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Category Archives: Cancer
Dr Ben George
Over the last 18 months, GenesisCare has treated more than 170 patients on the UK's first ViewRay MRIdian MR-linac and adopted SMART planning as a new way of working. Here, Ben George explains why this latest hypofractionated technique has proven to be one of the success stories of the COVID-19 era.
Stereotactic ablative radiotherapy (SABR) is growing in importance in the curative cancer pathway. Increasingly, it offers patients the opportunity to enjoy relatively long periods of disease control where previously they would have been considered for palliative treatments. During COVID-19, the scales have tipped even further in favour of hypofractionated techniques because protocols have been revised to limit the risk of patient infection. More recently, attention has turned to stereotactic ablative MR-guided adaptive radiotherapy (SMART) – the most exciting development in radiotherapy for years, with the potential to treat previously inaccessible targets.
GenesisCare has been the first in the UK to adopt SMART, installing the first ViewRay MRIdian MR-linac just over a year ago. Since then, we have treated over 170 patients, some of which are the most challenging in the world from a radiotherapy perspective, such as pancreatic, central lung and now renal cell carcinomas. MRIdian sits within our SABR offering, which is run by a specialist team of oncologists, physicists, dosimetrists, and radiographers. Over an intensive 18 months, we have adopted a completely new way of working and overcome the challenges of a pandemic to treat patients not just from across the UK, but also from around the world.
SMART explained
The MRIdian MR-linac combines a 0.35 T split superconducting magnet with a 6 MV linear accelerator. This gives it unique advantages over conventional external beam radiotherapy linear accelerators, which rely on kV cone-beam CT (CBCT) imaging, and enables an entirely new approach to treatment.
First, using MRI instead of CBCT provides superior soft-tissue visualisation. This increased imaging capability allows the treatment to be adapted at each fraction based on the daily position of the target and nearby organs at risk (OARs). This is in marked contrast to external beam treatment with CBCT, where anatomy captured in the CBCT is simply rigidly matched against a planning CT. This rigid registration is then used to calculate the movements required to shift the patient into the correct position for treatment.
Second, the MRIdian takes images continuously throughout the treatment period to not only monitor the patient position, but also turn the treatment beam on and off. This is carried out as the patient's anatomy moves through the breathing cycle.
This combination of enhanced visualisation and real-time imaging adds a layer of certainty in the delivery of treatment.
The MRIdian on-table adaptive planning system generates a new, optimised treatment plan for each fraction. This accounts for these day-to-day anatomical variations when the patient is in the treatment position.
Treatment delivery is then automatically gated so that the dose is only delivered when the target is in the optimal position. The machine is able to monitor every intrafraction motion caused by breathing or organ-filling.
As a result of these factors, we can design plans which deliver a higher dose, more precisely than with conventional SABR. There is no need for invasive fiducial marker insertion and any uncertainty is removed. Moreover, we can reduce planning target volumes, remove internal target volumes, and minimise the amount of tissue irradiated.
SMART has led to a paradigm shift in how some cancers are treated. In particular, it can benefit cancers in areas where there is significant inter- or intrafraction motion of either the target or OARs. Across the global community, MR-linac centres are now treating novel indications, such as renal, central lung and hepatobiliary tumours, and achieving clinical outcomes not previously thought possible. It is not simply a case of improving on an existing treatment – for some tumour types, SMART is facilitating new referral patterns for patients who may not typically be eligible for radiotherapy.
Pancreatic cancer – a new way of treating
Pancreatic cancer is one such example and of all the tumour sites we are now treating at GenesisCare, this is undoubtedly the one that is breaking most ground, offering new hope for both clinicians and patients.
For decades, surgical resection and adjuvant chemotherapy and radiotherapy have been the cornerstones of primary and secondary hepatobiliary tumours and pancreatic cancer treatment. However, options are limited for many patients. Less than 20% are resectable at diagnosis and not all patients are fit enough for an operation or effective chemotherapy regimens. There is, however, emerging evidence of a dose-response relationship, proving that escalated radiation doses are associated with improved local control as well as overall survival in borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC). Conventional radiotherapy delivers a comparatively homogenous radiation dose to the target volume. In contrast, SABR treatments combine advanced image guidance systems, accurate dose delivery and hypofractionated regimes. This is to facilitate a deliberate heterogeneous dose distribution across the target. This means the radiation tolerances of surrounding OARs are respected, while the tumour receives a higher, ablative radiation dose. A number of SABR studies have yielded good results in the treatment of large hepatobiliary tumours, with 1-year local control exceeding 90% and acceptable toxicity. Furthermore, delivering these hypofractionated ablative doses of radiation over a shorter treatment schedule has the potential to reduce the burden of treatment on patients.
However, with conventional SABR this therapeutic approach is often limited by concerns regarding organ motion and the possibility of developing small bowel radiation toxicity. As a result, many patients are only being treated with systemic agents. This is a prime example of where the elements of SMART on an MR-linac can facilitate an effective radiation dose escalation, while still respecting the radiation tolerance of normal tissues and surrounding OARs. In fact, using an MR-linac, it has been possible to successfully increase the prescribed dose in patients with primary pancreatic cancer. The previous standard dose was 33 Gy in five fractions, but SMART enables us to escalate the prescribed up to 40 Gy or even 50 Gy in five fractions. At the time of writing, 30 patients have been treated on the MR-linac for pancreatic tumours at GenesisCare.
Compassionate Access
The significance of MR-linac as an innovation in cancer treatment can't be understated and, although at GenesisCare we are offering it in a private setting, we are committed to sharing the benefits of this technology with the wider medical community. Patients with localised pancreatic cancer have variable access to precision radiotherapy in the UK. The n-SARS-CoV-2 pandemic has further disadvantaged this patient group by reducing the availability and safety of surgery and chemotherapy. Considering this, since 2020 GenesisCare in association with GenesisCare Foundation, UK charity, Pancreatic Cancer Research Fund, ViewRay and University of Oxford have been treating NHS patients with localised pancreatic cancer with SMART at no cost. The programme, which is run through a partnership with the University of Oxford, is generating preliminary clinical and patient-reported outcome data on a UK cohort. This will inform the design of subsequent randomised clinical trials and help to embed SMART in UK oncology practice.
A new way of working
With any new technology, there comes a learning curve. MR-linac represents a significant change in working practices. It demands a style of inter-disciplinary working which challenges the norms.
In a standard radiotherapy workflow, a patient will receive a treatment planning CT one to two weeks before the start of treatment. During this time, several steps are carried out by a team of dosimetrists, physicists, doctors and radiographers to produce a treatment plan ready for the patient's first fraction. These steps include contouring the treatment target and OARs and optimising the machine parameters to deliver the prescribed dose to the target while sparing critical structures. This is followed by reviewing the dose distribution, checking the planning process to ensure no errors have occurred and performing an independent dose calculation.
As part of the on-table adaptive workflow, the time taken for this process must be reduced from days to minutes. In order to achieve this, close inter-disciplinary working between the team is required. The need to undertake a number of complex tasks during each adaptive treatment also increases the time for each fraction to around one hour.
The MRIdian workflow involves a Clinical Oncologist on-site during treatment to oversee the daily adaption. To maintain a treatment schedule at GenesisCare, this has meant that clinicians had to be trained to contour all areas of anatomy, often working outside their main area of specialism. Equally challenging was the need to acquire skills in MRI interpretation, which for some specialities is not routinely used as a diagnostic modality. These were all skills that needed to be honed and validated before any patients could be treated on the MR-linac. In our case, we spent many hours learning with colleagues in MR-linac centres of excellence around the world. Twelve months later, we are experts in this field and have treated over 170 patients.
A body of evidence
There is a growing body of data as the global MR-linac community treats ever more and complex cases. We brought this international best practice to GenesisCare and have treated complex and challenging cases, including central lung, pancreas and reirradiation within our first year. We have many case studies available on our website genesiscare.com/mridian/case-studies. We already knew that the technology could deliver, but it was the confidence in our processes and the ability of our team to implement an adaptive workflow in a time-pressured environment, with a patient on the treatment table, which allowed us to embrace the opportunity that MR-linac presents in radiotherapy.
GenesisCare will install the second MR-linac in the UK in 2021. Through our MagNET programme, we are joining with NHS organisations to support education in the use of MR-guided radiotherapy. Enquiries to: James.Good@genesiscare.co.uk
Dr Ben George, Lead Physicist – MR Linac, GenesisCare
Ben is Lead Physicist – MR Linac at GenesisCare UK. He works as part of a multi-disciplinary team which has established a successful and world-leading SABR service delivering complex MR-guided adapted treatments. He has a PhD in Physics with a strong background in computer science, research and clinical computing. He has over ten years of experience as a Clinical Scientist specialising in radiotherapy in both the NHS and the private sector, and as a research scientist for the University of Oxford.
Posted in Cancer, radiotherapy, radiotherapy physics, Uncategorized	| Tagged Cancer, COVID-19, MR-linac, radiotherapy	| Leave a comment
Angela Young explains how the process of making a podcast helped not only others with a diagnosed brain tumour but gave comfort and support to herself as she embarked on a course of radiotherapy.
A brain tumour diagnosis, like all major events, can set in place a chain of emotions, among them anger, fear and denial. It can also make you adjust your priorities in life. I went through all this in 2015 when I discovered I had a Grade 1 benign posterior fossa meningioma. A resection at Addenbrooke's Hospital in Cambridge was very successful, leaving only a 3mm residuum.
I had been having regular follow up scans, and in 2019, it was thought the growth was significant enough to consider radiotherapy. After the initial shock, I realised that, if successful, it would prevent the cells from growing again and remove the need for annual scans with the associated "scanxiety". My decision to go ahead now rather than wait for symptoms to appear was influenced by the consultant radiologist Dr Sarah Jefferies who said the benefit of doing so now was that I was "young and fit", a nice thing to hear at the age of 59.
As a journalist and podcast maker, I am used to getting to grips with a variety of subjects quickly in order to explain them to others. It dawned on me that if I could tell the story of my own treatment, it would give me a sense of control over a process in which one can easily feel helpless. It might also provide information and some light relief to other people going through something similar and their families. The radiotherapy process would be the same for people undergoing treatment for a variety of conditions, not just brain tumours, and so creating a podcast on this topic could reach and potentially help a large audience.
I am very optimistic by nature and I like to see the funny side of things. I believe that if you look closely, you can find humour in most situations. Consequently, I decided the title of the podcast should be "A Sense of Tumour". I started recording everything that happened, whether by phone call (I had got all the kit I needed for doing this when lockdown started) or recording my own commentary during appointments and tests and arranging interviews, either face to face (with masks on) or via an audio recording platform.
People find podcasts in a variety of ways. One of those is to have a well-known personality or influencer or support group post about them. It helps if you can interview a celebrity or two who will do this. When I asked Victoria Derbyshire (via a mutual friend) if she would talk to me about documenting her very public battle against breast cancer, I had no idea she would later be taking part in the TV programme "I'm A Celebrity, Get Me Out Of Here!". Victoria appeared in Episode 1 and set the interview bar quite high. Luckily, the Brain Tumour Charity had come on board by this stage and offered to put me in touch with TV presenter Nicki Chapman, who had had a matching meningioma to mine removed last year. She readily agreed to be interviewed and candidly shared the highs and lows she experienced when going through treatment herself. For the final episode, I thought I would chance my luck and ask to speak to Tony Iommi, lead guitarist and song writer with Black Sabbath. He had had radiotherapy a few years ago and embraced some alternative therapies which I wanted to hear about. To my delight, he was more than willing to talk.
The series was meant to inform as well as entertain so I spoke to the medical professionals whom I was meeting and also those at the cutting edge of research into treatment. I interviewed the Chair of Cancer Research UK, Sir Leszek Borysiewicz, about funding for brain tumours. I also had conversations with the "Distinguished Scientist" from Elekta, one of the companies which makes the linear accelerator machine (not a bad job title!) and to many people from the team at Addenbrooke's, including a medical physicist and a research radiographer. I learned a lot and I hoped that sharing these conversations would also help listeners to understand some of the more complicated parts of the treatment and process more easily.
Bringing the podcast's listeners on my journey was supposed to feel personal too. I recorded as much as I could at every stage, including the baseline neurological assessment. This is an IQ-style test carried out before the start of a course of radiotherapy to the brain so that if there is any concern about future cognitive function, there is a baseline against which to compare it. One part of the test included listing as many words as possible beginning with the letter F; you can imagine what came to mind! When that episode was released, listeners I came across would shout out words beginning with F to me.
