014 Canadian Urological Association S183 2014 NS AUA ABSTRACTS P17 Robotic assisted Urachal Anomaly Excision A Technically Feasible
Moderated Poster Session 3: Oncology II
CUAJ ? September October 2014 ? Volume 8(9 10Suppl6) ? 2014 Canadian Urological Association S189 2014 NS AUA ABSTRACTS P30 Renal Cell Carcinoma Recurrence A Population based Cohort of
Moderated Poster Session 4: Trauma/Reconstruction & Voiding Dysfunction
CUAJ ? September October 2014 ? Volume 8(9 10Suppl6) ? 2014 Canadian Urological Association 2014 NS AUA ABSTRACTS S196 P46 Urethroscopy With a Rigid Ureteroscope Facilitates Urethroplasty
Moderated Poster Session 5: Laparoscopy/Robotics & Stones/Endourology
CUAJ ? September October 2014 ? Volume 8(9 10Suppl6) ? 2014 Canadian Urological Association 2014 NS AUA ABSTRACTS S202 P61 Use of Firefly Fluorescence Imaging Technology for Robotic
Moderated Poster Session 6: Basic Science, Education & Infertility
CUAJ ? September October 2014 ? Volume 8(9 10Suppl6) ? 2014 Canadian Urological Association S209 2014 NS AUA ABSTRACTS P78 Pudendal Nerve Stimulation Activates Spinal GABA A Receptors to
Moderated Poster Session 2: Basic Science
CUAJ ? October 2011 ? Volume 5(5Suppl3) ? 2011 Canadian Urological Association S175 2011 AUA NS AbStrActS P21 Effect of Antioxidant Supplements on the Response of Experimental Overactive
Moderated Poster Session 5: Renal Transplant, Laparoscopy & Female Urology
CUAJ ? October 2011 ? Volume 5(5Suppl3) ? 2011 Canadian Urological Association 2011 AUA NS AbStrActS S194 P70 Hydrogen Sulphide Improves Real time Renal Microvascular Flow and Attenuates
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CUAJ ? October 2011 ? Volume 5(5Suppl3) ? 2011 Canadian Urological Association S199 2011 AUA NS AbStrActS P82 President Wilson and the Management of Urinary Retention in 1919 Jennifer
Northeastern Section of the American Urological Association 68th Annual Meeting:...
Moderated Poster Session I: Oncology
Moderated Poster Session II: Reconstruction/Andrology
Moderated Poster Session IV: General/Endourology/Stones
Moderated Poster Session V: Oncology/Laparoscopy/Robotics/Basic Science
Moderated Poster Session VI: Education
Metabolic syndrome in patients with prostate cancer undergoing intermittent andr...
Poster Session 2: Pediatrics / Trauma / Reconstruction
Poster Session 3: Basic Science
Moderated Poster Session 4: Prostate and Testes Cancer

redpajama_set_name: RedPajamaCommonCrawl


Just bought the book. It is definitely a must for the library. Last week I posted a thread about gaining sideways momentum and this book describes it perfectly. I also have realized the my stride was extremely short by performing the towel drill. Where was this book 15 years ago?!!
Great book. I am glad I bought it.
A short stride is not the only thing that will keep you from hitting the target with the towel. Flaws in any of the 7 imperatives can keep you from getting there. For example, a late posture change, arms not opposite and equal at foot strike, poor hip and shoulder separation, no delay in shoulder rotation, failing to get stacked and track, failure to stabilize the glove out front, etc. can all cause your release point to pull back. Contrary to what many people think, the towel drill is about putting all of the mechanics together with proper timing. The goal is not to hit the target but to have perfect mechanics. Assuming you don't cheat by doing something like lunging, hitting the target is simply feedback that your mechanics were good.
The target is usually a glove held by a teammate. The glove is held at the height of the pitcher's eyes at foot strike and at a distance of the pitcher's stride plus 5 heal-to-toe steps. The pitcher holds a towel between the index and middle fingers such that about 12" of towel extends out from the hand. The pitcher goes through his delivery and, if his mechanics are good (and well-timed), he will stay on line with the target and get his release point out front enough to hit the target with the towel.
It is possible to cheat and do things like lunge at the target so hitting the target doesn't necessarily mean you did good. You need to be able to assess your own mechanics or you need to have a knowledgeable instructor watching you to ensure you aren't cheating.


