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Category: Sepsis
Why Hospitals Should Act Now to Create Clinical AI Departments
John Frownfelter, MD, FACP, Chief Medical Information Officer at Jvion
A century ago, X-rays transformed medicine forever. For the first time, doctors could see inside the human body, without invasive surgeries. The technology was so revolutionary that in the last 100 years, radiology departments have become a staple of modern hospitals, routinely used across medical disciplines.
Today, new technology is once again radically reshaping medicine: artificial intelligence (AI). Like the X-ray before it, AI gives clinicians the ability to see the unseen and has transformative applications across medical disciplines. As its impact grows clear, it's time for health systems to establish departments dedicated to clinical AI, much as they did for radiology 100 years ago.
Radiology, in fact, was one of the earliest use cases for AI in medicine today. Machine learning algorithms trained on medical images can learn to detect tumors and other malignancies that are, in many cases, too subtle for even a trained radiologist to perceive. That's not to suggest that AI will replace radiologists, but rather that it can be a powerful tool for aiding them in the detection of potential illness — much like an X-ray or a CT scan.
AI's potential is not limited to radiology, however. Depending on the data it is trained on, AI can predict a wide range of medical outcomes, from sepsis and heart failure to depression and opioid abuse. As more of patients' medical data is stored in the EHR, and as these EHR systems become more interconnected across health systems, AI will only become more sensitive and accurate at predicting a patient's risk of deteriorating.
However, AI is even more powerful as a predictive tool when it looks beyond the clinical data in the EHR. In fact, research suggests that clinical care factors contribute to only 16% of health outcomes. The other 84% are determined by socioeconomic factors, health behaviors, and the physical environment. To account for these external factors, clinical AI needs external data.
Fortunately, data on social determinants of health (SDOH) is widely available. Government agencies including the Census Bureau, EPA, HUD, DOT and USDA keep detailed data on relevant risk factors at the level of individual US Census tracts. For example, this data can show which patients may have difficulty accessing transportation to their appointments, which patients live in a food desert, or which patients are exposed to high levels of air pollution.
These external risk factors can be connected to individual patients using only their address. With a more comprehensive picture of patient risk, Clinical AI can make more accurate predictions of patient outcomes. In fact, a recent study found that a machine learning model could accurately predict inpatient and emergency department utilization using only SDOH data.
Doctors rarely have insight on these external forces. More often than not, physicians are with patients for under 15 minutes at a time, and patients may not realize their external circumstances are relevant to their health. But, like medical imaging, AI has the power to make the invisible visible for doctors, surfacing external risk factors they would otherwise miss.
But AI can do more than predict risk. With a complete view of patient risk factors, prescriptive AI tools can recommend interventions that address these risk factors, tapping the latest clinical research. This sets AI apart from traditional predictive analytics, which leaves clinicians with the burden of determining how to reduce a patient's risk. Ultimately, the doctor is still responsible for setting the care plan, but AI can suggest actions they may not otherwise have considered.
By reducing the cognitive load on clinicians, AI can address another major problem in healthcare: burnout. Among professions, physicians have one of the highest suicide rates, and by 2025, the U.S. The Department of Health and Human Services predicts that there will be a shortage of nearly 90,000 physicians across the nation, driven by burnout. The problem is real, and the pandemic has only worsened its impact.
Implementing clinical AI can play an essential role in reducing burnout within hospitals. Studies show burnout is largely attributed to bureaucratic tasks and EHRs combined, and that physicians spend twice as much time on EHRs and desk work than with patients. Clinical AI can ease the burden of these administrative tasks so physicians can spend more time face-to-face with their patients.
For all its promise, it's important to recognize that AI is as complex a tool as any radiological instrument. Healthcare organizations can't just install the software and expect results. There are several implementation considerations that, if poorly executed, can doom AI's success. This is where clinical AI departments can and should play a role.
The first area where clinical AI departments should focus on is the data. AI is only as good as the data that goes into it. Ultimately, the data used to train machine learning models should be relevant and representative of the patient population it serves. Failing to do so can limit AI's accuracy and usefulness, or worse, introduce bias. Any bias in the training data, including pre-existing disparities in health outcomes, will be reflected in the output of the AI.
Every hospital's use of clinical AI will be different, and hospitals will need to deeply consider their patient population and make sure that they have the resources to tailor vendor solutions accordingly. Without the right resources and organizational strategies, clinical AI adoption will come with the same frustration and disillusionment that has come to be associated with EHRs.
Misconceptions about AI are a common hurdle that can foster resistance and misuse. No matter what science fiction tells us, AI will never replace a clinician's judgment. Rather, AI should be seen as a clinical decision support tool, much like radiology or laboratory tests. For a successful AI implementation, it's important to have internal champions who can build trust and train staff on proper use. Clinical AI departments can play an outsized role in leading this cultural shift.
Finally, coordination is the bedrock of quality care, and AI is no exception. Clinical AI departments can foster collaboration across departments to action AI insights and treat the whole patient. Doing so can promote a shift from reactive to preventive care, mobilizing ambulatory, and community health resources to prevent avoidable hospitalizations.
With the promise of new vaccines, the end of the pandemic is in sight. Hospitals will soon face a historic opportunity to reshape their practices to recover from the pandemic's financial devastation and deliver better care in the future. Clinical AI will be a powerful tool through this transition, helping hospitals to get ahead of avoidable utilization, streamline workflows, and improve the quality of care.
A century ago, few would have guessed that X-rays would be the basis for an essential department within hospitals. Today, AI is leading a new revolution in medicine, and hospitals would be remiss to be left behind.
About John Frownfelter, MD, FACP
John is an internist and physician executive in Health Information Technology and is currently leading Jvion's clinical strategy as their Chief Medical Information Officer. With 20 years' leadership experience he has a broad range of expertise in systems management, care transformation and health information systems. Dr. Frownfelter has held a number of medical and medical informatics leadership positions over nearly two decades, highlighted by his role as Chief Medical Information Officer for Inpatient services at Henry Ford Health System and Chief Medical Information Officer for UnityPoint Health where he led clinical IT strategy and launched the analytics programs.
Since 2015, Dr. Frownfelter has been bringing his expertise to healthcare through health IT advising to both industry and health systems. His work with Jvion has enhanced their clinical offering and their implementation effectiveness. Dr. Frownfelter has also held professorships at St. George's University and Wayne State schools of medicine, and the University of Detroit Mercy Physician Assistant School. Dr. Frownfelter received his MD from Wayne State University School of Medicine.
Posted in AI, algorithms, Artificial Intelligence, Clinical Decision Support, clinical research, decision support, Department of Health and Human Services, depression, Health and Human Services, Health Information Technology, Health IT, Health Systems, Heart, Henry Ford, Jvion, Machine Learning, MD, model, Opinion, patient population, Physicians, Predictive Analytics, Radiologist, radiology, risk, Sepsis, social determinants of health
Transforming Care Delivery Through AI-Powered Predictive Surveillance
John Langton, Ph.D. Director of Applied Data Science, Wolters Kluwer, Health
Since the onset of the COVID-19 pandemic, hospitals and health systems have pushed forward with innovative technology solutions with great expediency and proficiency. Healthcare organizations were quick to launch telehealth solutions and advance digital health to maintain critical patient relationships and ensure continuity of care. Behind the scenes, hospitals and health systems have been equally adept at advancing technology solutions to support and enhance clinical care delivery. This includes adopting clinical surveillance systems to better predict and prevent an escalation of the coronavirus.
Clinical surveillance systems use real-time and historical patient data to identify emerging clinical patterns, allowing clinicians to intervene in a timely, effective manner. Over time, these clinical surveillance systems have evolved to help healthcare organizations meet their data analytic, surveillance, and regulatory compliance needs. The adaptability of these systems is evidenced by their expanded use during the pandemic. Healthcare organizations quickly pivoted to incorporate COVID-19 updates into their clinical surveillance activities, providing a centralized, global view of COVID-19 cases.
To gain insight into the COVID-19 crisis, critical data points include patient age, where the disease was likely contracted, whether the patient was tested, and how long the patient was in the ICU, among other things. Surveillance is also able to factor in whether patients have pre-existing conditions or problems with blood clotting, for example. This data trail is helping providers create a constantly evolving coronavirus profile and provides key data points for healthcare providers to share with state and local governments and public health agencies. In the clinical setting, the data are being used to better predict respiratory and organ failure associated with the virus, as well as flag COVID-19 patients at risk for developing sepsis.
What's driving these advancements? Clinical surveillance systems powered by artificial intelligence (AI). By refining the use of AI for clinical surveillance, we can proactively identify an expanding range of acute and chronic health conditions with greater speed and accuracy. This has tremendous implications in the clinical setting beyond the current pandemic. AI-powered clinical surveillance can save lives and reduce costs for conditions that have previously proven resistant to prevention.
Eliminating healthcare-associated infections
Despite ongoing prevention efforts, healthcare-associated infections (HAIs) continue to plague the US healthcare system, costing up to $45 billion a year. According to the Centers for Disease Control and Prevention (CDC), about one in 31 hospitalized patients will have at least one HAI on any given day. AI can analyze millions of data points to predict patients at-risk for HAIs, enabling clinicians to respond more quickly to treat patients before their infection progresses, as well as prevent spread among hospitalized patients.
Building trust in AI
While the benefits are clear, challenges remain to the widespread adoption and use of AI in the clinical setting. Key among them is a lack of trust among clinicians and patients around the efficacy of AI. Many clinicians remain concerned over the validity of the data, as well as uncertainty over the impact of the use of AI on their workflow. Patients, in turn, express concerns over AI's ability to address their unique needs, while also maintaining patient privacy. Hospitals and health systems must build trust among clinicians and patients around the use of AI by demonstrating its ability to enhance outcomes, as well as the patient experience.
3 keys to building trust in AI
Building trust among clinicians and patients can be achieved through transparency, expanding data access, and fostering focused collaboration.
1. Support transparency
Transparency is essential to the successful adoption of AI in the clinical setting. In healthcare, just giving clinicians a black box that spits out answers isn't helpful. Clinicians need "explainability," a visual picture of how and why the AI-enabled tool reached its prediction, as well as evidence that the AI solution is effective. AI surveillance solutions are intended to support clinical decision making, not serve as a replacement.
2. Expand data access
Volume and variety of data are central to AI's predictive power. The ability to optimize emerging tools depends on comprehensive data access throughout the healthcare ecosystem, no small task as large amounts of essential data remain siloed, unstructured, and proprietary.
3. Foster focused collaboration
Clinicians and data scientists must collaborate in developing AI tools. In isolation, data scientists don't have the context for interpreting variables they should be considering or excluding in a solution. Conversely, doctors working alone may bias AI by telling it what patterns to look for. The whole point of AI is how great it is at finding patterns we may not even consider. While subject matter expertise should not bias algorithms,
it is critical in structuring the inputs, evaluating the outputs, and effectively incorporating those outputs in clinical workflows. More open collaboration will enable clinicians to make better diagnostic and treatment decisions by leveraging AI's ability to comb through millions of data points, find patterns, and surface critically relevant information.
AI-enabled clinical surveillance has the potential to deliver next-generation decision-support tools that combine the powerful technology, the prevention focus of public health, and the diagnosis and treatment expertise of clinicians. Surveillance is poised to assume a major role in attaining the quality and cost outcomes our industry has long sought.
John Langton is director of applied data science at Wolters Kluwer, Health, where artificial intelligence is being used to fundamentally change approaches to healthcare. @wkhealth
Posted in AI, algorithms, Artificial Intelligence, Box, Care Coordination, Clinical Surveillance, clinical workflows, digital health, Health Systems, Opinion, patient experience, Patient Privacy, public health, risk, Sepsis, Telehealth, Wolters Kluwer