All the way through the treatment I was thinking how I would represent things aurally, such as the MRI machine. These make a variety of loud noises but would wreck any recording device in the vicinity. When I managed to open my eyes under the thermoplastic mask which holds the head in place on the linear accelerator, part of the machine going over me looked like a spaceship. Friends and family had each contributed a song for my radiotherapy playlist; that day the song was Mr Blue Sky and it had got to the instrumental part, which made me think of a science fiction movie. I was working out how to recreate the impression for the podcast. Thinking about this during the session took my mind off what was going on.
By the time you read this, I will have finished the treatment and will be waiting for a scan to see how successful it has been. I am, of course, hoping for the best. I would also like to think that the podcast series has been useful to patients and their families, to radiotherapists, to manufacturers and anyone else involved in this fascinating process. I also hope that it inspires anyone looking for a positive and creative way of dealing with a diagnosis of any kind to take control of what they can, focus on something meaningful and use their good days to bring strength to others. After all, positivity radiates.
Listen to "A Sense of Tumour" here
About Angela Young
Angela Young founded Cambridge Podcasts in 2018 to help clients showcase their expertise and establish themselves as the go-to person in their field. She is a former BBC radio journalist who has worked as a reporter, producer, news reader and news editor. She has taught law and journalism at the BBC and media handling at the prestigious Institute for Management Development in Lausanne. She studied law at Cambridge as a mature student and has lived in the city for 28 years. www.cambridgepodcasts.co.uk info@cambridgepodcasts.co.uk
Posted in Cancer, oncology, radiography, radiotherapy	| Tagged meningioma, scanxiety	| 1 Comment
The five-step guide to AI adoption in clinical practice
Jeroen van Duffelen proposes a five-step programme for adoption of artificial intelligence in clinical practice.
Adoption of medical imaging AI is about getting your hospital or screening programme ready to implement the right solution for a clinical need. Running into speed bumps along the way is common for early adopters. How do you define the needs, budget, and outcomes? Which boxes should you check when selecting vendors? How do you manage internal stakeholders? The adoption curve is steep. Luckily, you don't have to climb it alone.
Drawing from our experience deploying AI in clinical practice and lung cancer screening, I've designed a five-step guide to streamlined adoption. If you're looking to adopt artificial intelligence but don't know where to start, these actionable tips and advice will see you through. For the video breakdown of the steps, watch this presentation from ECR 2020.
1. Consider
Where do you start working with AI? First, look away from all the solutions out there, and focus on your organisation. Bring together all the stakeholders into a project team that includes the sponsor, if applicable, IT and legal representatives. Involving them from the beginning will expedite the process.
Start with defining the challenge you are looking to solve, or the specific clinical question that is relevant to your workflow. Some hospitals are looking to experiment with the technology, while others aim to solve a particular issue. Over the past years, I have seen the latter getting more out of AI, which is why my advice is to start from a clinical challenge.
When considering this challenge, make sure to already determine your expected outcomes. When is the adoption a success? Are you aiming to have an AI solution in use? Should it apply to a certain patient population, or yield specific results like time or cost savings?
Also, although it may seem early, this is also the stage to organise a budget dedicated to the AI solution. The size of this budget should relate to the cost or time savings a solution is expected to bring. Both the amount secured and its source will impact the next steps. For example, it will guide you to look for PhD researchers versus seeking a vendor that offers a mature solution.
2. Evaluate
The AI in healthcare space is widely populated; a Google search or a look at the list of vendors at the RSNA can confirm that. To weigh the existing options for your scope, do your (desk) research using this high-level checklist for each solution:
How was the AI solution validated?
It is important that the claim that the AI solution has validated covers the use case you identified in the previous step. Take the time to understand if the manufacturer has done studies confirming this claim.
How does it integrate into the workflow?
Try to get a feel of the amount of effort needed to add an AI system into your workflow. A good practice is to start with an AI solution that is easy to integrate with the current workflow and IT infrastructure. Workflow integration is of utmost importance for the radiologist; in this article, we explained why that is and how it works.
What regulations does the solution fulfill for use in clinical practice?
Commercialising medical devices requires a CE Mark in the EU and an FDA clearance in the US. Note that local regulations may apply to different countries. Again, pay attention to which claim is covered by the acquired certification.
3. Choose
By this stage, you should have narrowed your search down to a few vendors. This is the moment to go in-depth into the workflow and test if a specific solution is a good fit from both a clinical and a technical standpoint. A well-integrated AI system should not create hurdles for physicians, such as requiring them to leave their workstation to upload studies. It should further blend within the existing IT infrastructure.
There are two checks that are vital to make the right choice:
Validate the accuracy
Legitimate vendors would have done a study and can provide a clinical background for accuracy. To know if the solution is good at performing the defined task for your organisation, ask questions about the datasets used to develop and test the AI solution.
There are three datasets required to build an AI model: a training dataset, a validation dataset, and a test dataset.
The test dataset is the most relevant to look at because it is what the accuracy is based on. The performance on this dataset should be applicable to your hospital, with its specific protocols, type or number of scanners, and patients. To achieve this, the test set must cover the patient population your organisation serves (e.g. types of patients, comorbidities distribution, etc.). Thus, inquire about the specifics of the test set and the performance of the AI model on this dataset.
Secondly, you may want to know what the size of the training dataset is and how it was labelled. Both quantity and quality are important to train an accurate AI model. Labeling the data should be done by experienced radiologists, preferably with multiple readers per study.
Check the regulatory compliance
In Europe, medical device classification is divided up between risk Class I, Class IIa/b, or Class III. If looking for a solution for clinical practice, be wary of Class I medical devices. The new Medical Device Regulation, which will come into force in May 2021, will require many AI products currently classified as Class I devices to update their classification. For instance, software that supports diagnostic decisions should fall under Class II at a minimum. For more guidance on the new regulation, read our recent expert piece.
Apart from the regulatory approval, check if the vendor also has a quality management certification (e.g. ISO 13485). Reviewing the data processing policy and the cybersecurity measures in place will further help you understand if the AI company is going the extra mile in regard to safety.
A bonus tip for the choosing stage: do a reference check. Ask other organizations how they are working with the AI solution you have chosen. You may get the insights you need to make the final decision.
4. Approve
Approving the chosen solution internally requires the involvement of and coordination between IT and PACS administrators, procurement officers, physicians, often also privacy departments and legal officers. If you have a project team in place since the first step, you should be well on track.
To move forward and avoid delays, assign an internal AI champion responsible for driving the project. This may be an executive sponsor, a budget holder, or a department manager. One of my learnings from past deployments is that the risk of failure is high without a person fulfilling this role. What I have further learned as vendors is the importance of empowering the AI champion, by providing the necessary information and documentation in a timely manner.
Furthermore, make sure end users are trained to use the new medical device. If they don't benefit from it, the impact of the AI solution will be limited. Additionally, setting up a feedback mechanism with the AI vendor from the get-go will help improve the AI product.
5. Deploy (& evaluate)
All the paperwork is signed – well done! To make the deployment work, create a clear project plan, including actions, timelines, and owners. Depending on the type of deployment – on-premise or cloud-based – different actions will be needed. As outcomes, set the deployment and acceptance dates, make agreements on the service levels, fixes, and upgrades, and discuss post-market surveillance.
The initial or trial phase of using the AI solution should show if it answers the problem you were trying to solve. It is a good moment to revisit step one and start evaluating the results to decide if you will continue using the solution.
A common question I get at this stage is: "Do I need to do a full clinical study?" The answer fully depends on the purpose of using the product. It is necessary for research, but not for other use cases. What matters is validating that the AI solution is adding value to your clinicians and their patients.
AI adoption does not end with deployment. Service and maintenance are essential, and their quality often a differentiating factor between AI vendors. The implementation process usually acts as a good test for the AI companies fulfilling their promises and being prompt when handling requests.
Beyond these five steps, you and your organisation play a role in improving the chosen AI solution through valuable feedback and feature suggestions. The collaboration between humans and software allows us to achieve much more than humans would on their own. If done right, it can be transformative for patients.
Are you ready to start the AI journey? Get in touch!
Jeroen van Duffelen, COO & Co-Founder
Jeroen van Duffelen is COO and co-founder of Aidence. Jeroen's entrepreneurial spirit led him to teaching himself software engineering and starting his own company commercialising an online education platform. He then tried his hand in the US startup ecosystem where he joined a rapidly scaling cloud company. Jeroen returned to Amsterdam where he ran a high-tech incubator for academic research institutes, it is here Jeroen first got his taste for applying AI to healthcare.
Posted in AI, Artificial Intelligence, Cancer, radiography, radiology, X-ray	| Tagged AI, Artificial Intelligence, Radiography, radiology	| Leave a comment
Is artificial intelligence the key to effective and sustainable lung cancer screening?
Dr Lizzie Barclay explores how artificial intelligence can influence lung cancer screening.
Radiology as the starting point
Imaging plays a fundamental role in lung cancer screening programmes. So, when it comes to improving technology to support the programmes, the radiology department is a good place to start.
The goal of screening is to pick up early cancers which can be treated and potentially cured, therefore improving patient outcomes (as outlined in the NHSE long term plan). Low dose CT has been shown to provide sufficient image quality for detection of early disease, whilst minimising radiation dose in asymptomatic individuals. Thoracic radiology expertise is required to determine which lung nodules may be malignant and therefore require invasive investigation, and which are likely benign and can be monitored with intermittent imaging. Appropriate follow-up recommendation helps avoid unnecessary invasive procedures, such as biopsies, and minimise patient anxiety, which are important measures of the efficacy of lung cancer screening programmes.
End to end lung cancer screening involves input from many healthcare professionals, and intelligent computer systems across specialities would benefit multidisciplinary teamwork. Thus, beyond image analysis, there are many opportunities for technology to add further support for effective and sustainable screening programmes. For instance, it could aid in the optimisation of image acquisition, access to imaging reports and relevant clinical details, tracking patient follow up, or in communication between patients and GPs.
Where AI-based image analysis makes a difference
Reading and reporting CT scans is time-consuming, and within a workforce which is already under strain, introducing a new CT-screening programme seems like a tall order. AI-driven solutions can support radiologists and contribute to successful lung cancer screening by bringing improvements in three areas:
Computer intelligence can increase the performance and productivity of CT reporting, freeing up time for radiologists to spend on clinical decision making and complex cases. Specifically, AI software is well-suited for precise:
Detection of elusive lung nodules, and differentiation of subtle changes
Automatic volume measurements, to help determine the appropriate frequency of monitoring (e.g. stable vs growing nodule, according to the BTS guidelines).
What further distinguishes computers from humans is the absolute consistency in their high performance, without being impacted by common external stressors to which a radiologist would be exposed (e.g. time-pressure, workload and interruptions).
(E)quality
Having a 'second pair of eyes' looking at the scan can increase the confidence of the radiologist in their own assessment. Additionally, making the AI-driven, accurate measurements available regardless of the level of expertise of the reporting radiologist could not only benefit quality assurance, but also equality within the radiology department. The use of AI would reduce the need for all scans to be reported by the most experienced thoracic radiologists with interest in early lung cancer detection, and instead facilitate spreading the workload across the workforce.
Another use case concerns quality assurance when outsourcing to teleradiology companies. AI-based image analysis can improve consistency of reporting, drive the recommended terminology use, and, essential for lung cancer screening, ensure access to relevant prior imaging for comparison and change assessment over time.
Efficiency (via integration)
An intelligent computer system should not slow down reporting turnaround times, but improve efficiency, as well as quality, to ultimately minimize time to diagnosis (for example, the NHSE long term plan introduces a 28-days standard from referral to diagnosis or rule out).
Older CAD technology was often described as 'clunky' – requiring images to be uploaded to separate systems for analysis. Additional manual steps between image acquisition and the radiology report make the process time consuming, and often require radiology support staff to manage the workflow. It is important to consider allocative and technical efficiency which play important roles in the evaluation of screening programmes, and their impact on healthcare systems.
An AI-driven image analysis software which is fully-integrated in the radiologist's pre-existing workflow can provide automatic results, without needing additional departmental resources. An additional benefit of fully-integrated AI solutions is that their use is not restricted by time or place, therefore supporting flexible and remote working. In the context of the COVID-19 pandemic, it's been encouraging to see the increase in remote reporting, whilst maintaining a functioning department, in many hospital trusts. Going forward, it will be interesting to see whether radiologists will have the option to continue to work remotely where possible.
