text:
Aggiornamento del 27 novembre 2012
1. Gynecol Obstet Fertil. 2012 Nov;40(11):687-90. doi: 10.1016/j.gyobfe.2012.09.016.
Epub 2012 Oct 23.
reproduction]. [Article in French]
Boyer P, Tourame P, Gervoise-Boyer M.
Service de médecine et biologie de la reproduction, hôpital
Saint-Joseph-de-Marseille, 26, boulevard de Louvain, 13008 Marseille, France.
Electronic address: email@example.com.
Oocyte vitrification is a new technique in cryobiology that will lead to a number
of improvements in assisted reproduction practices, oocyte donation and the
preservation of female fertility. Professionals already versed in the techniques
of micromanipulation will be able to master the new procedures, which should not
be delegated to unqualified staff. When adopted by clinical units, oocyte
vitrification will require changes in laboratory and administrative organization.
The technique will also modify the ethical outlines of reproductive biology.
France today is running behind in the application of this major development in
cryobiology. The reasons are many and have to do with a long waiting period for
authorization from national health authorities, a lack of material and human
resources and a foreseeable shake-up in the nationally established egg donation
program. However, recently a new law of bioethics has recognized the breakthrough
that this new technique represents by allowing couples covered by the French
national health care program for Assisted Reproductive Technologies (ART) to
choose oocyte vitrification as an option.
Copyright © 2012 Elsevier Masson SAS. All rights reserved.
PMID: 23099025 [PubMed – in process]
2. Hum Reprod. 2012 Oct;27(10):2886-93. doi: 10.1093/humrep/des250. Epub 2012 Jul
Implications of oocyte cryostorage for the practice of oocyte donation.
Mertes H, Pennings G, Dondorp W, de Wert G.
Bioethics Institute Ghent, Ghent University, Ghent, Belgium.
As the efficiency of oocyte cryopreservation has increased rapidly in recent
years, oocytes are currently being stored either in the course of IVF treatments
or as a fertility preservation measure. These practices may have an impact on the
number of available donor oocytes due to two different dynamics: first, a certain
percentage of women for whom oocytes were cryopreserved will eventually not use
their oocytes and may decide to donate them to others; secondly, especially in
the practice of social freezing, women may opt to donate a portion of the
retrieved oocytes in 'freeze-and-share' schemes in order to reduce the costs. In
this article, we aim to sketch the ethical implications of such developments in
general and the issue of payment to oocyte donors in particular.
PMID: 22802093 [PubMed – in process]
3. Arch Dis Child. 2012 Sep;97(9):767-8. doi: 10.1136/archdischild-2012-301836. Epub
2012 Jul 11.
The ethical obligation to preserve fertility in the face of all therapies that
might adversely affect it.
Larcher V.
Adolescent Medicine, Great Ormond Street Hospital NHS Trust, Great Ormond Street,
London, UK. firstname.lastname@example.com
PMID: 22789439 [PubMed – indexed for MEDLINE]
4. Ceska Gynekol. 2012 Apr;77(2):163-6.[Medical, legal and ethical aspects of fertility preservation in cancer
survivor]. [Article in Czech]
Záhumenský J, Kucera E, Kosová T, Zmrhal J, Stejskal M, Stejskal D.
Gynekologicko-porodnická klinika 3. LF UK a FN KV. firstname.lastname@example.com
In recent years the number of the young women in fertile age which are
oncologically treated is increasing. For these women chemotherapy and
radiotherapy introduces potential risk of reproductive dysfunctions. Present
techniques of assisted reproduction are offering possibilities to save
reproductive functions even after the oncological treatment. As a perspective
outlook seems to be frozen premature oocytes with IVM and fertilisation. With
these fertility savings methods are naturally coming up some of the ethical and
legal issues.
PMID: 22702076 [PubMed – indexed for MEDLINE]
5. Best Pract Res Clin Obstet Gynaecol. 2012 Dec;26(6):853-63. doi:
10.1016/j.bpobgyn.2012.04.002. Epub 2012 May 16.
Ethical issues in infertility treatment.
Pennings G, Mertes H.
Bioethics Institute Ghent, Ghent University, Blandijnberg 2, Gent 9000, Belgium.
Electronic address: firstname.lastname@example.com.
Two currently contentious domains in infertility treatment are discussed:
assisted reproduction for same-sex couples and fertility preservation for women
with cancer. Despite an increasing recognition of the rights of same-sex couples,
in many countries they are still not eligible for assisted reproductive
technology. The main justification for excluding same-sex couples from treatment
is that the welfare of the future children would be compromised. Empirical
evidence, however, shows that this is not the case. Another group of
non-infertile women seeking assistance from reproductive medicine are women with
cancer who are at risk of impaired or lost fertility as a result of their illness
or cancer treatment. In this field, the future holds many promising options.
Several of these, however, are currently in an experimental phase, which elicits
ethical concerns about participant recruitment and research participation of
Copyright © 2012 Elsevier Ltd. All rights reserved.
PMID: 22595822 [PubMed – in process]
6. Gynecol Endocrinol. 2012 May 10. [Epub ahead of print]
Fertility preservation for women with malignant diseases: ethical aspects and risks.
Küçük M.
Department of Obstetrics and Gynecology, Faculty of Medicine, Adnan Menderes University , Aydin , Turkey.
As cancer treatment becomes more and more effective, there is greater life expectancy for cancer patients. Because of this, depending upon the modality used in the treatment of cancer, the matter of infertility emerges before us as an issue of increasing significance. Sperm cryopreservation and embryo cryopreservation are well-established methods of fertility preservation (FP). Besides these validated FP options, some FP techniques such as oocyte cryopreservation and ovarian tissue cryopreservation are as yet in the experimental stage. FP medicine has experienced some rapid developments in recent years. The advances in this branch of medicine, however, have also brought about new ethical, medical and legal issues. Some of these include problems with obtaining the informed consent of minors, issues that arise because of the experimental nature of some methods, financial problems and the accessibility of FP methods, and the question of what happens to gametes when a patient dies. This review seeks to discuss, in the light of current literature, some ethical and technical issues and risks related to the implementation of FP methods in women with cancer.
PMID: 22571650 [PubMed – as supplied by publisher]
7. Obstet Gynecol Int. 2012;2012:139193. Epub 2012 Feb 16.
Fertility preservation in girls. Michaeli J, Weintraub M, Gross E, Ginosar Y, Ravitsky V, Eizenman E, Mitrani E, Lebovich M, Laufer N, Kennedy S, Revel A.
Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical
Center, 91120 Jerusalem, Israel.
Children that undergo treatment for cancer are at risk of suffering from subfertility or hormonal dysfunction due to the detrimental effects of radiotherapy and chemotherapeutic agents on the gonads. Cryopreservation of ovarian tissue prior to treatment offers the possibility of restoring gonadal function after resumption of therapy. Effective counseling and management of pediatric patients is crucial for preserving their future reproductive potential. The purpose of this article is to review recent literature and to revise recommendations we made in a 2007 article. Pediatric hemato-oncology, reproductive endocrinology, surgery, anesthesia and bioethics perspectives are discussed and integrated to propose guidelines for offering ovarian cryopreservation to premenarcheal girls with cancer.
PMID: 22496695 [PubMed – in process]
8. Fertil Steril. 2012 May;97(5):1044-7. Epub 2012 Mar 3.
A persistent misperception: assisted reproductive technology can reverse the "aged biological clock".
Wyndham N, Marin Figueira PG, Patrizio P.
Center for Bioethics, Yale University, New Haven, Connecticut.
Delaying motherhood should be a free choice made in full knowledge of all the consequences, but modern women have alarming misconceptions about their own reproductive systems and the effectiveness of assisted reproductive technologies. Doctors and health professionals must begin to discuss fertility preservation with their patients and make sure that young women truly understand all their options. Preventing age-related infertility is the responsibility not only of doctors and medical practitioners but also of society at large. Social, economic, and personal pressures are causing women to decide to conceive later in life, yet those who choose to delay motherhood are stigmatized as being selfish and unconcerned about starting a family. This stigma must be banished, and age-related infertility should be faced as a medical problem.
Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
PMID: 22386844 [PubMed – in process]
9. Adv Exp Med Biol. 2012;732:187-96.
Fertility preservation in cancer patients: ethical considerations.
Bower B, Quinn GP.
PMID: 22210262 [PubMed – indexed for MEDLINE]
10. Pediatr Clin North Am. 2011 Oct;58(5):1201-15, x.
Optimizing potential for fertility: fertility considerations for the
Lee PA, Rogol A, Houk CP.
USA. email@example.com
Whether for the prepubertal or pubertal child, the goal of fertility preservation is to obtain cells or tissues to be used to produce future children. For the prepubertal child, preservation efforts involve germ cells, earlier forms of sperm, and immature follicles, rather than mature spermatozoa or follicles. Options for prepubertal children include for boys freezing testicular tissue and extracting testicular sperm or for girls obtaining ovarian cortical or follicular tissue for storage. These procedures involve extraction and storage of immature gametes for subsequent in vitro maturation, although attempts for sperm currently involve only animal studies. For adolescent subjects who have sufficient gonadal development and reserve, sperm, oocytes, and ovarian cortex can be retrieved as among adults.
Copyright © 2011 Elsevier Inc. All rights reserved.
