text:
Renee is a colleague I work with quite often. She is an amazing perfusionist as well as administrator, mom, and just a decent all around human being. She has a pretty scathing wit- so beware.
She offered to share a policy on the administration of CUSTODIAL THK Cardioplegia. This is a collaborative effort as I have added some other valuable background information- garnered from other articles on this topic 🙂
So I welcome you to read it and share it. It is well written, and hopefully we shall add Renee to our editorial staff.
Renee Toth, BS, CCP
Myocardial protection and preservation is a primary goal for open-heart surgery patients. To ensure that the patient's heart is protected during ischemic arrest, the Perfusionist is responsible for the delivery of the cardioplegia solution. Custodiol HTK (Histidine-Trytophan-Ketoglutarate) is a crystalloid cardioplegia, an understanding of its function and delivery is essential.
Cardioplegia solution is the means by which the ischemic myocardium is protected from cell death. This is achieved by reducing myocardial metabolism through a reduction in cardiac work load and by the use of hypothermia.
Chemically, the high potassium concentration present in most cardioplegia solutions decreases the membrane resting potential of cardiac cells.
Interestingly Custodiol uses two other cations, Na+ and Ca++, to arrest the heart.
By removing extracellular Na+ from perfusate the heart will not beat because the action potential is dependent upon extracellular Na ions.
However the removal of Na+ does not alter the resting membrane potential of the cell.
Likewise removal of extracellular Ca++ results in a decreased contractile force, and eventual arrest in diastole.
Custodial HTK (Histidine-Tryptophan-Ketoglutarate) is an example of a low [K+] low [Na+] solution.
Chemistry and Pharmacology
As a crystalloid cardioplegia solution, Custodiol HTK solution is considered an intracellular solution, i.e., electrolyte concentrations similar to an intracellular concentration, containing low concentrations of the electrolytes sodium, calcium, potassium and magnesium.
Custodiol HTK Solution also contains a high concentration of an amino acid buffering agent, histidine/histidine hydrochloride, the amino acid tryptophan a-ketoglutarate, and the osmotic agent mannitol.
The histindine/histidine hydrochloride buffering system provides normal osmolarity and enhances the solution's buffering capacity during the ischemic-induced acidosis. With the exception of mannitol, all constituents are normally found in the body.
Custodiol HTK Solution is devoid of colloid and has a viscosity of 1.8 cP, which is similar to the viscosity of water (1.0020 cP). The osmolality of Custodiol HTK Solution is 310 mosmol/kg.
The pH of Custodiol HTK Solution is 7.02 – 7.2 at 25°C.
The low sodium content makes it possible to use a high concentration of biological buffer systems, namely histidine and histidine HCL which confer a buffering capacity superior to that of blood.
The histidine/histidine hydrochloride buffering system provides osmolarity and enhances the solution's buffering capacity during ischemia-induced acidosis. Histidine is also an effective membrane protectant, and improves the provision of ATP.
Custodiol HTK Solution contains the amino acid tryptophan to protect cell membranes. a-ketoglutarate helps to stabilize cell membranes and is a substrate for anaerobic metabolism; it is an intermediary in the Krebs cycle and a precursor of nicotinamide adenine dinucleotide offering improved production of ATP during reperfusion and inhibiting the production of lactate through glycolysis.
Mannitol maintains physiological or slightly increased osmolality and thereby counteracts the colloidal osmotic pressure of intracellular protein to reduce cellular edema. Mannitol may also act as a free-radical scavenger.
The efficacy of the low sodium and low calcium concept of Custodiol HTK Solution, buffered with Histidine, has been demonstrated in a number of studies.
The advantages of Custodiol HTK Solution to improve clinical outcomes are, in part, based on the buffer effect of histidine/histidine hydrochloride which may enhance the efficiency of anaerobic glycolysis. Also, the addition of mannitol has been shown to decrease cellular edema.
Delivery Technique
Custodial HTK will be delivered at 3-40 Celsius, 20 ml/kg to a maximum of 2 liters for the initial dose; subsequent doses are delivered at 3-40 Celsius, 10ml/kg to a maximum of 1 liter. The delivery pressure for Custodial is different from blood based cardioplegia due to its low viscosity, which is similar to sterile water. The pressure drop with custodiol for the long plegia needle is only 25 mmhg and for the "push/pull" plegia catheter it is only 15 mmhg.
Initially Custodiol will be delivered at a line pressure of approximately 125 mmhg with the long plegia needle or approximately 115 mmhg with the push pull until an electrical arrest of the heart. The line pressure will then be reduced to approximately 75 mmhg with the Long plegia needle or approximately 65 mmhg with the push pull.
The nature of Custodial allows for extended ischemic periods. The perfusionist will notify the Surgeon at 90 minutes after the initial dose. An additional dose of 10ml/kg should be given before 120 minutes of myocardial ischemia has passed.
Due to the electrolyte properties of Custodiol HTK, systemic Na+ levels will drop precipitously, Ph may also drop and also the crystalloid load from the Custodial will need to be removed.
Add a Hemoconcentrator into your ECC
Therefore, to correct these imbalances, continuous hemoconcentration and ZBUF (Zero-Balance UltraFiltration) will need to be performed on all patients receiving Custodiol. After removing the crystalloid load, ZBUF will need to be performed using at least, 1 liter of 0.9% NaCl with 50ml of Sodium Bicarbonate added to it.
This will help to correct the sodium level and bring it within the normal range of 135-145 mmol/L as well as correcting the slight acidosis occasionally seen with Custodiol HTK. When sending blood gases you must check the Sodium levels.
Depolarizing Solutions
Most cardioplegia solutions can be classified as either depolarizing or hyperpolarizing solutions. The most common method of myocardial protection during cardiac surgery is depolarized diastolic arrest with a hyperkalemic infusion. During administration, myocardial cells depolarize, allowing sodium channels to open and sodium to flow into the cell like a normal action potential. But, because of the elevated extracellular potassium concentration, sodium channels are locked in an inactive state, preventing the cells from repolarizing and keeping them in an unexcitable state.
Depolarizing solutions have been used since the 1970s and are currently considered to be the gold standard of myocardial protection. These solutions tend to contain between 10-25 mEq/L of potassium which, when administered via an aortic root injection, raises cell membrane potential to approximately -50 mV from a resting membrane potential of -90 mV. Diastolic arrest occurs at – 50 mV because fast sodium channels, which have a threshold potential between -65 to -70 mV, are inactivated at this potential. The Nernst potential for sodium-calcium exchangers is also -50 mV, meaning at a diastolic arrest of -50 mV, no net movement of calcium or sodium ions should occur across the cell membrane.
Hyperpolarizing Solutions
Hyperpolarizing solutions are used as an alternative to hyperkalemic solutions and work by making the membrane potential more negative than resting potential. This is achieved by using solutions with no calcium and low sodium to induce an arrest. They also add procaine, a sodium-channel blocker, to prevent action potential propagation
Transmembrane ion gradients are maintained closer to normal physiologic levels by utilizing a hyperpolarizing arrest as opposed to hyperkalemic depolarized arrest. This approach has the theoretical benefit of reducing the severity of ionic imbalance during the ischemic period. Additionally, few ion channels and pumps are active and the metabolic demand of the myocardium is greatly reduced. The potential for influxes and overload of sodium and calcium during hyperpolarized arrest is reduced because at hyperpolarized membrane potentials, sodium and calcium channels are closed.
These channels have threshold potentials near -40 mV, which is close to predicted membrane potentials of cells exposed to depolarizing cardioplegia solutions. Rising intracellular calcium is a concern because it is associated with irreversible muscle contracture and myocyte necrosis. Additionally, placing cells in a prolonged depolarized state increases the consumption of high-energy phosphate stores when compared to hyperpolarizing solutions. Based on these concerns, some surgical teams prefer the use of hyperpolarizing solutions.
While cardioplegia solutions can be grouped into two general groups, additional differences exist in the additives used in each solution. Each additive used serves a specific purpose: ion channel blockers, buffer pH, and so on. A general understanding of some common cardioplegia additives is beneficial when choosing which solution to use. While formulations and techniques vary, the goals of each solution are the same: to lower cell metabolism, to achieve electrical and mechanical quiescence, and to reduce the impact of prolonged ischemia.
Cardioplegia consists of three major components: an arresting agent, hypothermia, and additional protective agents in the form of additives. Formulations vary between solutions and surgical preference. Some common additive agents are outlined below
Adenosine is used in depolarizing agents to enhance cardiac arrest. When compared to hyperkalemic solutions alone, a combination of adenosine and hyperkalemia reduces the time to induce cardiac arrest. This is thought to be associated with transient hyperpolarization caused by adenosine prior to the hyperkalemic-induced depolarization. Electrical arrest of the SA node conduction prior to mechanical quiescence produces a more rapid global arrest.
During hyperkalemic depolarized arrest, high extracellular potassium causes fast sodium-channels to be inactivated. Over time a sodium window current can allow calcium to enter the cell, leading to intracellular calcium accumulation and eventual cellular damage. Keeping sodium-channels in an inactivated state keeps the cell membrane depolarized, reducing sodium window currents, and preventing intracellular calcium buildup. Sodium-channel blockers, such as lidocaine or procaine, have been added to some cardioplegia solutions
. Sodium-channel blockers cause the cell membrane to become slightly polarized in comparison to depolarizing solutions without these agents. Hyperkalemic solutions containing sodium-channel blockers, such as del Nido cardioplegia, are classified as modified depolarizing solutions.
Custodiol HTK hyperpolarizes the heart to induce cardiac arrest. Hyperpolarizing solutions prevents calcium overload because few channels or ion pumps are active at hyperpolarized membrane potentials. Additionally, energy consumption is low and the metabolic demand of cardiac myocytes is minimal at these highly negative potentials.
One of the attractive qualities of HTK is its claim to offer adequate myocardial protection for a 3-hour period with a single dose, allowing the surgeon to complete complex repairs without the need to stop or slow down for additional doses. HTK is classified as an intracellular solution because it contains low sodium and calcium concentrations. When administered, it causes extracellular sodium washout, hyperpolarizes the cell membrane, and induces diastolic arrest.
The major advantage of HTK over conventional cardioplegia solutions is its immense buffering capacity because of the high content of histidine. Histidine is an amino acid which acts as the body's main intracellular buffer and promotes conditions optimal for hypothermic glycolysis to occur.
References and Citations:


text:
Now displaying: June, 2021
257. Cassie Brand: Curator of Rare Books for Washington University in St. Louis 0
Cassie Brand, Curator of Rare Books for Washington University in St. Louis, stopped by to speak with Nancy about the Olin Library and the Rare Books Collections at the University.
Cassie Brand: Curator of Rare Books Olin Library at Washington University
Cassie Brand has been Curator of Rare Books at the Washington University Libraries since 2017. She enjoys sharing rare books with others through outreach programs, teaching classes, and curating exhibits. Her research focuses on the intersection of the book as a physical and cultural object and on the histories of book collecting and libraries. Cassie received her library degree from Indiana University in 2011 and is currently working on a PhD. Cassie's dissertation, which is in progress, is tentatively titled "How Books Became Rare: The History of Special Collections in America 1880–1940."
Among the topics discussed is the rare copy of the Declaration of Independence held in the library's collections.
When the Julian Edison Department of Special Collections opened in 1962, the Washington University Libraries owned a small rare book collection, the finest pieces of which had been donated by St. Louis collector William Keeney Bixby. Now, the Rare Book Collections include over 70,000 printed pieces and represent all the disciplines the University Libraries collect.
The Rare Book Collections include books from all Special Collection areas. The collections' primary strengths are in the areas of literature; the material culture of the book, including the history of printing, graphic design, and the book arts; and aspects of American and world history.
Spanning seven centuries of written and visual communication, these collections support teaching and discovery across the University and are freely accessible to students, scholars, and visiting researchers.
256. Dan Reich: Curator & Director of Education at the St. Louis Kaplan Feldman Holocaust Museum 0
Dan Reich, Curator & Director of Education at the St. Louis Kaplan Feldman Holocaust Museum, stopped by to talk with Nancy about the mission of, and the happenings at, the museum. After 22 years at the museum, Dan Reich will be retiring soon.
Dan Reich. A photo from the museum's archives, depicting a Dachau Death March.
Among the topics discussed is the upcoming expansion of the museum. Set to open in mid-2022, the St. Louis Kaplan Feldman Holocaust Museum will quadruple the space of the existing facility to 35,000 square feet. The new facility will fuel the Museum's mission to preserve the legacy of the Holocaust, teach about the Museum's many purposes, and empower visitors to make the world a more tolerant place by rejecting all forms of hate, racism, and bigotry.
An artist's rendering of the upcoming expansion, set to open in mid-2022.
Also discussed is the moving story of Ben Fainer, Holocaust survivor and co-author of "Silent for Sixty Years." Ben Fainer spent the entire war as a Nazi prisoner, surviving for six years in six different camps. After losing his mother, three siblings, and over 250 other relatives in the Holocaust, Ben was liberated by American soldiers while on a final death-march in the spring of 1945. Ben didn't just survive, he thrived. He was able to put his tragic childhood behind and live an incredible post-war life. Ben became a speaker at the museum, sharing his story to honor the victims of the Holocaust. Ben passed away in 2016.
One of the aspects of Ben's story that is discussed is a bracelet... Ten years ago, a bracelet was uncovered in Germany that was made by Ben Fainer in his youth in a concentration camp. After Ben's passing, his family donated it to the museum to honor him. The bracelet will be part of the exhibition in the upcoming expansion.
Ben Fainer shares his story with students before his passing.
To hear stories from other Holocaust Survivors, click here.
255. Tom Ridgely: Producing Artistic Director of St. Louis Shakespeare Festival 0
Tom Ridgely, Producing Artistic Director of St. Louis Shakespeare Festival, stopped by to talk to Nancy about the 2021 festival its adjustments due to Covid.
The Festival this year includes a main stage Shakespeare in the Park performance of King Lear, which stars Tony, Grammy & Emmy winner André De Shields and is Directed by Carl Cofield. King Lear will run June 2nd through June 27th in Shakespeare Glen in Forest Park.
Also discussed, is the 2021 touring production of Othello, and the Shakespeare in the Streets program, which will focus this year on The Ville neighborhood. Shakespeare in the Streets is a "grassroots theatrical experience that invites St. Louis neighborhoods to tell their stories. A Festival-selected creative team leads the neighborhood in developing an original play based on one of Shakespeare's works—a play with themes that reflect the community's character."
Nancy and Tom also discuss the history of the St. Louis Shakespeare Festival.

redpajama_set_name: RedPajamaCommonCrawl


Avenue Trust Company Limited has a 63 year history of providing first-class fiduciary services to its clients. We discuss, plan and develop the best strategies to manage, protect, and grow the wealth of local and international, private and corporate clients.
Our clients benefit from our services in estate and succession planning to protect assets, maintain confidentiality, ensure business continuity and maximise tax efficiency.
These services are delivered to both Private Clients and Corporate and Institutional Clients, alike. A significant proportion of the company's client base is local to the Island of Guernsey and the service ethos for local clients is naturally extended international clients.
Avenue Trust Company Limited holds a Full Fiduciary licence issued by the Guernsey Financial Services Commission under The Regulation of Fiduciaries, Administration Businesses and Company Directors, etc. (Bailiwick of Guernsey) Law, 2000 to carry out fiduciary activities.
The principal company in the group, Lince Salisbury, was founded as a sole practice accountancy business by the late Denis Lince in 1953. The firm has evolved over the years. In March 2002, the partnership became a limited company under the name Lince Salisbury Limited. Its aim is to provide a holistic approach to clients in respect of audit, accounting, taxation, bookkeeping and statutory services.
While maintaining links with our heritage by retaining the 'Lince Salisbury' name, we are a member of the BKR International organisation, a highly respected international association of independent accountants. This association demands the highest standards of its members and provides a worldwide network of expertise. Through this association we have access to 160 businesses in over 500 offices in 80 countries around the world and work with our counterparts on numerous international structures.
The trust business is led by Tim Lowe. Our team structure and our commitment to the continued development of our staff at all levels which ensures that our clients receive an efficient, friendly and world class service.
With a business history spanning over six decades, we have built a substantial and diverse client base.