Valuing input from healthcare professionals
New lung cancer screening programmes will be monitored regularly to evaluate their effectiveness and determine areas for review. Commitment from all parties to work together will facilitate optimisation of the pathway to achieve better patient outcomes and positive impacts on healthcare systems.
In our experience, close collaboration between medtech and healthcare professionals is important for learning lessons along the way. Understanding radiologists' needs helps tech teams develop a clinically valuable tool.
For example, Aidence's interactive lung nodule reporting tool, Veye Reporting, was designed based on the needs of radiologists involved in reporting lung screening scans. From our conversations with them, we understood that following the detailed and complex reporting protocols in lung cancer screening programmes make for labour-intensive, repetitive tasks.
To help them produce reports that follow the standardised NHSE proforma and facilitate audit for quality assurance, we added Veye Reporting as a feature to Veye Chest, focusing on making it easy-to-use and efficient. With this tool, the radiologists further have control over which nodules to include in the report, different sharing options, and the choice to add incidental findings.
Cancer services have been impacted by the COVID-19 health emergency. In the UK, screening has been paused and planning to (re-) start at the end of 2020 or beginning of 2021. Talks of introducing screening are ongoing in various European countries, as are concerns of catching up with the backlog of screening scans.
The British Society of Thoracic Imaging and the Royal College of Radiologists released these considerations for optimum lung cancer screening roll-out over the next five years. Their statement below is a reminder of why it is worth overcoming challenges and leveraging technology to make screening programmes a success:
Dr Lizzie Barclay, Medical Director
Dr Lizzie Barclay's areas of interest are thoracic radiology and medicine, innovation, and improving patient outcomes and healthcare professionals' wellbeing.
Lizzie is originally from Manchester, UK. After graduating from the University of Leeds Medical School (MBChB), and Barts and the London School of Medicine (BSc sports & exercise medicine), Lizzie spent four years working as a doctor in Manchester and Liverpool NHS Trusts, including two years in Clinical Radiology. She has presented her work on lung cancer imaging at national/international conferences, and recently contributed to Lung Cancer Europe's "Early Diagnosis and Screening" event at the EU Parliament in Brussels.
https://www.aidence.com/
You may be interested in the BIR Lung Cancer Imaging: Update for the not-so-new normalon 11 September 2020. This will be available for members in the BIR online learning libraryafter the live virtual event.
Posted in AI, Artificial Intelligence, Cancer, radiography, radiology	| Tagged AI, Artificial Intelligence, Cancer, Health, imaging, Medicine, NHS, radiology, science	| Leave a comment
"The Radiology Reset Button – overcoming the normalcy bias"
Fodi Kyriakos explores how the COVID-19 pandemic could be the catalyst for change in radiology and encourages our community to grasp the opportunity to "seize the moment" and plan for recovery.
At the beginning of 2020, if someone had told radiology leaders that all NHS outstanding reporting backlogs would be reduced to virtually zero by May, I'm sure they would have looked at you in disbelief and asked what sorcery had been involved, but this situation is exactly where we find ourselves today.
Normalcy Bias – Noun [edit]
normalcy bias (plural normalcy biases)
The phenomenon of disbelieving one's situation when faced with grave and imminent danger and/or catastrophe. As in over focusing on the actual phenomenon instead of taking evasive action, a state of paralysis.
Historical challenges
In the past, it has often taken lots of effort to either invoke or accept change of any kind in radiology and for those managing services, there's also been a certain amount of risk associated with putting your head above the parapet or being a trailblazer. It has been sometimes easier to follow the well-trodden path rather than to create a new one. Workloads and budgetary constraints have also been a disabler, restricting decision making to the 'here and now'. This has resulted in failing, or in most cases, not being able to foresee or plan for events that have never happened before, such as an event like a pandemic crisis. Psychology refers to this state of being as normalcy bias. For those who are not familiar with the term, you will certainly be aware of its connotations and radiology now finds itself at this cross-roads.
Ever since the introduction of digital radiography and PACS, NHS radiology reporting backlogs have been a contentious issue among experts, and a recurring feature in the mainstream media! Often being highlighted (and with some justification) in relation to areas such as missed cancer diagnosis, where even the slightest of delays can have a significant bearing on the overall outcome.
Serious backlogs
The extent to which backlogs were a serious issue in the UK was further exacerbated by various Care Quality Commission (CQC) inspections, which raised concerns regarding reporting backlogs that resulted in delayed or missed diagnosis of conditions that may have otherwise been picked up.
By the end of February 2020, the situation of backlogs was as much an issue as at any time before. Insufficient reporting capacity had led to a build-up of outstanding reports, which in turn meant that outsourcing was at its highest ever levels and growing pressures to meet new deadlines, such as the cancer pathway targets, were increasingly exposing the lack of options available to resolve the problem.
So, you would have been excused if you thought that a crisis such as the COVID-19 pandemic would simply exacerbate the reporting challenges facing radiology. However, this has not been the case. Instead, we have witnessed radiology's own "clear the decks" exercise, where in fact the complete opposite situation has occurred, resulting in backlogs across the UK being virtually eliminated. Who would have thought that the worst crisis to hit the country (and the world) in 75 years would be a catalyst for NHS radiology departments to press the reset button?
Of course, we recognise the superficial nature of this situation. During the pandemic, practically all routine referral activity came to a grinding halt, which allowed radiology to concentrate on COVID-19 and Emergency Department (ED) patients. Chest X-rays and CTs were identified as two of the key diagnostic tools for the virus, but the volumes were manageable. Accident and Emergency footfall was reduced to almost 50% of its usual figures, so reporters were practically able to deliver a 'Hot-Reporting' examination for every patient requiring imaging. Something which ED and Intensive care unit (ICU) consultants have grown quickly accustomed to.
During this time, radiology was also still required to work to critical staffing levels, so radiographers and radiologists were covering 24/7 rotas, but due to the lack of activity outside of portable X-ray scanning in ICU, many staff were not being utilised. So, while this enabled the catch up in radiology reporting to take place, what we witnessed was the 'ying and yang' of radiology. On the one hand, integral to the continuity of a patient's pathway and critical to defining an outcome – AND on the other hand, completely dependent on throughput from referrers to maintain activity levels.
Seizing the moment!
So what happens next? Well, in a world where we can guarantee almost nothing, in this situation, we can guarantee that radiology will remain the centre point for the recovery phase of the pandemic, but with the added challenge of complying to 'social distancing' and 'equipment cleaning' guidelines, how do we manage the continuation of treating COVID-19 patients, while reintroducing 'business as usual' and 'deferred' patients whose treatment has been delayed?
The "Reset Button" has enabled something else to happen. For the first time, there is now some headspace to plan for the recovery phase and for the next phase at least, there is now funding available to support the recovery. So how do we avoid going back to where we were before the pandemic? How do we seize the moment?
Time to make the changes!
Albert Einstein once famously said: "We can't solve problems by using the same kind of thinking we used when we created them." This quote has never been more poignant in the present day and while the pressure to manage change will be at its highest, this is the right time to make these changes happen! With the benefit of 'The Reset Button', if we can learn from the past and apply new ways of working moving forward, we can avoid falling into the trap of the normalcy bias and witness the radiology reset button offering a new, efficient and more streamlined radiology department moving forward.
Everything you wanted to know about radiology but were afraid to ask…
On Wednesday 17 June, a live event organised by InHealth, in partnership with The British Institute of Radiology and the Society of Radiographers is taking place, titled: "The Radiology reset button has been pressed". The aim is to tackle these challenges and support radiology managers as they enter the recovery phase. It will bring together senior figures from radiology and within healthcare to offer insights, opinions and advice on how we can approach this coming period and use what positives we have experienced during the pandemic to create service improvements throughout radiology.
There will be opportunities for radiology managers, clinical leads, radiographers and radiologists to put their questions to the speakers in the panel discussions after their presentations.
REGISTER FOR THE RADIOLOGY RESET BUTTON HAS BEEN PRESSED HERE
(The event is free for all)
About Fodi Kyriakos
Mr Fodi Kyriakos is a former director of RIG Healthcare and founder of RIG Reporting,
the UK's first provider of external radiographer reporting services. In 2016 he joined The InHealth Group following its acquisition of RIG Reporting and is now the Head of Reporting across the Group. His service specialises in delivering plain film reporting solutions and is the only provider to offer both on-site and telereporting services.
Fodi has over 22 years experience in workforce and staffing solutions and 17 years working exclusive within Imaging and Oncology. He is a member of the Institute of Healthcare Managers and a regular contributor of professional development events across radiology.
Posted on June 8, 2020 by birblog2013.	Posted in Cancer, COVID-19, CT, MRI, radiography, radiology, radiotherapy, X-ray	| Tagged Health, Medicine, science	| 1 Comment
Bringing together Science, Faith and Cancer Care
The Revd. Canon Dr. Mike Kirby, Chair of the BIR Oncology and Radiotherapy Special Interest Group, has a wealth of experience as a senior radiotherapy physicist, working on national guidance, developing clinical practice and teaching radiography students. As if this doesn't keep him busy enough he has also taken on the role of Canon Scientist at Liverpool Cathedral where he is working to encourage dialogue and discussion about science and faith. Here he explains what the role involves.
I began work in the UK's National Health Service more than 30 years ago, as a Radiotherapy Physicist at the Christie Hospital, Manchester UK. Alongside my routine clinical work, my main research interest was in electronic portal imaging and portal dosimetry. I then helped set up Rosemere Cancer Centre in Preston, UK from 1996 as deputy Head of Radiotherapy Physics and Consultant Clinical Scientist there. During that time I contributed to and edited national guidance documents such as IPEM Reports 92, 93 and 94 and the multidisciplinary work, 'On-target'.
My work moved back to the Christie in 2007 and as Head of Radiotherapy Physics and Consultant Clinical Scientist for the Satellite Centres, I helped to lead their development in Oldham and Salford as part of the Christie Network. My research and development work has primarily focused on electronic portal imaging, developing clinical practice and equipment development.
More recently my focus has been on teaching and learning for radiotherapy education as a lecturer (Radiotherapy Physics), especially using VERT, for Radiotherapy programmes in the School of Health Sciences, Liverpool University; but always with a focus on the wider picture of radiotherapy development having served on both IPEM and BIR committees throughout my whole professional career.
Alongside my scientific work, I am a priest in the Church of England; having trained and studied at Westcott House and the Universities of Cambridge and Cumbria, I hold graduate and postgraduate degrees in Theology.
My ministry has mainly been in the Cathedrals of Blackburn, Chester, and Liverpool (Anglican) where I was Cathedral Chaplain. I have recently (Feb 2020) become a Residentiary Canon of Liverpool Cathedral, with the title of Canon Scientist the primary aim of which is to encourage dialogue and discussion about science and faith.
I am a member of the Society of Ordained Scientists and have given numerous talks on Science and Faith to schools, colleges, churches and other institutions. These have included organising lecture series with world renowned speakers at Blackburn (2016) and Chester (2018) cathedrals; a third series was delivered at Liverpool Cathedral in May 2019, and a fourth series is planned for May 2020.
My role is to consider all sciences (physical, clinical, social) in ecumenical and multi-faith environments. So I will look to work with initiatives already developing in other Christian traditions, other faiths and secular organisations to discuss current challenges, such as climate change, medical ethics, health initiatives and information for cancer, dementia and mental health issues etc..
My work will be part of the clear faith objectives of the cathedral as a place of encounter for everyone, through events and initiatives within the cathedral, but also beyond. This will include services focusing on health issues and pastoral challenges (such as bereavement and loss); events engaging with science, its wonders and challenges; fostering further relationships with local and wider communities on science and healthcare education, and with academic and scientific institutions too; encouraging scientific and ethical engagement with schools and colleges, as I have done so previously in both Chester and Blackburn dioceses.
I will be encouraging Christians and Christian leaders to understand science and engage with it more, alongside other national projects such as the recently announced ECLAS (Engaging Christian Leaders in an Age of Science) project of Durham and York universities and the Church of England. As a self-supporting minister (one whose paid employment is outside of the church), I will also look to encourage and highlight the tireless work of many others who already do this within the diocese and the wider national church.
Within all of this, I have always seen my vocation as being one within God's service, for all people, with my work for cancer patients being right at the heart of it.
If you have any questions for Mike, you can send him an email at sigs@bir.org.uk
Mike is the co-author of the international student textbook on On-treatment Verification Imaging: a Study Guide for IGRT, through CRC press/Taylor and Francis with Kerrie-Anne Calder. They are both contributors to the updated UK national guidance on IGRT due out in 2020.
Mike, with the support of the SIG, has helped to organise a range of events for radiographers, physicists, dosimetrists, radiologists and oncologists. See the full programme here
Posted on February 5, 2020 by birblog2013.	Posted in Cancer, Canon Scientist, oncology, physics, radiography, radiotherapy, radiotherapy physics	| Tagged Cancer, oncology, Radiography, radiology, radiotherapy, science	| Leave a comment