Culture-free alternatives for characterizing bloodstream infections
In the coming years, clinicians will be presented with a larger and more capable toolbox to aid in the diagnosis of sepsis, directly overcoming the drawbacks of culture-based diagnostics.
Posted in BioPharma, biopharma nl, Daily, Diagnostics, MedCity Influencers, Sepsis, SYN, Top Story
The Future of the ICU? How Clinical Decision Support Is Advancing Care
Kelly Patrick, Principal Analyst at Signify Research
Without a doubt 2020 has been a devastating year for many; the impact of COVID-19 on both personal lives and businesses has had long-term consequences. At the end of September, the number of COVID-19 cases fell just short of 350 million, with just over 1 million deaths reported. The expectation of a second peak in many countries exposed to the deadly illness is being handled with care, with many governments attempting to minimize the impact of an extreme rise in cases.
COVID-19 the aftermath will be the new normal?
Despite the chaotic attempts to dampen the impact of a second peak, it is inevitable that healthcare facilities will be stretched once again. However, there are key learnings to be had from the first few months of the pandemic, with several healthcare providers opting to be armed with as much information to tackle the likely imminent surge of patients with COVID-19 head-on. The interest in solutions that offer support to clinicians through data analysis is starting to emerge with several COVID-19 specific Artificial Intelligence (AI) algorithms filtering through the medical imaging space.
Stepping into the ICU, the use of analytics and AI-based clinical applications is drawing more attention. Solutions that collect relevant patient information, dissect the information, and offer clinical decision support are paving the way to a more informed clinical environment. Already, early-warning scoring, sepsis detection, and predictive analytics were becoming a focus. The recent COVID-19 outbreak has also driven further interest in COVID-19 specific applications, and tele-ICU solutions, that offer an alternative way to ensure high-risk patients are monitored appropriately in the ICU.
Signify Research is currently in the process of assessing the uptake of clinical decision support and AI-based applications in the high acuity and perinatal care settings. An initial assessment has highlighted various solutions that help improve not only the efficiency of care but also improve its quality. Some of the core areas of focus include:
Clinical Decision Support & Predictive Analytics
Due to the abundance of patient data and information required to be regularly assessed and monitored, the high-acuity and perinatal care settings benefit from solutions offering clinical decision support.
The ICU specifically has been a focus of many AI solution providers, with real-time analysis and support of data to provide actionable clinical decision support in time-critical situations. Clinical decision support solutions can collate data and identify missing pieces of information to provide a complete picture of the patient's status and to support the treatment pathway. Some of the key vendors pathing the way for AI in clinical decision support in the ICU include AiiNTENSE; Ambient Clinical Analytics; Etiometry; BetterCare; AlertWatch; and Vigilanz Corp.
Early-warning
Early-warning protocols are commonly used in hospitals to flag patient deterioration. However, in many hospitals this is often a manual process, utilizing color coding of patient status on a whiteboard in the nurse's station. Interest in automated early-warning systems that flag patient deterioration using vital signs information is increasing with the mounting pressure on stretched hospital staff.
Examples of early-warning software solutions include the Philips IntelliVue Guardian Solution and the Capsule Early Warning Scoring System (EWSS). Perigen's PeriWatch Vigilance is the only AI-based early-warning scoring system that is developed to enhance clinical efficiency, timely intervention, and standardization of perinatal care.
The need for solutions that support resource-restricted hospitals has been further exacerbated during the COVID-19 pandemic. Many existing early-warning vendors have updated their surveillance systems to enable more specific capabilities for COVID-19 patients, specifically for ventilated patients. Companies such as Vigilanz Corp's COVID Quick Start and Capsule Tech's Clinical Surveillance module for ventilated patients enables healthcare professionals to respond to COVID-19 and other viral respiratory illnesses with customizable rules, reports, and real-time alerts.
Sepsis Detection
Sepsis is the primary cause of death from infection, accounting for 20% of global deaths worldwide. Sepsis frequently occurs from infections acquired in health care settings, which are one of the most frequent adverse events during care delivery and affect hundreds of millions of patients worldwide every year. As death from Sepsis can be prevented, there is a significant focus around monitoring at-risk patients.
Several health systems employ their own early-warning scoring protocol utilizing in-house AI models to help to target sepsis. HCA Healthcare, an American for-profit operator of health care facilities, claims that its own Sepsis AI algorithm (SPOT) can detect sepsis 18-hours before even the best clinician. Commercial AI developers are also focusing their efforts to provide supporting solutions.
The Sepsis DART™ solution from Ambient Clinical Analytics uses AI to automate early detection of potential sepsis conditions and provides smart notifications to improve critical timeliness of care and elimination of errors. Philips ProtocolWatch, installed on Philips IntelliVue bedside patient monitors, simplifies the implementation of evidence-based sepsis care protocols to enable surveillance of post-ICU patients.
Tele-ICU
The influx of patients into the ICU during the early part of 2020 because of COVID-19 placed not only great strain on the number of ICU beds but also the number of healthcare physicians to support them. Due to the nature of the illness, the number of patients that were monitored through tele-ICU technology increased, although the complex nature of implementing a new tele-ICU solution has meant the increase has not been as pronounced as that of telehealth in primary care settings.
However, its use has enabled physicians to visit and monitor ICU patients virtually, decreasing the frequency and need for them to physically enter an isolation room. As the provision of healthcare is reviewed following the pandemic, it is likely that tele-ICU models will increase in popularity, to protect both the patient and the hospital staff providing direct patient care. Philips provides one of the largest national programs across the US with its eICU program.
Most recently, GE Healthcare has worked with Decisio Health to incorporate its DECISIOInsight® into GE Healthcare's Mural virtual care solution, to prioritize and optimize ventilator case management. Other vendors active within the tele-ICU space include Ambient Clinical Analytics, Capsule Health, CLEW Med, and iMDsoft.
Figure 1 Signify Research projects the global tele-ICU market to reach just under $1 billion by 2024.
Interoperable Solutions
More and more solutions are targeted toward improving the quality of patient care and reducing the cost of care provision. With this, the requirement for devices and software to be interoperable is becoming more apparent. Vendors are looking to work collaboratively to find solutions to common problems within the hospital. HIMMS 2020 showcased several collaborations between core vendors within the high acuity market. Of note, two separate groups demonstrated their capabilities to work together to manage and distribute alarms within a critical care environment, resulting in a quieter experience to aid patient recovery. These included:
– Trauma Recovery in the Quiet ICU – Ascom, B Braun, Epic, Getinge, GuardRFID, Philips
– The Quiet Hospital – Draeger, Epic, ICU Medical, Smiths Medical, Spok
About Kelly Patrick, Principal Analyst at Signify Research
Kelly Patrick is the Principal Analyst at Signify Research, a UK-based market research firm focusing on health IT, digital health, and medical imaging. She joined Signify Research in 2020 and brings with her 12 years' experience covering a range of healthcare technology research at IHS Markit/Omdia. Kelly's core focus has been on the clinical care space, including patient monitoring, respiratory care and infusion.
Posted in AI, algorithms, Artificial Intelligence, Case Management, Clinical Decision Support, Clinical Surveillance, Decisio Health, decision support, digital health, Figure 1, GE healthcare, Health IT, Health Systems, healthcare technology, iMDsoft, Opinion, Patient Care, Patient Monitoring, PeriGen, Philips, Physicians, Predictive Analytics, primary care, risk, Sepsis, Signify Research, Spok, Tele, Tele-ICU, Telehealth, virtual care, Vital
Sepsis Awareness Month: Why Sepsis Awareness Is More Important Than Ever
Denise Cardo, MD Director, Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases at the Centers for Disease Control and Prevention In these unprecedented times, Sepsis Awareness Month is a moment for us to reflect on and recommit to focusing on the needs of the patient. Sepsis is the body's extreme response to an infection, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. During this challenging time we are facing because of the COVID-19 pandemic, it is important to reflect on the connections with sepsis. It is known that
Posted in Infection Control and Prevention, Sepsis
Continued Care for COVID Recovery: How LTAC Hospitals Help Post-COVID Patients
Posted on June 11, 2020 by Nile
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<p>The latest research findings are honing in on the clinical conditions associated with COVID-19, along with the specific care pathways needed for patients, once stabilized, to fully recover. Specialized care after the initial hospital stay is proving to play a critical role. </p>
<p>Hospitalized COVID-19 patients often experience significant pulmonary complications, including severe pneumonia and acute respiratory distress-like syndrome. Further, many physicians are reporting that patients are developing post-intensive care syndrome (PICS) due to an intensive care unit (ICU) stay measured in weeks rather than days. The virus is also resulting in strokes, and causing sepsis, which can lead to multi-system failure and leave a patient with lasting damage to the lungs and other organs.</p>
<p><strong>This brief details COVID-19 patient care management strategies and research on how the clinical expertise of LTAC hospitals is uniquely suited for post-COVID patients.</strong></p>
<h2><strong>New Research on Care Solutions for Post-COVID Patients: The Role of LTACHs</strong></h2>
<p>A growing body of evidence indicates that the specialized services delivered in long-term acute care hospitals play a unique and positive role in treating patients recovering from COVID-19.</p>
<p>A recent study in the <em>Journal of Rehabilitative Management</em> stated that: “Early rehabilitation of the COVID-19 patients can enhance pulmonary, respiratory function, reduce complications, improve function, cognitive impairments and quality of life."<sup>1</sup></p>
<p>Hospitalized COVID-19 patients are receiving life-saving care in an ICU for much longer than the average stay of three to four days and are often reliant on a ventilator, both of which puts them at high risk of developing post-intensive care syndrome (PICS) – a condition that can include ICU-acquired weakness, cognitive or brain dysfunction and other mental health disorders. Specialized care interventions and rehabilitation are needed to address the short- and medium-term consequences of post-COVID patients experiencing PICS symptoms and recovering from extended mechanical ventilation.<sup>2</sup></p>
<p>Additionally, as published recently in <em>The Boston Globe<sup>3</sup></em>:</p>
<p style="padding: 0 50px;">Many recovering COVID-19 patients need to be weaned off of ventilators and slowly reintroduced to eating on their own. Some also require speech therapy, pulmonary therapy, and dialysis.</p>
<p style="padding: 0 50px;">…COVID-19 has reminded the world of the importance of facilities that occupy the middle ground of the critical care landscape.</p>
<p style="padding: 0 50px;">“In a pandemic, you really do need that kind of intensive care,” said Grabowski, who co-authored a paper advocating for the importance of long-term acute care hospitals. "For years, we said, ‘Why do we need long-term care hospitals?’ And all of a sudden with COVID, we’re saying ‘Why don’t we have more long-term care hospitals?’”</p>
<p>Lastly, a recently co-authored a post in <em>Health Affairs</em> highlighted the critical resource that LTAC hospitals can play during the COVID pandemic.<a href="#_ftn4" name="_ftnref4"></a><sup>4</sup> Specifically, the researchers suggest that <strong>the clinical expertise in LTAC hospitals with “critical care nurses, respiratory therapists, and intensivists” aligns with the ongoing needs of COVID patients. </strong>The experts conclude that, “During this unprecedented international crisis, [LTAC hospitals] offer additional opportunities to prepare for and manage the surge of COVID-19 patients experiencing respiratory failure.”</p>
<h2><strong>Unique Clinical Presentations Require Specialized Care</strong></h2>
<p>Due to the complex medical needs of post-COVID patients, long-term acute care (LTAC) hospitals are a key care setting. LTAC hospitals deliver care for the most difficult-to-treat, critically ill and medically complex patients – such as patients with respiratory failure, septicemia, traumatic injuries, wounds or other severe illnesses complicated by multiple chronic conditions, many of which have been symptoms of post-COVID recovery.</p>
<p>These specialty hospitals are unlike other post-acute care settings because they are licensed as a general acute care hospital by the state and certified by the Centers for Medicare & Medicaid Services (CMS) as an LTAC hospital, and accredited by the Joint Commission under acute care standards. Additionally, care is provided in an interdisciplinary fashion, featuring daily physician visits and specialty physicians based on patient needs. Clinicians are specially trained for the critical care setting and are able to support prolonged recovery times.</p>
<h2><strong>LTACH Expertise in Pulmonary Care and Recovery</strong></h2>
<p>A patient’s recovery and long-term lung health is directly dependent on the type and intensity of the care they receive. Distinct from all other post-acute settings, LTAC hospital clinicians are highly specialized in their ability to successfully liberate the most challenging ventilator patients, and LTAC hospitals feature hospital-level infection control, negative pressure rooms where needed and on-site laboratories and dialysis.</p>
<h2><strong>How Kindred Hospitals Can Help</strong></h2>
<p>We specialize in the treatment and rehabilitation of the post-intensive care and complex medical patient requiring continued intensive care, including specialized rehabilitation, in an acute hospital setting.</p>