PMID: 21981956 [PubMed – indexed for MEDLINE]
11. J Adolesc Health. 2011 Oct;49(4):337-46. Epub 2011 Mar 15.
Who decides? Decision making and fertility preservation in teens with cancer: a review of the literature.
Quinn GP, Murphy D, Knapp C, Stearsman DK, Bradley-Klug KL, Sawczyn K, Clayman
Florida, Tampa, Florida 33612, USA. firstname.lastname@example.com
PURPOSE: The knowledge that cancer treatment may impair fertility in pediatric populations is an emerging aspect of quality of life in this population. However, decision making and use of fertility preservation (FP) among adolescent cancer patients and their families has not been well studied. This review summarizes the available published data on aspects of decision making and FP in adolescent cancer patients.
METHODS: An electronic search was performed to identify peer-reviewed studies published between 1999 and 2009 using key Medical Subject Heading terms and inclusion criteria. Inclusion criteria limited eligible studies to those that focused on adolescent decision making in cancer treatment or FP, fertility concerns in pediatric oncology, capacity for decision making, and health decision making in pediatrics. Studies that did not meet at least one of these criteria were excluded.
RESULTS: A total of 29 articles were reviewed and summarized. Three categories of results were seen: a focus on adolescent decision making in oncology, decision making in chronic illness, and decision making in cancer-related infertility and preservation.
CONCLUSION: Most of the studies showed that adolescents have a strong desire to participate in decisions related to their cancer treatment and many have concerns regarding their future fertility, although barriers often prevented these discussions. More research is needed to explore the role of teenagers and parents in decisions about fertility in relation to cancer treatment.
Copyright © 2011 Society for Adolescent Health and Medicine. Published by
Elsevier Inc. All rights reserved.
PMCID: PMC3179606 [Available on 2012/10/1]
PMID: 21939862 [PubMed – indexed for MEDLINE]
12. Womens Health (Lond Engl). 2011 Sep;7(5):537-43.
Fertility preservation in women with cancer: importance of a multidisciplinary approach.
Treves R, Grynberg M, Hesters L, Frydman R.
Antoine Béclère, Clamart, France. firstname.lastname@example.com
For all patients affected by a disease that could impair fertility before or during the reproductive lifespan, strategies to preserve their fertility and the ability to bear their own children is likely to be of utmost importance. While fertility preservation is a promising option, most of the technologies currently used are far from being well-established or are still experimental. Patients should be aware that no method guarantees success. Psychological and ethical impacts of fertility preservation are major concerns and should be included in the multidisciplinary approach to the patients.
PMID: 21879822 [PubMed – indexed for MEDLINE]
13. Gynecol Obstet Fertil. 2011 Sep;39(9):497-500. Epub 2011 Aug 4.
[Female fertility preservation: feasibility of emergency IVF for embryo freezing].
[Article in French]
Courbiere B, Saias-Magnan J, Metzler-Guillemain C, Perrin J, Noizet A, Gamerre M.
Conception, 147 boulevard Baille, Marseille, France. firstname.lastname@example.com
With the improvement of the anticancerous treatments, the preservation of the feminine fertility before gonadotoxic treatment tends at present to stand out as a legal obligation, with a duty of information to patients. When emergency IVF can be performed, the cryopreservation of embryos is the best mastered method which offers most chances to patients to obtain a pregnancy after cancer remission thanks to the transfer of frozen embryos. This article proposes an overview about the indications, the feasibility and the ethical and practical limitations of IVF emergency for embryo freezing before gonadotoxic anticancerous treatment.
Copyright © 2011 Elsevier Masson SAS. All rights reserved.
PMID: 21820346 [PubMed – indexed for MEDLINE]
14. Int J Gynaecol Obstet. 2011 Oct;115(1):11-5. Epub 2011 Jul 20.
Medical, ethical, and legal considerations in fertility preservation.
Shah DK, Goldman E, Fisseha S.
Medical School, Boston 02115, USA. email@example.com
The past 2 decades have seen a significant rise in cancer survival rates, and an increasing proportion of survivors at reproductive age are interested in childbearing. Although assisted reproduction provides physicians with an array of potential possibilities to help patients whose fertility is compromised by cancer treatment, there is still a dearth of regulation regarding the application of this technology. The present paper reviews the current options for fertility preservation, with a particular focus on the legal and ethical challenges that confront providers of this type of care.
Copyright © 2011 International Federation of Gynecology and Obstetrics. Published
by Elsevier Ireland Ltd. All rights reserved.
PMID: 21767834 [PubMed – indexed for MEDLINE]
15. J Gynecol Obstet Biol Reprod (Paris). 2011 Oct;40(6):487-91. Epub 2011 Jul 1.
[Fertility preservation in cancer women: a multidisciplinary approach].
[Article in French]
Trèves R, Grynberg M, Hesters L, Fanchin R, Frydman R.
Service de gynécologie-obstétrique et médecine de la reproduction, hôpital
Antoine-Béclère, AP-HP, 157, rue de Porte-de-Trivaux, 92141 Clamart, France.
Over the past two decades, major advances in diagnostic modalities and treatment have markedly improved rates of cure for adult cancers. As a consequence, the number of long-term survivors is increasing, and fertility preservation has become a major issue for young patient about to start treatment for cancer. Whether fertility preservation is a promising option, most of the technologies currently used are far from being well established or are even still experimental. Patients should be aware that no method guarantees success. Psychological and ethical impacts of fertility preservation are major concerns and should be included in the multidisciplinary approach of the patients.
Copyright © 2011 Elsevier Masson SAS. All rights reserved.
PMID: 21723676 [PubMed – indexed for MEDLINE]
16. J Gynecol Obstet Biol Reprod (Paris). 2010 Dec;39(8 Suppl 2):S53-66.
[Preservation of fertility in case of sterilizing treatment].
[Article in French]
Bringer-Deutsch S, Belaisch-Allart J, Delvigne A.
France. email@example.com
The different options of fertility preservation must be approached with all patients before initiating any cancer therapy and physicians should refer each patient treated during their reproductive years to specialists in a specialized center that will evaluate the best available alternatives to preserve male and female fertility.The only efficiently proven ways of fertility preservation are sperm cryopreservation for men and embryo cryopreservation to preserve couple fertility. However, the recent progress observed with oocyte cryopreservation (in particular the oocyte vitrification) may change our practices in the future if vitrification is allowed in France. Although the law of Bioethics of 2004 authorizes the ovarian cryopreservation today, its modalities of use stay at present at the stage of the research. But in spite of the low number of published births today in France and in the world, the ovarian tissue cryopreservation is a promising technique. It remains the last possible alternative to protect fertility of prepubertal girls. The sperm cryopreservation must be systematically proposed to all men (even teenagers) undergoing a treatment for cancer potentially harmful for their fertility whatever their sperm quality. The testicular tissue cryopreservation is also a method to be discussed for adults, teenagers in case of failure of sperm banking or for prepubertal boys.
Copyright © 2010 Elsevier Masson SAS. All rights reserved.
PMID: 21185487 [PubMed – indexed for MEDLINE]
17. J Law Med Ethics. 2010 Winter;38(4):832-9. doi: 10.1111/j.1748-720X.2010.00536.x.
Insuring against infertility: expanding state infertility mandates to include fertility preservation technology for cancer patients.
Basco D, Campo-Engelstein L, Rodriguez S.
Northwestern University, Evanston, IL, USA.
In this paper, we recommend expanding infertility insurance mandates to people who may become infertile because of cancer treatments. Such an expansion would ensure cancer patients can receive fertility preservation technology (FPT) prior to commencing treatment. We base our proposal for extending coverage to cancer patients on the infertility mandate in Massachusetts because it is one of the most inclusive. While we use Massachusetts as a model, our arguments and analysis of possible routes to coverage can be applied to all states' seeking inclusive coverage for infertility treatment. Furthermore, our proposal can also be applied to people with other diseases who may be rendered infertile by treatment.
© 2010 American Society of Law, Medicine & Ethics, Inc.
PMID: 21105946 [PubMed – indexed for MEDLINE]
18. Clin Obstet Gynecol. 2010 Dec;53(4):717-26.
Ethical issues surrounding fertility preservation in cancer patients.
Patrizio P, Caplan AL.
Fertility preservation is a newly developed branch of reproductive medicine aimed at preserving the potential for genetic parenthood in adults of reproductive age or children, who are at risk of sterility before undergoing anticancer treatments. Except for embryo and semen freezing, all the available options to preserve fertility are considered experimental and thus, they raise ethical issues. In this study, we reviewed the informed consent and the risk-benefit analysis of offering experimental procedures for both adults and children when they are in vulnerable situations. In particular, children represent a special category of patients and their assent to treatment to be sought at anytime should be possible. Overall, there should be no ethical objections to offer these services as they are offered with the scope of preserving future fertility.
PMID: 21048439 [PubMed – indexed for MEDLINE]
19. Preservare la fertilità in età pediatrica: la crioconservazione di tessuto ovarico / Maria Luisa Di Pietro.
Medicina e Morale: rivista internazionale bimestrale di bioetica, deontologia e morale medica , p. 383-395, v.3(2010)