text:
Supermarket launches boxed Christmas dinner for two for only £12
It includes all the trimmings apart from vegetables
Molly Holt
Christmas has been made easy by The Co-op
If you want your Christmas dinner to be cheap and easy, the Co-op has come up with the perfect solution - a boxed festive meal for two costing just £12.
Its new Turkey and Trimmings box includes a British turkey breast joint wrapped in smoked streaky bacon, pigs in blankets, stuffing balls, gravy and a cranberry compote.
The Co-ops Turkey and the Trimmings box (Image: The Co-op)
The only thing it doesn't include is vegetables which need to be bought separately.
What will also appeal to convenience cooks is that once the ingredients have been take out of the box, all you need to do it shove everything in the oven on its metal trays, and get it out again in just 50 minutes.
Co-op's director of "delicious" food, Breige Donaghy, said to The Mirro r: "One or two people households account for almost one in four of the Co-op's shoppers and research shows they want an easy and simple Christmas dinner.
It means shoppers can spend more time together with loved ones instead of prepping for hours in the kitchen and it avoids waste and excess cost."
Vegetables are not included in the Christmas dinner box
"We love the idea of the Christmas 'good turn' – a neighbour or family member buying an elderly couple, or someone they know, a box to enjoy, when perhaps they can't get to the shops for the ingredients, or don't have the time/ energy to cook everything."
The Turkey and Trimmings box will be available in store from December 19, but won't be available online.
The Co-operative
Explosion at house in Bude amid strong smell of gas - live updates
Devon NewsEmergency services are at the scene

