Honda kicked off production of the all-new 2018 Honda Accord today and to celebrate the start of production, Honda also announced that it is investing $267 million and adding 300 new jobs to support production of the new Honda Accord and to increase production at the Marysville Auto Plant, in Ohio.
The Accord has been in continuous production at the Marysville Auto Plant since November 1982 – with cumulative U.S. production exceeding 11 million units over 35 years.
Even though the 2018 Accord is now rolling off the production line, Honda has not announced the pricing. The 2018 Accord will be available with a choice of two turbocharged four-cylinder engines, either a 192-hp 1.5L four-cylinder or a 252-hp 2.0L. The Accord Hybrid will also return with the third generation of Honda's two-motor hybrid technology. The 1.5L can be mated to either a six-speed manual or CVT transmission, while the 2.0L gets either a six-speed manual or 10-speed automatic.
Previous articleNissan electric SUV concept to be called IMX?


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Parenting is a powerful influence on brain development
7 June, 2017 by Matt Sanders
Good parenting not only helps children develop appropriate behavior but is vital to healthy biological development and brain functioning – and there's more and more research to confirm this.
The good news is, brain development is ongoing and it's never too late to provide kids with an environment that helps them be their best.
You can download an easy-to-digest summary of some recent research called Five Numbers To Remember About Early Childhood Development, from Harvard University's Center on the Developing Child.
Some of the most interesting information relates to a fairly new idea: that childhood experiences can have lifelong effects on not only mental health but physical health.
In the past, experts argued over whether "nature" (genetics) or "nurture" (environment) was the most important factor in child development.
But there's now increasing recognition of the interplay between the two. While we're only just starting to understand how chronic stress affects children's development, there's increasing evidence that providing parenting support to families, caregivers, and even other adults in children's lives such as teachers, can have important and wide-ranging benefits for children.
In a nutshell, family relationships are vital in shaping a healthy and successful future. And the more we can spread this message, the better.
parenting education research
Matt Sanders
Dr Matt Sanders is the founder of the Triple P – Positive Parenting Program. He is also Director of the Parenting and Family Support Centre at the University of Queensland, Australia.
Disclosure statement: The Triple P – Positive Parenting Program is owned by the University of Queensland. The University, through its main technology transfer company, UniQuest Pty Ltd, has licensed Triple P International Pty Ltd to publish and disseminate the program worldwide. Royalties stemming from published Triple P resources are distributed to the Parenting and Family Support Centre; School of Psychology; Faculty of Health and Behavioural Sciences; and contributory authors. Various staff and students from The University of Queensland are contributory authors. No author has any share or ownership in Triple P International Pty Ltd.
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Hexcel has announced the unveiling of the third H160 prototype from Airbus Helicopters, which features a striking carbon-inspired livery that represents the composite materials Hexcel supplies for the helicopter.
This gesture follows Hexcel's announcement in June that its reinforcements, prepregs, adhesives and honeycomb materials had been selected for the H160's composite fuselage structures and main rotor blades. The H160 was designed by Airbus Helicopters to create added value for customers in terms of performance, economic competitiveness, safety and comfort. The use of Hexcel's composite materials throughout the structure contributes to the lightweight, fuel saving design and performance optimisation.
Airbus Helicopters decided to promote the H160 programme and its high carbon fibre content in a way that recalls the livery previously used for the A350 XWB. The A350 XWB has a structure that is 53% composites and Hexcel supplies the carbon fibre prepreg for all of the aircraft's composite primary structures.


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Oxford Research Encyclopedia of International Studies
Oxford Research Encyclopedias International Studies
International Relations Theory
Political Sociology
Politics and Sexuality and Gender
Qualitative Political Methodology
Quantitative Political Methodology
Defining Federalism: Some Terminological Clarifications and Confusions
Classical Traditions of Federal Thought
Modern Approaches to Federalism
The Origins and Formation of Federal States
Multinational Federalism and Regional Autonomy
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Federalism and Regional Autonomy
Dejan GuzinaDejan GuzinaDepartment of Political Science, Wilfrid Laurier University
Federalism refers to the compound mode of government, combining a general government (the central or "federal" government) with regional governments (provincial, state, cantonal, territorial, or other sub-unit governments) in a single political system. Its distinctive feature is a relationship of parity between the two levels of government established, as exemplified in the founding of modern federalism of the United States of America under the 1787 Constitution. Federalism differs from confederalism, in which the general level of government is subordinate to the regional level, and from devolution within a unitary state, in which the regional level of government is subordinate to the general level. Instead, federalism represents the central form of the pathway of regional integration or separation. Leading examples of the federation or federal state include the Russian Federation, the United States, USSR, Canada, Mexico, Brazil, Germany, Switzerland, Australia, and India. Some also characterize the European Union as the pioneering example of federalism in a multi-state setting—a concept termed the federal union of states. Traditionally, federalism was defined as a simple league or inter-governmental relationship among sovereign states based upon a treaty. Whereas modern federalism is a system based upon democratic rules and institutions in which the power to govern is shared between national and provincial/state governments.
regional governments
confederalism
unitary state
federal union of states
modern federalism


You've watched your daughter grow and imagined her future—a future in which she soars realizing all her potential. Those dreams may have been challenged as you watched your daughter struggle with depression, anxiety, trauma, addictive behavior, and low self-esteem. At La Europa Academy we help your daughter step confidently into young adulthood with the resilience to meet life's challenges. La Europa is a place of healing where our students, adolescent girls ages 14-17 find themselves and unlock their potential through creativity, intensive therapeutic modalities, and expressive therapy groups. We combine a nurturing environment, a sophisticated clinical approach and challenging academic curriculum to help our students heal and grow as they develop coping skills, find their voice, discover their identity and find joy in their journey.
Parents often wonder how La Europa Academy will be able to reach their daughter and create change. Part of the answer lies in the ability of expressive therapies to reach beyond words. Students who have been involved in regular talk therapy often learn how to avoid talking about, and therefore dealing with issues that are emotionally difficult. Those same students find a language of their own as they participate in art, dance/movement, music, psychodrama, writing/poetry, trauma yoga or sand tray therapies. Students attend a combination of expressive therapy groups multiple times per week and will likely rotate through the majority of these groups while they are a La Europa Academy. Students often find the courage to face what they have been avoiding by using the expressive modalities, which are provided by master's level clinicians who are board-certified specialists in their expressive modality.
WE BELIEVE that Expressive Therapies have the ability to reach beyond words allowing a student to explore through a variety of modalities and create a pathway through her defenses.
WE BELIEVE that everyone is doing their best AND everyone can do better. Through DBT, we help our students translate their insight into concrete skills to change their behavior.
Dialectical Behavior Therapy (DBT) is both a philosophy to help student's view their challenges from a functional, strength-based perspective and a structure to help staff mentors move students toward positive change. Many of our students have had exposure to DBT skills and have struggled to implement the skills they have learned. They often feel hopeless and conclude that "DBT doesn't work". La Europa Academy helps students practice DBT skills in the moment when they are struggling. Students are able to figure out what works for them and how to best use the skills they are learning to decrease emotional reactivity. Parents are also taught to use DBT interventions to improve their interactions with their child.
Creative expression is essential to the process of healing. Many of our students come to us with a background of art, drama, dance, writing or music. Other students are creative, but still finding what they love or some might just enjoy crafts and creative activities. Students are given the chance for therapeutic expression through an artistic or creative medium. Our campus and caring staff provide students with the ability to discover their passion and find joy in creativity. With a dance studio, art studio, designated music room and other creative spaces, students can explore art, music, ceramics, dance, photography, psychodrama, singing, theater and much more.
WE BELIEVE that using creativity and expression helps our students discover their inner world, build confidence and create a healthy identity.
WE BELIEVE that a strong and challenging academic program is an important component of helping our students heal, develop resiliency and competency to establish a future direction in life.
Our academic program is a strong college preparatory curriculum. This curriculum can also be easily modified to accommodate the learning style of each student. Our students attend classes with highly qualified, full-time licensed teachers. La Europa Academy is accredited through Advanced Ed, a nationally recognized accrediting agency. Students feel supported and challenged with smaller class sizes, direct teacher instruction and individualized student goals to meet each student where she is on her academic journey. Whether a student has struggled in school or excelled, she will either find or continue to have a feeling of success in our school. As students experience academic success, this creates hope that they can overcome other challenges.


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Looping in Ruby vs. Looping in JavaScript and Ruby hash vs. JavaScript Objects

JavaScript implements 2 looping constructs. These are 'for' and 'while' loops, there is also a 3rd which is variant of the while loop and that is the 'do..while'

            Ruby implements 3. These include for , while, and until.

            Ruby, additionally has a group of looping methods that enable you to loop through each of the elements in a collection. The collection is a group of enumerable elements.

            These iterators include the 'each' iterator.

            The syntax for the use of the iterator is ...

              collection.each do |variable|
                code
              end

            In JavaScript, there is no 'each' iterator but with the use of the 'for' you can iterate over a group of elements much like you would if you used the .each iterator method in Ruby.

            The functionality of looping constructs in Ruby, 'for ', While', and 'Until', can all be implemented in JavaScript by using JavaScripts for, while and Do..While loops

            In JavaScript the for loop has the general syntax...

              for (var list_pointer ; condition ; increment_value){ code block };

            The 'var list_pointer', and 'increment_value' are actually optional and can be set elsewhere. this feature makes the 'for' loop in JavaScript very flexible and configurable.
            Below is an example of this feature

              myPointer = 0;

              for (; myPointer <= 20 ;){

                console.log('Pointer is ' + myPointer)

                myPointer += 2 //increment by 2

              };

              equivalent Ruby code using the 'step' iterator

              [0..20].step do |myPointer|

                puts "Pointer is #{myPointer}"

              end

Post 2

JavaScript

Ruby Hash vs. JavaScript Object

Hash objects are useful when you want to store and manipulate pairs or values that are related or associated with each other.

          Ruby has a specific hash object that allows you to store key:value pairs where the key can be non-numeric.

          JavaScript, doe's not include a specific 'hash' object, only an array object that requires a numbered key, but using JavaScript objects, you can  create an object that behaves like a Ruby hash.

          A comparison of how these look from a code perspective is below...