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In case you've been living in a cave on the side of a mountain for the past few months, we are in the middle of a major chicken sandwich war. The two heavy hitters in this war have been Chick-fil-A, which has sold its iconic chicken sandwich since 1964, and Popeyes, which introduced a remarkably popular (and quickly sold out) spicy chicken sandwich of its own last month.
Yesterday, however, fast-food giant McDonald's decided it was time to introduce its own spicy chicken sandwich--hoping to steal some of the thunder from its archrivals Chick-fil-A and Popeyes.
On September 11th, McDonald's will start selling its new Spicy BBQ Chicken Sandwich in restaurants nationwide. According to the company, the star of the show will be a buttermilk crispy chicken fillet on a sesame seed bun with slivered onions, pickles, and a spicy BBQ glaze.
In addition to this new chicken sandwich specifically designed to compete with Chick-fil-A and Popeyes, McDonald's is also introducing Spicy BBQ Glazed Tenders--essentially, a turbocharged chicken nugget.
So, how will McDonald's new spicy chicken sandwich stand up to the sandwiches sold by its rivals?
That remains to be seen.
Read more: https://www.inc.com/peter-economy/mcdonalds-just-revealed-a-surprising-new-product-that-is-a-huge-threat-to-chick-fil-a-popeyes.html

subset: commoncrawl


text:
Posted on April 10, 2017
Oh la la Friends!
We have something uber special for you today! Crystal and Devin were seeking the ultimate adventure wedding in Iceland… and guess what?! They found it! They married on the secret side of one of Iceland's 13 glaciers and held an epic 12+ hour adventure wedding to boot! So come along with us today and we share with you their incredible EXPERIENCE! Also head over to the fabulous POPSUGAR. blog for more!
What a knockout combo… THIS Iceland Wedding Dress and THESE Sorel Boots!
…and their Iceland Wedding Welcome Bags?! #yesplease!
Because our adventure weddings in Iceland begin early… We like to do the first look before we head out! Devin adored Crystal in her dress!
These two and their guests were so badass! They didn't care that it was raining, windy, or that they needed to cross some glacier rivers either!
Iceland Glacier Weddings make me totally SWOON! …and these two make it look easy!
Sometimes there are unexpected Iceland wedding guests!
These two were an Iceland wedding photographers dream come true!
…an adventure wedding in Iceland wouldn't be complete without a traditional BBQ of hot dogs and all their toppings!
Crystal and Devin ventured to some beautiful secret waterfalls throughout their Iceland wedding day too!
Then it was like they beamed themselves to MARS!
Crystal + Devin felt a special pull to Reynisfjara Black Sand Beach. Normally we do not adventure to tourist locations but we made an exception for the dreaminess below!
As the sun set, the adventure drew to a close and we retreated back to Hotel Ranga in Hella Iceland for their intimate wedding reception!
As unpredictable as Iceland can be, we tried to launch wish lanterns but sadly the wind one, so we switched to sparklers for their send off!
Congratulations Devin + Crystal!
What an incredibly unforgettable adventure wedding in Iceland you shared!
© 2017, Iceland Wedding Planner / Photos by Miss Ann, All Rights Reserved.
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Posted on December 22, 2016
Weddings in Iceland have always had a special place in my heart. Endless reasons, but the main one being that I actually met my husband during an elopement in Iceland years ago. Check out Iceland Wedding Planner for more specific details!
We are always extremely honored when a couple chooses us to plan and photograph their adventurous elopement in Iceland! Today I'm excited to share with you one of our favorite adventure weddings from this year: Marlene and Alan. They spent the day chasing waterfalls during their Iceland elopement. Enjoy getting lost in their Iceland wedding photo dreaminess!
With a smile, Ann Peters + Team (Iceland Wedding Photography and Planning)
© 2016, Your Adventure Wedding, All Rights Reserved.
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text:
Thursday, January 16, 2020
Sad Thursday
53 comments:
Sweet Ohs, we are sending purrs and prayers. Hugs and farewell sweet boy.ReplyDelete
A sad day indeed. Fly free, Ohs. There will be quite a crowd waiting to welcome you to The Bridge. Hugs and love to Mom Marg.ReplyDelete
Marg, I'm so very sorry. Sending Ohs, and you, lots of love and purrs, wishing him a peaceful, gentle passing. Tell him to look up Nicki and give him our love. ♥ReplyDelete
Kim and Derry
We are so very sorry to hear about Ohs. Sending you all many comforting purrs.ReplyDelete
Oh no. That's very sad news. (((hugs)))ReplyDelete
The Florida Furkids and Mom Sharon
I am so sorry at this news and wish Ohs a gentle passing.ReplyDelete
I'm so sorry, Marg. Big healing hugs my friend. ♥♥♥ReplyDelete
Oh no! I'm so sorry, Marg. Poor Ohs is tired and his body says it is time. RIP, dear stripey friend.ReplyDelete
We are so very sorry to hear about dear Ohs, we'll all miss that sweet guy. Hugs and love from all of us Marg.ReplyDelete
We are so very sorry. Fly free, Ohs. :-(ReplyDelete
Our good wishes will help you aloft, Ohs, and hopefully help mend your humom's heart when you leave.ReplyDelete
I'm so sorry. Gentle journey Ohs, fly free to the Bridge handsome boy. hugs to you Marg.ReplyDelete
I'm so sorry! He's been around as long as I've known you. Purrs to you and his feline family.ReplyDelete
We are so sorry to hear. May you be free to run and play Ohs. Purrs to Marg.ReplyDelete
I'm so sorry to hear about Ohs.. Sending warm hugs your way.ReplyDelete
We are sending you lots and lots of purrs, woofs, prayers, and thoughts. What a wonderful life you gave Ohs, Marg. He has been so blessed to have you.ReplyDelete
Ohs we are so very very sorry to see this. Fly high sweet angel.ReplyDelete
I'm so sorry about Ohs. :-(ReplyDelete
There is a wave os cats heading to the Bridge right now and Ohs tops the crest. No words take away the pain but know he goes with our tears and our deepest love.ReplyDelete
I'm sorry to read this. Ohs was the first cat I met when I read Marg's Animals; he seemed like he'd be around forever. Godspeed, Ohs...ReplyDelete
We're so sorry about sweet Ohs. Purrs and hugs to you.ReplyDelete
Dear Marg I am so very sorry to read about Ohs....what a gentle ginger man he was and beloved by allReplyDelete
With hugs
I'm so very sorry to hear this terrible news, Marg....Wishing you comfort at this sad time...XO...J, Halle, SukkiReplyDelete
I am so sorry to hear this news. I am no longer online every single day, I have to go and read that post. I am so deeply sorry. Ohs will be greatly missed (((hugs))))ReplyDelete
Oh no ! Purrs and hugsReplyDelete
Oh, we are so very sad for you today. Poor Ohs. Soft woos and gentle hugs from all of us.ReplyDelete
Woos - Lightning, Misty, and Timber and Mom
We were so very sad to read about Ohs. Each loss is just so heart-breaking. We are sending lots of purrs, gentle woofs, soft neighs and hugs.ReplyDelete
All of us at The Poupounette
We're so very sorry to hear about Ohs. Sending comforting purrs and soft woos for you. Hugs sent too.ReplyDelete
Sorry to heat that. Poor guy.ReplyDelete
I am so sorry. My heart is breaking for you. XOReplyDelete
Oh - we are so sorry that Ohs has to go to the Bridge. We send purrayers and POTP to all who love him - especially his brofur.ReplyDelete
Yes, it is a sad day when we have to say good-by to one of our beloved furries. So very sorry about Ohs, Marg! A warm hug.ReplyDelete
I am so sorry to hear that. Hugs and prayersReplyDelete
So sad to hear this news Marg. It's never easy to say goodbye to our beloved fur family. Sending lots of love to you all.ReplyDelete
We are so very sorry and sending purrsReplyDelete
So sad. RIP, little buddy. You will be missed. Prayers for your kitty and donkey friends and family.ReplyDelete
Love and licks,
We are so sorry you had to say goodbye to sweet Ohs.ReplyDelete
It is to say goodbye to a beloved kitty.
We know he had a good life with you,
so we send comforting purrs to you and some hugs.
Purrs,Georgia and Julie
and mum Nancy
RIP sweet boy. Marg, I'm so sorry to hear you had to say goodbye to Ohs. Keep all the good memories safely in your heart.ReplyDelete
My heart hurts for all of you.ReplyDelete
We're so sorry. Sending purrs and luv.ReplyDelete
Oh, sweet Ohs, we are so sorry to hear you were needed at the Bridge. Run fast and free, ginger angel.ReplyDelete
We are so sorry. Huge hugs♥ReplyDelete
We're so sorry of the loss of purrecious Ohs, Marg. Soft Pawkisses to comfort you🐾😽💞ReplyDelete
Fly free beautiful Soul💗💗💗
Godspeed Ohs, we are truly sorry and send you lots oh hugs and loves, and to mom and the family you leave behind as well..... we will never forget you buddy ♥♥♥♥♥♥♥♥♥♥♥♥ReplyDelete
tuna, mackerull, dai$y, dude, sauce and boomer ~~~~~
Our Best Purrs Of Comfort to all of you!ReplyDelete
I'm so very sorry for your loss :(ReplyDelete
You are now undertaking the long journey through grief. While others may share that grief we all walk it alone. There are no right or wrong paths, no proper way to carry oneself on the trek, no set amount of time to complete it. Some steps will come easier than others. There will be rogue waves of grief that you won't see coming, and knock you back days. But you will come through it. If you get lost let us know. We have been through it before and we might be able to help you find the way out.ReplyDelete
Oh dear, we are so very sorry. We're sending soft purrs and hugs your way.ReplyDelete
Oh, no. We're so sorry that sweet Ohs had to go to the Bridge. Sending gentle purrs and prayers for you all.ReplyDelete
Charlee: "We're very sorry to hear that Ohs had to go away."ReplyDelete
Chaplin: "Run free over the Rainbow Bridge, Ohs, and have fun chasing all those bugs and butterflies in the endless sunshine."
So sorry that your Ohs had to make his journey to kitty heaven.ReplyDelete
Hugs, and purrs...and some good doggy licks too.
((( ♥ )))