redpajama_set_name: RedPajamaCommonCrawl


Starting this week, web visitors can use the same login for two of the Christian Reformed Church's most popular websites.
"Your Network login can now be used for both The Network and The Banner," said Tim Postuma, web and e-communications manager for CRC Communications.
Soon the main Christian Reformed Church in North America site (crcna.org) and other CRC-related sites will also be part of the unified login.
Streamlining the login process means fewer passwords to remember and makes it easier for people to post comments on The Banner or join ministry discussions happening on The Network.
In addition, visitors have the option of logging in using their existing account with Facebook, Gmail, Yahoo, and many other services.
All existing Network accounts have been moved over to the new structure.
CRC Communications staff members are standing by to help users who have any trouble with the new login process.


text:
Nendaz (frankoprovensalska: Nînde) är en kommun i distriktet Conthey i kantonen Valais i Schweiz. Kommunen har  invånare (). Huvudort är Basse-Nendaz.

Kommunen består av orterna Aproz, Baar, Basse-Nendaz, Beuson, Bieudron, Brignon, Clèbes, Condémines, Fey, Haute-Nendaz, Saclentse, Siviez och Sornard.

Demografi
Kommunen Nendaz har  invånare (). En majoritet (93,9 %) av invånarna är franskspråkiga (2014). 78,6 % är katoliker, 4,9 % är reformert kristna och 16,6 % tillhör en annan trosinriktning eller saknar en religiös tillhörighet (2014).

Turism
Nendaz är känd för sin koppling till vintersport och huvuddelen av turisterna som besöker kommunen kommer under vintern. Liftsystemet är dock även är öppet under sommaren och hösten för vandrare och mountainbikecyklister. Merparten av turistbäddarna består av privata lägenheter, men endast en mindre del hyrs ut.

Haute-Nendaz liftsystem hänger ihop med orten Siviez som i sin tur hänger ihop med skidorterna Verbier och Thyon. Haute-Nendaz skidsystem ligger i huvudsak åt norr, vilket medför att snön inte slits av solen.

Referenser

Externa länkar

 Kommunens officiella webbplats
 Officiell turistwebbplats

Kommuner i Valais

redpajama_set_name: RedPajamaWikipedia


text:
William Hatton (June 9, 1849 – October 22, 1894) was one of Carmel Valley, California's earliest pioneers. He was manager of the dairy and cattle interests of the Pacific Improvement Company, acquired land of his own, and became one of the wealthiest dairymen in Monterey County.

Early life

William Hatton was born on June 9, 1849, in Aghowle, County Wicklow, Ireland. He was the fourth in a family of eight children. His father was Edward Hatton (1810-1890) and mother Ann Kelly (1815-1895). He left Ireland at age thirteen and went to sea as an apprentice sailor on board a merchant ship. He lived a seafaring life for seven years, achieve the title of first mate. At age 20, he settled in Charleston, South Carolina where he worked as an agent for the United States Revenue Cutter Service. This is where he met Katherine Harney (1851-1922) a native of James Island, South Carolina. Hatton and Kate came to Monterey County in 1870.

Hatton married Kate in 1875 in Monterey, California. They had nine children in 18 years, Anna M., Harriet H., Sarah J., Edward G., William H., Frank D., Howard I., Emily B, and Howard J. Their daughter, Anna Mary Hatton (1876-1939), married William E. Martin in 1903. William was the son of John Martin, which united two pioneering Carmel Valley families.

Professional life

Hatton took his first job as dairyman apprentice for E. St. John at the old St. John Dairy Ranch near Salinas, California. This job gave Hatton the funds to buy the  parcel of land from where he was working from the Pacific Improvement Company. He grew the dairy to 600 cows.

In 1888, the Pacific Improvement Company hired Hatton to manage two large Del Monte dairies, the Rancho Cañada de la Segunda in lower Carmel Valley and the ranching operations of Rancho Los Laureles in the upper Carmel Valley that the company purchased in 1882. The Del Monte Dairy became the sole supplier of cream, butter, and milk for the Hotel Del Monte. Hatton had the first telephone service in Carmel Valley, which was installed from Hotel Del Monte to his dairies.

In August 1889, Hatton, as Superintendent of PIC, purchased the  Joseph W. Gregg ranch southeast of the Carmel River mouth off Highway One, on what is now the Odello Ranch. The Odello Ranch got its name from Battista Odello (1885-1963) who came to American in 1909. His family worked the ranch until 1995. They sold the west side field to the State of California and the east side to actor Clint Eastwood in 1996.

Hatton Lower Dairy

Hatton managed the  Hatton Lower Dairy business at the Rancho Cañada location, which extended along the north bank of the Carmel River into the mouth of Carmel Valley. This is the site of the present-day The Barnyard Shopping Village and Palo Corona Regional Park. The land was once owned by Dominga Doni de Atherton, the widowed wife of Faxon Atherton (namesake of Atherton, California). In 1892, Hatton purchased the west half of the Rancho Cañada from Dominga for $55,000 (). The Hatton Lower Dairy had a large barn, cream separators, and wagons on the property. Hatton and his wife Kate built an eighteen room Victorian house, which was located at the entrance to the valley on land that is now Carmel Knolls. The house was completed in 1894, the year Hatton died. The Hatton neighbors included John Martin, Richard Snively, James Meadows, and Edward Berwick.

In 1921, the Hatton Fields was still being used for grazing cattle from the Hatton dairy.

In 1925, Paul Flanders purchased  of property from the Hatton estate for $100,000 (). He founded the Carmel Land Company to help develop Hatton Fields.

In July 1955, Frank Porter purchased the  parcel of the Hatton Ranch (once Rancho Cañada de la Segunda in Carmel Valley for $200,000 (). The land had been under lease to Kenneth Martin for cattle grazing. Porter subdivided  for homes and sold the remaining  as a ranch.

In September 1957, the county planning commissioners approved two parcels of  for two shopping centers at the mouth of Carmel Valley. Phillip Hatton, grandson of William Hatton, was an applicant who submitted plans to the planning commission.

On February 25, 1968, Gordon Knott and Nick Lombardo took a 55-year lease on  in Carmel Valley to open a 45-hole golf course that they named Rancho Caňada de la Segunda, the name of the original Spanish land grant. The name was shorted to Rancho Caňada a year later.

In November 2015, Rancho Cañada decided not to renew its lease. In 2016, The Monterey Peninsula Regional Park District acquired  of the Rancho Caňada Country Club and golf course in Carmel Valley, that provides public access to the Palo Corona Regional Park. In a statement announcing the deal, Dryden Branson Bordin, representing the Hatton family, said, "This land has been in the family and contributing value to the community since the late 1800s. After receiving multiple offers on the property and much consideration, the family decided to sell the property to a group that could create an even greater public good."

Hatton Middle Dairy

The Hatton Middle Dairy dates back to 1890, with the  tract that was deeded to Frank D. Hatton (1887-1943) in 1925, the son of William and Kate Hatton. The ranch was located on both sides of Carmel Valley Road about three miles east of Highway 1. The northern section of the property is forested with elevations up to . Frank Hatton managed the ranch until his death in 1943.

The Hatton dairy barn, built ca. 1890, on the south side of Highway 1, was restored in 2011 by Frank Tarantino and is one of the only surviving structures from the Hatton's dairy.

In 1966, Barbro Friden sold the ranch to Howard J. Morgens and his wife, who named it September Ranch at 676 Carmel Valley Road. The September Ranch includes a  equestrian facility.

In February 2018, the real estate investment fund, DLC Capital Partners, purchased the September Ranch. A press release announced that 90% of the  will be protected, including the barn, equestrian center, and hiking trail to Jack's Peak. The other 10% will be a residental subdivision.

Hatton Upper Dairy

In 1890, Hatton managed a second dairy up Carmel Valley called the Hatton Upper Dairy on the old Rancho Los Laureles. Guests from the Hotel Del Monte could visit the Los Laureles Lodge on the property to ride, hunt, and explore the trails. Hatton modernized the diary operations at the old Boronda adobe, adding Durham cattle to the Holsteins that increased the milk butterfat content. Large vats and presses were installed to manufacture Monterey Jack cheese. The Hatton's lived in a house built by Kinzea Klinkenbeard and raised their seven children there.