text:
module Internal.XCore.Default where

import Foreign
import Foreign.C.Types

import Hapstone.Internal.XCore

import Test.QuickCheck
import Test.QuickCheck.Instances

-- generators for our datatypes

instance Arbitrary XCoreOpType where
    arbitrary = elements [minBound..maxBound]

instance Arbitrary XCoreOpMemStruct where
    arbitrary = XCoreOpMemStruct <$> arbitrary <*> arbitrary <*>
        arbitrary <*> arbitrary

instance Arbitrary CsXCoreOp where
    arbitrary = oneof
        [ Reg <$> arbitrary
        , Imm <$> arbitrary
        , Mem <$> arbitrary
        , pure Undefined
        ]

instance Arbitrary CsXCore where
    arbitrary = CsXCore <$> (take 8 <$> arbitrary)

instance Arbitrary XCoreReg where
    arbitrary = elements [minBound..maxBound]
instance Arbitrary XCoreInsn where
    arbitrary = elements [minBound..maxBound]
instance Arbitrary XCoreInsnGroup where
    arbitrary = elements [minBound..maxBound]

redpajama_set_name: RedPajamaGithub


Roses & Cigarettes formed in 2013 when R&C guitarist Angela Petrilli joined the cover band lead singer Jenny Pagliaro was in.
The ladies quickly bonded over their shared love of artists like Ray LaMontage, Patty Griffin and Fleetwood Mac and soon left the cover band behind to form Roses & Cigarettes.
Roses & Cigarettes continue to play shows around Los Angeles and tour when Pagliaro's treatment schedule allows. They have opened for acts like Marc Broussard, Jim Lauderdale, Billy Bob Thornton & The Boxmasters, Elizabeth Cook, Amanda Shires and Eric Tessmer in Austin, TX.
Pagliaro and Petrilli work with Fishman and Martin Guitars. Petrilli is also signed with D'Addario and Fender.
Listen to Roses and Cigarettes now.


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RoadRunner Results: "+resultsLink+"", false)
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CloudTest Results: "+cloudTestResLink+"
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Tip: If the content isn't loading below, load the direct link above with HTTPS and accept the SSL.  Then refresh this page.
", false)
  summary.appendText("New Test Data: $rrCreateRespPretty", false)
  summary.appendText("

SOASTA Report Id:: $EXTERNAL_TEST_ID", false);
  summary.appendText("

SLA Results:: " + slaOutputMsg, false);
  summary.appendText("

Data Aggregation Results:: " + aggRespPretty, false);
} else {
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CloudTest Results: "+cloudTestResLink+"
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Tip: If the content isn't loading below, load the direct link above with HTTPS and accept the SSL.  Then refresh this page.
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summary.appendText("

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def restCall(def strUrl, def method, def queryString){
  def url = new URL(strUrl)
  def conn = url.openConnection()
  conn.setRequestMethod(method)
  conn.setRequestProperty("Content-Type", "application/json; charset=utf-8");
  conn.setRequestProperty("Accept","*/*")
  if(method == "POST" || method == "PUT"){
     conn.doOutput = true
     if(queryString.trim() != '') {
       def writer = new OutputStreamWriter(conn.outputStream)
       writer.write(queryString)
       writer.flush()
       writer.close()
    }
  } else {
    conn.doOutput = false
  }

  conn.connect()

  def respText = conn.content.text
  println "====== RESPONSE CODE: " + conn.responseCode
  println "====== RESPONSE TEXT: " + respText

  return respText
}

def getSoastaReportId() {
  println "getting Soasta Report Id..."
  def allNodes
  def soastaId = "0"
  def pattern = ~/.*\.xml/
  def dirname='/var/lib/jenkins/jobs/' + manager.build.getProject().name + '/builds/' + manager.build.getId() + '/archive/';
  def found = false;

  new File("$dirname").eachDirRecurse { dir ->
    if(!found){
        dir.eachFileMatch(pattern) {    myfile ->
          if(!found){
            try {
              allNodes = new XmlSlurper().parseText(new File("$myfile").text).depthFirst().collect{ it }
              for( n in allNodes){
                //println n.@resultID
                if(n.@resultID!=null && !n.@resultID.text().equals("")){
                  soastaId = n.@resultID.text()
                  printlin "found id of " + soastaId
                  found = true
                  break;
                }
              }
           //   soastaId = new XmlSlurper().parseText(new File("$myfile").text).testcase.@resultID.text().toString()

              found = true
            }catch(Exception e){
              // println e.getStackTrace()
            }
          }
        } // eachFileMatch
   } // end if !found
  } // eachFileMatch

  return soastaId
}</script>
        <sandbox>false</sandbox>
      </script>
      <behavior>2</behavior>
      <runForMatrixParent>false</runForMatrixParent>
    </org.jvnet.hudson.plugins.groovypostbuild.GroovyPostbuildRecorder>
  </publishers>
  <buildWrappers/>
</project>


The BPMN 2.0 standard includes an XML notation. It allows for the platform-independent exchange of BPMN 2.0 diagrams. To get more information about this XML standard or about the BPMN 2.0 specifications, go to http://www.bpmn.org.
Signavio Process Manager allows the export of business process diagrams (BPMN 2.0), conversation diagrams (BPMN 2.0) and choreography diagrams (BPMN 2.0) to BPMN 2.0 XML.
Select the diagram you want to export.
Click Import / Export, then Export BPMN 2.0 XML in the top drop-down menu of the Signavio Explorer.
Export diagrams to BPMN 2.0 XML.
Choose the diagram language and if subprocesses should be exported along with the diagram, if applicable, in the dialog that opens.
Click Export. The exported diagram will be downloaded by your browser.
If stakeholder-specific views were defined for a BPMN diagram, you can select one of them for the export. You can also decide to include subprocesses and choose the diagram language - if more than one is defined. If you would like to know more about how to create selective, stakeholder specific views of BPMN diagrams, see the chapter Creating views.


text:
Home » Tamil » News » Mumbai Express characters huge inspiration for Thappu Thanda: Director
Mumbai Express characters huge inspiration for Thappu Thanda: Director
Srikantan says characters from actor-filmmaker Kamal Haasan starrer "Mumbai Express" had a huge impact on his forthcoming Tamil crime comedy "Thappu Thanda".
By Khyati Sharma | September 5, 2017 06:37 pm | 7,680 reads | 0 comments
Debutant director Srikantan says characters from actor-filmmaker Kamal Haasan starrer "Mumbai Express" had a huge impact on his forthcoming Tamil crime comedy "Thappu Thanda".
"The comedy in 'Mumbai Express' is very different. You find the characters are doing something serious on screen but their actions make audiences laugh. The best example is of Pasupathy's character in the film. This is the same template I have used for my film," Srikantan told IANS.
"Kamal sir popularised this style of comedy. He has done it in films such as 'Michael Madana Kamarajan'," he said.
A dark comedy, the film will be on the lines of "Soodhu Kavvum".
"But it won't be exactly like 'Soodhu Kavvum'. The crime angle and its comic treatment will be the common elements. The story is set against the backdrop of election campaign and how the money exchanged during that period gets robbed," he said.
Slated for release on Friday, the film stars Sathya, Shweta Gai, Mime Gopi, Ajay Ghosh and John Vijay.
An erstwhile assistant of legendary filmmaker Balu Mahendra, Srikantan wants to make a mark with his own brand of cinema.
"I'm aware a lot of people would expect me to do his kind of cinema. But he had told me once do whata¿s important for survival. He said if I have to do certain type of cinema to sustain, then I should do it. Moreover, he said why two people should make similar kind of movies," he added.
Tags: Thappu Thanda
RRB Group D 2019: Admit Card is out on the website and THIS is where it can be downloaded
Padi Padi Leche Manasu Review: Sharwanand and Sai Pallavi starrer receives mixed response from the audiences
Maari 2 Twitter Review: Could Dhanush starrer manage to live up to the audiences' expectations? Check out
Kanaa movie review: Celebrities and audience can't stop praising this Aishwarya Rajesh starrer sports drama
Tamil actor Vishal arrested in Chennai after he tried to open a locked Tamil Film Producers Council office


For Chapel Porth, 1 km from St Agnes.
This is the Surf-Forecast page for St Agnes, Cornwall (North). Use the tab navigation above to view St Agnes sea temperature, St Agnes photographs, St Agnes detailed swell predictions, wind and weather forecasts, St Agnes webcams, current wind from Cornwall (North) live weather stations and St Agnes tide predictions. The United Kingdom swell maps link will open up the big picture showing United Kingdom and the surrounding seas. These swell maps can be animated to show the different swell components, wave energy, wave period, wave heights, together with wind and weather forecasts, current weather and sea state observations from United Kingdom wave-buoys, passing ships and coastal weather stations. Each of the forecast pages for this surf break feature a global and regional wavefinder tool to locate the best surf conditions in the area around St Agnes.