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In our house we have a rule, one thing in, one thing out. If we give it to charity or to friends, it doesn't matter, but to not put things on a pile we came up with this idea. But something we stack in big piles is the kiddos art. I have such a hard time throwing out Sam and Michas paintings, they now have a wall in their room (as showed on the pictures) and one wall in the kitchen. I would not say they are amazingly good at painting, really not, it looks like any kids mess, but its something with kiddos drawings overall that makes it so good I think. Cheap art on the walls in this house ;)
Tellkiddo startade 2014, baserade på Gotland


text:
Detangle and remove loose hair
Many pets love being groomed, so it's a nice relaxing time for them, and it can also help you to relax and de-stress! If your pet isn't so keen on grooming, we've got some helpful tips on how to gently introduce a grooming routine.
Remove the undercoat
DeShedding can actually help reduce the amount of fur your pet sheds around your home, because you remove the fur from the undercoat before it has a chance to shed.
Shampoo and condition
All pets will need to have a bath at some point, though some are better natural groomers than others. It also depends upon how active your pet is and how much time they spend outdoors.
Dispose of collected hair
You won't have to buy another lint roller or remove pet hair with sticky tape again. Our innovative and reusable tools allow you to pick up pet hair quickly and easily by rolling over the area you want to clean.
8in1 Pet Products GmbH
An der Schwanemühle 2
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Phone +49 (0) 54 22 / 1 05 -0
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General Management: Koord Janssen, Eric Beukeboom, Randal Lewis, Ehsan Zargar, Joanne Chomiak
Responsible with respect to § 55 Abs. 2 RStV: Christian Borghs,
Herrenteich 78, 49324 Melle
District Court: Osnabrück HRB 21007
VAT-No.: DE 245275758


text:
Simple Form Materialize
Simple Form Materialize is here to help generate your configuration needed to using simple form with materialized styles. This gem is not intended to live forever in your gemfile. It must be in your gemfile to load the resources needed from the generator. Below in the installation section will detail out which gems to install for all to work.
Change Log
Repository Updates
- Upgrade circleci to support 2.6 ruby testing
- Drop 2.2 support for ruby
- Overall Repo updates
Bugs Fixed
- Update Ralities support to be upto version 7 ( #7 )
Repository Updates
- Upgrade circleci to support 2.5, 2.4, 2.3, and 2.2 ruby testing
- Various Enhancements to the repo (Issue #4 )
Initial Release
Generate Materialize Configuration for Simple Form
- Javascript File
- Simple_form components File
- Simple_form configuration File
- Generate Materialize Configuration for Simple Form
Add these lines to your application's Gemfile, where applicable:
# Required gems so you don't have to add files manually
gem "materialize-sass"
gem "material_icons"
gem "simple_form"
gem "simple_form_materialize", "~>1.2.0"
simple_form , materialize-sass and material_icons are required in your gemfile to enable the views to generate without error and in the proper style.
Basic Usage
< rails g simple_form_materialize:install
This will generate your two config files and javascript file of initializers
├─ app/
| └─ assets/
| └─ javascript/
| └─ init_form_materialize.coffee
└─ config/
└─ initializers/
├─ simple_form_components.rb
└─ simple_form_materialize.rb
First and for most thank you for taking the time to look to contribute to Simple Form Materialize, any help is apprciated to make Simple Form Materialize better and stronger!
Code of Conduct
This project and everyone participating in it is governed by the Simple Form Materialize Code of Conduct
How can I Contribute
Reporting BugsBefore submitting a bug report
This section guides you through submitting a bug report for Simple Form Materialize. Following these guidelines helps maintainers and the community understand your report, reproduce the behavior, and find related reports.
Before creating bug reports, please check , this list, as you might find out that you don't need to create one. When you are creating a bug report, please include as many details as possible. Fill out the required template , the information it asks for helps us resolve issues faster.
Note: If you find a Closed issue that seems like it is the same thing that you're experiencing, open a new issue and include a link to the original issue in the body of your new one.
Suggesting Enhancements
This section guides you through submitting an enhancement suggestion for Simple Form Materialize, including completely new features and minor improvements to existing functionality. Following these guidelines helps maintainers and the community understand your suggestion and find related suggestions.
Before creating enhancement suggestions, please check , this list, as you might find out that you don't need to create one. When you are creating an enhancement suggestion, please include as many details as possible. Fill in the require template , including the steps that you imagine you would take if the feature you're requesting existed.
Code Contributions
Looking to contribute to Simple Form Materialize? You can look for any tickets tagged with
Pull Requests
The process described here has several goals:
- Maintain Simple Form Materialize's quality
- Fix problems that are important to users
- Engage the community in working toward the best possible Simple Form Materialize Interaction
- Enable a sustainable system for Simple Form Materialize's maintainers to review contributions
Please follow these steps to have your contribution considered by the maintainers:
- Follow all instructions in the template
After you submit your pull request, verify that all status checks are passing
What if the status checks are failing?If a status check is failing, and you believe that the failure is unrelated to your change, please leave a comment on the pull request explaining why you believe the failure is unrelated. A maintainer will re-run the status check for you. If we conclude that the failure was a false positive, then we will open an issue to track that problem with our status check suite.
While the prerequisites above must be satisfied prior to having your pull request reviewed, the reviewer(s) may ask you to complete additional design work, tests, or other changes before your pull request can be ultimately accepted.
Additional Notes
Issue and Pull Request Labels
This section lists the labels we use to help us track and manage issues and pull requests.
GitHub search makes it easy to use labels for finding groups of issues or pull requests you're interested in. For example, you might be interested in opening an Issue or perhaps opening a pull request. To help you find issues and pull requests, each label is listed with search links for finding open items with that label in Simple Form Materialize. We encourage you to read about other search filters which will help you write more focused queries.Type of Issue and Issue State
|Label Name
|search Search
|Feature requests.
|search Search
|Confirmed bugs or reports that are very likely to be bugs.
|search Search
|Questions more than bug reports or feature requests (e.g. how do I do X).
|search Search
|General feedback more than bug reports or feature requests.
|search Search
|The Simple Form Materialize team would appreciate help from the community in resolving these issues.
|search Search
|More information needs to be collected about these problems or feature requests (e.g. steps to reproduce).
|search Search
|Likely bugs, but haven't been reliably reproduced.
|search Search
|Issues blocked on other issues.
|search Search
|Issues which are duplicates of other issues, i.e. they have been reported before.
|search Search
|The Simple Form Materialize team has decided not to fix these issues for now, either because they're working as intended or for some other reason.
|search Search
|Issues which aren't valid (e.g. user errors).
|search Search
|Tagged on Issues that are new and have not been reviewed.
|search Search
|Items to clean up / refactor / restructure
|Label Name
|search Search
|Pull Requests which are still being worked on, more changes will follow.
|search Search
|Pull Requests which need code review, and approval from maintainers.
|search Search
|Pull Requests being reviewed by maintainers.
|search Search
|Pull Requests which need to be updated based on review comments and then reviewed again.
|search Search
|Pull Requests which need manual testing.


text:
Lotus Cortina MK1 1966
£57995Back to Stocklist
Lotus Cortina MK1, 1966 D registration
This genuine Lotus Cortina Mk. I was subject to a full restoration some 15 years ago and has covered approximately 9000 miles since. The quality of restoration work was clearly exceptional as the car is still in superb condition today. The white paintwork is virtually unmarked as is the interior. The fastidious owner has maintained the Lotus with a 'no expense spared' attitude and the engine has recently benefitted from a rebuild and a new clutch has also been fitted, over seven thousand pounds has been spent in the last three years. Supplied with a history file including some old mot's and various invoices. This matching numbers Lotus Cortina is a great opportunity to own a splendid example of these collectable and highly sought-after classics. Great fun to drive and turns heads everywhere it goes.Vehicle Finance


text:
Latest in Wallpaper
Harlequins Poetica have enchanting designs that reflect the natural beauty and intrinsic charm of the countryside and cottage gardens.
Gardinum (pictured above) is available as a wallpaper and also curtain fabric. It comes in colours ranging from dusky pink, eggshell blue through to the charcoal image shown.
The prints, weaves and wallpapers include botanical studies of daffodils, magolias, poppies, seed heads and ferns
complimented with an array of distressed textures and effects, giving the collection a modern edge. The designs are enhanced by a delicate
colour palette, from pared down vinatage hues to sultry shades.
A range of tactile wools, beautiful shimmering plains and enchanting embroideries further enhance this charming collection.