Iwanami shinsho., Aoban ;, 347.
Kanmatsu: Furoito no nenpyō (p. 8-12).
ix, 209, 24 pages ; 18 cm.
Seishin bunseki nyūmon". Be the first.
schema:isPartOf <http://experiment.worldcat.org/entity/work/data/8908338523#Series/iwanami_shinsho> ; # 岩波新書.


The earliest General Baptist Church was thought to be founded about 1608 or 1609. Its chief founder was John Smyth and it was located in Holland. Smyth's history begins in England where he was ordained as an Anglican priest in 1594. Soon after his ordination, his zeal landed him in prison for refusal to conform to the teachings and practices of the Church of England. He was an outspoken man who was quick to challenge others about their beliefs but was just as quick to change his own positions as his own personal theology changed. Smyth continually battled the Church of England until it became obvious that he could no longer stay in fellowship with this church. Thus, he finally broke totally from them and became a "Separatist".
In 1609, Smyth, along with a group in Holland, came to believe in believer's baptism (as opposed to infant baptism which was the norm at that time) and they came together to form the first "Baptist" church. In the beginning, Smyth was on track with the typical orthodox church position; but as time passed, as was so typical, he began changing his positions. First, Smyth insisted that true worship was from the heart and that any form of reading from a book in worship was an invention of sinful man. Prayer, singing and preaching had to be completely spontaneous. He went so far with this mentality that he would not allow the reading of the Bible during worship "since he regarded English translations of Scripture as something less than the direct word of God."5 Second, Smyth introduced a twofold church leadership, that of Pastor and Deacon. This was in contrast to the Reformational trifold leadership of Pastor-Elder, Lay-Elders, and Deacons.
Third, with his newfound position on baptism, a whole new concern arose for these "Baptists". Having been baptized as infants, they all realized that they would have to be re-baptized. Since there was no other minister to administer baptism, Smyth baptized himself and then proceeded to baptize his flock. An interesting note at this point that should be brought to bear is that the mode of baptism used was that of pouring, for immersion would not become the standard for another generation. Before his death, as seems characteristic of Smyth, he abandoned his Baptist views and began trying to bring his flock into the Mennonite church. Although he died before this happened, most of his congregation did join themselves with the Mennonite church after his death.
Charles Haddon Spurgeon (1834-92) was England's best-known preacher for most of the second half of the nineteenth century. In 1854, just four years after his conversion, Spurgeon, then only 20, became pastor of London's famed New Park Street Church (formerly pastored by the famous Baptist theologian John Gill). The congregation quickly outgrew their building, moved to Exeter Hall, then to Surrey Music Hall. In these venues Spurgeon frequently preached to audiences numbering more than 10,000—all in the days before electronic amplification. In 1861 the congregation moved permanently to the newly constructed Metropolitan Tabernacle.


Young people across the archdiocese have more time to sign up for Pope Benedict XVI's World Youth Day in Brazil next summer.
In part because the original deadline fell during the busy holiday season, sign-up for the faith-filled gathering in Rio de Janeiro has been extended from Dec. 1 to Feb. 28, 2013.
Although it began Dec. 12, Catholics across Nebraska can still participate in a prayer program leading up to the 40th anniversary of Roe v. Wade, the 1973 Supreme Court ruling that legalized abortion.
The "40 Days of Prayer and Reflection" started on the feast of Our Lady of Guadalupe, the patroness of the unborn, and ends Jan. 22, the 40th anniversary of the ruling.
Michael Crowe and his family made extra batches of Christmas cookies this year. They were gifts for the doctors and nurses Michael credits with saving his life.
The 23-year-old almost died in September from a heart infection, and said he is grateful for the care he received at two Omaha hospitals.
But more than care led to his recovery. Michael also credits God and the prayers of hundreds of people.
Archbishop George J. Lucas will dedicate a new altar and bless a new chapel during a Dec. 22 Mass at St. Columbkille Church in Papillion.
Catholic Charities of Omaha's annual fundraising appeal this year stresses how the organization helps people who are hungry, abused or fighting addictions.
"We try to capture through photographs and stories the difference people's support is truly making in the lives of those they may see in our community," said John Griffith, executive director.