            Creating a new hash

            'in Ruby'

            myHash = { one => 'Joe Bloggs', two => 'Tim Smith', three => 'Amy Jones'}

            Accessing a 'hash' value

            myHash['one'] , returns 'Joe Bloggs'

            Setting a hash value

            myHash['three'] = 'Adam Black'

            Adding a key:value pair

            myHash['four'] = 'Terry White'

            Deleting a key:value pair

            myHash['three'].delete //deletes the key 'three' along with its value

            'in JavaScript'

            var myHash = {one: 'Joe Bloggs', two: 'Tim Smith', three: 'Amy Jones'};

            Accessing a 'hash' value

            myHash['one']; , returns 'Joe Bloggs'

            Setting a hash value

            myHash['three'] = 'Adam Black';

            Adding a key:value pair

            myHash['four'] = 'Terry White'; //Adds the 'key' 'four' and sets it's value to 'Terry White'

            Deleting a key:value pair

            delete myHash['three']; //deletes the key 'three' along with its value

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Demand Justice is putting pressure on Sens. Heidi Heitkamp, D-N.D., Joe Manchin, D-W.V., and Joe Donnelly, D-Ind., in confirmation fight.
WASHINGTON — A progressive group working to sink President Donald Trump's Supreme Court nominee is launching its first round of advertising Friday in three key states to pressure Democratic senators to vote against Brett Kavanaugh.
The ads, obtained by NBC News, are complimentary of the Democratic senators' efforts to preserve the Affordable Care Act but caution that those actions could be nullified by the next high court justice.
Those three senators are primary targets of campaigns from both sides of the aisle as the confirmation process gears up because they represent states Trump won in 2016, are up for re-election in November and voted for Trump's first Supreme Court nominee, Neil Gorsuch.
Democrats are honing in on the issue of health care as a key argument against Kavanaugh's nomination. The Supreme Court could hear a case in the next term challenging pre-existing conditions protections. And the subject is proving to be a top issue on the minds of voters heading into the midterms.
With only 49 votes in the Senate, Democrats have little ability to block the nominee from moving forward. If all Democrats vote against the nominee, one Republican would have to join with the Democrats for Kavanaugh to fail.
Demand Justice is already airing ads in Maine and Alaska, targeting Sens. Susan Collins, R-Maine, and Lisa Murkowski, R-Alaska, both senators who are pro-choice and voted to uphold Obamacare. Both have said they are keeping an open mind and will examine Kavanaugh's record.


Promote Mission ConneXion events through our social media and other communications with church members (share at least one update/year).
Pray for Mission ConneXion events as they occur.
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Myrtle Beach is more than just a top-class resort town, though. Not only is it home to some of the world's best attractions and tourist amenities, it also caters to those who would rather take the road less traveled. If you're looking for a few great destinations found on the fringes of the typical tourist spots, Myrtle Beach has you covered. Here are a few of the more unusual spots in town that visitors should definitely check out.
Every town has its own museum. It's the best place for travelers to really learn more about the place they're in. Not every town, however, has a museum that exclusively caters to the world's premiere oddities. That's what makes Ripley's Believe It or Not! Odditorium in Myrtle Beach a must-see for all fans of the weird and the unusual.
The museum boasts of housing "the largest collection of the odd and unusual from all corners of the world," what with over 500 exhibits spread out across 12 themed galleries. Visitors can check out curiosities of all kinds ranging from the world's rarest egg and unique works of art to a real ninja shuriken and even a genuine shrunken head.
Aside from the museum exhibits, the Odditorium is also home to the chilling Haunted Adventure haunted house, the strangely named 5D Moving Theater, and the Ripley's version of that old carnival favorite, the Marvelous Mirror Maze.
Once you've checked out some of the world's strangest curiosities at the Odditorium, how about learning more about things that are most definitely not of this world? Indulge your inner science fiction buff and stop by the Encounters: U.F.O. Experience exhibit at Broadway at the Beach!
The exhibition is composed of seven galleries that point a spotlight on popular U.F.O.-related areas such as ancient alien, Area 51, and Rosswell. It features films, recordings, interactive experiences, and even a whopping 200 artifacts related to both real and fictional aliens.
The family-friendly exhibit just opened its doors to the Myrtle Beach community earlier this month and will be operating until May 25th. The exhibit will be available for viewing on Saturdays from 11 AM to 8 PM and on Sundays from 11 AM to 7 PM.
Up for a night of gambling? Yes, you can head out to a land-based casino and take in the sights and sounds there before turning in, but why not take things to a whole other level and book a trip on a casino cruise? That's what the SunCruz Aquasino is there for.
The SunCruz Aquasino is a veritable casino on the sea, offering gaming enthusiasts a host of games such as bingo, slots, roulette, blackjack, and poker. Online poker is all the rage these days, but why play online when you can bask in the cruise life for a few days? Just ask Poker Hall of Famer and Partypoker Million Cruise host Mike Sexton, who has been in more than a few poker cruises playing with the likes of poker legends Doyle Brunson and Chip Reese.
Over the years, Myrtle Beach has become almost synonymous with golf – which isn't really that hard a feat when you're voted the number one golf destination in USA Today. Aside from its numerous top-flight and world renowned 18-hole courses, Myrtle Beach has also become home to a large number of mini golf courses. Of these, one of the strangest has got to be Mayday Golf, also known as the "Home of the Big Yellow Airplane".
Just like any other mini golf course, Mayday has its own theme. Unlike other mini golf courses, Mayday's theme is quite a bit from left field. Remember that "Big Yellow Airplane" we mentioned earlier? The theme's setup has it crash land on an island. As luck would have it, the island you've landed on is a veritable tropical paradise that seems free from smoke monsters and malevolent inhabitants. Even more luckily, the island has a mini golf course and all your golf equipment went through the crash unscathed.
Yeah, the setup is more than a little unusual, but Mayday more than makes up for it by being one of the top mini golf courses in the Myrtle Beach area. It's a great way for the whole family to spend an afternoon.