The Del Monte Milk House dates to 1890 and still stands today in Carmel Valley Village, California just before the Robles del Rio Road, at the White Oak Plaza. A windowed tower at the building's top was designed to ventilate the milk inside. After the dairy closed, the Del Monte Milk House beame a residence and then in 1937, it became the Marion Meredith Inn. Marion married Philip Wilson, Jr. and by 1941, they renamed it the White Oak Inn. In 1949, Maarion made it into the Carmel Valley Art Gallery. It is now a wine tasting room.

In 1926, Frank B. Porter bought  of the Rancho Los Laureles and launched the first residential subdivision in Carmel Valley that became Robles del Rio. In 1928, Sam C. Fertig of Pennsylvania, purchased part of Rancho El Del Monte (once Rancho Los Laureles) that included the Boronda adobe and the Los Laureles Lodge. In 1936, Muriel Vanderbilt purchased  of the old Del Monte rancho for (), from Fertig, who retained 500 acres of the ranch property. In May 1946, Frank and his son Paul Porter bought the  farm from Muriel Vanderbilt Adams for an estimated $200,000 (). It was converted into the Rancho Del Monte subdivision and Rancho Del Monte Country Club (now Los Laureles Lodge).

In 1927, Marion Hollins, an athlete and a golf course developer, bought  in Carmel Valley. In 1936, Porter acquired  of the old Hollins ranch in Carmel Valley for $32,000 (). Porter sold a portion of the ranch to real estate developer Byington Ford for what is now the Carmel Valley Village and another became the C. E. Homan Ranch.

Death

Hatton died on October 22, 1894, in Carmel Valley, at the age of 45. He had returned to his ranch from Monterey and was caught up in a heavy shower when he caught cold. Newspapers said that the immediate cause of death was supposed to be a brain aneurysm. Further analysis determined it was bright's disease. He had an insurance policy for the sum of $25,000 (). He was a friend of the secretary of the Pacific Improvement Company, F. S. Douty who was also the administer of his estate. He was buried in Monterey, California. Every business in the city was closed from 12 pm until 3 pm out of respect for him. The funeral was from Masonic Hall under the sponsorship of the Watsonville Commandery No. 22, Knights Templar, and Monterey Lodge No. 217 F. & A. M. It was one of the largest funerals that took place in Monterey County.

Legacy

After his Hatton's death, his wife Kate and her brother John Harney managed the dairy until the 1900, when her sons took over the management with Andrew Stewart (stepson of John Martin). The Hatton land was left in equitable divisions among his heirs. Anna Martin was given the area known as the Martin Ranch (now Mission Ranch), Harriet, was given the area known as Rio Vista. Sarah was given the area known as Mission Fields. William, Jr. received the area now east of Rio Vista and bottom land, and Edward became owner of what was later called Hatton Fields.

In the 1900s the Pacific Improvement Company liquidated their holdings (10,000 acres) and the Del Monte Properties headed by Samuel F.B. Morse, acquired the land. In 1923, they divided the land into 11 parcels for sale. The Hatton dairies were sold to various landowners. Today, the Carmel Valley Village, the Holman Ranch, and the Palo Corona Regional Park are part of the Holman legacy.

See also
 Timeline of Carmel-by-the-Sea, California
 Hatton Fields

References

External links

 A Taste Of History
 Laureles Lodge
 Here's the History of That Old Hatton House

1849 births
1894 deaths
People from County Wicklow
People from Carmel Valley, California
Irish emigrants to the United States (before 1923)
19th-century American businesspeople
Businesspeople in the dairy industry


What is a Kundalini Care Assessment Consultation?
The fee for the consultation is $150.00. In order to use the time effectively Louise asks that you fill out the on-line questionnaire, which asks questions pertaining to your personal, spiritual and health history. After the questionnaire has been evaluated then a phone, in person or Skype session will be scheduled and payment options will be discussed.
This questionnaire is designed to give me an understanding of your Kundalini energy awakening process and overall life experiences. Your answers will allow me to better serve you in assessing your Kundalini related challenges and to make specific suggestions. All answers are honored and respectfully held in confidence. Feel free to answer these questions in whatever manner that feels comfortable for you.
If you have specific issues or questions that you would like addressed during our consulation let me know how frequently these issues come up in your life, when they first started and what steps you have taken to work with them?


text:
A young camgirl discovers that she's inexplicably been replaced on her site with an exact replica of herself.
Genre: Mystery, Thriller, Horror
Studio: Blumhouse Productions, Divide / Conquer, Gunpowder & Sky
Keyword: doppelgänger, social media, sex worker, cam girl, cam, sexual competition
Cast: Madeline Brewer, Patch Darragh, Melora Walters, Devin Druid, Imani Hakim, Michael Dempsey
David, a robotic boy—the first of his kind programmed to love—is adopted as a test case by a Cybertronics employee and his wife. Though...
12-year-old Regan MacNeil begins to adapt an explicit new personality as strange events befall the local area of Georgetown. Her mother becomes torn...
Matthew Bennell notices that several of his friends are complaining that their close relatives are in some way different. When questioned later they...
Kagemusha
Akira Kurosawa's lauded feudal epic presents the tale of a petty thief who is recruited to impersonate Shingen, an aging warlord, in order to avoid...
Blonde Betty Elms has only just arrived in Hollywood to become a movie star when she meets an enigmatic brunette with amnesia. Meanwhile, as the two...
The true, harrowing story of a young Jewish girl who, with her family and their friends, is forced into hiding in an attic in Nazi-occupied Amsterdam.
A genetically engineered assassin with deadly aim, known only as "Agent 47" eliminates strategic targets for a top-secret organization. But when he's...
The Invasion
Washington, D.C. psychologist Carol Bennell and her colleague Dr. Ben Driscoll are the only two people on Earth who are aware of an epidemic running...
A young woman left her family for an unspecified reason. The husband determines to find out the truth and starts following his wife. At first, he...
Dragon Ball Z: The Tree of Might
Goku and friends must stop a band of space pirates from consuming fruit from the Tree of Might before it's destructive powers drain Earth's energy.
In the heat of the summer lays a lonesome house in the countryside where nine year old twin brothers await their mother's return. When she...
Via a magic mirror, Twilight Sparkle travels into an alternate universe in order to recover a crown that was stolen from the Crystal Empire. Upon her...
When Chef Carl Casper suddenly quits his job at a prominent Los Angeles restaurant after refusing to compromise his creative integrity for its...
A mild-mannered college professor discovers a look-alike actor and delves into the other man's private affairs.
Ash is transported back to medieval days, where he is captured by the dreaded Lord Arthur. Aided by the deadly chainsaw that has become his only...
The tale of a new breed of cultural insurgent: a punk genius who sparked a revolution and changed the face of human interaction for a generation, and...
Husband and wife Gabe and Adelaide Wilson take their kids to their beach house expecting to unplug and unwind with friends. But as night descends,...
A harmless game of "Truth or Dare" among friends turns deadly when someone—or something—begins to punish those who tell a lie—or...
Bring It On: Worldwide #Cheersmack
When Destiny, captain of three-time national champions "The Rebels," is challenged to a global cheer showdown by an edgy new team called "The Truth,"...


Floor standing mirrors can act as a great design feature to be incorporated in your existing decor. They are typically oversized or extra large mirrors designed to be used on a floor surface and possibly lean on a wall for support.
Some traditional versions come with frames or support structures that allow them to be free-standing. More recent designs are meant to be placed at diagonal angles to the floor and are continually becoming common features in offices and homes.
So, what is the big deal about oversized mirrors on the floor? For starters, extra large floor standing mirrors have reflective properties that give a room depth and the illusion of being large than its actual size. The larger the mirror the more powerful it is in terms of creating depth illusions. Let's take a quick look at some of the benefits of using Floor Standing Mirrors.
· Won't Warp: most mirrors that are fixed on the wall eventually end warping or bending as a result. A warped mirror can lead to a reflection that makes you look too fat or too thin. A standing mirror will give you the true reflection of yourself, unlike some wall mirrors.
· Allows Your Full Reflection: Most mirrors fixed on the wall require that you back really far or stand on something to see your full reflection. This can be quite annoying especially if you are in a hurry leaving for work. With floor standing mirrors, you don't have to strain and struggle to see your full image from head to toe.
· Takes up lesser Floor Space: most floor standing mirrors take up much less space due to their compact nature. This makes them a perfect choice for people with limited space. Common standing floor mirrors barely take more than a square foot, so if you have a small bedroom, you can still enjoy their benefits without worrying that they will eat up your space or get into your way.
· Allow You To Free Up Wall Space: using standing floor mirrors allows you to free your wall space for other decors such as paintings and photos. Standing mirrors also offer a quick solution if you don't have wall space in the first place. You can still enjoy the benefits if a full-length mirror using a simple floor standing mirror.
With many designs and shapes available, choosing a standing mirror can be a bit difficult. The exact design you choose will obviously depend on your personal preferences and requirements. Despite the wide range of options available, floor standing mirrors come in three distinct types; the full length, cosmetic and cheval type.
Full-length types allow you to see your entire body while the cosmetic types are smaller, typically round and affixed on a movable base. Cheval mirrors, on the other hand, can rotate within their frame allowing you to position them at a specific angle. With that basic information at hand, it shouldn't be that difficult to choose a floor standing mirror. If you want to be more specific, you can go ahead and choose either a wooden, plastic or silver frame.