Here's a look at some selected work I've done for the film, television and practical effects industry as well some personal explorations. Much of my work involves a blend of 2D and 3D toolsets to achieve the finished product. Have a look around.


text:
Hamilton Construction Management Corp
The Hamilton Company Charitable Foundation
Stay up to date with our latest developments
Allston workforce housing complex gets underway on Gardner Street
by: TOM ACITELLI
Renderings via the Hamilton Co.
Developer the Hamilton Co. has started construction on 40 units of what it describes as "moderately priced 'workforce' housing" at 79-83 Gardner Street in Allston.
While there are no income requirements that potential tenants will have to meet—like withthe under-construction 101 Beverly Street—the rents at the Gardner Street project will be lower than what one might find in newer apartments in Boston.
A lot lower, in some cases: Hamilton says that the average rents for the 40 units—39 of them two-bedrooms and one one-bedroom—will average $2,700 to $2,900 a month, or about 30 percent to 40 percent less than for similar properties in Back Bay or the Seaport District.
Interestingly, the Gardner Street project involves preserving one of the last remaining freestanding Victorian houses in Allston's Packard's Crossing area. The house will serve as a lobby for the larger complex, which includes a new four-story building; and it will also contain the lone one-bedroom apartment as well as a pair of two-bedrooms.
39 Brighton Ave Boston, MA 02134
Phone - 617.783.0039
Hours: Monday - Friday 8:30am - 5:00pm
Employee Login & Broker Portal


Advancements in science, technology and healthcare have made at least one thing crystal clear, it will take everyone's best efforts to improve health in communities all over the world.
This far-flung realization has led to a wealth of career opportunities for people who are passionate about health. There are many exciting professional paths that center on the singular goal of better health, opening up a broad variety of options.
Understanding the nuances of public health vs. health promotion management helps prospective practitioners expedite and enhance their professional journey.
From the ever-increasing life expectancy to childhood obesity, global pandemics and even the environment, public health is a concept that touches everyone. It's a hotbed issue that's deeply ingrained at the political, organizational and personal level.
Health promotion is the science and art of helping people, organizations, and communities change lifestyle behaviors to move toward a state of improved health, resulting in decreases in chronic disease and health care costs.
Virtually anyone within the broad spectrum of the health field could reap benefits from a public health degree program.
While a public health degree certainly can prove useful in private sector positions, it's particularly applicable in the nonprofit, government and medical sectors.
In other words, earning a degree in public health is an important step toward protecting people from a wide variety of health concerns.
When American University started the first U.S. degree program combining the concepts of health and wellness with the principles of business and management, it put a new spin on public health. HPM students learn about everything from individual decision-making and corporate America to government policy in an effort to promote healthy behaviors and improve quality of life.
Whether serving in a Fortune 500 company's health and wellness department or as a leading decision-maker at a think-tank, an HPM graduate has the tools to improve health and well-being from the ground up.
If you are interested in the multi-sector impact of a degree in Health Promotion Management, learn more about American University's Master's in HPM Program.


text:
The SCWC Team
SCWC approaches issue education from a statewide perspective, which allows our organization to participate in all aspects of water policy and equips our members for the rapidly shifting world of California water.
Delta Issues
Water Energy
Modernized Delta Conveyance
The Sacramento-San Joaquin River Delta (Delta) is the hub of our state's water delivery system and home to one of California's most important ecosystems. But the current Delta Conveyance system no longer works. Aging dirt levees are all that protect our main source of water from catastrophic earthquakes, floods and rising sea levels. The environment is deteriorating and water deliveries are constrained by tightening regulations.
We need a modern system that can protect water supplies for people, the environment, farms and the California economy. We need improved Delta Conveyance.
TASK FORCE CHAIR:
Kern County Water Agency
Your Voice is Needed!
California's aging water infrastructure needs your help. Efforts to modernize the state's water system relied upon by 27 million Californians are once again gaining momentum.
The state's environmental review process for modernized Delta Conveyance is ongoing and expected to conclude in 2022. SCWC has a long history of supporting modernized Delta Conveyance. We led the coalition in support of the earlier version of this project, known as California WaterFix. In 2019, the California WaterFix project was revised and renamed. Today, the Delta Conveyance project consists of one pipeline instead of two, but the goal remains the same: improving water supply resiliency for Californians.
The Delta Conveyance project is a key action in Governor Newsom's Water Resilience Portfolio, a comprehensive document accounting for the challenges and opportunities facing the state and its communities as we seek to secure every Californian's right to water.
Latest Updates from the California Dept. of Water Resources
On June 18, 2020, the California Department of Water Resources (DWR) announced next steps to modernize its water infrastructure.
In a blog, DWR provided an update on its activities related to the Delta Conveyance project, a proposed tunnel to move water supplies underneath the fragile ecosystem of the Sacramento-San Joaquin Delta. The state's water supply system is aging, vulnerable and in desperate need of improvement to boost the state's resilience from the impacts of climate change as well as the risk of earthquakes. The Delta Conveyance project is the solution to those problems.
Among the highlights in DWR's blog:
More than 800 comments were received as part of the environmental review's scoping period. These are being reviewed now and scoping report will be published in coming months. (You can read our letter of support and comments on scoping process HERE.)
DWR expects the draft environmental impact review report to be published in 2021 for public review and comment.
A path forward has been created for federal involvement through the U.S. Army Corps of Engineers in the planning process.
Read the full blog here to learn more about DWR's processes for meeting California Environmental Quality Act requirements, tribal consultations and engagement, environmental justice and disadvantaged communities engagement, engineering and design and more.
Biological Opinions Lawsuits
You may have read about a series of lawsuits regarding the operations of the State Water Project and the Central Valley Project. Together, the two water projects provide water to 29 million Californians and 3.3 million acres of farmland. Both projects export water from the same watershed, but today they operate under two different sets of rules because of state and federal disagreements. The federal and state governments have a long history of coordinating the operations of the State Water Project and the Central Valley Project and SCWC would like to see them return to that coordination. SCWC supports a science-based approach to determining how water flows and urges both parties to return to the negotiating table to work out voluntary agreements rather than pursuing litigation.
As the State of California, water contractors in California and the federal government take to the courts to resolve differences in how water is exported from the Central Valley Project and the State Water Project, SCWC has begun collecting relevant documents and updates on this page.
Learn More about Delta Conveyance
For more general information about efforts to improve water infrastructure so critical to our state, check out our Delta Conveyance Project resources and stay connected with us to stay updated on the project and opportunities for engagement. Subscribe to our newsletter to receive regular updates delivered directly to your email box.
© The Southern California Water Coalition
Site by: Strategic Communication Consultants


text:
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    ctor: function () {
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         var _this_ = this;
         var takePicture = ca.CAButton.create(ca.CAButton.Type.SquareRect);
         takePicture.setLayout(ca.DLayout.set(ca.DHorizontalLayout_W_C(240, 0.5), ca.DVerticalLayout_H_C(54, 0.07)));
         //设置Button标题的显示文本和字体大小
         takePicture.setTitleForState(ca.CAControl.State.Normal, "拍照");
         //添加回调事件
         takePicture.addTarget(function(){
            var imgPicker = ca.CAImagePickerController.create(ca.CAImagePickerController.SourceType.CameraDeviceRear);
            imgPicker.open(function(img){
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        var photoAlbum = ca.CAButton.create(ca.CAButton.Type.SquareRect);
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        //设置Button标题的显示文本和字体大小
        photoAlbum.setTitleForState(ca.CAControl.State.Normal, "相册");
        //添加回调事件
        photoAlbum.addTarget(function(){

            var imgPicker = ca.CAImagePickerController.create(ca.CAImagePickerController.SourceType.PhotoLibrary);
            imgPicker.open(function(img){
                var img2 = ca.CAImageView.createWithImage(img);
                img2.setLayout(ca.DLayout.set(ca.DHorizontalLayout_W_C(448, 0.5), ca.DVerticalLayout_H_C(700, 0.6)));
                _this_.getView().addSubview(img2);
            });
        }, ca.CAButton.Event.TouchUpInSide );
        this.getView().addSubview(photoAlbum);
    },
});


I'll get to that part later.
All this leads to a period which it is easier to observe from the outside than as an observer on-the-spot – if you like the good lifeor.
Most of the characters were identifiable.
I imagine that management took a vacation and left the writers on the honor system for this one- bad for them, good for us.
This movie engages the viewer on many levels: intellectual, political, visual, human, humorous and does it all entertainingly.
The story itself is beautifully told, and is one of the only A-list movies that portrays a Christian man, as a normal kind human without agnostic or atheistic bias.
Love the time era as well!
I must add the Gentlemen Actors make my eyes Happy too.
You won't want to stop once you start.