Money raised during Lent through Catholic Relief Service's Operation Rice Bowl is helping stock food pantry shelves in the archdiocese this Christmas season.
The archdiocese's Office of Missions and Justice recently donated $5,000 to Catholic Charities and $3,000 to Together Omaha.
About 75 percent of money raised during Operation Rice Bowl goes overseas, but 25 percent stays in the archdiocese, said Omar Gutierrez, manager of the missions' office.
A shared name prompted members of an Archdiocese of Omaha parish to reach out to Catholics in Newtown, Conn., in the wake of the Dec. 14 shooting at Sandy Hook Elementary School.
Nearly 100 people in St. Rose of Lima Parish in Crofton signed a letter after Masses Dec. 15 and 16, offering sympathy and prayers to members of St. Rose of Lima Parish in Newtown, which lost at least eight parishioners in the shooting. The letter was mailed Dec. 17.
After sharing a traditional Czech fish dinner at home, Shane and Alice Spence squeeze into a pew at St. Mary Magdalene Church in downtown Omaha at about 11:15 p.m. on Christmas Eve to listen to carols before the midnight Mass.
Going to Christmas midnight Mass has been a tradition for the couple since they married 12 years ago, and it's something Shane, who moved to the Omaha area when he was 10, and Alice, a native of the Czech Republic, both did as children with their families.
U.S. Air Force Chaplain Father Andy Sohm will be away from his family this Christmas, an experience he shares with many people he serves at Holloman Air Force Base in New Mexico.
For Father Sohm, it will be the first Christmas away from Iowa in 36 years.
And while it will be difficult, he told the Catholic Voice he has found a sense of family in New Mexico, and he plans to spend the holiday with members of St. Joseph, the Catholic parish on base.
"I'm so thankful I do not have to sit in my home alone," Father Sohm said.


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Have a look at our December 2017 edition of The Source.
Welcome to the latest edition of "The Source" – prepared by the team at Gladman with the specific aim to inform you of curent news and views in land & planning.
We're pleased to extend this welcome to our many readers who have recently joined our continually expanding list of subscribers. Please use the links below to view all the back issues of "The Source" from the experts in the strategic residential development industry.
Government's Neighbourhood Plans Claim Rejected by the Courts
Back in December 2016, the then Housing and Planning Minister, Gavin Barwell, released a Written Ministerial statement which, amongst other things, declared made neighbourhood plans "that plan for a housing number that have on average planned for approximately 10% more homes than the number for that area set out by the relevant local planning authority."
RTPI Concerned that OAN Methodology does not Consider Future Growth
The RTPI have expressed concerns that the new OAN methodology would simply entrench existing housebuilding patterns by failing to recognise the importance of employment projections or grown aspirations. The new OAN methodology was subject to consultation in September 2017, through which the concerns of the RTPI and other organisations were raised, mainly with regard to the lack of a forward looking approach and the failure to address the need for a mix of housing tenures and types.
Landbanking – Housebuilder Hits Back
Britain's largest housebuilder, Barratt Developments, has published a report to disprove accusations from Secretary of State, Sajid Javid that housebuilders are piling up so-called land banks. The criticism centres on housebuilders allegedly seeking to secure additional profit by holding onto land with planning permission in order to speculate on land price increases.
The Value of Place – Turning NIMBYs into YIMBYs
Create Streets' new report, 'Beyond Location', tries to answer the little discussed question of what we mean by the value of an actual neighbourhood and what actually drives that value by way of the inherent qualities of a place.
Local Plan Intervention – Sajid Javid Steps in Over Local Plan Failures
Communities Secretary, Sajid Javid, has said the government is prepared to take direct action and intervene in the local plan process at 15 local authorities across England in an effort to tackle the "broken" housing market.
Housebuilder News
Latest news from the sector
Countryside Confirms Excellent Year of Growth
The housebuilder saw total completions rise 28% to 3,389 homes against the equivalent period in 2016, on total adjusted revenue of £1,028.8 million, up 32%.Countryside Properties full year results for the year ending September 2017 has reported an "excellent" year of growth.
The group's private average selling price declined as planned, to £430,000 from 2016's £465,000 and the forward order book rose 8% to £242.4 million. The net reservation rate was above its target range at 0.84 reservations per open sales outlet (2016: 0.78) on an increased number of open sales outlets at 47 against 2016's 43.