<p>Our team of skilled and caring clinicians in our long-term acute care hospitals can be the right partner for you for your patients who have been in an ICU or a critical care unit, or who are chronically ill and readmit to the hospital frequently. We have proven success in treating patients with pulmonary disease and respiratory failure, including a long history of liberating patients from mechanical ventilation and artificial airways.</p>
<p>Many of our hospitals have or are in the process of achieving disease-specific certification from The Joint Commission in key conditions such as respiratory failure and sepsis.</p>
<p>We also have decades of experience treating post-intensive care syndrome (PICS). Under Kindred’s expert interdisciplinary care, patients receive targeted services including:</p>
<li>Daily physician oversight</li>
<li>Physician specialists</li>
<li>ICU-level care and staffing when necessary</li>
<li>24/7 respiratory therapy coverage</li>
<li>IV pain control management and narcotic/opioid weaning</li>
<li>Early mobilization of both ventilated and spontaneously breathing patients</li>
<li>Antimicrobial management to complete sepsis treatment and prevent antibiotic resistance</li>
<li>Interdisciplinary teams to clarify interventions and monitor progress</li>
<li>A patient-centered, goal-directed care plan addressing function, cognition and medical impairments</li>
<li>Family-focused discharge planning, whether directly to home or to less intense levels of post-acute care</li>
<p><strong>If you have a post-COVID patient, or other patients in need of care after a hospital stay, call a Kindred Clinical Liaison for a patient assessment. Our experts will help you determine the most appropriate care setting for your patient’s next stage of treatment. If you are unsure of who your Kindred representative is, please feel free to <a href="https://www.kindredhealthcare.com/our-services/transitional-care-hospitals/healthcare-professionals" target="_blank">contact us</a> and speak with a Registered Nurse who can assist.</strong></p>
<p>References</p>
<li><span style="font-size: 12px;">Fary Khan, MBBS, MD, FAFRM (RACP), Bhasker Amatya, DMedSci, MD, MPH, <em>“Medical Rehabilitation in Pandemics: Towards a New Perspective,”</em> Journal of Rehabilitative Management, Vol. 52, Issue 4, April 9, 2020</span></li>
<li id="ftn2">
<p><span style="font-size: 12px;">Stam HJ, Stucki G, Bickenbach J. Covid-19 and Post Intensive Care Syndrome: A Call for Action. J Rehabil Med. 2020;52(4):jrm00044. Published 2020 Apr 15. doi:10.2340/16501977-2677</span></p>
<p><span style="font-size: 12px;">Dasia Moore, "COVID-19 patients are recovering, but with nowhere to go," The Boston Globe, May 19, 2020</span></p>
<li><span style="font-size: 12px;"><em>“How Can We Ramp Up Hospital Capacity To Handle The Surge Of COVID-19 Patients? Long-Term Acute Care Hospitals Can Play A Critical Role,”</em> Health Affairs blog, April 13, 2020, DOI: 10.1377/hblog20200410.606195</span></li>
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Posted in COVID-19 Recovery, Improving Outcomes, Intensive Care Recovery, Post Intensive Care Syndrome, Pulmonary Care, Readmissions, Respiratory Failure, Sepsis, Ventilator
Treating Sepsis in a World of Value-Based Care
<a class="btn btn-blue _gt" data-category="Hospital" data-action="Click-Button" data-label="Blog-Treating Sepsis in a World of Value-Based Care" href="https://www.kindredhealthcare.com/docs/default-source/default-document-library/kindred-treating-sepsis-in-a-world-of-value-based-care.pdf?sfvrsn=a3518cea_4" title="Treating Sepsis in a World of Value-Based Care" target="_blank">Download this article as a PDF</a></div>
<p>A recent study indicates that <strong>the incidence of sepsis among hospitalized patients is increasing by 8.7%</strong> per year.<sup>1 </sup>Due to the severity of the condition, these patients are at a high risk of returning to an acute care setting to receive the appropriate clinical treatment.</p>
<p>To improve patient outcomes and decrease the possibility of costly readmissions for this at-risk population, providers should not only continue to enhance their internal clinical capabilities but also team with post-acute partners with expertise in treating sepsis.</p>
<p><strong>In this whitepaper, we outline the latest statistics and resources regarding sepsis and the post-acute strategies providers should consider to enhance outcomes for this critical population.</strong></p>
<div class="center-align"><img src="https://www.kindredhealthcare.com/images/default-source/blog-images/the-kindred-continuum/hd-sepsis-infographic.jpg?sfvrsn=9d6a8cea_0" data-displaymode="Original" alt="The incidence of sepsis among hospitalized patients is increasing by 8.7% per year" title="The incidence of sepsis among hospitalized patients is increasing by 8.7% per year" /></div>
<h2><strong>The Sepsis Crisis</strong></h2>
<p>Sepsis is a major problem. Here is what we know:</p>
<li>Between 750,000 and 1.7 million Americans develop sepsis each year.<sup>2,3</sup> </li>
<li> The sepsis mortality rate is between 25-35%, meaning more than 270,000 people die from sepsis each year.<sup>3</sup></li>
<li>Sepsis accounts for more than 50% of hospital deaths.<sup>1</sup></li>
<li> Mortality increases dramatically with greater disease severity: 10–20% for sepsis, 20–40% for severe sepsis, and 40–80% for septic shock.<sup>1</sup></li>
<li> In a global study, sepsis was identified during the ICU stay in 29.5% patients, including 18.0% who exhibited sepsis at ICU admission.<sup>4</sup></li>
<li> Sepsis is very expensive to treat, with an annual price tag of approximately $17 billion.<sup>2</sup></li>
<li> Sepsis readmissions cost the U.S. more than $3.5 billion per year, or an average of $16,852 per readmission, according to a study published in March 2019 in Chest Journal. For reference, the annual readmission cost for the four conditions Medicare’s Hospital Readmissions Reduction Program aims to reduce — acute myocardial infarction, congestive heart failure, COPD and pneumonia — is $7 billion combined.<sup>5</sup></li>
<img class="float-right" src="https://www.kindredhealthcare.com/images/default-source/blog-images/the-kindred-continuum/hd-sepsis-info2.jpg?sfvrsn=ef6a8cea_0" data-displaymode="Original" alt="Sepsis readmissions cost the U.S. more than $3.5 billion per year, or an average of $16,852 per readmission" title="Sepsis readmissions cost the U.S. more than $3.5 billion per year, or an average of $16,852 per readmission" />
<p>Innovative treatments and care strategies are required to combat the growing impact of sepsis, especially in light of healthcare’s continued push toward value-based care, which puts heightened pressure on managing total care costs and readmission rates.</p>
<p>To that end, this focus on reducing readmissions and total cost of care highlights the need for those in charge of discharge and placement after a hospital stay to accurately determine the most clinically appropriate post-acute setting for each unique patient. </p>
<p><strong style="color: #4183aa; font-size: 20px;">Resources and Case Studies to Help Improve Sepsis Outcomes</strong></p>
<p>To combat the growing rate of sepsis in hospitalized patients, providers should evaluate how this critical population is cared for. Fortunately, there are several existing resources providers can use as a base to build their own protocols:</p>
<li><strong><a href="http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018.pdf" target="_blank">The Surviving Sepsis Campaign Bundle: 2018 Update</a></strong><strong>: </strong>The Surviving Sepsis Campaign launched a new one-hour bundle for sepsis patient management that outlines the most critical steps to take within the first hour of sepsis identification.<sup>6</sup> </li>
<li><strong><a href="https://www.advisory.com/research/physician-executive-council/tools/2019/the-sepsis-cvr-starter-kit" target="_blank">The Sepsis CVR Starter Kit</a></strong><strong>: </strong>This kit can help providers build a successful sepsis care variation reduction (CVR) strategy, including tips on governance and care standard design resources.<sup>7</sup> </li>
<li><strong><a href="https://www.advisory.com/research/physician-executive-council/studies/2014/ten-imperatives-to-reduce-sepsis-mortality" target="_blank">Ten Imperatives to Reduce Sepsis Mortality</a>: </strong>Check out this online list from The Advisory Board for ways to build a system of care that promotes early identification, coordinates care team responsibilities and delivers timely treatment for every sepsis patient.<sup>8</sup></li>
<li><em> <strong></strong></em><strong>The <em>Journal of the American Medical Association</em> – findings on New York’s “Rory’s Regulation”: </strong><em><strong></strong></em>The recent findings of a multi-year study attributes a drop in sepsis mortality rates in the state of New York since the law was enacted to three practices:<sup>9</sup>
<li>More patients receiving evidence-based sepsis care, including early antibiotics and resuscitation </li>
<li>Hospital staff across the state being educated on how to recognize and treat sepsis </li>
<li>Healthcare professionals statewide paying closer attention to sepsis
<p>By identifying areas for improvement, many hospitals have been able to improve their sepsis mortality rates through enhanced early identification and streamlined treatment processes.</p>
<h2><strong>The Clinical Benefits of LTAC Hospitals in Treating Sepsis: Reducing Readmissions</strong></h2>
<p>In addition to looking internally, providers should seek post-acute partners who are capable of identifying and treating at-risk sepsis patients in order to avoid costly hospital readmissions. Long-term acute care hospitals are the most clinically appropriate post-acute setting for treating sepsis because of the condition’s severity and the hospital’s capabilities.</p>
<p>Sepsis must be treated in a hospital setting and long-term acute care (LTAC) hospitals are well equipped to both identify and treat sepsis. Because LTAC hospitals have the same licensure and accreditation as acute care hospitals, they are clinically capable of treating septic patients, thereby avoiding readmission. In contrast, if a high acuity patient is discharged directly to a skilled nursing facility and then requires sepsis treatment, the patient would need to readmit to the hospital setting for care.</p>
<p>While LTAC hospitals provide care for a very high-acuity niche patient population, they play a vital role in achieving more efficient recovery of patients who have a high risk of readmission due to their clinical complexity. By transitioning these challenging patients to an LTAC hospital, when it is the most appropriate site of care for their needs, a significant portion of financial losses due to readmission penalties for short-term providers can be avoided.</p>
<h2><strong> <strong>Kindred’s Sepsis Program: How Kindred Can Help Your Sepsis Patients</strong></strong></h2>
<p>Kindred Hospitals specialize in the post-intensive care treatment of patients with complex medical cases who require continued intensive care and specialized rehabilitation in an acute hospital setting. With daily physician-directed care, ICU- and CCU-level staffing ratios and ACLS-certified nurses, specially trained caregivers, we work to improve outcomes, reduce costly readmissions and help patients transition home or to a lower level of care. </p>
<p> We are committed to pursuing innovations in care delivery and payment models to provide new tools and solutions to our patients and their families as well as to our provider partners. Many of these resources and initiatives are designed to ensure efficient care management for each patient.</p>
<p>One such initiative is our effort to achieve disease-specific certification from The Joint Commission for sepsis in all Kindred Hospitals across the country. The certification recognizes healthcare organizations that provide clinical programs across the continuum of care for sepsis. It evaluates how organizations use clinical outcomes and performance measures to identify opportunities to improve care, as well as to educate and prepare patients and their caregivers for discharge.</p>
<p>We have proven success in treating patients with sepsis. We have already instituted the following sepsis protocol in all of our hospitals:</p>
<li> A review of every new admission’s chart to establish whether or not they qualify for our Sepsis Program.</li>
<li>An assessment and evaluation at least once every shift of all patients who qualify for our Sepsis Program.</li>
<li>A robust Sepsis Protocol includes STAT interventions for any patient who screens positive, including blood lactate level and blood cultures run prior to administration of antibiotics.</li>
<li>An individualized plan of care and creation of interdisciplinary goals for the patient.</li>
<li>Treatments and therapies based on evaluation of the patient in relation to our assessment of their health.</li>
<li>Extra care and education for the patients and their families while they are enrolled in the Sepsis Program.</li>
<p>We are committed to continued clinical growth and furthering our expertise in areas of care this population will demand. </p>
<p><strong> <strong>To learn more about how Kindred Hospitals can help you achieve enhanced outcomes for your critically ill patients, </strong><a href="https://www.kindredhealthcare.com/our-services/transitional-care-hospitals/healthcare-professionals/make-a-referral">Contact Us</a>.</strong></p>
<p>References:</p>
<li><span style="font-size: 12px;">Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. <em>Epidemiology and Costs of Sepsis in the United States-An Analysis Based on Timing of Diagnosis and Severity Level.</em> Crit Care Med. 2018;46(12):1889–1897. doi:10.1097/CCM.0000000000003342</span></li>
<li><span style="font-size: 12px;"> https://www.centerfortransforminghealthcare.org/improvement-topics </span></li>
<li><span style="font-size: 12px;">https://www.cdc.gov/sepsis/datareports/index.html </span></li>
<li><span style="font-size: 12px;">Sakr Y, Jaschinski U, Wittebole X, et al. <em>Sepsis in Intensive Care Unit Patients: Worldwide Data From the Intensive Care over Nations Audit.</em> Open Forum Infect Dis. 2018;5(12):ofy313. Published 2018 Nov 19. doi:10.1093/ofd/ofy313
</span></li>
<li><span style="font-size: 12px;"><em>Epidemiology and Predictors of 30-Day Readmission in Patients With Sepsis</em> Gadre, Shruti K. et al. CHEST, Volume 155, Issue 3, 483 – 490 </span></li>
<li><span style="font-size: 12px;">http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018.pdf
<li><span style="font-size: 12px;"> https://www.advisory.com/research/physician-executive-council/tools/2019/the-sepsis-cvr-starter-kit </span></li>
<li><span style="font-size: 12px;">https://www.advisory.com/research/physician-executive-council/studies/2014/ten-imperatives-to-reduce-sepsis-mortality </span></li>
<li><span style="font-size: 12px;">https://www.healthleadersmedia.com/clinical-care/new-yorkssepsis-protocols-lower-death-rates</span>
Posted in Healthcare Trends, Improving Outcomes, Intensive Care Recovery, Readmissions, Sepsis
Health Disparities (9)