text:
October 31st A much more pleasant day that unfortunately provided poor reward for plenty of searching. A Yellow-browed Warbler was reported briefly at Avalanche Road but subsequent searches for it drew a blank; rarity interest was otherwise limited to a fly-over Lapland Bunting at the Bill. A handful of thrushes, finches and Reed Buntings passed overhead, but the only birds of note on the ground were a couple of Firecrests at the Bill and another at Avalanche Road, and a thin sprinkle of Blackcaps, Chiffchaffs and Goldcrests at all the suitable sites. Seawatching at the Bill produced 7 Common and 4 Velvet Scoters, a Mediterranean Gull and a single unidentified diver.
October 30th The early promise of a still and overcast dawn soon fizzled out as heavy rain and gale force winds swept in through the morning to spoil any birding during the rest of the day. A few thrushes, finches and Reed Buntings passed through again at the Bill, and there were good counts of 44 Goldcrests and 11 Chiffchaffs at Pennsylvania Castle, but the only scarcer migrants found were 11 Firecrests scattered around the south of the island and a lone Treecreeper at Pennsylvania Castle.
Lesser Redpoll - Portland Bill, October 29th 2003 © James Lees
October 29th After a night of heavy rainfall there was a small arrival of grounded migrants but overhead passage all but petered out. A Serin made another brief appearance at the Obs, but otherwise the best of the scarcer migrants were a respectable island-wide count of at least 13 Firecrests, 3 Short-eared Owls between the Bill and Barleycrates Lane, and single Treecreepers at Old Hill and Pennsylvania Castle. Noteworthy counts of commoner migrants included 12 new Blackcaps at the Obs.
Pallas's Warbler - Southwell, October 28th 2003 © Martin Cade
October 28th The long-awaited first Pallas's Warbler of the autumn was today's highlight: it showed well all day at Southwell School. Further rarities and scarce migrants included 4 Firecrests at the Bill, 3 Black Redstarts at the Bill and Southwell, 2 Woodlarks flying over at Portland Heights, a Merlin at the Bill, a late Yellow Wagtail over Top Fields and Weston, a Treecreeper at Old Hill and a Serin at Barleycrates Lane. Thrushes, finches and Reed Buntings continued to pass through in some numbers and there was also an influx of new Goldcrests; Swallows still linger on, with at least 30 at the Bill alone.
October 27th Same weather, same trickle of birds. Bramblings and Reed Buntings, with counts of 25 and 20 respectively, were conspicuous at the Bill early in the morning where all the other usual suspects also passed through in small numbers; a fly-over Serin, 3 Mistle Thrushes, a Merlin, a Black Redstart and a Firecrest were the best of the oddities there. The only news from other sites was of 2 Firecrests at both Pennsylvania Castle and Avalanche Road.
October 26th Another day of typical late autumn passage that produced small numbers of all the expected commoner migrants. Less regular species around the island included Firecrests at Verne Common (5), the Bill (3) and Wakeham, 4 Yellowhammers, a Merlin and a Woodlark at the Bill, a Short-eared Owl at Barleycrates Lane, a Treecreeper at Pennsylvania Castle and a Black Redstart at Broadcroft Quarry.
October 25th More of the same today, although rarities and scarce migrants were all but absent. Counts from the Bill area included 20 Redwings, 15 Bramblings, 8 Fieldfares, 5 Redpolls, 3 Siskins, 3 Reed Buntings, 2 Firecrests, a Golden Plover and a Ring Ouzel. Elsewhere there were 32 Redwings, 11 Fieldfares, a Mistle Thrush and a Firecrest at Verne Common, a late Whinchat lingering on at Barleycrates Lane, a Black Redstart at Easton and further Firecrests at Avalanche Road (2), Pennsylvania Castle (2), the Grove (2) and Southwell.
October 24th A calmer day that saw plenty of common migrants on the move again (with a week of the month still to go, the total of more than 1250 birds trapped and ringed already constitutes the highest October ringing total recorded at the Obs). Thrushes and finches were again numerous, and there were still good numbers of alba Wagtails, Meadow Pipits, Stonechats, Goldcrests and Reed Buntings passing through. In the very fine weather it was no surprise that none of the rarities and scarcer migrants reported lingered for more than a few minutes; highlights included a Serin at Culverwell, a Richard's Pipit and 2 Lapland Buntings at Reap Lane, a Woodcock, a Woodlark and a Corn Bunting at the Bill and another Woodcock at Verne Common.
Brambling - Portland Bill, October 23rd 2003 © James Lees
October 23rd Quite a disappointing day, with the stir-up in the weather yesterday failing to produce any obvious reward today. Thrushes and finches, including a Mistle Thrush and a Ring Ouzel at the Bill, were still on the move in small numbers, but the only slightly scarcer migrants seen were 2 Firecrests at the Obs and another at Verne Common, a Short-eared Owl at the Bill and a Water Rail at Culverwell. Three Teal were the only birds of note passing through on the sea at the Bill.
Lapland Bunting - Blacknor, October 22nd 2003 © James Lees
October 22nd The first substantial rainfall for many weeks made serious birding a less than inviting proposition and there were relatively few observations to report. A settled Lapland Bunting at Blacknor was the best find of the day, whilst scarcer migrants still around included single Ring Ouzels at the Bill and Priory Corner, a Merlin at the Bill and several Firecrests at the Bill, Avalanche Road and the former Weston Craft Centre. A few thrushes and finches trickled through but otherwise the rain seemed not to have dropped many new common migrants.
Dartford Warbler - Portland Bill, October 21st 2003 © James Lees
October 21st The calmest day for a couple of weeks saw a good selection of typical late autumn birds recorded around the island. Highlights included a Yellow-browed Warbler at Avalanche Road, and a Great Spotted Woodpecker, a Woodlark, a Dartford Warbler and a Lapland Bunting at the Bill. Common migrants, particularly Chiffchaffs, Goldcrests and a variety of finches, passed though in good numbers again, whilst scarcer species included 6 Firecrests at the Bill and another single at Avalanche Road, 2 Black Redstarts at Tout Quarry, single Ring Ouzels at Tout Quarry and the Bill, a Short-eared Owl at Suckthumb Quarry and a Merlin at the Bill.
October 20th The still brisk and cold wind edged into the north after a weak weather front had passed through during the night, and thrushes and finches again moved through in quantity for a couple of hours after dawn. New common migrants were otherwise not particularly plentiful, although Ring Ouzels and Firecrests were still scattered around the island in some numbers, and lone Short-eared Owls were at the Bill and Portland Heights. The rarities of the day proved frustratingly difficult to get to grips with: a very vocal Red-throated Pipit roamed the fields immediately to the north of the Obs for a while early in the afternoon but afforded flight views only; a Richard's Pipit was flushed from Top Fields and left strongly to the north; a Lapland Bunting was another 'fly-over only' at the Bill; and finally, a Yellow-browed Warbler found late in the afternoon at Avalanche Road was heard calling frequently but couldn't be seen.