text:
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text:
Gem County is named for the nickname of Idaho, the "Gem State", and the fruit growers called the valley "Gem of Plenty".
Created: March 15, 1915
County Seat:
Emmett 1915 – present
County Courthouse – Emmett
Location: 415 East Main Street / South McKinley Avenue
Built: 1938 – 1939
Style: Art Deco
Architect: Frank Hummel of Tourtellotte and Hummel of Boise
Contractor: David Richardson of Caldwell
Description: The building faces north and is a two story gray colored stone, concrete and glass structure. The center section projects from the main building and rises above the roof line. The entrance is recessed with a recessed window above on the second story. Vertical dividers separate the windows. The roof line is flat. The building was constructed as a Works Project Administration project.
N – Adams County
E – Valley County and Boise County
S – Ada County and Canyon County
W – Payette County and Washington County
Photos taken 2009


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The Healthiest Dog Food - Is Your Dog Eating it - Family - PetsThe Healthiest Dog Food - Is Your Dog Eating it?В В by Tom
in Family / Pets В В (submitted 2011-07-25)
What does healthy food mean to you? You probably make sure that your family eats healthy food, but what about your dog? The healthiest food is homemade; are you willing to give your dog the healthiest dog food possible at mealtime? If you think your store bought dry dog food is healthy, you may be surprised that it's not as healthy as the manufacturer wants you to think.
Have you heard of ethoxyquin or propylene glycol? You may not have but you should know that they could be, and that is not a good thing. Ethoxyquin is considered a carcinogenic and propylene glycol is an additive that is also known to cause cancer. Ethoxyquin is used as a preservative, and in fact, it doesn't even have to be listed on the list of ingredients! If the dog food manufacturer purchases fat from another company who used ethoxyquin in their product then this carcinogenic doesn't have to be noted; there doesn't have to be a disclaimer and this is legal.
Propylene glycol is used as a binder in many dog foods and dog treats on the market today. Recently, a discovery was made that this product causes cancer in cats. Due to this discovery, this product is no longer allowed to be used in cat products, but it is still being used in dog food products. Is this the healthiest dog food that you are giving to your furry friend?
Let's face it, the healthiest dog food isn't on the shelf at your local pet food store but in your kitchen right now. Homemade dog food is the best that you can give your dog. I am not referring to the scraps from the table but truly healthy foods that are good for your pet. Don't you want to know exactly what your dog is eating? If your pet is one of the family, then you will want to ensure that he gets only the best.
By making homemade foods, you are able to monitor and adjust the ingredients accordingly to your dog's needs, and not what the manufacturer thinks they need. There are hundreds of great recipes to make both foods and treats that are full of good nutrition. Proper nutrition comes from fresh foods such as fruits, vegetables, meat and fish. Foods like bananas, apples, turkey and tuna. Although you can give your dog just about everything you would give your family, don't offer any foods that contain avocado or chocolate as they are toxic. Other foods that should be avoided are caffeine, hops, yeast dough, grapes and citrus oil.
Why would anyone go so far to make homemade food for their beloved pooches? Those who want only the best healthiest dog food for their canine pals. Okay, so this isn't the only reason. What if your dog is allergic to certain foods? What if your dog needed more good fats and proteins than the "healthiest" dog food on the market? What if your dog had digestive issues and a very strict diet could be offered?
Giving your dog the healthiest dog food is offering them a meal that is as free as possible from bad fats, carbohydrates, additives and preservatives. A meal that is high in nutritional value can extend your dog's life. You would do this for your family, so why not do the same for your dog? After all, they are a part of the family too!
© F&B Catering | All Rights Reserved.
Let us create a magical backdrop for you to do your own magic


text:
Get ready for the ride of your life. Introducing SlacklifeBC's SkyPilot webbing – a line that transforms walking into flying. Simply the best Nylon webbing available anywhere! Take control and float in the air on this webbing is a chance to create your own aerial playground. Like to surf, bounce, and dance 1000ft up in the air? Sky Pilot is your new friend. And, as any good friend would, it will catch you in the most gentle way possible with its soft, silky smooth edges. You guys are going to have a lot of fun! Designed and manufactured 100% in Canada.
Pre Cut Pieces ship the next day!
Includes: Skypilot Nylon Webbing + Two sewn loops on both ends


text:
The following article is a paid Community News Advertising Feature
Say Belly Buster to anyone from Ewing or The College of New Jersey and they will instantly know you are talking about their local favorite sandwich shop, Ray's Sub Shop. Nowhere else can you find a whopping 6" wide, 14" long hoagie made with specialty bread. They can feed four or more and are exclusive to Ray's. Fans revel in turkey, roast beef, chicken, ham and more with all the toppings.
But Ray's is so much more than this one menu item. Especially popular with The College of New Jersey crowd, owner Ramsis (Ray) Azab's shop earned the 2014 Golden Grub Award from grubhub.com. His location contributes to his popularity. The shop at 1540 Pennington Road is convenient to major roadways. Ray's is not far from TCNJ. And the college crowd knows its food.
Azab emigrated to the States in 1998 and immediately began learning the business at some of New York City's famous eateries. He hones his skills catering to the demanding tastes of New York foodies. Aiming to own his own establishment, he saw an opportunity in 2007 to purchase a shop at the Pennington Road location and it's been a success. Azab revamped the menu and designed his signature Belly Buster.
Ray's is noted for keeping prices reasonable. "I heard an executive from a fast food franchise say that if you take care of the customers, the business will take care of itself. That has been my personal business model," says Azab. Testimonials from devoted fans attest to the extra effort the staff make to ensure customers get exactly what they wish. Ray's aim to keep his menu reasonable resonates with the college crowd and local diners as well. Review after review focus on the great service and the homey atmosphere. Ray's offers great food, pure and simple, not a pretentious atmosphere at a fancy price.
Beginning with breakfast, the menu offers a wide variety of choices. Omelettes are three egg big and are served with toast and home fries. But don't forget the buttermilk pancakes.
Sandwich offerings include paninis, hot and cold wraps, hoagies (also known as subs or grinders), and burgers made with a full half-pound of certified Angus beef. He also offers a falafel hoagie, jumbo buffalo wings, lamb or chicken gyros, the list goes on and on. In other words — there is something for everyone.
Beyond visiting Ray's for a great meal, bring the tempting choices to the office or your next event. Ray's caters with party platters, six foot and three foot grinders, and more.
Dine in or call for delivery. Discover what everyone is talking about at Ray's Sub Shop.
Ray's Sub Shop. 1540 Pennington Road. (609) 771-8006.


text: THE NATIONAL – Lieutenant Colonel Faxradin Najmaldin, a Kurdish officer in charge of a mine clearing unit on the Kirkuk front line, is no stranger to explosives. Drafted into Saddam Hussein's army in 1985, he became a so-called "sapper" — or mine clearing expert — during the Iran-Iraq war. Continue reading.


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I am a participant in a facebook group called The Travelling Lensbabies. This is a "fan" driven group where the group members take turns borrowing two beta version Lensbabies.
The lenses are dating from around 2003, and are kindly loaned by Lensbaby founder Craig Strong. They are extremely basic, consisting of a piece of vacuum pipe pulled through a hole made in a camera body cap, and with an eye-loupe mounted at the end of the pipe. You can see pictures of the beta type in chapter 3 of the Lensbaby history. Basically, this is a bendable thingamabob with a fixed aperture of f/5.6, where focusing is done by bending and sqeezing. I loved it!
I found the lens very intuitive to use, and today marks a sad day as I am shipping it off to the next participant. However, I do have a Lensbaby 2.0 in my camera bag, so no need to feel sorry on my behalf..! If you want to take part, you can find the group here. Tell them I sent you!
I am taking part in a Lensbaby blog circle. On the first of each month there will be a new blog post, where you can navigate to the other participants' blogs through a circle of links. You may have gotten here from Kleine Fotokiste (Jessica); please click the button to visit the next blog:


text: Research ReportClinical Reasoning: Survey of Teaching Methods and Assessment in Entry-Level Physical Therapist Clinical EducationHuhn, Karen PT, PhD; Black, Lisa PT, DPT; Christensen, Nicole PT, PhD, MAppSc; Furze, Jennifer PT, DPT, PCS; Vendrely, Ann PT, EdD, DPT; Wainwright, Susan PT, PhDAuthor Information Karen Huhn, is an assistant professor, 65 Bergen St, Newark, Rutgers The State University of New Jersey, Newark, NJ email@example.com Lisa Black, is an associate professor, Director of Clinical Residency Education Programs, Creighton University, Omaha, NE firstname.lastname@example.com Nicole Christensen, MAppSc, is an associate professor, Samuel Merritt University, Oakland, CA email@example.com Jennifer Furze, is an associate professor, Creighton University, Omaha, NE, email@example.com Ann Vendrely, is a professor of Physical Therapy, 1 University Parkway, Governors State University, University Park, IL 60484 email@example.com Susan Wainwright, is an associate professor, Thomas Jefferson University, Philadelphia, PA email@example.com The authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.aptaeducation.org) Supplemental Digital Content is Available in the Text. Journal of Physical Therapy Education: September 2018 - Volume 32 - Issue 3 - p 241-247 doi: 10.1097/JTE.0000000000000043 Free SDC Metrics Abstract Background. Clinical reasoning skills have been identified as an integral part of physical therapist education developed in both the academic and clinical settings. There is limited understanding of clinical instructors (CIs) expectations related to the anticipated level of clinical reasoning (CR) skills achieved by students and how CR is taught and assessed in the clinic. Objective. The purpose of this research was to explore how CIs teach and assess student physical therapists' CR skills and garner an understanding of CIs' expectations related to CR skills attained at various levels of clinical experience. Design. A descriptive, cross-sectional survey was used to gather data from CIs. Methods. Participants identified from an American Physical Therapy Association database of credentialed CIs were asked to complete an 18-question electronically delivered survey. Results. A nationwide sample of 749 CIs completed the survey. The data clearly demonstrated that CIs value and recognize the importance of clinical education in the development of CR. They also value the use of engaged discussion and reflection to foster the development of reasoning skills. Most CIs did not expect students to achieve entry-level CR skills during the third year. Conclusions. Clinical instructors see the importance of clinical experiences and engaged discussion to foster the development of CR. Further research is needed to understand why most clinical educators did not expect students to achieve "entry-level" CR skills as defined by the Clinical Performance Instrument by the final year of the program. INTRODUCTION AND BACKGROUND The dynamic and rapidly changing environment of health care increasingly demands a high level of accountability for practitioners to produce effective, meaningful improvement in patients. Physical therapists rely on their clinical reasoning (CR) process to decide how to manage a patient to facilitate maximal improvement. This CR process is a highly complex, multi-faceted skill that is developmental in nature and requires a substantial amount of practice with realistic patients to develop. The American Physical Therapy Association (APTA) and The Commission on Accreditation in Physical Therapy Education recognize the importance of CR skills by mandating it as an expected outcome of both education and practice.1,2 Our understanding of the CR process used by physical therapists is still evolving and is substantially derived from work in medicine and nursing. What is known is that the process includes several different types of reasoning and that a therapist will use more than 1 type of reasoning in any given situation meaning that it is context dependent.3,4 In addition, it is believed that developing therapists move through a continuum of skill development. A lack of clinical experience leads novices to rely heavily on basic science knowledge.5 As they gain some experience in clinical practice through their clinical affiliations, they begin to chunk information together or build scripts related to patients they have seen. This script formation makes the CR process less cognitively cumbersome and thereby more efficient and effective.6 As a therapist continues to gain clinical experience, the CR process becomes even more refined; therapists can quickly and efficiently identify what should be done based on previous patient experiences. Learning theories that support the development of CR skills include constructivism, in which the main tenet is that knowledge should be gained in the context in which it is to be used.7 Situated learning stresses the importance of learning and participating in an activity to form a professional identity rather than learning "facts."8 Deliberate practice theory supports the use of longitudinal mentoring again in realistic situations to help identify specific activities to be deliberately practiced to improve performance.9 Given this knowledge that CR skill development is highly contingent on clinical experience, the role of clinical instructors (CIs) in supporting students' development of CR skills becomes increasingly evident. The Clinical Reasoning Curricula Assessment and Research Consortium (CRCARC) (http://acapt.org/index.php/consortia/itemlist/category/33) of the American Council of Academic Physical Therapy was created to develop best practice standards for teaching and assessing CR in physical therapist education. In listening to discussions among consortium membership at several meetings, it became apparent that members were not all talking about CR in the same manner. CR was being defined, taught, and assessed with substantial variability among both academic and clinical educators. To move the consortium's agenda forward, it was decided that a better understanding of how both academic and clinical educators were defining, teaching, and assessing CR was required. Consortia members designed two surveys; 1 directed at academic educators, the results of which are published elsewhere10 and a second one directed at clinical educators. Both surveys included a definition of CR consortium members derived from the literature to encourage respondents to consider CR from a similar perspective. The operational definition of CR was: "Clinical reasoning is a nonlinear, recursive cognitive process in which the clinician synthesizes information collaboratively with the patient, caregivers, and the healthcare team in the context of the task and the setting. The clinician reflectively integrates information with previous knowledge and best available evidence to take deliberate action."11-13 Results of the survey of academic educators indicated a lack of consensus on how CR is taught and assessed in academia. Most academic educators were using multiple frameworks, tools, and assessments and relying on instructor-created tools.10 As stated earlier, CIs play a significant role in the growth of students' CR skills. Therefore, researchers believed that it was important to present the views of CIs in conjunction with those of the academic educators. This project reports on the findings of the second survey directed at clinical educators. The purpose of this research was to explore the perceptions of CIs regarding teaching and assessing student physical therapists' CR skills. A second aim was to promote greater awareness of the state of CR in physical therapist clinical education. METHODS A descriptive cross-sectional survey designed to explore how CR is defined, taught, and assessed in academic DPT programs was modified to examine how CR is defined, taught, and assessed by CIs. The study was reviewed and approved by the Institutional Review Boards at Creighton University, Thomas Jefferson University, Governors State University, and Rutgers the State University of New Jersey. Development of the Survey Members of the CRCARC designed a survey intended to assess how academic educators define, teach, and assess CR skills. Consortia members then refined the academic survey to gather the same information and additional data relevant to teaching CR skills in the clinical education setting. Specifically, the branched questions asked CIs to describe the level of CR ability (beginner, advanced beginner, intermediate, advanced intermediate, and entry-level) expected of affiliating students during clinical experiences in their first, second, and last year of professional education. These questions used terminology from the Clinical Performance Instrument (CPI) to define the forced choice categories.14 The survey provided the following rating scale from the CPI: beginner = 100% supervision; advanced beginner = 75–90% supervision with patients with simple conditions, 100% supervision with patients with complex conditions; intermediate = <50% supervision with patients with simple conditions, 75% supervision with patients with complex conditions; advanced intermediate = independent with patients with simple conditions, <25% supervision with patients with complex conditions or new patients, 75% caseload management; and entry-level = capable of managing patients with simple or complex conditions 100% of the time. There was also interest in understanding whether CIs encouraged students to self-reflect and whether they believed that academic programs adequately prepared students for the clinic. The final CI survey (Appendix 1, Supplemental Digital Content 1,http://links.lww.com/JOPTE/A23) consisted of 18 total questions, including six branched questions directly related to CR and 12 on demographics and experience levels of CI respondents. A sample of convenience drawn from an APTA database of credentialed CIs received the survey. Approximately 40,000 credentialed CIs were included in the database. Only 6,983 allowed their email addresses to be used for research purposes. Survey results were anonymous as emails, and the names of respondents were not visible to the researchers. No attempt was made to meet a representative sample because of the limited number of emails available. The authors did not have access to US postal addresses, so no attempt was made to send paper surveys. QuestionPro Online Survey Software was used to deliver the survey and compile results. APTA staff members managed the distribution of the survey. The survey software identified who had not yet completed the survey and sent two later email requests. QuestionPro software calculated frequencies of response. Four of the researchers (K.H., L.B., S.W., and A.V.) individually coded the open-ended responses and then discussed findings through several conference calls leading to the development of a coding scheme representative of the participants' responses. Reliability of the content analysis was confirmed by 100% percent agreement among the researchers.15 These codes were then categorized into themes. Trustworthiness of the data was ensured through presentation of direct quotes from the participants to support the themes.15 RESULTS The survey was delivered electronically by the APTA to 6,983 email addresses, 4,780 of which were deliverable. Two subsequent email requests were sent to those who did not complete the survey. Final survey results indicate that 1420 participants viewed the survey email, 934 opened the survey, 885 began it, 770 completed all but the demographic questions, and 749 completed the entire survey for an overall response rate of 15%. A spreadsheet of geographical distribution and highest degree earned of all credentialed CIs was obtained from the APTA. The demographics of respondents to geographical distribution and data of the highest degree of all CIs were compared to decide whether the sample was a true representation of CIs (Figures 1 and 2). Results indicated a good match for general representativeness for geographic location. The exception was a lack of survey respondents whose highest degree earned was a certificate as our survey had 0%. In the sample, 72% of respondents reported holding the basic level of APTA CI training, whereas 18.5% had advanced certification, and 8.8% had not completed the APTA credentialing course. The survey was originally sent only to credentialed CIs. However, CIs were allowed to share it with colleagues and that may account for the low number of respondents who were not credentialed. In the sample, 87% of respondents had not completed a residency or fellowship, and 67% had not completed clinical specializations. The 33% who achieved American Board of Physical Therapy Specialties certification represented eight specialty areas, 15% Orthopedics, 5% Neurology, 4% Sports, 3% Geriatrics, 3% Pediatrics, 1% Cardiovascular and Pulmonary, 1% Women's Health, and .5% Clinical Electrophysiology.Figure 1.: Geographical representativenessFigure 2.: Highest degree earnedThe vast majority (98.3%, n = 736) of CIs concurred with the definition of CR outlined by the CRCARC, and 91% (n = 681) of CIs indicated that they explicitly taught CR skills to their students. Clinical instructors were asked to rate the level of CR skills they expected from the students they supervised. The rating scale from the CPI as listed earlier in this study was provided. When asked to rate the level of CR skills CIs expected from students participating in a clinical experience in their first professional year, 37.8% (n = 283) indicated beginner, whereas 48.4% (n = 362) indicated advanced beginner. Students participating in clinical experiences in their second professional year were primarily expected to have intermediate-level skills 64.2% (n = 480). Students participating in clinical experiences in their last professional year were primarily expected to be at advanced intermediate 50% (n = 374) or entry-level 42.4% (n = 317). The survey asked respondents to indicate which tools they use to assess students' CR skills. Fifty-four percent (n = 404) reported using the CPI, and 15 percent (n = 112) reported using the Guide to Physical Therapist Practice.16 Respondents had an opportunity to enter "other" tools they use to assess CR (n = 52) (Table 1).Table 1.: Additional Tools to Assess Clinical ReasoningMost CIs (71%, n = 531) responded that academic programs adequately prepare students to use CR skills effectively in the clinical setting. Twenty-nine percent (n = 217) of respondents did not believe that academic programs adequately prepared students. The survey asked those respondents to indicate which of the following they believed would help students: patient simulations (28.55%), mentoring programs (23.93%), more clinical fieldwork (21.3%), specific courses (19.83%), or other (6.32%). Again, respondents had an opportunity to enter "other" suggestions to facilitate students' CR skills in the didactic portion of their education. Investigators evaluated these 37 responses for themes. Table 2 provides the most frequently reported themes with sample responses.Table 2.: Additional Methods to Facilitate Clinical Reasoning SkillsRespondents were then asked whether they encourage students to engage in self-reflection on reasoning abilities and, 88% (n = 659) reported they do. A follow-up question asked how they encourage self-reflection, and respondents were provided the following options: debriefing with CI (44.51%), think aloud during treatment or other (27.04%), and journal assignments (16.7%). Once again, respondents entered information in response to the "Other" prompt in this question, and 191 responses were entered. The authors evaluated these "other" responses for themes (Table 3).Table 3.: Additional Methods to Encourage Self-ReflectionDISCUSSION The purpose of this research was to explore the perceptions of CIs regarding expectations for student physical therapists' CR skills and to gain insights into how these skills are defined, taught, and assessed. Survey results indicated that CIs agree