This project, through a unique and innovative joint effort between the anti-racist (ENAR) and feminist (EWL) movements, is a key step in a broader advocacy strategy that aims to get the Member States of the European Union to adopt specific strategies on the inclusion of Muslims and to demonstrate the need for an improved implementation of EU equality law.
Basement Studio, Bristol Old Vic, King St, Bristol, BS1 5ED.
Easton Community Centre alongside Baljinder Bhopal and London based poet Sundra Lawrence with the Poetry Can.
She has also performed at open mic nights and various venues such as Chicane cafe, The Croft, The Cube Microplex, The Landsdown, Il Bordellos, Bath's Doolallys, Delfta Krug, The Michael Tippett Centre, Bath's Little Theatre and Swansea's Dylan Thomas Centre.


Each day, 6,600 Africans die of AIDS. By 2005, Ethiopia alone had hundreds of thousands of orphans who had lost their parents to AIDS.
The raw numbers don't convey the unfathomable suffering captured in Melissa Fay Greene's arresting new book, There Is No Me Without You, the story of an Ethiopian woman who began caring for orphans after the deaths of her husband and a daughter.
Haregewoin Teferra was paralyzed with grief when she agreed in 1999 to take in a 15-year-old girl who was living on the streets. Haregewoin quickly became known as a caring soul who would house desperate orphans, including those who were HIV-positive. Friends told her she was crazy.
In taut prose that reads like fiction, Greene describes the flood of children who show up on Haregewoin's doorstep in Addis Adaba, a city with "orphans as numerous … as pigeons." One day, a skeletal woman comes to the gate, gives over her baby, and keels over, dead. More children continue to arrive. Haregewoin converts a rusty boxcar into a combination dining hall and classroom. Older children help care for younger ones. Haregewoin loses count of how many orphans she houses.
Greene set out to write "a hagiography, a chapter for Lives of the Saints" until she discovered that Haregewoin, like any saint, was human. The result is a nuanced, and believable, portrait.