Mute Swan - Portland Bill, October 19th 2003 © Martin Cade/James Lees
October 19th With strong, cold easterly winds continuing to dominate there were plenty more birds to be seen everywhere. Thrushes, Stonechats, Chiffchaffs, Goldcrests and finches were conspicuous and appeared to be arriving throughout the day; rarities and less regular migrants included at least 12 Ring Ouzels and 6 Firecrests scattered around the island, a Merlin and a Short eared Owl a the Bill, a Yellow-browed Warbler heard briefly at Southwell School, a Continental Coal Tit at Avalanche Road and a Lapland Bunting overhead on the West Cliffs. Another 160 Black-headed Gulls passed through off the Bill, along with 30 Common Scoter, 3 Wigeon, a Brent Goose and Mediterranean Gull. The most peculiar incident of the day concerned the arrival in off the sea and subsequent capture of the first Mute Swan to be ringed at the Bill; having escaped the attention of marauding gulls and made landfall on the East Cliff, this hapless individual was spectacularly plucked from the sky as it tried to take to the air again and duly became one of the more unlikely species to be ringed at the Obs.
October 18th More of the same today. The Continental Coal Tit was still present at the Obs and a second individual was found at Old Hill. A Lapland Bunting was a new arrival at the Bill, where there were also 8 Firecrests and 8 Ring Ouzels; another 2 Firecrests and 7 Ring Ouzels were scattered around the centre and north of the island, and single Short-eared Owls were seen at the Bill and Church Ope. Grounded and fly-over migrants were reasonably plentiful everywhere, and included a noteworthy count of 66 Stonechats between Tout Quarry and the Bill, as well as late records of lone Lesser Whitethroats at Wakeham and Delhi Lane, and a Reed Warbler at the Bill. Black-headed Gulls continued to feature off the Bill, where 352 were counted moving east during the morning.
October 17th Another day of clear skies and strong easterly winds. Grounded migrants were not plentiful, but there was plenty of visible passage overhead and a few more interesting scarcities showed up. A Yellow-browed Warbler was a new arrival at the former Weston Craft Centre, a Treecreeper showed up at Pennsylvania Castle, another Woodlark passed through at the Bill, the Continental Coal Tit remained in the Obs garden, and 15 Ring Ouzels, 7 Firecrests and a couple of Merlins were scattered widely around the Island. An hour-and-a-half sample count of overhead passage at the Bill provided totals of 205 Meadow Pipits, 160 Starlings, 141 Chaffinches, 115 Linnets, 84 Greenfinches, 55 alba Wagtails, 23 Skylarks and smaller numbers of a good variety of other species. Another 102 Black-headed Gulls passed through off the Bill, along with 12 Teal and 5 Brent Geese.
Continental Coal Tit - Portland Bill, October 16th 2003 © Martin Cade
October 16th The wind remained firmly in the east and there was another interesting selection of rarities and scarce migrants on view around the island. A Yellow-browed Warbler remained at Culverwell, and a Great Crested Grebe, a Jack Snipe and a Continental Coal Tit were all new arrivals elsewhere in the Bill area. A fly-over Woodlark at Cheyne Weare was a first for the autumn, whilst there were still 6 Ring Ouzels, 6 Firecrests, 2 Merlins and a Short-eared Owl scattered widely. The variety of common migrants was rather similar to yesterday, although visible passage was a good deal less conspicuous. Seawatching at the Bill produced 102 Black-headed Gulls, 47 Common Gulls, 11 Common Scoter, 3 Great Skuas, a Brent Goose and a Red-breasted Merganser.
Ring Ouzel - West Weare, October 15th 2003 © James Lees
October 15th Another bird-filled day, although birding itself remained very difficult in almost gale force easterlies. Notable new arrivals included a Red Kite over the Verne and Church Ope, a Hen Harrier over Church Ope, a Barn Owl at Wide Street, an 'eastern' Chiffchaff at Old Hill and reports of 1 or more Yellow-browed Warblers at Culverwell; a Cetti's Warbler at Bumpers Lane may have been the individual first seen at the same site (in fact in the same bush!) several weeks ago. Grounded migrants were less numerous than in recent days, although still included at least 23 Ring Ouzels dotted around the north of the island, and 3 Firecrests and 2 Short-eared Owls at the Bill. Ouzels aside, thrush numbers dwindled and the majority of overhead passage consisted of Skylarks, pipits, wagtails and finches moving north; an hour-and-a-half sample count at the Bill in the morning produced totals including 670 Linnets, 440 Meadow Pipits, 105 alba Wagtails, 60 Starlings and 28 Skylarks. Seawatching at the Bill provided a typically motley selection of sightings including 75 Black-headed Gulls, 21 Brent Geese, 9 Teal, a Wigeon and a Pintail.
Kestrel - Portland Bill, October 14th 2003 © Martin Cade
October 14th Rather surprisingly, all of yesterday's rarities had moved on and, although common migrants were still passing through in quantity, the only quality arrivals in their place were a Quail and a Lapland Bunting at the Bill. Thrushes again featured prominently everywhere, with a minimum of 20 Ring Ouzels scattered around the island, as well as counts of 250 Blackbirds, 200 Song Thrushes, 200 Redwings, 10 Fieldfares and 2 Mistle Thrushes passing through at the BIll. Further interest was provided by 3 Black Redstarts, 2 Merlins, 2 Firecrests and a Short-eared Owl at the Bill, and a Hobby over Reforne, whilst among the commoner species there was the first good passage of Starlings of the autumn and a good count of 9 Snipe at the Bill. On the sea, Common Gulls were on the move for the first time, and 12 Wigeon, 3 Dunlin, 8 Brent Geese, 2 Teal, a Curlew and a Little Gull also passed the Bill.
Radde's Warbler, Chiffchaff and 'eastern' Chiffchaff, and Yellow-browed Warbler - Portland Bill, October 13th 2003 © Martin Cade/James Lees
October 13th A storming good day today with several excellent quality rarities and plenty of common migrants. The highlight was a Radde's Warbler trapped and ringed in the Obs garden and released in the Obs Quarry where it showed well throughout the day; the strong supporting cast included a Common Rosefinch in and around the Obs garden for a while at dawn, single Yellow-browed Warblers at the Obs, Southwell and Wakeham, an 'eastern' Chiffchaff trapped and ringed at the Obs, an Osprey and a Marsh Harrier flying south at the Bill and, finally, a elusive Siberian Stonechat that was found at Barleycrates Lane late in the day. Counts of commoner migrants included 460 Chaffinches overhead in the centre of the island, 100 Blackbirds at the Bill, 100 Redwings at both the Bill and Weston, 75 Song Thrushes at Weston and 10 Bramblings at both the Bill and Weston, whilst scarcer migrants included 4 Firecrests at the Bill, 3 Mistle Thrushes at the Bill, Ring Ouzels at Priory Corner (2) and Reap Lane, and a Dartford Warbler at the Bill.
October 12th A howling south-east gale had set in by dawn and with shelter at a premium birding was hard work and pretty unrewarding. Substantial numbers of wagtails, pipits, thrushes and finches were on the move overhead, but the best of the few grounded migrants were 2 Ring Ouzels and 2 Firecrests at the Bill. The hoped-for busy seawatch came to nothing, with only 14 Common Scoter, 2 Grey Plover, a Red-breasted Merganser and an Arctic Skua logged passing the BIll.