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About JCM
Evaluation of the Etest ESBL and the BD Phoenix, VITEK 1, and VITEK 2 Automated Instruments for Detection of Extended-Spectrum Beta-Lactamases in Multiresistant Escherichia coli and Klebsiella spp.
Maurine A. Leverstein-van Hall, Ad C. Fluit, Armand Paauw, Adrienne T. A. Box, Sylvain Brisse, Jan Verhoef
Maurine A. Leverstein-van Hall
Eijkman-Winkler Institute for Microbiology, Infectious Diseases & Inflammation, University Medical Center, Utrecht, The Netherlands
For correspondence: M.LeversteinvHall@lab.azu.nl
Ad C. Fluit
Armand Paauw
Adrienne T. A. Box
Sylvain Brisse
Jan Verhoef
DOI: 10.1128/JCM.40.10.3703-3711.2002
Seventy-four isolates of multiresistant Escherichia coli and Klebsiella spp. recovered during a 3-year period and 17 control strains with genotypically identified beta-lactamases were tested for the production of extended-spectrum beta-lactamases (ESBLs) by using the Etest and the VITEK 1, VITEK 2, and Phoenix automated instruments. The use of the Etest was evaluated by investigating its accuracy in detecting the ESBLs of the control strains and by comparing interpretation results of laboratory technicians and experts. The accuracy of the Etest was 94%. With the Etest as the reference for the clinical strains and the genotype as the reference for the control strains, the automated instruments detected the ESBLs with accuracies of 78% (VITEK 2), 83% (VITEK 1), and 89% (Phoenix). No significant difference between the systems with regard to the control strains was detected. The VITEK 2 did, however, perform less well than the Phoenix (P = 0.03) on the collection of clinical isolates, mainly because of its high percentage of indeterminate test results (11%). No significant difference between the performances of the VITEK 1 and either the VITEK 2 or the Phoenix was found. However, because of its associated BDXpert system the Phoenix showed the best performance. The Etest was found to be an accurate test but was limited by its indeterminate results (4%), its inability to differentiate between K1 hyperproduction and ESBLs, questionable guidelines concerning mutants inside the inhibition zones, and the inability of the technicians to recognize subtle zone deformations.
Members of the Enterobacteriaceae commonly express plasmid-encoded β-lactamases (mostly TEM-1, TEM-2, and SHV-1) that confer resistance to penicillins but not to expanded-spectrum cephalosporins. In the mid-1980s, however, bacteria that also express resistance to the expanded-spectrum cephalosporins were detected. Investigation into the mechanism of this resistance revealed that mutations had occurred within the structural genes encoding the older enzymes, which altered the configuration of the enzymes near their active sites. This shape change was found to increase the enzyme's affinity to and hydrolytic ability for oxyimino-cephalosporins (e.g., ceftazidime and cefotaxime) as well as for older penicillins and cephalosporins. These new enzymes were given the name extended-spectrum beta-lactamases (ESBLs) to reflect the fact that they are derivatives of older enzymes but have the capability to hydrolyze a broader spectrum of beta-lactam drugs (24). In recent years, more plasmid-mediated broad-spectrum beta-lactamases, such as the CTX-M-type enzymes (3, 6), have appeared. These enzymes are not evolved from previously known smaller-spectrum beta-lactamases but are thought to be unaltered from their original chromosomally encoded forms. Recent literature generally refers to these acquired enzymes (with exception of the AmpC enzymes and carbapenemases) as ESBLs as well, in contrast to the chromosomally encoded broad-spectrum beta-lactamases (e.g., K1 in Klebsiella oxytoca and AmpC in Enterobacter spp.) (3, 8, 16, 24). The present study uses this extended definition of ESBL.
Generally, ESBL-producing microorganisms exhibit high-level resistance to benzylpenicillins and narrow-spectrum cephalosporins. The MICs for aztreonam and expanded-spectrum, broad-spectrum, and "fourth-generation" cephalosporins (e.g., cefpirome, cefepime), however, vary greatly, because the various mutations confer different phenotypic expressions. ESBL-mediated resistance, therefore, poses problems for in vitro susceptibility testing, first, because of the limited number of cephalosporins routinely tested in the laboratory, and second, because the MICs may not reach National Committee for Clinical Laboratory Standards (NCCLS) breakpoints for resistance when the standard inoculum of 105 CFU/ml is used. Both in vitro and animal studies, however, have shown that the ESBL-producing organisms may become resistant as the inoculum increases (10, 17, 29, 30). Reported treatment failures, suboptimal clinical outcome, and the increased mortality of patients infected with ESBL-producing strains that have MICs in the susceptible range and treated with cephalosporins, suggest that this inoculum effect occurs in clinical infections as well (21, 27, 28). Therefore, it is recommended and generally accepted that ESBL-producing isolates (even when MICs are in the susceptible range) be reported as resistant to all penicillins, cephalosporins, and aztreonam (14, 18, 21). Whether beta-lactam-beta-lactamase inhibitor combinations should be reported as resistant is still unclear (4, 22, 29). An additional reason for detecting the production of ESBLs in the clinical laboratory is the discovery that infections with ESBL-producing Escherichia coli and Klebsiella pneumoniae are associated with significantly longer hospital stays (12, 27) and greater hospital costs (12). The NCCLS recently provided guidelines for performing standard broth microdilution or disk susceptibility testing and confirmatory tests for the detection of ESBL production in E. coli, K. pneumoniae, and K. oxytoca (18). If these guidelines are followed, however, the detection of ESBL production becomes an elaborate and costly procedure in the daily routine of a large microbiology laboratory. Automated susceptibility testing systems with an additional test for the detection of ESBL production, therefore, are a welcome asset in such laboratories. There are three automated systems currently available in Europe that include an ESBL detection test: (i) the VITEK 1 system (bioMérieux S.A., Marcy-l'Etoile, France), (ii) the VITEK 2 system (bioMérieux S.A.), and (iii) the recently developed Phoenix automated microbiology system (Becton Dickinson Biosciences, Sparks, Md.).
The aim of this study was to evaluate the abilities of the VITEK 1, VITEK 2, and Phoenix systems in detecting ESBL production by a collection of multiresistant isolates of E. coli and Klebsiella spp. and by a number of strains with genotypically identified beta-lactamases. The results of the automated systems were then compared by using the Etest ESBL (AB Biodisk, Solna, Sweden) as the reference for the clinical strains and the genotype as the reference for the control strains. In addition, the use of the Etest ESBL for the detection of ESBLs in the clinical laboratory was evaluated by investigating its accuracy in detecting the genotypically identified beta-lactamases and by comparing the reading and interpretation results of laboratory technicians and experts.
Bacterial isolates.The 74 multiresistant Enterobacteriaceae isolates (34 E. coli, 26 K. pneumoniae, and 14 K. oxytoca isolates) included in this study were obtained from 49 patients admitted to the University Hospital Utrecht between 1994 and 1996. Ten patients carried more than one species. The main criterion for selection was either a VITEK 1 ESBL-positive result (n = 42) or a VITEK 1 ESBL-negative result combined with a phenotype suspect of ESBL production (i.e., resistance to a cephalosporin combined with resistance to at least two other classes of antibiotics) (n = 25). Seven multiresistant but cephalosporin-susceptible VITEK 1 ESBL-negative strains from patients from whom another Vitek 1 ESBL-positive isolate had been collected were also included. Isolates of the same species collected from the same patient were included only if the VITEK 1 had yielded opposite outcomes with regard to ESBL production (14 isolates from seven patients).
Controls included 17 isolates with genotypically identified beta-lactamases: eight non-ESBLs (OXA-1, OXA-2, OXA-3, TEM-1 [two strains], TEM-2 [two strains], K1 [KOXY] hyperproduction) and nine different ESBLs (TEM-3, TEM-4, TEM-5, TEM-7, TEM-9, TEM-10, SHV-2a, SHV-4, SHV-5), kindly provided by E. E. Stobberingh (University Hospital Maastricht, Maastricht, The Netherlands). We confirmed the identification of the TEM- and SHV-beta-lactamases by PCR and subsequent sequencing. When these PCRs were performed on the isolates with OXA and KOXY beta-lactamases, no amplicons were obtained.
Detection and identification of blaSHV and blaTEM genes.The presence of blaSHV and blaTEM genes was determined for all clinical isolates for which at least one of the three automated systems or the Etest ESBL yielded discordant results in the ESBL test. In addition, a collection of randomly chosen clinical isolates, for which the outcome of all methods was the same, was analyzed in the same way. The mutants were also analyzed to determine whether single colonies within the inhibition zone of the Etest ESBL carried the same ESBL genotype as the mother strain.
PCR primers for blaSHV and blaTEM gene amplification (GenBank accession no.: for blaTEM, J01749; for blaSHV, AF124984) were blaTEM-F (5′-CGTGTCGCCCTTATTCCC-3′), blaTEM-R (5′-AGGCACCTATCTCAGCGATC-3′), blaSHV-F (5′-ATGCGTTATATTCGCCTGTG-3′), and blaSHV-R (5′-TTAGCGTTGCCAGTGCTC-3′). The PCR conditions for TEM were as follows: 35 cycles of 1 min at 94°C, 1 min at 60°C, and 2 min at 72°C. Those for SHV were 5 min at 95°C followed by 35 cycles of 1 min at 95°C, 30 s at 57°C, and 2 min at 72°C, followed by an extension of 5 min at 72°C. The amplified DNA was then purified by using MicroSpin G-25 columns (Pharmacia). In addition to the amplification primers, the following primers were used for double-stranded sequencing in an ABI 377 automated sequencer (Applied Biosystems): blaTEM-F (5′-ACAACGATCGGAGGACCG-3′), blaTEM-R (5′-GCGGTTAGCTCCTTCGGT-5-3′), blaSHV-F (5′-CCGCAGGATTGACTGCC-3′), and blaSHV-R (5′-AGGCGGGTGACGTTGTC-3′). The resulting sequences were then aligned with the gene sequences available from GenBank.
Etest ESBL.The Etest ESBL test was performed in accordance with the guidelines of the manufacturer. The synergic activity of clavulanate with both ceftazidime and cefotaxime was confirmed by means of two different Etest strips containing ceftazidime and cefotaxime with or without clavulanate. Isolates were considered ESBL producers when clavulanate caused a ≥3 twofold-concentration decrease (ratio, ≥8) in the MIC of ceftazidime or cefotaxime, in combination with a ceftazidime MIC ≥1 μg/ml or a cefotaxime MIC ≥0.5 μg/ml, respectively. Additionally, a strain was considered ESBL positive if a phantom zone or a deformation of the ceftazidime and cefotaxime zone could be observed, independent of the ratios or MICs. The outcome of the test was indeterminate when both MICs were outside the test range of the test device. This phenomenon may suggest the presence of an inhibitor-resistant TEM or AmpC enzymes. The outcome was also indeterminate when the result of one strip was ESBL negative and the result of the other strip was indeterminate.
Two technicians from the clinical laboratory and two experts from the manufacturing company interpreted the inhibition zones blinded and independently of each other. The technicians from the clinical laboratory had been asked to read the Etest ESBL package insert thoroughly before conducting the analysis.
VITEK 1 analysis.VITEK cards for identification (GNI) and susceptibility testing (GNS-522) were inoculated and incubated according to the manufacturer's recommendations. The results were interpreted by using software version AMS R09.1. The substrates of the ESBL test were included in the GNS-522 panel, and the interpretation was based on the comparison between the reduction in growth caused by cefotaxime-clavulanate and ceftazidime-clavulanate and that caused by the cephalosporins alone (24). The outcome of the test was either ESBL positive or ESBL negative.
VITEK 2 analysis.VITEK cards for susceptibility testing (GNS AST-N010) were inoculated and incubated by a technician from the manufacturing company according to the manufacturer's recommendations (5). The name of the species of the strain, as determined by VITEK 1, was manually entered into the instrument. The results were interpreted by using software version VTK-R01.02, an advanced expert system (AES) designed to analyze the results generated by the VITEK 2 system (7, 14, 25, 26). The AES is based on over 2,000 phenotypes and 20,000 MIC distributions, which have been derived from the published literature, internal data generated at bioMérieux S.A., and outside experts. Once an organism has been identified and/or tested for antimicrobial susceptibility, the software provided by the AES begins to search the MIC distributions in its knowledge base to ascertain if the results are consistent with any of the phenotypes established for the organism in order to establish a biological validation. Based on this comparison, the AES determines if the identification is consistent with the susceptibility pattern and if the MICs are consistent with a specific phenotype. There are four possible phenotypes relevant to beta-lactam antibiotics: wild type, acquired penicillinase, cephalosporinase, and ESBL. Then, the AES provides one of the following comments: (i) results are fully consistent with identification; (ii) results are not fully consistent with identification; therefore, modify the susceptibility results as suggested by the AES, or retest isolate; (iii) results are not fully consistent; therefore, modify the susceptibility results, or change the identification as suggested by the AES, or retest isolate; and (iv) results are not fully consistent, and the isolate should be retested. In addition to comments i through iv, the AES may also suggest therapeutic corrections in the antibiogram. A printed report of each test indicates the actual MIC, the raw categorizations, the categorizations after interpretation, and the inferred mechanism of beta-lactam resistance. In the present study, the VITEK 2 test was repeated and a confirmatory test for identification was performed in response to comments ii to iv. In the comparative analysis with the other automated systems, all outcomes earmarked by the AES as fully consistent (either in the first or second test) were regarded as definitive outcomes. All others were regarded as indeterminate.
Phoenix analysis.NMIC/ID-5 Phoenix panels (combined susceptibility and identification card) were inoculated and incubated according to the manufacturer's recommendations. The Phoenix ESBL test uses growth response to selected expanded-spectrum (cefpodoxime) and broad-spectrum (ceftazidime, ceftriaxone, cefotaxime) cephalosporins, with or without clavulanic acid, to detect the production of ESBL. The result of this test is integrated into the antibiogram through the action of the BDXpert system. This system consists of a series of rules, which are triggered by various conditions, such as the ESBL test or specific bacterial identification and antibiotic susceptibility pattern. Each rule is identified by a numeric code. When a rule is triggered, a cautionary message is appended to the AST report, and where appropriate the interpretations for individual antibiotics are modified from the interpretive result based on the MIC. The BDXpert rule associated with a positive ESBL test for E. coli, K. pneumoniae, and K. oxytoca is rule no. 1505: "Enterobacteriaceae with ESBLs are resistant to all beta-lactam drugs, except carbapenems." If the BDXpert system detects resistance mechanisms related to ESBLs (e.g., AmpC in E. coli or K1 in K. oxytoca), the supplementary ESBL rule no. 1502 is noted: "Enterobacteriaceae that are susceptible to a carbapenem and resistant to ureidopenicillins and 3rd generation cephems or cefpodoxime or aztreonam are also resistant to all beta-lactams, except carbapenems." Alternatively, rule no. 106 may be provided: "Screening test suggests a possible ESBL producer; confirmatory testing is recommended." If the ESBL test is negative, then no rule is supplied. A printed report of each test indicates the actual MIC, the raw categorizations, the categorizations after interpretation, and the rule applied.
API 20E identification.If the AES of the VITEK 2 detected an inconsistency in the susceptibility results and organism identification, the identification was repeated by using an API 20E test (BioMérieux S.A.).
Typing by PFGE.To determine whether single colonies within the inhibition zone of the Etest ESBL represented mutants or contamination, the genotypes of these colonies and the mother strain were compared by using pulsed-field gel electrophoresis (PFGE) as previously described (13). Isolates of the same species collected from the same patient, but with VITEK 1 results yielding opposite outcomes with regard to ESBL production, were also typed by PFGE.
Study design.Unless the system advised a retest, the first test results were used for the evaluation and comparison of the different automated systems. The susceptibility patterns of all isolates were compared before the results were included in the analysis. If the susceptibility patterns suggested the loss of plasmid, a new isolate was obtained from the stock and tested. The Etest ESBL results for the clinical isolates, determined by the manufacturers' experts, and the results of control isolate genotyping were used as references in the comparative analyses.
Statistical analysis.The accuracy (i.e., the proportion of the test panel for which the tested method obtained an outcome identical to that of the reference method), sensitivity, and specificity of each automated system were calculated. Differences in proportions were evaluated by using the chi-square test.
Nucleotide sequence accession numbers.The nucleotide sequences of the two new TEM-variants, TEM-HM and TEM-FHM, detected in this study have been deposited in the EMBL data library under accession numbers AY130285 and AY130284, respectively.
Evaluation of tests with regard to control strains.The results of the Etest ESBL and the three automated systems for the 17 control strains are shown in Table 1. Both the Etest ESBL and the VITEK 2 showed 100% sensitivity; sensitivity for the Phoenix was 89%, and sensitivity for the VITEK 1 was 78% (Table 2). The specificity of all four tests was 87%. The specificity of both the Etest ESBL and the VITEK 1 was hampered due to the positive result given to a K. oxytoca strain (no. 8) showing hyperproduction of chromosomal K1 (KOXY) beta-lactamase. The VITEK 2 and Phoenix correctly identified this strain as ESBL negative, but each yielded an indeterminate result for another strain. The discordant results of the VITEK 2 and Phoenix are discussed together with the results of the clinical strains in Discussion.
Results of the Etest ESBL and the VITEK1, VITEK 2, and Phoenix systems for the control strainsa
Agreement of the methods with the reference method for the detection of ESBL productiona
Evaluation of tests with regard to clinical strains.The results of the Etest ESBL and the three automated systems showed agreement for 26 ESBL-positive and 19 ESBL-negative clinical isolates (19 E. coli, 19 K. pneumoniae, and 7 K. oxytoca isolates). At least one method yielded a discordant result for each of the remaining 29 isolates (39%) (Table 3). This will be discussed separately for each method.
Discordant ESBL test results obtained with the Etest ESBL and the VITEK 1, VITEK 2, and Phoenix systems on 29 multiresistant clinical isolatesa
(i) Etest ESBL.Interpretation of the Etest ESBL inhibition zones proved difficult for the multiresistant isolates. MICs should be read at the intersection of the inhibition ellipses with the strips. Due to the presence of mutants along the zone border, however, the intersection was not always obvious. Even the manufacturers' experts had trouble reading the MICs of four isolates. These included four clinical K. oxytoca isolates (no. 37 to 40) with one or two mutants in the inhibition zone of the cefotaxime-clavulanic acid strip. Excluding the mutants yielded a ratio for the cefotaxime strip >8, indicating ESBL production. Including the mutants, however, increased the denominator of the ratio in such way that the test results became negative. Three mutants possessed the same PFGE type as the mother strain; the PFGE pattern of the fourth mutant (no. 40) differed from that of the mother strain by two bands. Neither a TEM nor an SHV ESBL genotype was identified in any of these mutants or mother isolates. Repetition of the Etest with the mutants yielded MICs of ceftazidime ranging from 0.75 to 3 mg/liter, MICs of ceftriaxone ranging from 3 to 5 mg/liter, and a negative ESBL test result in both strips. These findings are not compatible with an ESBL or a K1 hyperproducer. Therefore, the mutants most likely lost the plasmid encoding an ESBL, reverted to a non-ESBL genotype, or acquired an additional mutation elsewhere. The experts decided to regard these four isolates as ESBL negative (Table 3).
The results of the Etest were indeterminate for four clinical isolates (4%). Two were E. coli isolates (no. 43 and 44) for which the MICs were above the test ranges. The other two were an E. coli isolate (no. 45) and a K. pneumoniae isolate (no. 46) collected from the same patient. The ratios for cefotaxime/ cefotaxime-clavulanic acid were <12, while the ceftazidime strips yielded negative results. A ratio of <12 is indeterminate, because it can imply a ratio of either ≥8 (ESBL positive) or <8 (ESBL negative). None of the automated systems detected ESBL production in isolates 45 and 46.
(ii) VITEK 1 analysis.Susceptibility testing of the 74 clinical isolates gave the following results: 90% of the isolates were resistant or intermediately susceptible to gentamicin, 73% to tobramycin, 3% to amikacin, 84% to cotrimoxazole, 94% to ampicillin, 82% to piperacillin, 83% to amoxicillin-clavulanic acid, 89% to cephalothin, 45% to cefuroxime, 28% to ceftriaxone, 15% to ceftazidime, and 14% to ciprofloxacin. No decreased susceptibility to meropenem was detected.
Inherent to the design of the VITEK 1 system, no indeterminate results were obtained with regard to ESBL production. For seven patients, the VITEK 1 ESBL test yielded opposite outcomes for two consecutive clinical isolates of the same species collected at different times in the hospital. The Etest ESBL, however, indicated the presence of ESBL production in both members of four pairs of these isolates, indicating a false-negative result of the VITEK 1 (no. 30, 32, 34, and 35). The Etest ESBL confirmed the VITEK 1 results for the other three pairs, indicating the acquisition or loss of the ESBL-encoding gene(s) by the isolates during colonization or infection of the patient.
(iii) VITEK 2 analysis.Of the 91 isolates tested (74 clinical isolates, 17 control strains), the AES found the results for 73 (80%) to be fully consistent with the organism identification, suggesting no biological corrections or necessary repetitions of identification by testing. Two isolates (2%) failed to grow sufficiently in the instrument. The AES reported inconsistencies between the susceptibility results and the organism in 16 isolates (18%) and made the following recommendations: (i) antibiogram correction regarding a single MIC (11 isolates) or repeat of test, (ii) correction of a single MIC or change of identification in the proposed species or repeat of test (1 isolate), and (iii) repeat of the test (4 isolates) (Table 4). The test, therefore, needed to be repeated for 18 (20%) of the 91 isolates tested; this occurred for 17 isolates. Retesting provided full consistency for 7 of the 17 isolates (41%). The outcome for 7 (41%) of the remaining 10 isolates was the same as in the first test, while it changed for the other three strains from "inconsistency" to "repeat the test," from "insufficient growth" to "inconsistency," and from "repeat the test" to "insufficient growth," respectively. Thus, the final result was indeterminate for 10 isolates (11%), including 1 control and 9 clinical isolates (Table 2).
Outcome of VITEK 2 Advanced Expert System for 18 isolates that had had indeterminate outcomes in the first testa
For all 16 isolates for which the AES detected an inconsistency between the susceptibility results and the organism identification, the identification was repeated with the API 20E test. This included two isolates (no. 2 and 5) (Table 4) for which the AES had proposed an alternative species. The API 20E test confirmed the initial identification of all isolates. In conclusion, repetition of the identification test in the case of a detected inconsistency by the AES proved to be of no value and the proposed alternative species were incorrect.