In less that 10 minutes I had me a wonderful and uber delicious nutty, choclatey, bananas with the incredible sweetness of kahlua – all in all a happy ending to a night. And for the folks who commented or are wondering – This is not a Jewish dish!
Set in fridge for about an hour and serve chilled.
That was an innovative recipe and a wonderful name to it…. would lov to try it out….
Wow delish. That looks different.
Wow looks super irresistible and tempting..
Thats an excellent recipe…nice name….
delicious combination and looks so yummy !!
Yum, what a interesting combination of ingredients..looks wonderful and well delicious…would love to try this..thanks for sharing!
That's a cool name for a cool dessert! You rock!
that sounds soo good to me right now!…pass it to me!…any leftovers?
Lovely combination and sounds delicious!
That is one dessert my kids would inhale!
Lovely dish…so innovative and must have tasted delicious.
he recipe is really very creative and new to me. Lovely clicks.
This is something new, looks yum!
This is one super easy and wonderful dish.Loved the name its very catchy.
Looks dleicious dessert, easy to put together.
Sounds innovative…and looks fabulous and delicious..
Very delicious dessert, name itself sounds very interesting and creative..
Sure a devotee need such a delicious treat. I also try to follow his words every now and then.Cool name too.
Kahlua and Nutella- two of my favorites- make this irresistible! I love the name you made up for your creation. It sounds delicious!
ahh ! this looks SOOOOOOO GOOD !
ima gonna have to ask my 21+ year old friends to buy me a bottle ot make this dessert. haha!
Superb and something new to me.
very tasty and yummy recipe … this is totally new to me … will make this kids will love to have it ….
What a dreamy dessert. I might just make this.
Beautiful combination and cute name for the dish:) Must be so delicious love it!!


Do you want to spend an unforgettable Christmas? We propose you create an advent calendar full of memories. It´s really easy with the app 1 Second Everyday, which allows you to make a 1 second video every day in order to generate an entire movie. What a great idea! You´ll be able to capture the best moments of this Christmas holiday. And in less than a month, you´ll be able to reminisce on all the good times you´ve spent as a family.