October 11th Yesterday's Yellow-browed Warbler showed up briefly in Southwell early in the morning but it was again the only sighting of any great note on the island. In fine, sunny weather grounded migrants were relatively thin on the ground, with the best being 13 Stonechats, 9 Reed Buntings, a Golden Plover, a Whinchat, a Redstart and a Dartford Warbler at the Bill; among the commoner species there were conspicuous influxes of Dunnocks, Great Tits and Greenfinches. Overhead passage was again quite heavy, and included counts of 200 alba Wagtails, 45 Siskins, 12 Bramblings and 5 Redpolls at the Bill.
October 10th After a lean few days for rarities the appearance of a Yellow-browed Warbler in a private garden at Southwell was welcome. Unfortunately the day was otherwise very quiet, with grounded and over-flying migrants in short supply. The Bill area produced just 10 Chiffchaffs, 5 Blackcaps, 4 Goldcrests, 2 Wheatears, a Merlin and a Firecrest on the ground, as well as 500 Linnets and small numbers of pipits, wagtails and other finches passing through overhead. The only report from elsewhere was of a lone Reed Bunting at Suckthumb Quarry.
October 9th Plenty more routine October passage but still not a hint of anything remotely out of the ordinary. Overhead passage again dominated at the Bill, where 800 Linnets, 300 Meadow Pipits, 300 alba Wagtails, 50 Siskins, 40 Chaffinches, 15 Skylarks and 3 Reed Buntings passed through. On the ground there were more Stonechats in evidence, but otherwise just a sprinkle of Blackcaps, Chiffchaffs and Goldcrests everywhere; a late Redstart was at Wakeham and a late Whitethroat at the Bill, but the only scarcer migrants were a Merlin and a Firecrest at the Bill. Seawatching at the Bill produced 17 Common Scoter, a Red-throated Diver, a Sooty Shearwater and an Arctic Skua.
October 8th A milder but still overcast day that produced quite a bit more movement. Overhead passage was surprisingly heavy, with totals at the Bill of 1300 Linnets, 200 alba Wagtails, 150 Goldfinches, 75 Chaffinches, 35 Siskins, 3 Reed Buntings, 2 Redpolls and 2 Bramblings flying south. Grounded migrants included small numbers of Blackcaps, Chiffchaffs and Goldcrests everywhere, but still nothing better than a Merlin and a Firecrest at the Bill. Only sheer persistence provided any reward on the seawatchhing front, with the majority of the total of 8 Great and an Arctic Skua seen at the Bill passing through during a brief flurry of action during the afternoon.
October 7th The blustery north-westerly weather continued and land and sea were both pretty quiet. Seawatching at the Bill produced 4 Arctic and 3 Great Skuas as well as a report of a lone Leach's Petrel, and there was little more interesting than a Merlin and a Reed Bunting on the land there. Elsewhere there were 4 Brent Geese at Ferrybridge and a Firecrest at Pennsylvania Castle.
Common Rosefinch - Portland Bill, October 6th 2003 © Martin Cade
October 6th After a wet and at times quite stormy night it was a surprise that there were a few new arrivals on the land. The highlights were another Common Rosefinch trapped and ringed at the Obs (the sixth island record this year) and a Dartford Warbler reported at Southwell. Among the scatter of Blackcaps, Chiffchaffs and Goldcrests at the Bill there was also a Redstart, a Garden Warbler and a Reed Bunting. Despite the wind veering back into the north-west the sea provided some interest, with 5 Arctic and 3 Great Skuas and a lone Balearic Shearwater passing the Bill.
Pied Wagtail - Portland Bill, October 5th 2003 © Martin Cade
October 5th Overhead passage dominated again today, with Meadow Pipits, alba Wagtails, Chaffinches and Linnets still on the move in quantity; among the variety of other species logged there were 90 Siskins over the Bill, the first 2 Bramblings of the autumn at Culverwell, 3 Lapland Buntings over Southwell and a Snow Bunting over Barleycrates Lane. On the ground there were still fair numbers of Chiffchaffs and Goldcrests everywhere, whilst oddities included 2 Firecrests, a Short-eared Owl, a Turtle Dove and a Ring Ouzel at the Bill, another Turtle Dove at Barleycrates Lane, another Firecrest at Avalanche Road and a Treecreeper at Southwell School. The sea remained very quiet in the strong offshore winds, with nothing more interesting than 2 Arctic Terns and an Arctic Skua off the Bill.
October 4th The return of chilly, blustery north-westerlies saw to it that there were fewer grounded migrants but a lot more overhead passage today. Visible passage totals at the Bill included 1500 Meadow Pipits, 1500 Linnets, 400 alba Wagtails, 300 Goldfinches, 100 Chaffinches, 55 Siskins, 6 Golden Plovers and 5 Reed Buntings. Blackcaps, Chiffchaffs and Goldcrests made up the bulk of the few grounded migrants everywhere, with the only oddities reported being a Merlin and a Firecrest at the Bill, a Ring Ouzel at Reforne, and a flock of 23 Ravens over Verne Common. Seawatching at the Bill produced 2 Little Egrets, 2 Brent Geese, a Great Northern Diver, a Red-breasted Merganser and a Pomarine Skua, whilst waders at Ferrybridge included 4 Bar-tailed and a lone Black-tailed Godwit.
Chiffchaff - Portland Bill, October 3rd 2003 © Martin Cade
October 3rd After a long time of waiting, dawn saw almost perfect 'fall' conditions over the island and the few birders around were certainly not disappointed by the events of the day. Chiffchaffs and Blackcaps dominated, with totals at the Bill alone of 400 and 200 respectively; other counts from there included 500 House Martins, 300 alba Wagtails, 300 Linnets, 40 Siskins, 30 Song Thrushes, 25 Chaffinches, 8 Redstarts and 6 Redwings. Trapping effort at the Obs and Culverwell produced a joint day total of 253 new birds ringed - more than double the previous highest day total this year. Scarcer migrants around the island included at least 4 Firecrests and a couple of Ring Ouzels, whilst rarity interest was provided by a Cirl Bunting briefly at Culverwell (the first island record for ten years), a Common Rosefinch at Tilleycombe and a presumed Siberian Chiffchaff at Culverwell.
October 2nd More variety today although numbers remained pretty poor. The only rarity reported was a Red Kite that did a round of the island during the morning. The Bill area produced counts of 30 Wheatears, 25 Chaffinches, 10 Chiffchaffs, 6 Yellow Wagtails, 5 Redstarts, 3 Tree Pipits, 3 Song Thrushes, 3 Whinchats, a Hobby, a Snipe, a Dunlin, a Turtle Dove, a Ring Ouzel, a Sedge Warbler, a Garden Warbler, a Goldcrest and a Siskin. Elsewhere there were 3 Firecrests at Easton and 2 Turtle Doves at Suckthumb Quarry.
Common Rosefinch - Portland Bill, October 1st 2003 © Martin Cade
October 1st There was an encouraging start to the new month when a Common Rosefinch was trapped and ringed in the Obs garden early in the morning. Searching for common migrants was hard work in very strong easterly winds and, as the day went on, increasingly heavy rain; however, the Bill area produced the first flurry of migrant Blackbirds of the autumn, as well as a sprinkle of other common migrants, 5 Grey Herons, 2 Hobbies, a Golden Plover and a Snipe. Six Wigeon and 2 Great Skuas were the only birds of note on the sea.