with the Consortium's definition of CR. Respondents requested that the definition be kept simple without too much jargon. The authors believe that this is the first time that interested stakeholders have been asked to agree or disagree with a definition of CR. CIs expect a developmental improvement in CR skills with movement from advanced beginner to intermediate over the first 2 years. Just over half of the respondents indicated that they expected students would achieve entry-level skills by the time they graduate; however, 49.8% of respondents reported that they expect a student to achieve advanced intermediate CR skills rather than entry-level in their final professional year. Advanced intermediate was defined as independent with simple patients, <25% supervision with complex or new patients, and management of 75% of a caseload. There are a few possibilities to explain why half of the surveyed CIs do not expect students to achieve entry-level skills relative to CR. One possible factor is the descriptions provided for rating students. The description of Entry-level is 100% of caseload with no provision for supervision or assistance, a 25% increase in caseload management from the next lowest rating of advanced intermediate, and elimination of any type of supervision. Sass et al17 found evidence that clarification of terms has an impact on how CIs apply ratings. They provided CIs with an entry-level definition based on but not identical to the one used in this study and reported that CIs believed more clarification was needed to understand terms such as "highly skilled" and "complex".17 A second possibility is that many CIs may not consider the achievement of "entry-level" CR ratings by students to be a realistic expected outcome of students before entering independent practice. The findings of Sass et al. support this hypothesis when they reported that their respondents also questioned the ability to achieve a high level of competence in all practice settings.17 Findings from a study of clinical mentors in nursing suggest that registered nurses and academic faculty differed in their perceptions surrounding the level of clinical skills first-year students should have during their first clinical experience. Clinical mentors emphasized a range of basic skills and acknowledged that many skills could only be learned through experience.18 In addition, the nursing literature identifies a gap between knowledge and skills required in academic contexts and those needed for clinical practice.19 Published research findings clearly describe observed differences in the ways novice and expert clinicians clinically reason and self-reflect in practice.20 Clinical instructors use multiple "formal tools" to assess CR, with most (54%) reporting using the CPI and the majority reporting use of more than 1 tool. Many were also using a variety of facility-specific tools, indicating a lack of a "gold standard" to assess CR skills across clinical education sites. The data represent more than seven hundred responses to this question, which may indicate the level of importance and value CIs place on assessing CR skills. It is interesting that only 54% of CIs reported using the CPI as a tool to assess CR. Considering this finding in light of the limited scope of criteria within the CPI that directly address aspects of CR performance, it is not surprising that CIs use other means of assessing this complex, multi-faceted aspect of clinical practice. It is possible that CIs value a more interactive method of assessing CR. The data support this interpretation. Responses of the "other" tools used to assess CR included statements related to discussion, think-aloud activities, and observation of student performance. Our findings are congruent with recommendations in the educational literature promoting the use of direct observation and think-aloud activities to support the development of CR skills in future health professionals.11 Most CIs (71%) believed that academic programs adequately prepared students to use CR in the clinic. Feedback to academic programs from CI respondents about how to improve DPT students' CR skills fell into two categories: 1) increasing opportunities students have in the classroom to learn the skills necessary for effective CR and 2) increased and varied experiential learning activities. Specific to providing more opportunities to have faculty model and students demonstrate CR skills, CIs suggested techniques (Table 3) they use in the clinic be applied consistently in the classroom. This raises additional questions about what the most effective educational strategies are when teaching CR in an educational setting as compared to the clinical setting. In the academic learning context, there are typically a large number of students and small number(s) of faculty as compared to the clinical setting where most commonly only 1 or two students are working with a single CI. There is likely a continuum of CR teaching and facilitation strategies that should be explored to determine best practices in both didactic and clinical education to foster effective development of CR skills throughout entry-level education. Intentional and explicit application of reflection to the reasoning process is necessary to develop the reasoning skills consistent with expert practice.21 Clinical instructors' clearly value the role of reflection, with 97% indicating that they encourage student reflection. This finding is consistent with previous reports that critical reflection contributed to student learning by increasing validation, empowerment and broadening perspectives,22 and developing CR skills.23,24 Analysis of free text responses indicated that CIs encourage both reflection-for-action (thinking back on an experience and exploring the reasons around and the consequences of, their actions) and reflection-on-action (planning for future experiences within the context of past experiences.25,26 Reflection-for-action was evidenced by CIs' numerous reports of requiring students to plan for patient interactions by discussing or writing a plan of care before treatment or using evidence to plan a treatment. Reflection on action seemed to fall into two categories, including asking students to reflect on their performance through journaling, discussion with CI or others, and setting weekly goals for themselves. In addition, CIs encouraged students to reflect on patient performance to formulate goals and adjust plans of care. This facilitated reflection is consistent with recommendations from the literature. Schon identified that reflection is much more effective when it is facilitated by a mentor and done as a social activity.26 Reflection, with context, dialog, and time are key elements of the critical-thinking process necessary to arrive at a clinical decision.23 The interaction reported between CIs and student physical therapists in the free text responses provides time and opportunity for dialog to facilitate reflection within the situated learning environment of clinical practice. Further, the CIs reported frequent use of think-aloud and dialoged interactions to facilitate this reflection. As these students are novice, their use of reflection is notably observed when confronted with ambiguity in clinical practice.27 Consistent with a previous study of novice physical therapists, reflection-in-action was not a focus of CI and student interaction.28 Although DPT students may be limited in their ability to use reflection-in-action to assess the patient, as well as their own performance, acknowledging the value of developing these skills would serve to further develop CR abilities in both academic and clinical settings. The findings of this survey provide a more complete picture of what is occurring in professional DPT education when combined with published results about CR in the academic setting.6 It is clear that educators in both academic and clinical settings value development of CR skills. Instruction in CR is incorporated into both academic and clinical settings using a variety of methods that seem to be both setting and instructor specific. There are marked differences in how CR is assessed across the academic and clinical settings. Traditional written and practical examinations, as well as the CPI, are predominately used in the academic setting.10 Although the CPI is also used in the clinical setting, CIs rely on a variety of CR assessment tools, application of evidence-based practice, CR frameworks, and their own judgment when assessing student CR abilities. There are several limitations in this work. The overall response rate was 15%. Although this is clearly a low response rate, recent research has called into question the assumption that a high response rate indicates quality results. There has been no identification of a strong relationship between nonresponse rates and nonresponse bias.29 In addition, response rates for web-based surveys are typically lower than those of paper-based surveys.30 We used a sample of convenience, which limits the ability to generalize the findings. There is the possibility of coverage error, which can occur when a list of potential subjects does not include all members of the group.31 In the case of this survey, the sample includes only those CIs who agreed to share their emails, which was not the entire list of credentialed CIs. Capturing the views from all CIs would be challenging but perhaps attempting to reach CIs through the various geographical consortiums would yield a greater return. It is clear from the respondents that CIs place value and importance on the facilitation of CR skills and on their role as educators. They recognize the importance of clinical experience in the development of CR and suggest more and varied clinical experiences. These CIs also value the use of engaged discussion and reflection to foster the development of reasoning skills. The findings provide an understanding of the current state of CR assessment and instruction, which may help formulate the most effective curricular activities across both academic and clinical settings. The finding that 49.8% of CIs do not expect students to reach entry-level CR skills at the end of education warrants further exploration. Delving deeper into why CIs believe entry-level CR skills are not expected and whether there are certain aspects of entry-level CR skills students are not expected to achieve might provide insights as to changes that might need to be made to physical therapist education.ACKNOWLEDGMENTS The authors acknowledge the members of the Clinical Reasoning Curricula and Assessment Research Consortium and the American Council of Academic Physical Therapy/Lisa McLaughlin. REFERENCES 1. Commission on Accreditation for Physical Therapy Education. Standards and Required Elements for Accreditation of Physical Therapist Education Programs. CAPTE; Alexandria, VA USA 2014. Cited Here 2. Association. APT. Physical therapist clinical performance instrument. 2006. http://www.apta.org/PTCPI/. Accessed June, 2016. Cited Here 3. Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen G. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84(4):312-330. Cited Here | PubMed | CrossRef 4. Higgs J, Jones MA, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3rd ed. London: Elsevier; 2008. Cited Here 5. Boshuizen HP, Schmidt HG. On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cogn Sci. 1992;16:153-184. Cited Here | PubMed | CrossRef 6. Norman G. Building on experience-The development of clinical reasoning. N Engl J Med. 2006;355(21):2251-2252. Cited Here | View Full Text | PubMed | CrossRef 7. Jensen G, Mostrom E. Handbook of Teaching and Learning for Physical Therapists. 3rd ed. Saint Louis, MO: Elsevier; 2013. Cited Here 8. Ratcliffe T, Durning S. Theoretical concepts to consider in providing clinical reasoning instruction. In: Trowbridge R, Rencic J, Durning S, eds. Teaching Clinical Reasoning. Philadelphia, PA: American College of Physicians; 2015. Cited Here 9. Ericsson KA. An expert-performance perspective of research on medical expertise: the study of clinical performance. Med Edu. 2007;41(12):1124-1130. Cited Here 10. Christensen N, Black L, Furze J, Huhn K, Vendrely A, Wainwright S. Clinical Reasoning: survey of teaching methods, integration and assessment in entry-level physical therapist academic education. J Phys Ther. 2016;97(2):175–186. Cited Here 11. Higgs J. Fostering the acquisition of clinical reasoning skills. New Zealand J Physiother. 1990;18:13-17. Cited Here 12. Higgs J, Jones M. Clinical reasoning in the health professions. 2nd ed. Boston, MA: Butterworh Heineman; 2002. Cited Here 13. Newble D, Norman G, VanDer Vleuten C. Assessing Clinical Reasoning. 2nd ed. Oxford: Butterworth-Heinemann; 2000. Cited Here 14. Association APT. Physical therapist clinical performance instrument (PT CPI). http://wwwapta.org/PTCPI/. Accessed March, 2016. Updated June 15, 2016. Cited Here 15. Patton M. Qualitative Evaluation and Research Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 1990. Cited Here 16. American Physical Therapy Association Guide to physical therapist practice 3.0. American Physical Therapy Association; Alexandria, VA, USA 2015. Cited Here 17. Sass K, Frank L, Theile A, et al. Physical therapy clinical educators' perspectives on students achieving entry-level clinical performance. J Phys Ther Edu. 2011;24:46-59. Cited Here 18. Astin F, McKenna L, Newton J, Moore-Coulson L. Registered nurses' expectations and experiences of first year students' clinicial skills and knowledge. Comtemporary Nurse. 2005;18(3):279-291. Cited Here 19. Santucci J. Facilitating the transition into nursing practice: concepts and strategies for mentoring new graduates. J Nurses Staff Dev. 2004;20(6):274-285. Cited Here | View Full Text | PubMed | CrossRef 20. Norman G, Brooks L, Cunnington JPW, Shall V, Marriott M, Regehr G. Expert-novice differences in the use of history and visual information from patients. Acad Med. 1996;71(10):S62-S64. Cited Here | View Full Text | PubMed | CrossRef 21. Wainwright SF, Shepard KF, Harman LB, Stephens J. Novice and experienced physical therapist clinicians: a comparison of how reflection is used to inform the clinical decision-making process. Phys Ther. 2010;90(1):75-88. Cited Here | PubMed | CrossRef 22. Scully R, Shepard K. Clinical teaching in physical therapy education: an ethnographic study. Phys Ther. 1983;63:349-358. Cited Here | PubMed 23. Forneria S. Exploring the attributes of critical thinking: a conceptual basis. Int J Nurs Scholarship. 2004;1(9):1-18. Cited Here 24. Dreifuerst K. Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. J Nurs Edu. 2012;51(6):326-333. Cited Here 25. O'Donnell A, Reeve J, Smith J. Educational Psychology: Reflection for Action. 3rd ed. Hoboken NJ, ed. Wiley & Sons; 2011. Cited Here 26. Schon D. The Reflective Practitioner: How Professionals Think in Action. New York, NY: Basic Books Inc; 1983. Cited Here 27. Mamede S, Schmidt HG, Rikers RMJP, Penaforte JC, Coelho-Filho JM. Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning. Med Edu. 2007;41(12):1185-1192. Cited Here 28. Embrey DG, Guthrie MR, White OR, Dietez J. Clinical decision making by experienced and inexperienced pediatric physical therapists for children with diplegic cerebral palsy. Phys Ther. 2006;76(1):220-214. Cited Here 29. Curtin R, Presser S, Singer E. The effects of response rate changes on the index of consumer sentiment. Public Opin Q. 2000;64:413-428. Cited Here | PubMed | CrossRef 30. Cook C, Heath F, Thompson R. A meta-analysis of response rates in web- or internet-bases surveys. Educ Psychol Measurement. 2000:60(6):821-836. Cited Here 31. Draugalis J, Plaza C. Best practices for survey research reports revisited: implications of target population, probablity sampling, and response rate. Am J Pharm Edu. 2009;73(8). Cited Here Keywords:Clinical Reasoning; Assessment; Teaching and Learning Supplemental Digital Content JOPTE_32_2_2018_03_12_HUHN_JOPTE-D-18-00047_SDC1.pdf; [PDF] (155 KB) © 2018 Academy of Physical Therapy Education, APTAView full article text