The therapeutic corrections suggested by the AES in this study were limited to two suggestions. The first was to report the ESBL-positive strains as being resistant to all penicillins (including piperacillin) and cephalosporins except cefoxitin. The second was to change the susceptibility report for cefoxitin from S (susceptible) to I (intermediately resistant) (no. 2 and 48) (Table 4).
(iv) Phoenix analysis.Of the 91 isolates tested (74 clinical isolates, 17 control strains), the outcome was indeterminate for 4 (4%), and in those cases rule no. 106 suggested the performance of a confirmatory test. The BDXpert system noted rule no. 1502 for five isolates, i.e., the isolates are resistant to all beta-lactam antibiotics except carbapenems. The outcome of the Etest ESBL was indeterminate for two of these five isolates (no. 44 and 45). The other three (no. 12, 27, and 29) represented three of the four isolates for which the Phoenix failed to detect an ESBL in comparison with the Etest ESBL. This indicates that the BDXpert system was able to compensate partially for the false-negative results.
Comparative analysis of the automated systems.The results of the comparative analysis between each of the automated systems and the reference method are shown in Table 2. For the comparative analysis of the automated systems, the number of clinical isolates was reduced to 70 after the 4 clinical isolates for which the Etest ESBL found an indeterminate result were removed. No significant difference between the performances of the systems was detected when the control strains were tested. When testing the clinical isolates, however, the accuracy of the ESBL test of the VITEK 2 AES (74%) was significantly lower (chi-square test, P = 0.03) than that of the Phoenix (89%). This was mainly due to the high number of indeterminate test results by the VITEK 2, because removal of the isolates from the test panel for which the VITEK 2 provided indeterminate results did increase the accuracy of the VITEK 2 to 85%. No significant difference between the performances of the VITEK 1 and either the VITEK 2 or the Phoenix was found. The specificities of the three tests did not show significant differences. It should be noted, however, that by excluding the mutants in the cefotaxime-clavulanic acid ellipse in the Etest ESBL of the four K. oxytoca isolates mentioned above (no. 37 to 40), the specificities of the VITEK 1, the VITEK 2, and the Phoenix rose to 95, 90, and 91%, respectively. This had little influence, however, on the sensitivities of the systems (85, 67, and 92%, respectively).
Identification of the beta-lactamases of the clinical isolates.Fifteen (56%) of the 26 isolates for which all methods yielded a positive ESBL test result were analyzed. An ESBL genotype was identified for 10 (67%) of them: SHV-5 (K. pneumoniae), SHV-2a (K. pneumoniae, 2 isolates; and E. coli), TEM-FHM (K. pneumoniae, 2 isolates; and E. coli, 2 isolates), TEM-HM (E. coli), and the combination of TEM-FHM and SHV-2a (K. pneumoniae). TEM-FHM and TEM-HM are new TEMs with amino acid substitutions that have been described before for multiple ESBLs, but not in these particular combinations (http://www.lahey.org/studies/webt.htm). Both mutants possess an Arg164His and Thr265Met mutation, while TEM-FHM contains an additional Lys21Phe mutation. Since the Arg164His mutation is considered to be an important mutation for the production of an ESBL phenotype (3, 11), we considered these TEMs as possible ESBLs. No TEM- or SHV-derived ESBL genotypes could be identified for the remaining five isolates (33%).
Eleven (58%) of the 19 isolates for which all methods yielded a negative or indeterminate ESBL test result were then analyzed. An SHV- or TEM-derived ESBL genotype could not be identified in any of them. Of the 18 isolates with a positive Etest ESBL result and a negative result with at least one of the other tests, 5 (28%) were found to carry an ESBL genotype (TEM-FHM) (Table 3). Of the seven isolates with a negative ESBL-Etest result and a positive result with at least one of the other tests, one was found to carry a TEM-HM genotype (no. 42). Of the four isolates with an indeterminate ESBL-Etest result, one (no. 45) contained an SHV-2a genotype. No ESBL genotype could be identified in the other three isolates.
Evaluation of the Etest ESBL in the routine laboratory.The Etest ESBL was evaluated by comparing the interpretations of the experts with those made by two laboratory technicians. Comparing the MICs found by the experts with those found by the technicians revealed differences for 9% of the strips without clavulanic acid and for 29% of the strips with clavulanic acid; these differences were due to the presence of mutants in the inhibition zone. This resulted in different final test results for four isolates. The outcome was false positive for three of the four K. oxytoca isolates (no. 37 to 40) mentioned above and false negative for another K. oxytoca isolate (no. 52).
The technicians also failed to recognize the phantom zone or ellipse deformation in about 30% of the strips. The experts detected this phenomenon in 48 strips (19 ceftazidime and 29 cefotaxime) used on 37 E. coli and K. pneumoniae isolates, while the technicians recognized it in 33 strips used on 30 isolates. This did not result in any false-negative results of the tests, because either the technicians detected the phenomenon on the other strip or the calculated ratios already indicated the presence of an ESBL.
In conclusion, there was full agreement on the Etest ESBL results for all E. coli and K. pneumoniae isolates interpreted by the laboratory technicians and experts. However, the agreement was 80%, the sensitivity was 91%, and the specificity was 50% for the 15 K. oxytoca isolates.
The three automated systems detected ESBL production with an accuracy ranging from 78% (VITEK 2) to 83% (VITEK 1) to 89% (Phoenix). The comparative analysis showed no significant difference between the outcomes of the systems when the control strains were tested. With regard to multiresistant isolates of E. coli and Klebsiella spp., however, the VITEK 2 performed worse than the Phoenix (P = 0.03), while no significant difference was found between the performance of either of these systems and that of the VITEK 1. The significant difference between the VITEK 2 and the Phoenix can be explained by the high percentage of indeterminate test results reached by the VITEK 2. The AES detected inconsistencies in 20% of the first tests. When this happened, it was impossible to make a well-founded choice between the options provided by the AES, i.e., make either a correction in the identification or a biological correction in the MIC. This problem was also noted by Sanders et al. (26). As a result, repeat testing in the VITEK 2 and a confirmatory test on the identification were indicated in all cases, leading to an important delay of results and an increase in costs. Full consistency was obtained on repeat testing for only 41% of the isolates, leaving 11% of the initial 91 tested isolates with an indeterminate result. Furthermore, in retrospect, none of the confirmatory identification tests were indicated and both identifications suggested by the AES were incorrect. In line with these findings, the most recent update of the VITEK 2 software (R02.01) does not any longer suggest a change in identification in the case of inconsistencies.
Unexpectedly, the performances of the newly developed VITEK 2 and the older VITEK 1 were comparable. The substantial extra effort required from the staff and the increased material costs needed to attain these same results, however, make the VITEK 2 a less attractive alternative.
There was no significant difference in the accuracy of the ESBL tests of the VITEK 1 and the Phoenix. The Phoenix did, however, tend to have a higher sensitivity (92 versus 83%). Moreover, for three of the four ESBL-positive isolates that were missed by the Phoenix, the associated BDXpert system suggested therapeutic corrections in the antibiogram comparable with those applied to an ESBL-positive isolate. The BDXpert system also recommended that a confirmatory test be performed on half of the false-positive results; the VITEK 1 (inherent to the design of the system) did not do so. In conclusion, the Phoenix performed better than either of the VITEK systems on ESBL detection.
The main limitation of the present study was the use of the Etest ESBL as the reference method for testing the clinical isolates. Although it fulfils the criteria for a confirmatory test for ESBL detection as recommended by the NCCLS (18), the Etest ESBL is not a microdilution or disk susceptibility test. It could not differentiate between a chromosomal K1 (KOXY) beta-lactamase or an ESBL in K. oxytoca strains. However, only 3 of the 29 isolates with discordant results were K. oxytoca isolates with Etest ESBL-positive results, for which only the VITEK 2 gave ESBL-negative results. This shortcoming, therefore, may have posed just a small relative disadvantage to the specificity of the VITEK 2 but generally had limited influence on the outcome of the comparative analysis. Other shortcomings of the Etest ESBL were the indeterminate results for four isolates (5%) and the questionable outcomes for another four. The latter were clinical K. oxytoca isolates with sporadic mutants in the inhibition zone of the cefotaxime-clavulanic acid strip. When these mutants were excluded from the analyses, reading of the MICs yielded a positive test result, indicating the production of ESBLs. Including these mutants in conformity with the package insert and the advice of the experts, however, resulted in a negative outcome. The experts' decision to include the mutants decreased the specificities of all of the automated systems to some degree but had little influence on their sensitivities.
In strong support of the use of the Etest ESBL as the reference method, however, was the 100% sensitivity obtained with the control strains, including six different TEM-type and three different SHV-type ESBLs. In addition, the Etest ESBL showed 100% sensitivity for TEM-FHM and the SHV-type ESBLs detected in the clinical isolates. Only once was the Etest ESBL possibly false negative, due to the negative result for one of the two isolates with a TEM-HM. Taken together, these results justify in our opinion the use of the Etest ESBL as a reference method for the comparative analysis with clinical isolates. Previous studies of eight different TEM-like and four different SHV-like ESBLs showed that the Etest ESBL had a sensitivity of 81% (32), while testing only SHV-like ESBLs yielded a sensitivity of 52% (19). Those studies, however, used only a ceftazidime strip. The manufacturers of the Etest ESBL have since added a cefotaxime strip to the test, and the criteria for interpreting the test results have been extended. Besides a changed ratio, minimal MICs for ceftazidime and cefotaxime have also been introduced and the deformation of the inhibition ellipse has been added as a single criterion for the presence of an ESBL.
The evaluation of the Etest ESBL for the detection of ESBL production in E. coli and Klebsiella spp. in the clinical laboratory revealed that the reading of the inhibition zones was frequently complicated by the presence of mutants along the zone border, causing discrepancies in the MICs obtained by experts and technicians. Neither these differences in MIC reading nor the failure of the laboratory technicians to recognize the ellipse deformation or phantom zone in 30% of the cases influenced the outcome of the test results. The lack of clear guidelines regarding sporadic mutants inside the inhibition zone of the cefotaxime-clavulanic acid strip, however, did lead to discordant test results between technicians and experts. In conclusion, the Etest ESBL may be an accurate test if the following conditions are fulfilled. First, guidelines regarding sporadic mutants inside the inhibition zone of the cefotaxime-clavulanic acid or ceftazidime-clavulanic acid strip should be defined. In the present study, the experts decided to include the mutants in the reading of the MICs. In view of the therapeutic consequences, however, it is questionable whether the test result of a single mutant should be allowed to prevail over the other 108 CFU/ml tested. Second, besides thoroughly reading the package insert, laboratory technicians should be trained in the recognition of subtle ellipse deformations and phantom zones before conducting the analyses. Third, it should be decided whether additional tests need to be done in order to differentiate between K. oxytoca strains with hyperproduction of a K1 beta-lactamase or an ESBL (e.g., additional susceptibility tests for aztreonam) (16). This differentiation will probably not have therapeutic implications, but it will reveal whether the enzyme is plasmid encoded or chromosomal. If it is plasmid encoded, especially on R-plasmids, horizontal transfer to other bacteria can be anticipated and more-stringent hospital control measures may be taken as a result. Many hospitals have already experienced outbreaks of ESBL-producing Enterobacteriaceae, and subsequent molecular analysis of those isolates has often indicated the occurrence of horizontal transfer (1, 13, 33).
The results of the present study show that the detection of ESBLs in this collection of multiresistant isolates posed problems for both the automated systems and the Etest. All of the automated methods performed less well in this study than in the few previously published studies (7, 15, 24-26; D. Turner, M. Gosnell, J. Sinha, V. Kenney, T. Wiles, and J. Reuben, Abstr. 101th Gen. Meet Amer. Soc. Microbiol., abstr. C-2261, 2001). First, this may be a result of the character of the ESBLs in the present collection. The isolate panel tested in this study included multiresistant isolates collected within one university hospital over a period of 3 years. As a consequence, the diversity of the identified ESBL genotypes was limited. Genotyping revealed four different ESBLs (two that were TEM-like and two that were SHV-like) among the 55 clinical isolates analyzed, three of which were represented among the isolates with discordant ESBL test results. No TEM or SHV ESBL was detected in the majority of the isolates with discordant results or in one-third of the isolates for which all methods yielded a positive test result. It is plausible, therefore, that other ESBLs were circulating in the hospital at the time of this study. Because of the diverse combinations of MICs towards the different cephalosporins that were expressed by these strains (data not shown), however, it is unlikely that this was a single enzyme. If these ESBLs had not been previously identified, they were probably absent from the databases used for the development of the expert systems. This would explain, at least in part, the high number of discordant results. Second, the suboptimal result may be a consequence of the multiresistant character of the isolates. Multiresistance in Enterobacteriaceae is often associated with the presence of plasmids, which may encode different (extended-spectrum) beta-lactamases (1, 2, 6, 9, 13, 28, 35, 36). Simultaneous expression of the different beta-lactamases, possibly in combination with outer membrane porin changes (2, 23, 34), may result in an uncommon phenotype not recognized or recognizable by the automated systems. For example, the presence of an ESBL may be masked by the concurrent expression of an AmpC-type enzyme in the same strain, because no inhibitory effect of clavulanic acid can be detected due to the clavulanate-insensitive AmpC-type enzyme (2, 31). It is doubtful, therefore, whether any method based on the phenotype of the beta-lactamase(s) produced will be 100% sensitive or specific for the accurate detection of all ESBLs produced by multiresistant Enterobacteriaceae. Although nucleotide sequencing is considered the standard for the determination of the specific beta-lactamase gene present in a strain (3), this method also has its limitations for the detection of ESBLs: (i) the results of the sequencing may vary depending on the methods used (4); (ii) the results are dependent on the number of ESBL families (e.g., TEM, SHV, OXA, or CTX-M) and other beta-lactamases (e.g., AmpC or metallo-beta-lactamases) that are sought and on the available knowledge concerning the biochemical properties of the encoded beta-lactamase, especially if the sequence results reveal new (combinations of) amino acid alterations; (iii) sole detection of the gene does not predict the level of expression, since this is also dependent on the strength of the promoters, the gene copy number, and other genes (8, 20); and (iv) the phenotypic profile may be influenced by outer membrane porin changes, the inocula tested, and the growth conditions used.
We conclude that the ESBL test of the Phoenix system performed better than that of the other automated systems tested in detecting the ESBLs produced by multiresistant E. coli and Klebsiella spp. in our hospital. The Etest ESBL was found to be an accurate test that can be reliably interpreted by technicians in a clinical laboratory, with the prerequisites that they are well trained and some additional guidelines are introduced for reading and interpreting the test. To date, there are more than 100 ESBLs known worldwide (http://www.lahey.org/studies/webt.htm). Since they are subject to rapid evolution and are involved in a dynamic epidemiology (8), it should be noted that the results of this study or any other study addressing the same question might not be applicable to every laboratory worldwide at any moment in time.
We are grateful to Becton Dickinson for placing the Phoenix instrument at our disposal and providing the consumables and to Oxoid for providing the Etest ESBL strips. We thank T. Smeets (AB Biodisk, Solna, Sweden), M. Hautvast (Oxoid, Haarlem, The Netherlands), K. P. Jaling, and M. Riemens for their reading and interpretation of the Etests and M. Klootwijk, S. de Vaal, and K. Kusters for performing the Phoenix tests.
Received 15 April 2002.
Returned for modification 30 May 2002.
Accepted 12 July 2002.
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Livermore, D. M., M. Struelens, J. Amorim, F. Baquero, J. Bille, R. Canton, S. Henning, S. Gatermann, A. Marchese, H. Mittermayer, C. Nonhoff, K. J. Oakton, F. Praplan, H. Ramos, G. C. Schito, J. van Eldere, J. Verhaegen, J. Verhoef, and M. R. Visser. 2002. Multicentre evaluation of the VITEK 2 Advanced Expert System for interpretive reading of antimicrobial resistance tests. J. Antimicrob. Chemother. 49:289-300.
Livermore, D. M., and D. F. J. Brown. 2001. Detection of beta-lactamase-mediated resistance. J. Antimicrob. Chemother. 48:S59-64.
Medeiros, A. A., and J. Crellin. 1997. Comparative susceptibility of clinical isolates producing extended spectrum beta-lactamases to ceftibuten: effect of large inocula. Pediatr. Infect. Dis. J. 16:S49-S55.
National Committee for Clinical Laboratory Standards. 2001. Performance standards for antimicrobial susceptibility testing: 11th informational supplement. Approved standard M100-S11. National Committee for Clinical Laboratory Standards, Wayne, Pa.
Nuësch-Inderbinen, M. T., H. Hächler, and F. H. Kayser. 1996. Detection of genes coding for extended-spectrum SHV β-lactamases in clinical isolates by a molecular genetic method, and comparison with the E test. Eur. J. Clin. Microbiol. Infect. Dis. 15:398-402.
Nuësch-Inderbinen, M. T., H. Hächler, and F. H. Kayser. 1995. New system based on site-directed mutagenesis for highly accurate comparison of resistance levels conferred by SHV beta-lactamases. Antimicrob. Agents Chemother. 39:1726-1730.
Paterson, D. L., W. C. Ko, A. von Gottberg, J. M. Casellas, L. Mulazimoglu, K. P. Klugman, R. A. Bonomo, L. B. Rice, J. G. McCormack, and V. L. Yu. 2001. Outcome of cephalosporin treatment for serious infections due to apparently susceptible organisms producing extended-spectrum beta-lactamases: implications for the clinical microbiology laboratory. J. Clin. Microbiol. 39:2206-2212.
Paterson, D. L. 2000. Recommendation for treatment of severe infections caused by Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs) Clin. Microbiol. Infect. 6:460-463.
Rasheed, J. K., G. J. Anderson, H. Yigit, A. M. Queenan, A. Domenech-Sanchez, J. M. Swenson, J. W. Biddle, M. J. Ferraro, G. A. Jacoby, and F. C. Tenover. 2000. Characterization of the extended-spectrum beta-lactamase reference strain, Klebsiella pneumoniae K6 (ATCC 700603), which produces the novel enzyme SHV-18. Antimicrob. Agents Chemother. 44:2382-2388.
Sanders, C. C., A. L. Barry, J. A. Washington, C. Shubert, E. S. Moland, M. M. Traczewski, C. Knapp, and R. Mulder. 1996. Detection of extended-spectrum-beta-lactamase-producing members of the family Enterobacteriaceae with VITEK ESBL test. J. Clin. Microbiol. 34:2997-3001.
Sanders, C. C., M. Peyret, E. S. Moland, C. Shubert, K. S. Thomson, J. M. Boeufgras, and W. E. Sanders, Jr. 2000. Ability of the VITEK 2 advanced expert system to identify beta-lactam phenotypes in isolates of Enterobacteriaceae and Pseudomonas aeruginosa. J. Clin. Microbiol. 38:570-574.
Sanders, C. C., M. Peyret, E. S. Moland, S. J. Cavalieri, C. Shubert, K. S. Thomson, J. M. Boeufgras, and W. E. Sanders, Jr. 2001. Potential impact of the VITEK 2 system and the Advanced Expert System on the clinical laboratory of a university-based hospital. J. Clin. Microbiol. 39:2379-2385.
Schiappa, D. A., M. K. Hayden, M. G. Matushek, F. N. Hashemi, J. Sullivan, K. Y. Smith, D. Miyashiro, J. P. Quinn, R. A. Weinstein, and G. M. Trenholme. 1996. Ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection: a case-control and molecular epidemiologic investigation. J. Infect. Dis. 174:529-536.
Siu, L. K., P. L. Lu, P. R. Hsueh, F. M. Lin, S. C. Chang, K. T. Luh, M. Ho, and C. Y. Lee. 1999. Bacteremia due to extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in a pediatric oncology ward: clinical features and identification of different plasmids carrying both SHV-5 and TEM-1 genes. J. Clin. Microbiol. 37:4020-4027.
Thauvin-Eliopoulos, C., M. F. Tripodi, R. C. Moellering, Jr., and G. M. Eliopoulos. 1997. Efficacies of piperacillin-tazobactam and cefepime in rats with experimental intra-abdominal abscesses due to an extended-spectrum beta-lactamase-producing strain of Klebsiella pneumoniae. Antimicrob. Agents Chemother. 41:1053-1057.
Thomson, K. S., and E. Smith Moland. 2001. Cefepime, piperacillin-tazobactam, and the inoculum effect in tests with extended-spectrum beta-lactamase-producing Enterobacteriaceae. Antimicrob. Agents Chemother. 45:3548-3554.
Tzouvelekis, L. S., A. C. Vatopoulos, G. Katsanis, and E. Tzelepi. 1999. Rare case of failure by an automated system to detect extended-spectrum beta-lactamase in cephalosporin-resistant Klebsiella pneumoniae isolate. J. Clin. Microbiol. 37:2388.
Vercauteren, E., P. Descheemaeker, M. Ieven, C. C. Sanders, and H. Goossens. 1997. Comparison of screening methods for detection of extended-spectrum beta-lactamases and their prevalence among blood isolates of Escherichia coli and Klebsiella spp. in a Belgian teaching hospital. J. Clin. Microbiol. 35:2191-2197.
Wiener, J., J. P. Quinn, P. A. Bradford, R. V. Goering, C. Nathan, K. Bush, and R. A. Weinstein. 1999. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA 281:517-523.
Wu, T. L., L. K. Siu, L. H. Su, T. L. Lauderdale, F. M. Lin, H. S. Leu, T. Y. Lin, and M. Ho. 2001. Outer membrane protein change combined with co-existing TEM-1 and SHV-1 beta-lactamases lead to false identification of ESBL-producing Klebsiella pneumoniae. J. Antimicrob. Chemother. 47:755-761.
Yan, J. J., W. C. Ko, and J. J. Wu. 2001. Identification of a plasmid encoding SHV-12, TEM-1, and a variant of IMP-2 metallo-beta-lactamase, IMP-8, from a clinical isolate of Klebsiella pneumoniae. Antimicrob. Agents Chemother. 45:2368-2371.
Yang, Y., N. Bhachech, P. A. Bradford, B. D. Jett, D. F. Sahm, and K. Bush. 1998. Ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli isolates producing TEM-10 and TEM-43 beta-lactamases from St. Louis, Missouri. Antimicrob. Agents Chemother. 42:1671-1676.
Journal of Clinical Microbiology Oct 2002, 40 (10) 3703-3711; DOI: 10.1128/JCM.40.10.3703-3711.2002
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The Self is Pure Consciousness , as it is presupposed by all modes of consciousness , which function in the form of consciousness of external conditions or objects . Human consciousness is characterized by . . .
This knowing Subject is unseizable , indestructible , unattached , unbound , changeless , unaffected . It stands opposed to everything that is objective , as light is set against darkness .
Knowledge is not the attribute but the very stuff of Reality . It is the Essence of Existence . Hence , this Reality is unknowable as an object of knowledge . It manifests Itself as the first principle in all thought and action .