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Chef Marco Pierre White, famous for his sharp tongue and brutal honesty, is launching a new tv show called Kitchen Wars.
In the show the celebrity chef travels the UK With a mobile kitchen unit or 'the battle kitchen' with teams of couples who run restaurant invited to board the mobile kitchen and demonstrate their skills in the kitchen.
Families, friends, husband and wife duos - the teams vary but the restaurants just be run by a group rather than individuals as Marco says this reflects the way restaurants used to be run.
The chef explained "When I started out many years ago, a lot of the best restaurants were run by couples" and with that in mind Kitchen Wars aims to put couple and family run eateries back on the map.
Those who impress the fierce chef will be invited to cook in his specially designed kitchen with a chance to serve their food to the public.


text:
Eagle Rock hosting live Q&A with Ella Fitzgerald doc makers
Buddy Iahn | June 24, 2020 | Jazz/Easy Listening, Radio/TV/Film/Broadway
Event is Sunday, June 28th
Following the virtual cinema premiere of the documentary Ella Fitzgerald: Just One Of Those Things, Eagle Rock Entertainment will host a special live conversation with producer/author Reggie Nadelson, who conducted all of the film's interviews, and three of the film's participants — Pulitzer Prize winning author/journalist Margo Jefferson, renowned music critic/author Will Friedwald, and singer/saxophonist Camille Thurman of the Jazz at Lincoln Center Orchestra. They will discuss the film during this free event on Sunday, June 28th at 7 pm EST/4 pm PST — two days after the national virtual cinema release. Tickets for this event are available at the film's website.
Directed by award-winning documentarian Leslie Woodhead, Ella Fitzgerald: Just One Of Those Things is an intimate look at the life and journey of The First Lady Of Jazz. Blending archival footage with anecdotes/ruminations from Smokey Robinson, Tony Bennett, Johnny Mathis, Itzhak Perlman, dancer Norma Miller, the late Andre Previn, and Ella's son Ray Brown. Jr, Just One Of Those Things reveals a personal look into Fitzgerald's journey, in life and in music.
A trailblazer for women of color in the music business and beyond, Fitzgerald is famously quoted as saying "it isn't where you came from; it's where you're going that counts." She proved the true meanings of these words, from her life as an orphaned, penniless teenager living on the streets of Harlem, to her big break at amateur night at the Apollo Theater, which skyrocketed her career as a singer, bandleader, and public figure. Her innovative style of scat singing broke new ground in jazz vocalization, along with her interpretations of the Great American Songbook. She would go on to inspire countless singers, musicians, and artists, leaving an extraordinary legacy, as stated by Bob Dylan recently in the New York Times: "Ella Fitzgerald as a singer inspires me."
Ella Fitzgerald: Just One Of Those Things is presented by over 100 theaters nationwide as a virtual cinema release, as well as several in-house screenings in select theaters, starting June 26th.
Peter Jackson details new Beatles film
CMA Awards honoring Charley Pride
'The Music of Nashville, Season 4, Volume 2' set for May 13th
AXS TV premieres 'Chicago: The Terry Kath Experience'

redpajama_set_name: RedPajamaCommonCrawl


Sydney Mitchell LLP is committed to providing a high quality service to all our clients. We take very seriously all expressions of dissatisfaction from our clients.
Complaints should be addressed to the person handling your matter in the first instance. If you are not satisfied with their response, you may raise your concerns with our Client Care Manager, Nik Heelam at Chattock House, 346 Stratford Road, Shirley, B90 3DN, or by telephone on 0121 746 3300; e-mail address n.heelam@sydneymitchell.co.uk. If the matter cannot be resolved informally, you may be asked to fully detail your concerns in writing, to avoid our misunderstanding your concerns. It would also help us if you would let us know how you would like your concerns to be resolved.
We aim to acknowledge complaints within 7 days of receipt, whereupon the name of the person responsible for handling the complaint will be confirmed. A full reply will be sent as soon as the matter has been investigated and our proposals for dealing with your concerns have been agreed upon. If you would prefer to discuss the matter at a meeting you should indicate as much and a meeting will be arranged. If you wish, you may bring a friend or family member with you. In any case, we will aim to provide a full written response within 21 days of acknowledgement of your complaint, or of any meeting. If that is not possible, an interim response will be given explaining why it is not possible and when we expect our investigations to be completed and our response finalised. If we accept your complaint in whole or in part we will offer appropriate redress. Please note that no charge is made for the time spent in investigating or responding to a complaint.
If you are still not satisfied you should contact us again and we will arrange for the firm's senior partner to review the decision and we will aim to write to you within 14 days of receiving your request for a review, confirming our final position on your complaint and explaining our reasons.
What happens if there is no will?
No Will? Who gets what?


Gorgeous 1 Story Classic Ranch House with Permitted GUEST House on Over 1/2 Acre of Flat, Usable Land! Property also Includes separate Multi-Purpose Workshop. Main House: 3 Bed, 2 1/2 Bath, 2228 SqFt. Guest House: 1 Bed, 1 Full Bath, 1017 SqFt. Main House w/Brazilian Chestnut Floors in all living areas and bedrooms. Front Facing Bay Window, Built-in Shelving & Fireplace, Recessed Lights & Crown Molding throughout. Formal Dining Room. Perfect for Entertaining! Bright & Sunny Breakfast Room w/View of Patio & Backyard. Updated Kitchen w/Granite Counters & Cabinets w/Soft Close Hardware & 2 Lazy Susans . Modern gas Range Contemporary Hood, Breakfast Bar, Walk-In Pantry. Kitchen Opens to Family Room which features Ceiling Fan & 2nd Fireplace. Master Suite w/Walk-In Closet, Master Bath w/Dual Sink Vanity, Walk-In Shower & Jetted, Soaking Tub. 2 Additional Bedrooms. Updated Full Hallway Bath. "Inside Laundry Wing" featuring Spacious Laundry Rm w/Sink, Ample Cabinets, Half Bathroom & Access to the 2-Car Garage. Separate Guest House (Potential Rental Income or Next Gen Living) has Full Kitchen, Dining Area, Living Room w/Wood Burning Stove, Bedroom, Full Bath & Laundry Room. Spacious Multi-Purpose Workshop w/Wood Burning Stove can be used Many Ways: Office, Gym, Craft Room etc. Large Backyard w/Potential Horse Property. Amenities Galore: Excellent Curb Appeal, Circular Drive, Lush Landscaping, Electric Side Gate, Small RV/Boat Parking, A Definite Must See!


Love happens. . .when you least expect it! Out of the blue... or the night.
Brenna returned home to Rainbow Bayou just a few months ago and now the first storm of the season delivers a surprise. She has a premonition and when that happens, she pays attention. A stranger attempts to enter her cabin during the storm and she whacks him with a fireplace iron creating an even bigger problem—he awakens thinking she and this handsome burglar are a couple.
As their relationship deepens images from his past begin to surface and Brenna finds herself hoping the clues don't mean what she thinks they do and that their new love can last forever.
Livia Quinn is the author of the Calloways of Rainbow Bayou, a contemporary small town romance series centered around the Calloways and their cousins - the Larues - in the Rainbow Bayou area of Louisiana.
About Rainbow Bayou The bayou that surrounds the town was named by the Native Americans for its reflection of the colorful sky as it flowed from the river to the lake. Rainbows bring to mind notions like hope, renewal, second chances, and the promise of new beginnings. In their legends double rainbows represented serendipity.
The Calloway novels are stories of love, community and life—of hope and second chances, reminding one that love can happen out of the blue, when you least expect it.
More about the series,If you love emotional heartfelt stories with a little suspense built in, this one is for you. The first four books in the series were previously published but have been revised and rebranded with new content to reflect its true romance genre, that of a contemporary family romance series.
Are the books standalones? Yes, all the books are standalones but all characters' stories continue to progress throughout the series so some readers may wish to read them in order. Each couple in the series gets their happily-ever-after, cause it's romance!
5.0 out of 5 starsSuspenseful swoon-worthy romance!
The Handsome Stranger (or HS for short) is knocked unconscious (thanks to Brenna) and he reminds Brenna of James Bond, especially when she discovers a gun in his wet clothes. Brenna knows she has to care for him until the storm passes or his death will be forever on her hands. When he wakes up in a hospital three days later, he has amnesia and doesn't remember a thing. Wait a sec, he does remember one name: Brenna.
Thus begins a romantic suspense filled with twists and turns. The more Brenna is around him, the harder she's falling for him. He keeps her at arms length (while devouring her with his eyes) until his memory comes back. There's a connection between them that neither can explain and when the truth is revealed and his memory returns, will their love grow stronger or be split in two?
Only the Heart Remembers is one of the best romantic suspense I've read in quite awhile. I spent most the book trying to figure out who the James Bond look-a-like is and what he's doing in the middle of the storm. Suspenseful, swoon-worthy romance and Brenna's best friend (Declan) is sensational comic relief. I will never look at Southern Comfort the same, thanks to Quinn.
Favorite Character/Quote: Brenna. I found a kindred spirit in Brenna and not just because we have an unnatural fear of storms. She's the kind of character most women can relate to, either they know someone like her or are her to a certain extent. Brenna has a deep-seated fear of lightning and with just cause. Yet, she battles her fear to rescue a complete stranger. No matter what life throws her way (and there's plenty thanks to Livia), she manages to make it through. She's such an amazing woman and I loved reading her story.
Brenna is wonderfully real and I loved seeing her fighting to overcome her flaws- at least temporarily- to help someone. Nick doesn't remember anything but her name, but is still determined to support her as much as possible. The story is full of action and adventure and keeps you interested until the very end.