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Jeb Bush, Derek Jeter Moving Full Steam Ahead on Miami Marlins Bid
In his first public remarks about his bid for the Miami Marlins, Jeb Bush sounded an optimistic note despite the nearly $1 billion that he and his partner Derek Jeter must raise to secure the deal.
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Speaking at the Milken Conference today in Los Angeles, CA, the former governor of Florida said he has support from the City of Miami and a group of investors, suggesting a deal is in reach.
As FOX Business recently reported, the duo's $1.34 billion bid for the team is hardly a lock; the duo must raise around $800 million to $900 million in cash from outside investors given Major League Baseball's preference that they purchase the team without incurring massive debt.
At the conference, Bush said Jeter, a former star New York Yankee shortstop, would handle the day-to-day baseball operations of the club. Bush also noted he would be more immersed on the business side, including possibly expanding team reach to Latin America, which he described as a potential huge new market for the MLB. If his bid is approved, Bush said he would methodically manage the team not by embarking on a free agent spending spree, but instead would aim to "build the team patiently."
"Baseball doesn't have a salary cap, which is what you have to self-impose as an owner," Bush said. "You have to have the discipline to identify players the right way…There's no correlation between high salaries and winning."
Bush and Jeter are leading the group bidding to buy the Marlins from oft-maligned owner Jeffrey Loria, who has run a money losing enterprise since buying the team in 2002, ladened with a significant amount of debt. Loria can command a piece well above the $158 million he paid 15 years ago because of the scarcity value of professional baseball teams. Other potential bidders including a team led by Tagg Romney, the son of 2012 GOP presidential candidate Mitt Romney, have placed bids for the team albeit lower than Jeter and Bush. [moved this grx]
The Miami mayor's office did not return FOX's calls for comment at the time of publication. A Marlins spokesman had no comment.
Bush also took a swipe at President Trump, who beat the former Florida governor during the often brutal 2016 GOP presidential sweepstakes, in which Trump coined him "low energy."
While Bush said he likes some of Trump's actions such as his Supreme Court pick, Neil Gorsuch, and several of his cabinet appointments, he advised Trump to "chill out" with the spontaneous tweeting, citing the president's comments on North Korea, his unpopular proposed gas tax and supporting a government shutdown.