I just spent a glorious week with mom and sister in Greece and a few days in Paris with friends before that, so the transition back to being solo has been rough.... really rough. I know it will pass but I pretty much want to cocoon from life right now. Without a project to throw myself into, I'm acutely aware of my alone-ness of being on the road. Directionless. Floating. It feels funny to complain about gallivanting around Europe but traveling was never the intention for this year so it feels empty. What I really want is to settle in for a few months, get to know a city, and dig into some interesting mind-expanding work.
I feel a little lost when it comes to what I'm supposed to be doing with my life right now. This year was supposed to be the year of learning and it all of a sudden isn't anymore... or at least not in the way I'd envisioned. The refrain "What was I thinking?" has been playing on repeat in my head. On really bad days, I have even considered heading home. I couldn't help but laugh aloud when I saw an Instragram post that said My life has a superb cast but I can't figure out the plot. Amen sister.
After sulking for a few days in Athens, I decided I'm done with that. I'm going to be fearless and move forward, regardless of the limbo I'm in. We are never stuck due to some injudicious or because life is picking on us. We are usually stuck for a purpose. So maybe I'm stuck for a reason and maybe I'm learning exactly what I'm supposed to be learning.
I extended my time in Greece for another week and planned self-imposed reading (because I cannot afford to continue paying baggage fees at airport hauling yet-to-be-read books around) and writing "retreat" on Milos. The Greek island of Milos is where the Venus de Milos was discovered so I figure it must have good creative energy flowing and I'll be inspired. It did not disappoint.
And then as if through synchronicity, a little miracle happened. Just as I was about to write my friend Sarah who lives in Aarhus, Denmark about a long-overdue visit, she and her boyfriend would be vacationing for a month in Canada. Half joking, I asked if she needed a house sitter while they were away because my destiny a homeless vagabond was days away. Because she's awesome, she agreed.
Moments later, I bit the bullet and changed my flights again, switching the the return leg of my of Athens-Paris journey to Athens-Copenhagen to make things a big easier travel wise with my behemoth of a bag... I'm only wishing I had known to change it when I extended my time in Greece instead of paying the airline change fee twice!
With great love for authors that create alternate worlds, different paths for us to explore, I'm reminded of the J.R.R. Tolkien quote "Not all those who wander are lost." So I'm not going to worry as much about how my future plans aren't really plans and work on the here and now. Taking it one day at a time.
So here I am. In Limbo. Trying.
Today, I whispered in the Devil's ear, "I am the storm."
This post was so spot on. I can totally relate!