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    end
  end
end


CLASSROOM BLOG: What's Happening in Howland's Room?
Welcome to Mrs. Howland's class page!
EXTRA HELP: I am available for extra help after school Tues-Fri. Please arrange with me beforehand in case of a scheduling conflict.
We have made the move to SCHOOLOGY for all of your course materials and assignments.


text:
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Gender equity in private enterprise Purplewashing or are we really getting the batteries?
July 27 , 2018 // Specialty
Published in El Diario
The PSOE Government has submitted a law to achieve equity for men and women also in private companies. The intention of the Government (after discussing and negotiating all groups) would be to give companies a term of five years to adapt to `parity '. Are the boards of directors without female presence finished or will it only be applied in the lowest positions? Undoubtedly, there will be many resistances to this law in a country like Spain where the number of women in many organizations is low.
It will be very interesting to see the speeches that are created around these measures. Surely the relief is on how complicated it is to reorganize companies so that more women or men enter as the case may be.
It will be said that women do not want to work in traditionally male sectors such as stowage or mechanics and that men will not want to be florists or work in cosmetics stores. It will be said because we still have much to walk in the destruction of the binary genre. It will be said because the Real Life Test is still used to diagnose gender dysphoria in most communities (although some steps are taken) and because Spanish cinema is full of sex and gender stereotypes that, unfortunately, are examples of the current social construction.
However, the reality is different, the stowage is being populated by women and the excuse that there are no changing rooms for them in the port of Algeciras is not shared in all the ports. The academic sector has also put the batteries and has subscribed initiatives like #NoSinMujeres refusing to participate in discussion tables where there are no women.
Some companies have discovered the goose that lays the golden eggs and have realized that parity makes their companies earn more and fulfilling that part of civil responsibility means an increase in their reputation. The same happens in the film industry and festivals where there are more and more women in the cartel, although the number of sound techniques or organizers does not increase, as Mafalda claims in this mini-documentary. And the excuse that there are not enough female groups falls under its own weight.
The parity in private companies, even if it is a positive discrimination at the beginning, is more than desirable to bring equality, but if it is not accompanied by a decrease in the wage gap and a couple of stones that, at least, crack the glass ceiling will serve us little.
Recall that the current Equality Act has a very low degree of compliance, so it will be important to see what will be the instruments to enforce the Law and if there will be sanctioning procedures. As always, what will differentiate if this proposal is a facelift of the PSOE or a real change are the amendments contained in the Law and not the journalistic symbolism that represents its presentation.
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And also those three need to honestly be uniting up to an also much bigger, particular idea. Anyhow, take those tips or that suggestion as well as take the upcoming basic action.
Simply choose out some icon - whether this is actually a personality, a description, a thing ... and so on - that assists reveal the text message's or texts' perspective towards that significant concept. Now you can get right into an elaboration from a certain symbolic representation as well as big concept within your writing.


Anyone who has been to Rome has experienced the frustration of seeing spectacular ancient ruins and monuments… but sharing this experience with hundreds of others, elbowing each other to get a photo, yelling over one another, crowding, pushing against barriers that keep the masses from seeing the said monument up close and personal. Such is Rome. Sigh.
Not your cup of tea? Escape Rome for a day and experience Ostia Antica, an entire ancient city left to decay in the 9th century. No elbowing, no crowds… just a peaceful day of walking amongst ruins, imaging what this city looked like in its prime. No crowds, no lines, no security guards, no stress.
Founded in the 7th century BC, Ostia Antica was once a thriving port town just 19 miles northeast of Rome. The town served as Rome's seaport, although thanks to natural composites of sediment, centuries later, it sits three kilometers from the sea.
At its peak during the 2nd and 3rd centuries AD, Ostia Antica had 75,000 inhabitants. It is unclear why the city was deserted, although several factors probably contributed to its decay. A new harbor town, Portus, was built in the 1st century AD and became the primary harbor for Rome, causing many to lose business and move to other locations. War was also a factor: there are many reports of the city being attacked by Arab pirates throughout the centuries as well as records of a naval battle in 849 between Christians and Saracens called the Battle of Ostia, which is said to have prompted the remaining citizens of Ostia to move to Gregoriopolis.
The ancient city is a quick train ride from Rome and a beautiful day trip. Highlights include the amphitheater, organized public latrines, public baths, and the Ostia Synagogue, the oldest synagogue in Europe to date. It is an excellent opportunity to see the layout of wealthier homes: many still have portions of the mosaic floors in tact, and several have statues.
Perhaps the most exciting part of visiting Ostia Antica is how up close and personal visitors are to the ruins. There are walking paths; however, visitors are free to walk amongst the ruins, walk through the houses and military camps, and wander through this deserted city. It is a beautiful way to spend a day, and a highly recommended day trip out of Rome.
Click here to enjoy our photo gallery of Ostia Antica.


Moise whose stage name is 'Burberry Perry' has been accused of trade mark infringement over the use of the pseudonym. The lawsuit filed at the US District Court for the Southern District of New York states that Moise has also used Burberry's signature checked pattern and equestrian logo on both his album artwork and social media page to promote his self-titled EP. The Complaint filed on Monday 25 July 2016 states "Defendant adopted 'Burberry Perry' as his stage name, without the authorisation of Burberry, and is using the fame and renown of the Burberry trade mark for his own personal gain." Further in the complaint Burberry notes that it has owned US-based trade marks for its name since 1929 and has sold products under the Burberry name for "well over a century". Burberry also added that Moise "has long been a fan" of Burberry's clothing and accessories and the "Defendant's affection for Burberry and his intent to be associated with the brand is well documented in images of the defendant wearing Burberry clothing- many of which the defendant posted to the internet himself".
It is reported that upon the release of his debut album Burberry attempted to contact Moise on multiple occasions to request that he cease-and-desist from all uses of the "Burberry" word mark, but Moise failed to comply with these requests.
Burberry is now seeking a court order to order Moise to cease use of all of its trade marks including both the name and checked logo. The legal action against Moise is particularly timely given Moise is planning to release new music in August, drop a mixtape in September and embark on a multi-city tour throughout the U.S. and Canada during August and September.
A key reason for Burberry's action against Moise is that music is heavily associated to the Burberry brand. In 2010, the company founded a digital platform that commissions and celebrates emerging artists with exclusive performances, this is called Burberry Acoustic. In September 2015, Burberry was the first fashion brand to get its own channel on Apple Music. Burberry's legal team are concerned that there is a possibility of consumer confusion when "Burberry" is searched on music streaming outlets such as Apple Music or Spotify.
Representatives for Burberry have released the following statement "As a global luxury brand, Burberry considers the protection of its intellectual vital for the health of its business and to safeguard its customers. As such, Burberry goes to great lengths to protect its creative designs and will take all necessary action against the abuse of Burberry trade marks".


The Invisible Man is a US television series made in 1975. Although the series claims to be based on the HG Wells novel, there really is no connection beyond the premise of a man turning invisible. It only lasted for twelve episodes (plus pilot), and is rather dated, but still manages to be an interesting and enjoyable watch.
David McCallum and Melinda O Fee play husband and wife scientists Daniel and Kate Westin. Daniel accidentally turns himself invisible, but is unable to reverse the process. Initially using make-up, and then special gloves and masks for his hands and face, he is able to live and work in everyday society. In exchange for the resources of the KLAE Corporation, which he and Kate use to try and make him visible again, the two of them take on various secret missions under the codename "The KLAE Resource". Basically, the KLAE Corporation rents out their services to the government and other organisations, for large sums of money.
There are a number of differences between the pilot and the series proper, as the producers tweaked things to make the concept more workable on a weekly basis. This includes the switch from make-up to masks to conceal the invisibility, and the setting up of "The KLAE Resource".
The series works quite well within its limited framework. The writers manage to vary the plot lines so the series doesn't get too formulaic, as it very easily could have. So we have everything from corporate espionage to international intrigue, and even some more personal cases that include corruption in small-town judiciary and a humorous (and rather silly) Las Vegas gambling ep. McCallum and Fee have a great onscreen chemistry and their scenes together have a ring of truth about them… even if the circumstances are often rather fantastical (and sometimes even a bit daft). It is their relationship that makes this such a watchable series. Craig Stevens as Walter Carlson, the man behind "The KLAE Resource" is well cast and is a welcome addition to the team.
The special effects are interesting, even if they're not all that special by today's standards. The blue-screen unmaskings are obvious but good for their day. Unfortunately, the strings are often visible when the invisible man is moving things around. And this seems to get worse as the series progresses — perhaps an indication of mounting time constraints. But, to a certain extent, it is also part of the show's charm. The real flaw of the series is the concept of the facemask, which magically gives Daniel realistic eyes, teeth, tongue and inside of mouth.
The theme is by Henry Mancini, as is the score for the first few episodes. Perhaps not one of his more memorable scores, but still rather nice.
It's interesting to note some of the names involved on the production side of things — people who would go on to make other more high profile shows, such as Steven Bochco (Hill Street Blues, NYPD Blue and Doogie Howser, MD), Harve Bennett (the Star Trek feature films) and Leslie Stevens (Battlestar Galactica and Buck Rogers in the 25th Century).
Unfortunately there is little in the way of extras on this release — an image gallery and some production paperwork… and that's it.
All up, The Invisible Man is an enjoyable watch. And a good example of one of the better genre shows of the 1970s.
The Invisible Man is released on DVD in Australia by Madman.


text:
Q: How to remove the hypelink from WPF RichTextbox at runtime? I have a WPF RichTextBox and using FlowDocument I have added a Paragraph.  Inside that Paragraph I have also added multiple Hyperlinks.
I want to remove the hyperlinks at runtime and replace them with some text.
All hyperlinks share the same event handlers, so I think I should write the hyperlink removal code inside the hyperlink click event handler.
How can I remove that particular hyperlinks from the Paragraph which is clicked?