text:
Gameweek 2: The good, the bad and the.......holy fuck, did anyone watch the Chelsea match?
So after an opening gameweek which was only occasionally dull with individual flashes of 'Holy shit' this week gave us...........pretty much more of the same. Only the dull was even duller and the shit even more holy. It was a prolonged weekend of fake results, deserved results and WTF results so let's examine the finer points to try to see what the hell is going on, if indeed anyone knows anymore..........
Man U Vs Villa: Van Gaal's insomnia cure keeps on rollin'........
After the snooze-fest of the previous week United had a decent opportunity to chalk that one up to first game jitters and steal a march on the season proper. With Villa a club in transition and no-where near a similar level of quality across the board, United were expected to rack up the goals alongside the points. Now, while they took all three points the manner of the game will have even the most die-hard United fan shitting themselves. United were, again, rancid and were bailed out again courtesy of a one brief moment of average play leading to a deflected goal. In a dazzling display that will have any League two team pissing their shorts (laughing) United lolled around the pitch not doing much and not looking like they were trying to do much either, with the key stat being that Rooney didn't touch the ball in the opposition box until the 93rd minute. 93 fucking minutes.
If you've ever wondering what it would be like if a team fielded a chest of drawers as a central striker you'd be hard pressed to come up with a more apt example. He looks completely shot and, while I know making judgements two games in is asking for it, I reckon he's finished as a top-tier player. United only world-class player (De Gea) sat this one again and, for all of Villa's improvement, so could have Romero. Some was due to a re-vamped solid looking defence (Smalling was really very good) and some was due to a lack of any kind of cohesion in Villa's attack. But alas, again, United were there for the taking and, again, the opponent failed to capitalise. The match seemed doomed, as with last week, to end in a rotten 0-0 draw when Mata produced one the few moments of brightness in the game to play in Januzaj, starting for the time in six months, to sweep home a shot which deflected off Clark and into the far corner. How United will deal with a team who will punish them, they host Swansea in two weeks time remember and Ayew and Gomis are no doubt licking their lips at this showing, is anyone's guess but expect riots if Van Gaal does not add another striker before the window closes.
Soton Vs Everton: The manager wasn't the only one on crutches.........
What a difference a week makes eh? Or for Southampton it doesn't. For Everton, however, a week was all it took for them to finally find that groove that makes the team work, at least for a game. While credit is due to Everton for the ruthlessness of their attack they have to concede that they were up against a poor facsimile of the Southampton team that shocked everyone last season. It seems that they've lost whatever screen they've needed in front of the defence and their shipping goals for fun now. Last week a decent Newcastle team stretched them to the limit and the worry was , if Everton actually showed up, they could be in for a bad time.
Oh how right they were. Lukaku was rampant and, combining with Barkley, Kone and Coleman, took Southampton apart with an ease that would've been impossible at any point last season. While Pelle was unfortunate not to score today he looked like the only Southampton play who was trying as the rest of his team turned in probably their worst performance under Koeman to date. A last ditch Shane Long goal saved them a point last week. This time they needed a miracle or at least a massive improvement. They go away to Watford next week and, judging how they took Everton to the brink it's difficult to not see them getting their first win if this is a sign of things to come. After shipping two goals to Lukaku in the first half, Southampton played better in the second half and were unlucky not to pull one back through a superb strike for Mane bettered only by the quality of the save Howard made to keep it out. Everton, however, soaked up the pressure and when it look about to break, Barkley added a goal to his assist, cutting in from the left and swerving a stunning shot past Stekelenburg to firmly put the nail in the coffin of this match and put the cherry on top of this victory. And they'll need it because they host City next week while Southampton have a Thursday Europa match followed by Watford on Saturday. It could be one of those weeks.....
Spurs Vs Stoke: Arsenal aren't the only London club with a self-destruct button......
One wonders if Spurs this season will run out of ammo first before they run out of their own feet to shoot. Having gone ahead to a Dier header from a typically excellent Erikson corner they had assumed control of the match due to Stoke playing so deep their defenders were playing the ball-boys onside they doubled their lead at the best time possible, just on the stroke before half time, with some more slack defending allowing Chadli to thump home a volley at the near post. While they did not have the entire half to themselves, Lloris was on hand to again make some properly world-class saves, they made enough of a mark to walk into the dressing room at half-time with their heads held high and assured of the three points.
Only no-one told Stoke this. One thing Hughes has always been able to breed into his teams is a never-say-die attitude and it served them so well this day. Having a quality bench helps too. An obviously tired and leggy Kane scuffed his only chance of the game to make it 3-0, denied by a super save from Butland and then Stoke applied the pressure. The pressure arrived in the 59th minute in the form of Stephen Ireland. A fringe player so far at Stoke despite the obvious love Hughes holds for him, his link up play with both Arnautovic and Diouf was what allowed Stoke to really crank up the heat. Alderweireld stupidly tugged back Joselu, another new signing, in the box leaving the ref with no option but to point to the spot. He put it away with aplomb on the 78th minute and on the 83rd Ireland crossed for a hilariously unmarked Diouf to head home to seal the draw and the point. Booed by a section of their own fans, Spurs will have to pick themselves up after this and their thoughts will be with how they'll manage against better teams with Kane tired and with the newly incumbent Njie as the only other viable striking option. For Spurs, it's a worrying thought.
Norwich Vs Sunderland: The crowning of the whipping boys.........
Let's face it, Sunderland seem pretty fucked. After an torrid display in their opening game a second game against a newly promoted team seemed like just the ticket. Only Norwich played quite well against a robust Crystal Palace team and it was only their slack marking that undermined what was a decent performance. Sunderland have none of the qualities that marked out that Palace performance; skill, grit, determination and that potential for a flash of genius to light up a game. The only thing Sunderland lit up today was the exit signs at half time as their fans left in droves. The only reason the booing wasn't louder was because so many had left by the end, silver linings and all, I suppose.
For Norwich it's a well deserved three points and a fine showing for their Irish contingent as both Brady and Hoolihan (2) picked up the assists with some lovely interplay with the strikers, Redmond especially. For Sunderland it's the reality that their policy, of simply throwing shit at a wall and staying up solely because the other guys' shit didn't stick too well, has finally caught up with them. With barely any investment in the squad Sunderland fans have actually taken to wondering if Mike Ashley might be better than Ellis Short, which is surely the footballing equivalent of arguing about which barrel of the shotgun you want to be shot with. Season after season of wretched displays still haven't dis-heartened what must be the most loyal fanbase in history, 41,000 fucking thousand turned out to watch this crapfest, and they want more, no, they deserve more.
Swansea Vs Newcastle: Karma is a bitch..............
Not so long ago McClaren was one of the rounding voices urging more British (emphasis on English) players being bought and fielded by Premier league clubs. So much so, that he added his name to a letter which resembled a papal bull which was sent to the FA. Now he's at the helm of arguably his biggest club ever he............fields only one English player, another as a sub and then splurges 35 million on a Dutchman, a Congolese and a psychotic Serbian. Sticking to your guns eh, Stevie? Well fucking done there. Bet the FA and Hodgson are falling over themselves to applaud your efforts to help them out. Being out-played by a Swansea team fielding eight British players (including subs) was just the karmic filling in the humble pie.
None of this wanton hypocrisy, however, detracts from the fact that Newcastle never deserved to win this. Pressed back their 18 yard line at times, Newcastle could barely draw breath, let alone play football. Despite showing a good degree of pluck after Janmaat getting himself sent off ridiculously for a second yellow on 41 minutes, Newcastle were never in this game and were outplayed to a man. The trio of Ayew, Montero and Gomis were just fucking brilliant today, along with a fantastic assist from Shelvey. It's no surprise that Janmaat was sent off for dragging back Montero although his exposure could be part McClaren's fault as pairing him up with Sissoko (who laughs in the face of his defensive duties) didn't help. But it was sheer luck that Newcastle weren't stuffed and Swansea fully controlled the match from start to finish. Mitrovic again getting himself booked within minutes of coming on really should have McClaren shaking his head at his decision to buy him so hard he'd need a neck brace.
I'm telling you, their game against Sunderland next week is going to be fucking bloodbath...
Watford Vs West Brom: Hornets are missing their Sting.........
Watford were keen to continue their hard and fast method of football having only collected a point against Everton last week and were certainly hoping for more luck against a Brommie team reeling from a comprehensive 3-0 destruction at the hands of Man City. Flores has whipped his team into a fast paced, high tempo whirlwind and, while it sure as hell shocked the West Brom players who at times looked like super fans who just wandered onto the pitch, he could not be expecting his team to be this blunt in attack. His team enjoyed almost 65% of the possession and out-passed West Brom almost 4 to 1 yet they could not kill the game off and it'll certainly leave a bitter taste in his mouth that all the best chances fell the Brommie attackers, particularly Berahino who headed narrowly wide on the 80th minute.
Last week, Pulis held his hands up and conceded that he really shouldn't have gone with two strikers against a team as strong as City. Today he fielded three at one point and, worryingly, they just as ineffective. He'll be thanking his lucky stars that Watford lacked even a tenth of the finishing verve of their previous opponents, with the Watford attacks doing nothing more than beef up Myhill's fantasy football score. For both teams, however, the time for easy points may be up already as Watford's next three games are against Southampton, Man City and Swansea respectively and they'll be lucky to salvage a point from those three fixtures. Same goes for Bromich as their next three are Stoke, Chelsea and Southampton and they would surely be fortunate also to garner more than a point from that run......
West Ham Vs Leicester: Swings and roundabouts I suppose.......
Fresh off arguably the major upset of last week, West Ham were looking to extend their fine start with a comfortable romp over a Leicester team that would have surely posed easy pickings a week ago. Leicester's 4-2 trouncing of Sunderland having the sheen taken off it by the subsequent toxic Sunderland performances, the Hammers could go into this knowing they were clearly favourites. Maybe it was this hubris that was their undoing or maybe Tinkerman has found his working formula and will probably tinker quite a lot less in the future?
West Ham fielded pretty much the same team that trod all over Arsenal, bar Jenkinson at left back, and would've been happy with the rushing out of the blocks right at the start, Schmichael flapping his hands at a curling Payet free-kick in and Reese Oxford (who picks up his school exam results on Thursday for fucks sake!) heading just a fraction over. This fast start was an illusion, however, because either Leicester put their foot down or West Ham took theirs off (or both) the tide of the game turned swiftly. Leicester's hustle and energy in attack was compounded by West Ham virtually ignoring the flank play that saw them so much success at the Emirates and they played almost right into the Leicester midfield.
This congestion tied them up whilst releasing Leicester's own wide players to bring havoc to the Hammers defence. Vardy and Okazaki had a field day today, they surely will not enjoy better fruits as this. They sliced through the West Ham defence almost at will and it's no surprise that both were at the hearts of both goals. The first was from a stunning Vardy cross met first time by Okazaki which required Adrian's inhuman reflexes to stop. Unfortunately, his save succeeded in only palming the ball straight up and Okazaki just had to stand there and allow the ball to drop onto him to score his first PL goal. The two then combined to tee up Mahrez for his third, carving open the defence to leave him free to thump home. Payet pulled one back but Ranieri shut up shop at that point and rode the crest of the wave to another, deserved, three points.
Crystal Palace Vs Arsenal: Right, last week doesn't count right?..........
After blowing their chance to kick off the season in style against West Ham last week the Gunners had probably soaked up a lifetimes worth of pressure before this match, which is not ideal at the best of times and far less so now. Selhurst Park is renowned as one of the few remaining "Lion's den" grounds left in the PL. The fans are so close that, when they shout, you can feel their breath on your neck in the centre circle. And shout they do. Palace fans bring the fucking noise and ,at home, they can sound a lot like a cross between a zombie hoard and a marching band filled to the tits with amphetamines.
They've a decent team too. Smoking Norwich 3-1 last week really put a spring in their step and smashing the Arsenal at home would be the cherry on top of a fine premier league start. However it was not to be. The Arsenal that showed up this week actually remembered how to play football, how to mix it up and how to score goals. And mix it up they did, I've never seen an Arsenal team sling in this many crosses and each one seem to put the shits up the Palace defence. I hope they keep this aspect of their game up as it's really great to finally see them stick it in like this. One aspects fans will hope not to see is the recurrence the "Only score the perfect goal" mentality. Alexis really should've had a hat-trick inside of fifteen minutes if only he'd remember to pull the fucking trigger a second earlier. Ozil put on an absolute fucking masterclass and was only short a goal himself to make it a perfect game. He racked up an assist and mis-placed only one pass the entire game (He attempted 55) most of them being in the Palace final third (37 of 38).
Giroud took his goal very well considering the ball, crossed very well, was a bit behind him and his volley completely wrong-footed McCarthy. Palace pulled one back through a well taken Dann strike into the far bottom corner which both Koscielny and Cech really should've done better for. Koscielny, in particular makes no attempt to even stop the shot, he just turns around to watch it sail into the bottom corner, whilst Cech seemed to almost pull his hands back at the last moment for fear he might actually touch the ball. Wickham would hit the post later on but when Bellerin slung in a cross (yes, BOTH Arsenal goals came from crosses!, yeah I know!) Alexis practically vaulted over Dann to thunder home a header that Delaney could only direct into his own net.
Man City Vs Chelsea: Yeah, Karma REALLY is a bitch..............
I reckon there's a lot of medical staff toasting this one even a few in Chelsea colours. The first meeting between two of the top four was likely either to be an all or nothing affair. City were looking to kick on from as good a start as anyone could hope for and Chelsea were looking to kick on from an opening match that loomed so close to disaster is was palpable. Even without Courtois, hands down one of the best keepers around, Chelsea have a brilliant understudy in Begovic and one the most water-tight defences in the league. City also have a potent squad that, at times, has failed to click but when it does it's so difficult to play against given that there are virtually no weak points.
This potential clash of the titans, however, could not have gone more wrong for Chelsea. Their only positive point is that the scoreline actually flattered them. Begovic was immense in goal, he alone was responsible for the deficit not being three times more than it was at half-time. The Chelsea defence was hilariously porous and vulnerable to the speed that City fielded. Sterling, clearly taking notes from the Swansea game, was given licence to run at both Ivanovic and Cahill while Terry was so unable to deal with Aguero that he was subbed, for the first time in 177 games, at half time for Zouma in a last ditch attempt to add some speed to the backline.
Right from the start City just flew at Chelsea with near reckless abandon but never exposed themselves. Kolorov and Sagna by-passed the Chelsea midfield almost as if it didn't exist while Silva and Toure, both of who collected all the assists, pegged straight through the centre with no real resistance. The first goal was signposted long before it came, Toure blitzing through midfield and fed Aguero who was given entirely far too much time, with three defenders around him, in the box to turn and sweep home with his left foot. Chelsea weren't much better after the interval and they conceded a second from a standard corner. Kompany out-muscling Ivanovic to glance home. City's total control was beginning to show, Chelsea were epitomised by the figure of Costa frustrated at being in Mangala's pocket the whole match, and when Fernandinho capped his stunning MOTM performance with an equally stunning strike in the 85th minute Chelsea were just about ready to lie down and die.
Liverpool Vs Bournemouth: Here are the new rules.....same as the old rules.....
If Bournemouth had harboured any aspirations of taking a big team scalp they won't get much of a better opportunity here. Liverpool are still in transition and lack fluidity but given that Rodgers picked the exact same squad that played Stoke it's obvious what his preferred lineup is. That lack of cohesion nearly cost them, and really should've, inside the first ten minutes. Ritchie had a serious amount of success down the flank and his corner was perfectly delivered for Elphick to jump and head home. The goal was harshly judged to be a foul on Lovren, when he'd done little more than lean on him. It proved to be a turning point of sorts for the match and Liverpool steamed forward whilst simultaneously killing off Bournemouth's own counter-attacks. Coutinho was, again, Liverpool's main source of attacking threat and invention but it was either sheer dumb luck or incompetence that didn't see him ruled offside for Benteke's goal.
Henderson managed to catch the entire Bournemouth defence on the hop by playing a corner back for Clyne to set him up to cross in from a better angle. Bournemouth sprung the offside trap expertly, catching Coutinho offside who swiped at the ball, the attempt leaving Boruc in no-mans land. Benteke swept in at the back post and converted. Under the new interpretation of the offside rule, Coutinho met all three terms of intent, proximity and impact on the opponent and was the very clearest definition of offside. It's sad that this match was decided by a grey interpretation of a rule that was specifically designed to have no grey area. Yet the goal stood and the match ended in a flurry of activity for both teams with Benteke hitting the post and Coutinho seeing some good chances spurned or blocked and the final whistle brought relief and three welcome points and some controversy.
Gameweek 2: The good, the bad and the.......holy f...


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