Ian Sutcliffe, Countryside's group CEO, said: "With completions up 28%, 2017 has been another outstanding year of growth as our mixed-tenure model has met the demands of the housing market. We are pleased that the actions we have taken during the year to ensure our product meets the areas of strongest demand are delivering results."
Crest Nicholson Record a Robust Market
Open market average selling prices improved 5.4% to £391,000, whilst underlying sales rates for 2017 (excluding PRS) averaged 0.77 sales per outlet per week against 2016's 0.81. The housebuilder calculates that growth in revenues and reported sales for the year will be around 6-7% higher than 2016.Crest Nicholson have issued positive financial year updates, experiencing increases in overall housing unit completions, up 2.3% in 2017 (2,935 homes) against 2016, with average number of sales outlets also up 8.5% to 51. As of the end of October, Crest's total forward sales were 13.6% ahead of 2016 at £391.4 million.
Stephen Stone, Crest's CEO, said: "I am pleased to report yet another year of growth for the group. The business continues to increase the number of homes built and carries positive momentum into 2018 with strong forward sales."
Demand continues to build at Barratt
Barratt have declared a "strong start" to their new financial year, spanning the period from July 1 to November 12 2017.
In addition, total forward sales grew 8.4% to a value of £2,876 million, equating to 12,843 plots compared to 11,733 plots in 2016.Robust demand was reflected in net private reservations per average week which rose to 268, against the 265 of the equivalent period in 2016. They also launched 79 new developments during the period, against 2016's figure of 69, with the number of active outlets operating rising to 373 compared to 2016's 370.
David Thomas, Barratt's CEO, stated: "We have started the financial year strongly with a good sales rate, driven by customer demand for new homes and supported by an attractive lending environment. We remain committed to quality, build excellence and market leading customer service and are working hard to increase the supply of houses across the UK."
The Outlook is Positive for Bovis
The housebuilder claims pricing remains "robust" and expects to deliver an increase in the average selling price for the 2017 financial year and also stated that their HBF Customer Satisfaction rating on completions since February 2017 has averaged 75% (equivalent to a 3-star rating) and they remain confident in attaining their medium term target of a 4-star rating.Bovis has described their annual financial progress as "encouraging" in a recent trading update, stating they are fully sold for their targeted 2017 completions, with an average sales rate over the period of 0.52, up on the first half year rate of 0.48.
Greg Fitzgerald, group CEO said: "We expect to have a net cash position of at least £100 million as at 31 December 2017. Trading is in line with expectations, the market remains strong and we are on track to deliver another disciplined period end."
A Strong Second Half Statement by Taylor Wimpey
The volume housebuilder said that although their current total order book is slightly down on last year, at 8,751 homes (2016: 8,981), standing at around £2.2 billion against 2016's £2.3 billion sales, rates for this second half of the year were 0.71 sales per outlet per week against the 0.70 achieved in the equivalent period last year.Taylor Wimpey recently announced that they performed "strongly" during the second half of 2017, though they are remaining "alert to the potential risks from heightened political and economic uncertainty".
Pete Redfern, Taylor Wimpey's CEO, said: "Taylor Wimpey has performed strongly during the second half of 2017, delivering excellent sales rates and making further good progress against our operational targets" and "we have continued to see stability in trading patterns."
McCarthy and Stone Turn to Bungalows
Chief Executive, Clive Fenton, has dubbed the market 'difficult', stating in The Telegraph that: "Our full year completion volumes were in line with the prior year despite some headwinds as a result of the increased level of uncertainty in the secondary market." For example, immediately after the Brexit vote, they slowed down building due to market concerns but have recently boosted building and aiming to build 3,000 homes a year in the next few years.McCarthy and Stone's revenue rose by 4% to £635.9m in the year to 31stAugust, whilst their pre-tax profit fell by 1%. The retirement housebuilder does not benefit from any government policy designed to boost demand for new homes but rely on the second-hand market to sell its homes. The retirees to whom it sells its homes usually must sell in order to downsize and as the level of transactions has slowed, the company has suffered as a result.
The company is also working with housing association Places for People to help diversify the model by building rental retirement homes. Mr Fenton has recognised this as: "a very big and undersupplied market", as well as noting that the company were looking to bring back bungalows, the supply of which has recently slowed as buying land for them is not as profitable.