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You are here: Home / Health / Researchers Look to MRI and Biomarkers to Help Improve Detection of Aggressive...
Researchers Look to MRI and Biomarkers to Help Improve Detection of Aggressive Prostate Cancers
July 1, 2015 /in Health, Southern Africa, Wellness /by ganewsadmin
A patient's wife once told urology surgeon Peter Pinto, MD, that there was no way she'd agree to have a dozen biopsy needles stuck blindly into her breast just because a blood test suggested she might have cancer.
But that's exactly what happens with many men whose cancer screening test reveals an elevated level of prostate-specific antigen, or PSA, in their blood. Although mammography provides images of suspicious breast lesions to guide biopsy needles, prostate cancer is the only type of solid organ tumor that is usually diagnosed sight unseen with hit-or-miss tissue biopsies.
Magnetic resonance (MR)/ultrasound fusion combines MR images of the prostate (bottom left, red line) with real-time ultrasound images of the prostate (top left, red line) to assist in targeted biopsy of a previously identified lesion (green line). The location of the biopsy can be recorded (yellow line), and a reconstructed 3-dimensional map of the prostate can be generated at the conclusion of the biopsy (right). Standard biopsy cores and targeted biopsy cores are highlighted here for comparison.
Rita Rubin, MA
Imaging the prostate simply doesn't offer enough information for disease detection. Transrectal ultrasound, routinely used during prostate biopsies, provides images of the gland but not of the tumors inside of it. For decades, urologists have used a systematic but blind approach to sample prostate tissue in men with an elevated PSA level and no palpable lesion, taking up to 18 core needle biopsies in scattered sections of the organ. But they can't be sure that they haven't missed an aggressive tumor hidden in the 99% of tissue that's not biopsied, and they sometimes end up sticking needles into men who have no tumors, only an elevated PSA level.
Before the PSA test became available nearly 30 years ago, physicians didn't look for prostate tumors in asymptomatic men, let alone treat them, and autopsy studies found that some died with indolent cancers that never caused any harm. But the simple blood test has led to what many consider the overdiagnosis and overtreatment of low-risk prostate cancers, which can leave men impotent, incontinent, or both.
The PSA test's imperfections have spurred scientists to search for new imaging approaches and biomarkers to improve the diagnosis and management of prostate cancer, expected to cause 27 540 deaths in the United States this year (http://bit.ly/1IKzCOd). It's not clear whether these tools could ever be used as primary screens for prostate cancer, but they hold promise as a next step after PSA screening suggests a man might have the disease. The goal: to better detect high-risk tumors and distinguish them from low-risk tumors, thereby optimizing the chance that men who are most likely to benefit from biopsies or treatments will be the most likely to get them.
One approach combines transrectal ultrasound's ease of use with the wealth of information magnetic resonance imaging (MRI) can provide. Thanks to a recent advance called multiparametric MRI, specially trained radiologists can gauge the aggressiveness of a prostate lesion not only by how it looks but also by how tightly its cells are packed, how blood flows through it, and its chemical makeup.
For now, a urologist must biopsy the lesion in question to confirm the radiologist's findings, but performing the procedure while a man is in the MRI tube is cumbersome, time-consuming, and expensive. Instead, urologists can electronically fuse MRIs with real-time transrectal ultrasound in their office and then aim biopsy needles directly at lesions.
The US Food and Drug Administration has approved a handful of systems that fuse prostate MRIs with transrectal ultrasound. For the most part, however, the technology remains the bailiwick of research centers trying to pinpoint its place in the prostate cancer diagnostic continuum.
In a new prospective study published recently in JAMA, Pinto, a faculty member in the urologic oncology branch at the National Cancer Institute (NCI), and his colleagues analyzed data from 1003 men referred for an elevated PSA level or abnormal digital rectal examination. The investigators found that targeted biopsy using MR/ultrasound fusion diagnosed more high-risk cancers and fewer low-risk cancers than conventional biopsy (Siddiqui MM et al. JAMA. 2015;313[4]:390-397). Pinto's team used a platform called UroNav, the result of nearly a decade's research conducted mainly at the NCI, although the NCI scientists have no financial stake in the product.
The study began enrolling men in 2007, but "this paper does not have the long-term follow-up to see improvements in prostate cancer–specific mortality or overall mortality. For prostate cancer, that often takes years and decades," Pinto says. "We are following these patients and look forward to future publications."
MINIMIZING BIOPSY RATES
MINIMIZING BIOPSY RATES | ROLE IN ACTIVE SURVEILLANCE
Medicare beneficiaries undergo more than 1 million prostate biopsies each year, according to a recent analysis (Loeb S et al. J Urol. 2011;186[5]:1830-1834).
Although the outpatient procedure is often described as simple, the study found that 6.9% of men who underwent a prostate biopsy were hospitalized within the next 30 days, compared with only 2.7% of control participants who had not had a prostate biopsy. Although the hospitalization rate after a prostate biopsy declined from 1991 to 2007, the period studied, the risk of infectious complications requiring hospitalization after biopsy significantly increased.
Minimizing biopsy rates is an important goal in the effort to prevent overtreatment of prostate cancer, says Laurence Klotz, MD, a urology surgeon at the University of Toronto. "Men don't like biopsies," Klotz says. "They get infections. They get erectile dysfunction."
Klotz estimates that one-half to two-thirds of men with an elevated PSA level won't have a lesion on multiparametric MRI. Even if MRI reveals what appears to be a tumor, he says, chances are that 2 or 3 biopsy needles would suffice instead of the standard dozen used in conventional systematic prostate biopsy procedures. "If it were me, I would elect to have a targeted biopsy …any day," Klotz says.
At the University of California, Los Angeles (UCLA), virtually all men with a PSA level between 4 and 10 get a multiparametric MRI before proceeding to biopsy, urology professor Leonard Marks, MD, says. "It does raise the price of poker when you do the MRI before biopsy," Marks says. But without an MRI, you'd have to biopsy 4 men to find 1 cancer, and only half of those cancers would be potentially life-threatening, he says. "A lot of these men undergo biopsies over and over again."
Still, those blind biopsies miss aggressive tumors, Marks says, citing the case of a UCLA dental school faculty member who, because of an elevated PSA level, underwent 8 systematic biopsy procedures, all negative, over 10 years. It wasn't until he had a multiparametric MRI that an aggressive tumor was detected and, with MR/ultrasound fusion, biopsied, resulting in a prostatectomy.
Even if nothing suspicious is seen on the MRI, Marks says, he will still do a systematic biopsy procedure in men with an elevated PSA level using an MR/ultrasound fusion device called Artemis. Artemis allows him to map the biopsy for future reference. "Some important tumors, maybe 20%, are 'MRI invisible,' so it's important at least once to do the mapping biopsy," he says.
Urologist Geoffrey Sonn, MD, who trained with Marks at UCLA and is now on the faculty at Stanford, notes that for now, "we don't know for sure what a negative or normal MRI means," which is why he also performs a "mapping biopsy" if no lesion is seen. However, Sonn says, the tumors that multiparametric MRI is most likely to miss are small, low-grade cancers. "We think that the vast majority of the ones we want to find are visible on the MRI."
A study by Sonn and Marks and other colleagues at UCLA supports his point (Sonn GA et al. Eur Urol. 2014;65[4]:809-815). The researchers found that MR/ultrasound fusion biopsy revealed prostate cancer in 36 of 105 men with elevated PSA values who previously had a negative conventional biopsy. And most of those cancers were clinically significant.
The day is coming when urologists will feel confident enough about a negative multiparametric MRI finding to stop needing to perform a confirmatory mapping biopsy with MR/ultrasound fusion, Pinto predicts. "My personal opinion …is that MRI will become a filter to avoid unnecessary biopsies."
Still, Marks says, "MRI is never going to be as easy as a PSA blood test. MRI is the next level. What we need is a better screening test." Concern about overtreatment and overdiagnosis led the US Preventive Services Task Force in 2012 to advise against screening average-risk men with no prostate cancer symptoms (http://bit.ly/1JfANpa). And in 2013, the American Urological Association (http://bit.ly/1KK6WJ3) and the American College of Physicians (http://bit.ly/1utrosM) published prostate cancer screening guidelines recommending that physicians discuss the risks and benefits of screening with patients before proceeding.
As with multiparametric MRI, commercially available biomarker tests, such as those that measure various forms of PSA in the blood (http://bit.ly/1umbhrn), can be used after screening detects an elevated PSA level.
One biomarker entering the prostate cancer screening arena is prostate cancer antigen 3 (PCA3), a gene that is overexpressed in prostate cancers and can be measured in urine (http://bit.ly/1J8I3Vr). A recent NCI study at 11 medical centers concluded that the use of PCA3 testing among men screened with PSA could reduce the burden of prostate biopsies in men undergoing a repeat biopsy (Wei JT et al. Clin Oncol. 2014;32[36]:4066-4072). A high PCA3 score in men who haven't had a biopsy significantly increases the likelihood that an initial biopsy will identify cancer, the researchers found.
Additional advances have suggested the potential diagnostic and prognostic utility of multipanel urinary biomarker screens that measure PCA3 along with the TMPRSS2:ERG fusion transcript, which has been reported to be present in more than 50% of PSA-screened prostate cancers (Tomlins SA et al. Sci Transl Med. 2011;3[94]:94ra72; Leyten GH et al. Eur Urol. 2014;65[3]:534-542).
However, many of these tests are not currently in widespread clinical use, and studies are ongoing to further validate their clinical utility.
ROLE IN ACTIVE SURVEILLANCE
Some urologists predict that multiparametric MRI could be useful for men who have opted for active surveillance—sometimes called "watchful waiting"—instead of treatment for what appears to be indolent prostate cancer. "In the ideal world, every single patient going on surveillance would have an MRI," says Klotz, coauthor of a recent review article about using MRI in active prostate cancer surveillance (Schoots IG et al. Eur Urol. doi:10.1016/j.eururo.2014.10.050 [published online November 15, 2014]).
About 1 in 4 men who chose active surveillance actually harbor a more aggressive cancer than their original systematic biopsy suggested, he says. Over a period of 15 years, perhaps 1 in 50 men on active surveillance die because their aggressive cancer wasn't detected soon enough, Klotz says.
Klotz is the principal investigator in a multisite clinical trial seeking to determine whether MR/ultrasound fusion biopsy can improve selection of patients eligible for active surveillance (http://1.usa.gov/1yrhbNd). He says the study has nearly finished enrolling 300 active surveillance patients who are being randomized to receive either a conventional systematic biopsy or an MR/ultrasound fusion targeted biopsy a year after they enter the study, so the results won't be available until 2016.
"I do have patients for whom I am more likely to recommend active surveillance …just because I'm reassured by having an MRI that doesn't look that abnormal," Sonn says.
Johns Hopkins offers active surveillance patients the opportunity to have an MRI during their first year in the program, says H. Ballentine Carter, MD, director of the adult urology division and codirector of the active surveillance program. "We offer it as a way of decreasing the risk that we're misclassifying people," Carter says. "We try to emphasize to them that we're still learning about MRI. We don't have all the answers. We don't know that this test will provide any outcomes that will be meaningful to them."
Although he doesn't think that MRI adds much for men who meet all of the criteria for Hopkins' active surveillance program, more than 90% ask for one, Carter says. "It's another piece of information …to help ensure that we're monitoring the right person." If nothing suspicious is seen on the MRI, doctors will still perform a systematic biopsy. "Our hypothesis is that men who have nothing suspicious on an MRI are extremely unlikely to have something serious later on," he says.
Carter and the other physicians expressed concern that marketing practices for MR/ultrasound fusion technology are ahead of the science. For example, search for "UroNav" or "Artemis" on Google, and you'll find several community urology practices touting that they have it.
"That kills me," Pinto says. "All we can do is continue to publish and continue to train."
Radiologists who are inexperienced in interpreting prostate MRIs tend to see tumors around every corner, Klotz says. "Reading these multiparametric MRIs is a fairly specialized skill, and that skill is just diffusing out there."
Still, he predicts, multiparametric MRI might one day supplant the need for prostate biopsies, as computed tomographic scans have in the treatment of kidney cancer. Says Klotz: "The imaging is so powerful."
read more at JAMA
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