A: I know it's too late, but I found a much simpler way to remove a hyperlink :
Hyperlink hyperlink = sender as HyperLink;
// we make a selection from BEFORE the hyperlink to AFTER the hyperlink
rtb.Selection.Select(hyperlink.ElementStart, hyperlink.ElementEnd);
// we replace the hyperlink element by a simple text
rtb.Selection.Text = rtb.Selection.Text;

It works pretty well for me.

redpajama_set_name: RedPajamaStackExchange


text:
The Vedic Period of India: Migrations, Settlements and Literary
Read this article to learn about the Vedic period of India, its migrations, settlements and literary:
Migrations and Settlements:
India, as is well known, derives its name from the Sindhu (Indus) and the earliest civilisation of this country which was predominantly urban had its cradle in the valley of the same river, called the Indus civilisation.
Far different is the picture of another civilisation which had its principal home higher up in the Indus valley called the Vedic or Rig Vedic culture.
The people who evolved this culture called themselves Aryas or Aryans and were probably an invading or immigrant people, whose first arrival in India is dated a little earlier than 1500 B.C. We do not find clear and definite archaeological traces of their advent. The Aryan migration to Indian was not a single concerted action, but one covering centuries and involving many tribes.
Image Source: aryaninvasionmyth.files.wordpress.com/2012/10/bourshot-1996.jpg
In the Rigveda, the land where the Vedic Aryans lived is called by the name of Sapta-Sindhu or the 'land of the seven rivers' which included the Indus or Sindhu with its principal tributaries on the west and the river Saraswati on the east. The region of Sapta-Sindhu witnessed the composition of the sacred hymns which describe the early growth and development of the Vedic culture.
The earliest life of the Aryans seems to have been mainly pastoral, agriculture being a secondary occupation. The Aryans did not lead a settled life, with the result that they could not leave behind any solid material remains.
The Vedic age spans almost a millennium of Indian history (1500-600 B.C.), a period which witnessed crucial changes in North India. These developments are evident in a number of spheres-social, economic, political and religious.
Original Homeland:
The identification of the original home of the Aryans has been a very difficult riddle to solve with claims and counter-claims being made by several scholars. The word Aryan literally means of high birth, but generally refers to language, though some use it as race.
Max Muller, the great German Scholar declared emphatically that the term "Aryan, in scientific language, is utterly inapplicable to race. It means language and nothing but language". Philological studies by Filippo Sasetti, (a Florentine) in the late 16th century led to the discovery of close affinities between Sanskrit and some of the principal languages of Europe such as Greek, Latin, Gothic, Celtic and also Persian.
These similarities could have been only when their ancestors must have lived together for a sufficiently long time. In 1786, Sir William Jones in his address to the Asiatic Society of Bengal tried to prove a definite relation between the Vedic Sanskrit and the principal European languages.
The scholars have given a common name 'Indo-European' to this group of languages and the people speaking them were known as Indo- Europeans. On this basis it has been surmised that this Indo-Europeans migrated or dispersed to the various parts of the world, including India. The Indo-Aryans in due course of time orally composed the Rigveda Samhita which on linguistic grounds is dated between 1500 and 1000 B.C.
The language of Zend Avesta, which is the oldest text in the Iranian language, is also similar to the Rig Vedic Sanskrit. The two texts use the same names for several gods and even for social classes suggesting that the Vedic culture and the ancient Aryan culture of Iran seem to have derived from one and the same Indo- Iranian culture.
There is archaeological evidence outside India to show that in Asia Minor and other countries of Western Asia there was some activity of the Aryans. Some inscriptions of about 1400 B.C. found at Boghaz-koi in Cilicia (Asia Minor), the capital of the ancient Hittites, mention some Aryan deities such as Indra, Varuna, Mitra and Nasatyas. On the evidence of Indian archaeological objects, it is assumed that the Aryans were the authors of the Painted Grey Ware Culture (1100-600 B.C.) with its epicentre located in the Ganga-Yamuna doab.
Originally the Aryans seem to have lived somewhere in the Steppes, stretching from southern Russia to Central Asia, bordering the Oxus and the Jaxartes, and the Aral and Caspian seas. From this base sections many of them may be presumed to have pushed up the highlands of Afghanistan, and then to have descended from this base into the plains of the Punjab.
In the opposite direction other Aryan tribes from the same region moved westwards into Iran. The main tribes known among the Aryan speaking people are the Hittites, Indo-Aryans, Iranians, Kassites, Mitannis and Greeks. While Hittites migrated to Cappadocia (Asia Minor) in about 1950 B.C., the Indo-lranians came to the Pamirs and the Oxus and Jaxartes valleys in about 2000 B.C.
Then the Iranians went to Iran and the Indo- Aryans entered India in about 1500 B.C., but not earlier than 2000 B.C. Kassites occupied Babylonia in about 1760 B.C., while the Mitannis migrated to other parts of Mesopotamia around 1500 B.C. Finally the Greek Aryans went to Greece around 1200 B.C.
Many scholars like Ganganath Jha, D.S. Trivedi, L.D. Kalla, etc., tried to prove that the Vedic Aryans were the indigenous people, who regarded Sapta-Sindhu as their original home. This view, though highly favoured at one time, has not many supporters now. Had India been the original home of the Aryans they would have certainly tried to fully Aryanise the whole of the sub-continent.
Besides, the vast disparities between the Harappan and vedic cultures further prove that had the Aryans been the indigenous people these disparities would not have been noticed, particularly when the epicenter of both these cultures was the Indus region.
Bal Gangadhar Tilak was of the opinion that the original home of the Aryans was the Arctic region. This view was propounded by him in his book, 'The Arctic Home of Aryans.' According to Swami Dayanand Saraswati and Pargiter, the original home of the Aryans was Tibet. The view has been expounded by them in the 'Satyarth Prakash' and 'Ancient Indian Historical Traditions' respectively.
Dating the Vedic:
As regards the age of the Vedas, Jacobi's view was that the Vedic civilization flourished between 4500 and 2500 B.C. According to Dr. Winternitz "The available evidence merely proves that the Vedic period extends from an unknown past say X to 500 B.C., none of the dates 1200-500 B.C., 1500-500 B.C. and 2000-500 B.C., which are usually assumed, being justified by facts. Only it may be added, as a result of recent researches, that 800 B.C. should be substituted for 500 B.C. and that the unknown date more probably falls in the third rather than in second millennium before Christ."
Home ›› History ›› India ›› Vedic Period ›› Vedic Period of India
Vedic Culture and the Indus Civilization | Indian History
Life of Aryan People in the Vedic Age of India
The Literary Evidences of the Vedic Period in India
Vedic Period: Geographical Expansion of India During Vedic Period
History, India, Vedic Period, Vedic Period of India
Vedic Period: The Rituals and Practices observed during the Vedic Period
Religious and Philosophical Ideas in the Vedic Period


text:
Batterikikare är en typ av binokulär kikare där vardera strålgången passerar igenom varsitt periskop, detta för att objektiven skall vara ovanför användarens huvud vilket ger möjlighet observera omgivningen utan att användaren behöver exponera sig. Genom att de två periskopen är monterade i en vinkel från lodlinjen får man ett större avstånd mellan objektiven än mellan okularen, detta ger ett ökat djupseende vilket underlättar avståndsbedömningar. Då batterikikare vanligtvis har en hög förstoring monteras de på ett stativ. Det primära användningsområdet för batterikikare har varit eldledning för artilleriet där möjligheten att observera i skydd och möjlighet att gör korrekta avståndsbedömningar har varit viktigt, numera har små laseravståndsmätare gjort instrumentet överflödigt. För eldledning för fartygsartilleri så användes vanligtvis stereoskopisk avståndsmätare istället för batterikikare då dessa faktisk kunde mäta avstånd med god precision istället för att bara underlätta avståndsbedömningen för observatören, men dessa instrument är betydligt mer skrymmande och känsliga vilket gör att de är olämpliga att använda för eldledning av fältartilleri.