Analysis has shown that McCarthy and Stone's performance demonstrates how precarious the market can be without schemes such as Help to Buy. With diversification, they are rising to the challenge and, with growth in construction, sales are expected to grow and outweigh market challenges.
Interesting Appeal Decisions
At Gladman, we monitor all residential appeal decisions issued by the Planning Inspectorate, to better understand current interpretations of government planning policy.
Green Belt released in Queen's backyard
An appeal for 12 dwellings in Ascot, Windsor and Maidenhead was allowed despite being located within the Green Belt and a made neighbourhood plan area. The proposal was allowed as the council are currently unable to demonstrate a five year housing land supply, the openness of the Green Belt would be preserved and that the council will need to review and redraw Green Belt boundaries in any event, so the inspector allowed the appeal.
Appeal slips up on gravel in Yorkshire. Yes, gravel…
An appeal for 97 houses by Gleeson Developments was dismissed despite Barnsley being unable to demonstrate a 5-year housing land supply. The inspector found that the appellant's affordable housing provisions were inadequate and the necessary financial contributions had not been met. It was also determined that the proposed driveways were unsafe; the gravel used could result in serious accident for a pedestrian or cyclist. There were also concerns about their appearance and the detrimental impact on character should the driveways be unkempt. It was therefore concluded that despite the LPA only demonstrating 4.01 years in deliverable housing sites, this proposal would represent an unsustainable form of development and should therefore be dismissed.
Scheme is generally satisfactory, despite landscape harm
Inspector Kenneth Stone has allowed an appeal for 94 dwellings in Newport, Uttlesford after grappling with impact on character and appearance of Newport and safe operation of the highway network. The inspector found that development outside the settlement limits would result in harm to the overall landscape character and street scene. The harm, whilst weighing against the proposal, would be limited and localised by the contained nature of the site. Council and appellant agreed that no five year housing land supply existed and that it most likely sits between 3.1 and 4.2 years. Issues of noise, flooding, best agricultural land, living conditions and locational sustainability were all somewhat dismissed by the inspector and not considered harmful in the planning balance.
50% affordable scheme in AONB allowed in presence of a 5 year supply
An appeal for 30 dwellings has been allowed in Chipping Campden by Inspector JP Roberts after determining that there would be limited harm to the AONB. While Chipping Campden is completely washed over by AONB, the council accepts that some development will have to take place due to the town being a "Principal Settlement". The Inspector acknowledged that the council can demonstrate a 5 year supply of housing, but that due to the scheme being 50% affordable housing would help accommodate the shortfall in the area. The Inspector concluded that the scheme was small scale and that the impact on the AONB would be very limited whilst benefits outweighed the impacts and allowed the scheme.
Settlement Boundary does not an unsustainable scheme make
Inspector Cullum Parker has allowed an appeal for 25 dwellings and Doctor's Surgery in Great Bentley, Tendring. The Council argued that the scheme was not sustainable however the Inspector stated that "whether the appeal site is on one side or the other of a settlement boundary line is not definitive of the sustainability of the proposal" and found the appeal site is sustainable. The Council went on to state that they could only demonstrate a 4.6 year supply and therefore the tilted balance was applied. It was concluded that the benefits of the scheme outweighed the limited impacts and so the appeal was allowed.
Inspector pulls footpath from under appellant's feet
An appeal in Pensilva has been dismissed by Inspector JP Roberts for construction of 46 dwellings. The main issue addressed by the applicant was the footpath linking the site to local services, since the development did not have control of the land in question it could only use adopted highways to produce a footpath. Turning his attention to the highway, the inspector deemed the footpath too narrow to be safe to use as a pedestrian access. While the Inspector noted the economic and social benefits of the scheme through construction and affordable housing, it was stated that "the highway safety shortcomings are so severe that they outweigh all other considerations" and therefore dismissed the appeal.