In this code examples, 2x16=32words is tranmitted using SPI and received back in ping-pong mode. This operation happens contineously.
In this code examples, 2x16=32words is tranmitted using SPI and received back in ping-pong mode.


Today there are some 1,200 Crime Stoppers programs in communities around the world that take tips to assist investigators to solve crimes including homicides, sexual assaults, drug trafficking operations and robberies, just to name a few. Programs have also received information that has prevented school shooting and criminal acts by terrorist organizations.
Crime Stoppers programs are operated not for profit and are managed by a volunteer board of directors. The board is responsible for fundraising and paying rewards to individuals who anonymously call or submit online tips with information that helps solve crime.
Rewards are paid for tips that lead to the arrest and indictment of people charged with felony offences and to date, Crime Stoppers statistics show a conviction rate of some 95 percent.
Because Crime Stoppers works, it is an extremely effective crime fighting concept that solves crime and keeps our streets safe. Statistics show an average conviction rate of 95 percent and tips to Crime Stoppers save law enforcement agencies thousands of dollars in investigation time. Calls and online tips submitted to Crime Stoppers assist in putting police on the right track by identifying individuals who are responsible for committing crimes.
Today there are some 1,200 Crime Stoppers programs in 20 countries, including the United States, Canada, the United Kingdom, Australia, South Africa, Central America and the Caribbean. On an accumulative basis since 1976, tips to Crime Stoppers have been responsible for the arrests of around 600,000 individuals and led to the seizure of close to $7 billion in stolen property and illicit drugs.
These are the people that dedicate themselves tirelessly each and everyday to make sure you area is safe and you get paid. Please be courteous to them!
The One and Only —-> On the right side!
They dedicate there days to crime fighting and giving crimestoppers the most tips. You have the option to put your face in or put something else here in your stead. But you as the citizen deserve to be here we couldn't do it without you!