Optiska instrument
Militär utrustning

redpajama_set_name: RedPajamaWikipedia


The cost of Renewable energy is coming down, and it's now the cheapest form of energy in over 58 countries, but while it might be clean and increasingly popular, as more cities in the US, such as Las Vegas, hit their 100 percent renewable energy goals, it's not always reliable. For example, when the Sun vanishes behind clouds or the wind dies down this is why all of a sudden you'll see the amount of energy coming into your home, or onto the grid, decline, and that's why today whether it's your home, or the grid, we're increasingly reliant on being able to store energy cheaply and reliably for long periods of time – all just so you can turn your lights and power your electric cars on when the clouds roll over.
In order to counter some of this variability today energy companies are forced to combine a range of different sources, such as solar, wind, hydro, tidal, and biomass, with large grid scale energy storage systems, but, while these systems are getting better and cheaper they're still expensive – especially if you plan on using them in anger.
Now though a team from MIT has developed a new type of battery that could make grid scale energy storage cheaper, by about 80 percent, and it does it by breathing air.
The new design is what the team call a "rechargeable flow battery," meaning its Cathode and Anode components are liquids, called Catholyte and Anolyte, that can pass ions back and forth to store or release energy. In this case, the Anolyte is made up of sulfur dissolved in water, and the hunt for an equally abundant material for the Catholyte led the team to an oxygenated liquid salt solution.
The clever part of the battery is the fact that the Catholyte "breathes" in air in from outside while discharging, and exhales while recharging. Using this mechanism, the battery creates negatively-charged hydroxide ions in the Catholyte while inhaling, and while recharging that oxygen is released, creating hydrogen ions which then send electrons back into the Anolyte.
Lithium-air batteries use the same mechanism, but sulfur, water and salt are far cheaper materials than Lithium, and, if we want renewable energy to be our future then we've got to cut down the cost of these grid scale storage systems, like the one Elon Musk is famous for deploying across a variety of islands, as much as possible.
The team also say their battery would cost far less to make and run than today's ubiquitous Lithium-ion batteries, while retaining almost the same energy density, and once in use they estimate a scaled-up version of their flow battery would cost between US$20 and $30 per kWh stored to run, compared to about $100 per kWh for other storage systems.
The current prototype is about the size of a coffee cup but they're confident the design can be scaled up for use in larger applications, and next they plan on making it more efficient, less expensive, and expand its working life from its current 1,500 hours.


text:
package com.facebook.buck.rules.macros;

import static org.junit.Assert.assertEquals;
import static org.junit.Assert.assertTrue;
import static org.junit.Assert.fail;
import static org.junit.Assume.assumeFalse;

import com.facebook.buck.core.cell.TestCellBuilder;
import com.facebook.buck.core.cell.nameresolver.CellNameResolver;
import com.facebook.buck.core.exceptions.HumanReadableException;
import com.facebook.buck.core.macros.MacroException;
import com.facebook.buck.core.model.BuildTarget;
import com.facebook.buck.core.model.BuildTargetFactory;
import com.facebook.buck.core.model.ConstantHostTargetConfigurationResolver;
import com.facebook.buck.core.model.UnconfiguredTargetConfiguration;
import com.facebook.buck.core.rules.ActionGraphBuilder;
import com.facebook.buck.core.rules.BuildRule;
import com.facebook.buck.core.rules.impl.FakeBuildRule;
import com.facebook.buck.core.rules.resolver.impl.TestActionGraphBuilder;
import com.facebook.buck.io.filesystem.ProjectFilesystem;
import com.facebook.buck.io.filesystem.impl.FakeProjectFilesystem;
import com.facebook.buck.jvm.core.HasMavenCoordinates;
import com.facebook.buck.jvm.java.JavaLibraryBuilder;
import com.facebook.buck.rules.args.Arg;
import com.facebook.buck.rules.coercer.CoerceFailedException;
import com.facebook.buck.rules.coercer.DefaultTypeCoercerFactory;
import com.google.common.collect.ImmutableList;
import com.google.common.reflect.TypeToken;
import org.junit.Before;
import org.junit.Rule;
import org.junit.Test;
import org.junit.rules.ExpectedException;

public class MavenCoordinatesMacroExpanderTest {

  @Rule public ExpectedException thrown = ExpectedException.none();

  private ActionGraphBuilder graphBuilder;
  private MavenCoordinatesMacroExpander expander;

  @Before
  public void setUp() {
    graphBuilder = new TestActionGraphBuilder();
    expander = new MavenCoordinatesMacroExpander();
  }

  @Test
  public void testHasMavenCoordinatesBuildRule() {

    String mavenCoords = "org.foo:bar:1.0";

    BuildRule rule =
        JavaLibraryBuilder.createBuilder(BuildTargetFactory.newInstance("//test:java"))
            .setMavenCoords(mavenCoords)
            .build(graphBuilder);
    try {
      String actualCoords = expander.getMavenCoordinates(rule);
      assertEquals(
          "Return maven coordinates do not match provides ones", mavenCoords, actualCoords);
    } catch (MacroException e) {
      fail(String.format("Unexpected MacroException: %s", e.getMessage()));
    }
  }

  @Test
  public void testNonHasMavenCoordinatesBuildRule() {
    assumeFalse(
        "Assuming that FakeBuildRule does not have maven coordinates",
        FakeBuildRule.class.isAssignableFrom(HasMavenCoordinates.class));

    BuildRule rule = new FakeBuildRule("//test:foo");

    try {
      expander.getMavenCoordinates(rule);
      fail("Expected MacroException; Rule does not contain maven coordinates");
    } catch (MacroException e) {
      assertTrue(
          "Expected MacroException that indicates target does not have maven coordinates",
          e.getMessage().contains("does not correspond to a rule with maven coordinates"));
    }
  }

  @Test
  public void testHasMavenCoordinatesBuildRuleMissingCoordinates() {
    BuildRule rule =
        JavaLibraryBuilder.createBuilder(BuildTargetFactory.newInstance("//test:no-mvn"))
            .build(graphBuilder);
    try {
      expander.getMavenCoordinates(rule);
      fail("Expected MacroException; Rule does not contain maven coordinates");
    } catch (MacroException e) {
      assertTrue(
          "Expected MacroException that indicates target does not have maven coordinates",
          e.getMessage().contains("does not have maven coordinates"));
    }
  }

  @Test
  public void testExpansionOfMavenCoordinates() throws Exception {
    String mavenCoords = "org.foo:bar:1.0";
    BuildTarget target = BuildTargetFactory.newInstance("//:java");
    BuildRule rule =
        JavaLibraryBuilder.createBuilder(target).setMavenCoords(mavenCoords).build(graphBuilder);

    ProjectFilesystem filesystem = new FakeProjectFilesystem();
    CellNameResolver cellPathResolver =
        TestCellBuilder.createCellRoots(filesystem).getCellNameResolver();
    StringWithMacrosConverter converter =
        StringWithMacrosConverter.of(
            target, cellPathResolver, graphBuilder, ImmutableList.of(expander));

    String input = "$(maven_coords //:java)";

    String expansion = coerceAndStringify(filesystem, cellPathResolver, converter, input, rule);

    assertEquals("Return maven coordinates do not match provides ones", mavenCoords, expansion);
  }

  @Test
  public void testMissingBuildRule() throws Exception {
    BuildTarget target = BuildTargetFactory.newInstance("//:java");
    BuildRule rule = JavaLibraryBuilder.createBuilder(target).build(graphBuilder);

    ProjectFilesystem filesystem = new FakeProjectFilesystem();
    CellNameResolver cellNameResolver =
        TestCellBuilder.createCellRoots(filesystem).getCellNameResolver();
    StringWithMacrosConverter converter =
        StringWithMacrosConverter.of(
            target, cellNameResolver, graphBuilder, ImmutableList.of(expander));

    thrown.expect(HumanReadableException.class);
    thrown.expectMessage("no rule //:foo");

    coerceAndStringify(filesystem, cellNameResolver, converter, "$(maven_coords //:foo)", rule);
  }

  private String coerceAndStringify(
      ProjectFilesystem filesystem,
      CellNameResolver cellNameResolver,
      StringWithMacrosConverter converter,
      String input,
      BuildRule rule)
      throws CoerceFailedException {
    StringWithMacros stringWithMacros =
        new DefaultTypeCoercerFactory()
            .typeCoercerForType(TypeToken.of(StringWithMacros.class))
            .coerceBoth(
                cellNameResolver,
                filesystem,
                rule.getBuildTarget().getCellRelativeBasePath().getPath(),
                UnconfiguredTargetConfiguration.INSTANCE,
                new ConstantHostTargetConfigurationResolver(
                    UnconfiguredTargetConfiguration.INSTANCE),
                input);
    Arg arg = converter.convert(stringWithMacros);
    return Arg.stringify(arg, graphBuilder.getSourcePathResolver());
  }
}


I love Psalm 119. I remember a time when reading my Bible was boring. I did it to check it off my list. Occasionally, I was enlightened, but most of the time I was fighting sleep. I knew in my head I should love and enjoy God's word, but I didn't. Then I discovered Psalm 119. It was all about God's law, commandments, precepts, etc. The guy who wrote it obviously loved God's word. I asked God to help me love the Bible like the psalmist. I began to memorize Psalm 119 with a dear friend. As I memorized that Psalm, I began to see all the benefits the psalmist claimed about God's law. That was the beginning of my romance with God's word.
Psalm 119:92,93 contains one benefit of loving and knowing God's word. In the midst of the valley of our lives, God's word can keep us from giving up completely. The psalmist had experienced some very trying times, yet it was God's law that kept him going. He said he was saved by God's word. He would never forget the word that saved him from despair.
I know there are countless times when I have been confused or discouraged about a situation and the Holy Spirit brings a verse to mind. He either brings up a verse I have memorized or he highlights a verse or two as I'm reading a passage. Then I repeat that verse or verses to myself over and over. I have learned that renewing my mind on his word can produce joy and hope in the midst of the valley.
I'm so thankful God answered my prayer. I love his word! It had been a life raft for my soul in those dark days when life doesn't make sense. Do you need a life raft? Get into his word and hold on for dear life. Even if you aren't in the valley right now, get into his word to store it up for the future.


As an adopted child, she longed to be a mother. But in her teens, she received a medical diagnosis that she would never be able to bear children. How has her Christian faith helped Chelsea Patterson Sobolik help with the questions and doubt and what word does she have for others who similarly face infertility? Chelsea joins the podcast to talk about her life story, her journey through suffering, and how she encourages churches to help those who suffer from infertility.


Just joined the Traditional Fisherman's Forum, why not pop into this forum and introduce yourself.
A very warm welcome to the Forum Hannes. Us pipe smokers have to stick together! By the way, your English is probably better than mine and I was born here!!!!!
Welcome to the forum Hannes. Your english is just fine, so don't worry about that, because when it comes to fishing, we all speak the same language.
Worry less about who you might offend, and care more about who you might inspire.
A very warm welcome to the forum, Hannes.
Bamberg certainly seems to be a `happening' place, with its high concentration of breweries and traditional fishermen, to say nothing of Martin's pack of adopted dogs. We look forward to reading your posts.