Village edge appeal fails as it marks transition between village and countryside
An appeal against Derbyshire Dales for 14 dwellings in Doveridge was dismissed by Inspector Gareth Wildgoose after giving consideration to consistency with locational and housing supply policies and impact on character and appearance. The inspector found no reason to take a different view to previous inspectors who found a demonstrable 5 year housing land supply. Saved Policies H4 and SF4 relating to housing supply were considered out of date in the Council's original decision, but the inspector found this approach incorrect and stated that saved policies should not be regarded as out of date simply because the Local Plan is time expired. In this instance, the proposal contradicted both saved policies and emerging policies in relation to the location and supply of housing. Ultimately, the appeal site and its immediate surroundings made too great a contribution to the character and setting of Doveridge by their contribution in transitioning to the countryside around the settlement. The inspector found that this would significantly outweigh the benefits of the appeal which was therefore dismissed.
Issue 30 – November 2017
Issue 32 – January 2018


No. Click "Product Comparisons". Sounds like they're running a sale where they're retailing a version for the price of the next version down.
That being said, Vegas Platinum is a solid editor with a lot of features for those that don't need something industry standard like Premiere or Final Cut. I have Vegas Platinum 11 on my laptop and Premiere on my desktop.
I must be going blind, as I don't see "Vegas Movie Studio Ultimate."
Never used any of the CyberLink software, so I can't really say. It looks about on par with Premiere Elements and the lower versions of Vegas and Pinnacle Studio, the latter I can say is absolute crap.


My thanks to some of my loyal and cherished clients who took the time to help me build a "recommendations" page, which is an awkward but necessary reality in self-promotion ;-). Sigh.
"The thought of entering the Vancouver real estate market was quite intimidating. I was referred to see Christine by a beloved friend who stated Christine was great to work with. That being said I was still greatly intimidated and hesitant to settle for the first real estate agent I met. I will never forget my first contact with Christine. She was/is the real deal. Not dressed in designer clothes head to toe and not driving a fancy car... just a genuine smile and kind eyes. She was able to put my intimidation to rest and seemed to be the person I needed to get my foot in the market. I left my search for the perfect real estate agent at Christine. Christine was well informed about the market and knew so much about all the buildings. I felt at peace knowing I had her in my corner."
We are so happy that we found Christine! She was knowledgeable and skilled, reliable and honest and, above all, patient with us! We are so grateful to have benefited from her expertise and would call on her again in an instant if we were to enter another real estate venture.
I have had two transactions with Christine. The first one went smoothly, whereas the second one required extra work due to a competitive market and mortgage hurdles. Christine connected me with the right broker and used her negotiating skills to navigate between the listing agent, the broker, and the bank to meet deadlines and to secure acceptance of my offer. Thank you Christine.
" you are very honest, reliable, a good listener, not pushy realtor. You are a realtor who would work in the best interest of the client. You are very transparent and pointed out all benefits and risks before making any decision. Your response rate was 100%, I am so glad we worked with you. In the future we will definitely reach out to you if we need another property or sale this one. Last but not the least you have a ton of experience that would help the clients. You are phenomenal!!!!! Thank you so much for your help!
I have engaged Christine's services since the beginning of her career and continue to recommend her to many people I know . From the very beginning she has been thorough and knowledgeable in skillfully navigating through the complexities of the crazy world of real estate transactions . The thing that sets her apart is that she actually listens to what the client wants , doesn't try to up- sell , doesn't rush her clients , is honest ( that's a rare one ) and as I have said before but needs to be reiterated , she is thorough . In the past out of pressure from other parties I have used another agent and came to regret it . However , it was a good experience since it showed me that Christine's service is obviously a cut above the rest . I guarantee that you will not be disappointed .
There's a smart and funny girl named Christine, To me, a kindred spirit she's been. Gourmet, art lover, writer supreme, She helped me find the house of my dream!
We have used Christine on three transactions so far and will deal through her in the future. She is very knowledgeable about her market and works hard to know the details on individual listings. She prepares professional comparisons of similar listings to assist us in evaluating pricing and keeps us up to date on an ongoing basis with timely emails. Christine's sunny disposition makes it fun to deal with her, and we trust her implicitly. We have purchased homes in Vancouver and other cities in the US and France, and we feel that Christine is one of the most professional and pleasant real estate agents we have dealt with.
A few comments on Christine Saulnier's real estate practice. 1. I've worked with her for over 4 years now and with one particularly difficult sale. Christine handled this sale professionally and with excellent results. 2. She always goes the extra mile and works diligently to find a successful balance for the seller and the buyer. 3. Christine goes out of her way to help the seller and to make sure she has the right buyer. 4. She is energetic, polite and very helpful.


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