• A total made-over with designer style and great attention paid to every detail.
• Well planned storage space throughout the living and dining room and bedrooms.
• Master suite contains a walk-in closet and a contemporary ensuite bathroom in cool grey colour.
• Another bedroom could be converted into a study room or child's room.
• Guest bathroom is also stylishly designed with high quality fittings.


text:
Featured Tracks & Videos
Scores & Parts
Chuck Iwanusa
"Tone Deaf Little Weasel" Released - A Remotely Recorded International Ensemble
The premier performance of my latest composition, Tone Deaf Little Weasel, was indefinitely postponed due to the Covid-19 pandemic quarantine and subsequent cancellation of the 2020 BMI Jazz Composers Workshop Annual Recital.
Although the cancellation was a disappointment, it provided an opportunity for me to recruit some of my favorite musicians from the United States, Canada, and Germany to remotely record this performance. Each of the musicians on this project have had a significant impact on my musical journey, and there are no words to adequately express my gratitude for their generous participation in this project.
While producing this recording, I was pleasantly surprised to learn that, in addition to being an accomplished saxophonist and composer/arranger, my friend Paul White is also a talented audio engineer. Paul spent countless hours synchronizing, balancing and fine-tuning each of the 17 individual recordings to create the final mix.
Rounding out the production team is singer/songwriter, instrumentalist, band leader, audio engineer, film editor, and my son, Matthew Iwanusa. (Do I sound like the proud father?) He, too, spent many hours mastering the final mix and synchronizing the individual video recordings with the final audio mix.
I am extremely grateful for the commitment and talents that everyone brought to this project. It would not have happened without them!
So until we have an opportunity to perform Tone Deaf Little Weasel (and my other compositions) before a live audience, please listen to it here. If you enjoy this performance, I hope you will make a contribution to support the musicians who made it possible!
Chuck Iwanusa & the Quarantine Jazz Orchestra
Marc Phaneuf, soprano saxophone (New York City)
Ben Kono, soprano saxophone (New York City)
Quinsin Nachoff, tenor saxophone (New York City)
Paul White, tenor saxophone (Washington, DC)
Alden Banta, baritone saxophone (New York City)
John Lake (New York City)
Alexander Brown (Toronto)
Dave Smith (New York City)
Jesse Malone (Toronto)
Alan Ferber (St. Louis, MO)
Dr. Paul Brewer (Grand Rapids, MI)
Michael Rorby (New York City)
Max Seigel (New York City)
Reg Schwager, guitar (Toronto)
Billy Test, piano (Cologne, Germany)
Evan Gregor, bass (New York City)
Curtis Nowosad, drums (New York City)
Paul White - Audio Mix
Matthew Iwanusa - Audio Mastering & Video Editing
Chuck Iwanusa - Composer & Producer
Tone Deaf Little Weasel, (Copyright © 2020 Chuck Iwanusa, All Rights Reserved)
Irene Christensen NYC
Absolutely a great composition. Very contemporary and American.
sandra smiling nc
Mike Malone Hamilton Ontario
Great writing Chuck! And a beautiful performance and recording. Congrats to everyone involved!
Scott Church Port Deposit, MD
Sweet! great composition and production. Thanks for sharing
Sunny Wilkinson Michigan
Jul 9 2021 12:56 PM
Congratulations Chuck. What a great piece!
Copyright © 2021 Chuck Iwanusa Music


text:
What is SAA?
What is sex addiction?
Am I a Sex Addict?
The Twelve Steps
The Twelve Traditions
Links to SAA International
SAA Homepage
SAA Meetings in Australia
The Sydney Intergroup of SAA is an autonomous fellowship of registered groups of recovering sex addicts who follow the Twelve Steps and Twelve Traditions of Sex Addicts Anonymous (SAA). The views expressed on this website are those of Sydney Intergroup and do not necessarily represent those of Sex Addicts Anonymous as a whole. The official website of Sex Addicts Anonymous is overseen by the ISO of SAA, Inc., through its Board of Trustees who are elected by delegates who represent its member groups.
The Sydney Intergroup of SAA has no affiliation with and does not endorse Google. The link to Google Sites is provided as a requirement of our web host provider.
Sex Addicts Anonymous is a fellowship of men and women who share their experience, strength and hope with each other so they may overcome their sexual addiction and help others recover from sexual addiction or dependency.
The Third Tradition of SAA states: Membership is open to all who have a desire to stop addictive sexual behaviour. There is no other requirement. SAA is open to all people regardless of age, race, religion, and gender or sexual preference.
Our common goal are to become sexually healthy and to help other sex addicts achieve freedom from compulsive sexual behaviour.
SAA is supported through voluntary contributions from members. We are not affiliated with any other Twelve Step program, nor are we part of any other organisation. We do not support, endorse or oppose outside causes or issues.
Sex Addicts Anonymous is a spiritual program based on the principles and traditions of Alcoholics Anonymous. We are grateful to A.A. for this gift which makes our recovery possible.
Sex Addicts Anonymous recognises that peoples' needs are different and thus individual recovery programmes are different. SAA empowers individuals to choose and create a program that will lead to a self affirming expression of sexuality. The core of our program is the Twelve Steps which come from the Big Book of Alcoholics Anonymous.
Reprinted from the pamphlet "Getting Started in Sex Addicts Anonymous" © ISO of SAA, Inc.


There are numerous factors that influence indoor air quality, from humidity levels to the presence of dust mites. One class of compounds that can lower your air quality, yet often goes overlooked, is volatile organic compounds, or VOCs.
VOCs are a group of chemicals that are released into the air by everything from building materials to air fresheners. Here's a closer look at VOCs, the risks they present to your family and how you can remove them from your indoor air.
What Are Some Common VOCs?
The term "volatile organic compound" technically refers to any organic chemical that easily becomes a gas at room temperature. Thousands of chemicals meet this definition. However, there are a few specific VOCs that are most commonly found in homes and are known to have negative effects on health.
Benzene is a VOC that is found in tobacco smoke and may also off-gas from plastic and resin items like carpets and fabric furniture. It is heavier than air, so it tends to sink towards the bottom of the room and may settle on food and water that you later consume.
Formaldehyde is slowly emitted from many building materials, including paints and adhesives. The higher the humidity levels in your home, the more formaldehyde you can expect to off-gas into the air.
Perchloroethylene is used in dry cleaning. If you have your clothing or drapes dry cleaned, the residue will slowly be released into your indoor air.
What Are The Health Consequences of VOCs?
Short-term exposure to high levels of VOCs can cause symptoms ranging from dizziness, to headaches and nausea. This may occur if you spend a lot of time painting or staining inside a home with poor ventilation. Long-term exposure to lower levels of VOCs is more common, and since this exposure does not usually cause any apparent and worrisome symptoms, it often goes overlooked.
An increased risk of certain cancers.
Damage to your liver and kidneys.
Central nervous system damage that results in a loss of coordination, memory impairment, and visual disorders.
Scientists are still researching the many negative health effects of VOCs. Certain VOCs have been linked to specific health problems. For example, benzene is a known human carcinogen that can lead to leukemia and other cancers of the blood. Formaldehyde is also a known human carcinogen linked to blood, lymphatic and brain cancers. Perchloroethylene causes respiratory issues like worsening asthma.
How Can You Keep VOCs Out Of Your Home?
There are a few simple lifestyle changes you can make to reduce the levels of VOCs in your indoor air. First, make sure you open the windows to let in plenty of fresh air whenever you use paint, stains, adhesives and aerosol products. Throw away partially used containers of chemicals, and try to buy low-VOC formulations of building products whenever possible.
You can also reduce the levels of VOCs in your indoor air by keeping your home's humidity levels under control. Keep your AC unit running in the summer, as it will remove excess moisture from the air. Consider having a whole-home dehumidifier installed to remove excess moisture on cooler days when you don't want to run the air conditioning.
One of the most effective ways to do away with VOCs is to have an ultraviolet air purifier installed. These devices clean your air as it circulates through your HVAC system, removing not only toxic substances like benzene and formaldehyde but also infectious agents like bacteria and viruses.
To learn more about UV air purifiers, or to have one installed in your home, contact the experts at HELP. Cleaner indoor air is essential for your ongoing health and happiness.


text:
package graficos;

public class MiPortfolio extends Ventana /*implements ActionListener*/ {

	public MiPortfolio() {
		super();
		LaminaPortfolio l = new LaminaPortfolio();
		add(l);
		setTitle("Mi Portofolio");
		setVisible(true);
	}
	/*public void actionPerformed(ActionEvent e) {

	}*/
}


text:
package android.demo;

import android.app.AlertDialog;
import android.os.Bundle;
import android.support.design.widget.Snackbar;
import android.support.v4.app.Fragment;
import android.support.v7.app.AppCompatActivity;
import android.util.Log;
import android.view.Gravity;
import android.view.LayoutInflater;
import android.view.View;
import android.view.ViewGroup;
import android.widget.Button;
import android.widget.Toast;

public class NotificationsFragment extends Fragment {
	static final String TAG = NotificationsFragment.class.getSimpleName();

	View view;

	@Override
	public View onCreateView(LayoutInflater inflater, ViewGroup container,
			Bundle savedInstanceState) {
		if (container == null) {
			return null;
		}

		view = inflater.inflate(R.layout.notifications_fragment, container, false);

		view.findViewById(R.id.AlertButton).setOnClickListener(new View.OnClickListener() {
			@Override
			public void onClick(View v) {
				// AlertDialog usage sample
				AlertDialog.Builder builder = new AlertDialog.Builder(getActivity());
				builder.setTitle(R.string.dialog_title);
				builder.setMessage(R.string.dialog_message);
				builder.setPositiveButton(R.string.dialog_yes, null);
				builder.setNegativeButton(R.string.dialog_no, null);
				builder.create().show();
			}
		});

		view.findViewById(R.id.ToastButton).setOnClickListener(new View.OnClickListener() {
			@Override
			public void onClick(View v) {
				// Toast usage sample, gravities and durations work!
				Toast toast = Toast.makeText(getActivity(), R.string.toast_text, Toast.LENGTH_SHORT);
				toast.setGravity(Gravity.CENTER, 0, 0);
				toast.show();
			}
		});

		view.findViewById(R.id.SnackBarButton).setOnClickListener(new View.OnClickListener() {
			@Override
			public void onClick(View v) {
				Snackbar snackBar = Snackbar.make(null, getString(R.string.snackbar_text), Snackbar.LENGTH_LONG);
				snackBar.setAction(R.string.snackbar_action, new View.OnClickListener() {
					@Override
					public void onClick(View v) {
						Toast toast = Toast.makeText(getActivity(), R.string.toast_text, Toast.LENGTH_SHORT);
						toast.setGravity(Gravity.CENTER, 0, 0);
						toast.show();
					}
				});
				snackBar.show();
			}
		});

		return view;
	}

	@Override
	public void onResume() {
		super.onResume();
		((CommonActivity) getActivity()).onFragmentResumed(getString(R.string.sidebar_notifications), false);
	}

}


Listen to "Daily Devotional - Pulled out of the pit of despair" on Spreaker.
Thank you for the kind emails of those that noticed I did not post a devotional yesterday. All is well, I'm here today. ;-) Tonight, the devotional is a message for us all. Myself, included. So listen closely, take check of yourself and then ask yourself, how has dwelling on the negatives pulled you into a peit of despair? Love you all, in Jesus name.
I waited patiently for the Lord to help me, and he turned to me and heard my cry. He lifted me out of the pit of despair, out of the mud and the mire. He set my feet on solid ground and steadied me as I walked along.
Thank you Jesus!!! You are loved so much Jesus!!!


text:
Home > Member Benefits > Member Profiles > Martha Mathews Libster
Dr. Martha Libster and Golden Apple Healing Arts
Entertainment & Culture, General Non-Fiction, Biography & History, Fiction & Literature, Cooking / Food & Wine, Poetry
Martha Mathews Libster
Dr. Martha Mathews Libster, is the author of 7 books including the award-winning history Herbal Diplomats, which received the 2005 Lavinia Dock Award for Excellence in Historical Research and Writing from the American Association for the History of Nursing. A native of Ohio, Martha holds a doctoral degree in Humanities - Medical History from Oxford Brookes University in Oxford, England, a master's degree in Psychiatric Nursing from the University of Colorado Health Sciences Center, and bachelor's degrees in Dance Education from New York University and Nursing from Mount St. Mary's University in Los Angeles. She has been awarded a Research Grant from the Vincentian Studies Institute in Chicago (2007), North Carolina Arts and Humanities Council Grants (2008, 2009), and served as Visiting Research Scientist at Northwest University in Mafikeng, South Africa funded by the Medical Research Council (2010). In 2013, she held a Faith Andrews Research Fellowship in Shaker Culture from the Winterthur Museum, Garden, & Library. Martha served as Associate Editor for the Journal of Holistic Nursing (2009-2013) and Guest Editor for 3 international nursing journals. She has been an invited keynote and endnote speaker at such international venues as the World Health Organization in Geneva (2003), the National Museum Te Papa New Zealand (2014), the United State Botanic Garden (2007), the Royal College of Nursing (2002), and the Philip and Elkin Alston Lecture at the Atlanta Botanical Garden (2007). Her research has taken her to the British Library in London, medical libraries and Shaker Villages throughout the USA, the archives of religious communities such as the Sisters and Daughters of Charity in Paris, Ohio, Indiana, and Maryland and the Archives of the Church of Jesus Christ of Latter-Day Saints in Salt Lake City, and numerous botanical medicine collections, such as the Lloyd Library in Cincinnati.
Dr. Martha's histories, Enlightened Charity (2009) and Herbal Diplomats (2004), are vivid depictions of the lives of American women nurses in antebellum America, whose health care expertise enacted in their religious communities' infirmaries and hospitals, contributed to the reform of American health care and establishment of some of the country's most noted health care institutions. Her forthcoming book, a historical fiction titled Near and Dear Sisters, is a history of the Shakers, whose spiritual inspiration and international achievement as expert botanical medicine makers, led them to found the American pharmaceutical industry as they led the national struggle for reforming health care and building caring community anew.
Herbal Diplomats
*LAVINIA DOCK AWARD 2005 for Excellence in Research and Writing
*American Health Care Reform
*19th-Century Populism
*Women's History (Nursing)
*Herbal Medicine
*Cultural Health Diplomacy
Perspectives on Cultural Diplomacy (Volume 1 - Nursing)
Science of Energy Flow: Foot Reflexology with Herbal Stress Relief
2012 (Color EBook 2017)
The Nurse-Herbalist: Integrative Insights for Holistic Practice
Enlightened Charity
Delmar's Integrative Herb Guide for Nurses (Book and CD-Rom)
Demonstrating Care: The Art of Integrative Nursing
2005 Lavinia Dock Award for Exemplary Historical Research and Writing – Book Publication, American Association for the History of Nursing – Herbal Diplomats. 2013 Faith Andrews Research Fellowship in Shaker Culture, Winterthur Museum, Library and Gardens.


Our photo gallery contains pictures from various events throughout the year. Many events include photos of senior citizens from the Oak Park, River Forest, and Forest Park area. Most of our activities & events are free and open to the public. Click on a photo to view pictures within a gallery.