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Presentation on theme: "Jackie Raleigh RD, LD, CDE /Shelley Knight RD,LD,CDE Courtney Assir RD,LD,CDE/Karmen Cunningham RN, CDE Anna Harrison RN MARCH 2, 2013 Alternate Caregiver."— Presentation transcript:
Jackie Raleigh RD, LD, CDE /Shelley Knight RD,LD,CDE Courtney Assir RD,LD,CDE/Karmen Cunningham RN, CDE Anna Harrison RN MARCH 2, 2013 Alternate Caregiver Training
Goals—Caregivers will learn: Basic understanding of what diabetes is Fundamentals of insulin and carbohydrates How to check blood sugar How to treat high or low blood sugar Basic carb counting How to give insulin via injection or pump What to do in case of emergency
What is diabetes? Autoimmune diabetes (commonly referred to as “Type 1” diabetes) Beta cells—cells that make insulin are recognized as foreign Beta cells attacked by body until T1D is unable to produce their own insulin Insulin from the external source (i.e.: via injection or insulin pump) is the only treatment—is NOT a cure
What does that mean? Without insulin, the body cannot properly metabolize carbohydrates Carbohydrates are the body’s main source of fuel Insulin is the gatekeeper to the cells; if there is not enough insulin, carbohydrates will not get into the cells and will be left elsewhere in the body Causes blood sugar to rise above ideal levels
How do I know what the blood sugar is? You must CHECK it!
To test blood sugar: Be sure to change your lancet EVERY time you test Place the FORK side of the strip into glucometer with the GOLD side up. Clean the finger that you will be using thoroughly using either alcohol or hand washing with soap and water for 15 seconds. Use the sides of the finger for sample. Make sure the finger is warm before trying to lance it—otherwise it will be difficult to get a sample.
To test blood sugar (cont’d): Make sure your lancing device is ready before placing on sample area On One Touch lancing device, this is the top of the lancing device—you will press down to click and load On One-Touch Delica lancing device, is the lower black button—you will pull back to load
Testing blood sugar (cont’d) You are now ready to place lancing device over the sample area Push button to activate the lancet On One Touch Delica, this is the blue button at the bottom
Testing blood sugar (cont’d) If having difficulty obtaining sample, you can “milk” the finger or toe, and hold downward to help blood flow to the area faster Bring glucometer to the blood sample, hold the strip to the blood sample, and let it “draw” the blood in Wait 5 seconds for the result or “number” to appear.
What does the number mean? Goals for blood sugar Under age 6: 80-200 before meals and bedtime Greater than age 6: 70-150 before meals and bedtime If blood sugars are above or below these target ranges, you must take action
Hyperglycemia High blood sugar Symptoms Feels hot Thirsty Urinating more often than usual Hungry Nauseated Complains of headache Mood swings Drowsy
Hyperglycemia (cont’d) What do I do? You must always test blood sugar first! If blood sugar is above target goal before meal or bedtime, give correction factor as prescribed by the doctor Insulin should never be given sooner than 3-4 hours apart. Therefore, you do not need to retest any sooner than 3-4 hours Regardless of when tested, if blood sugar is over 300, you must test for ketones
Hypoglycemia Signs of low blood sugar Shaking Sweating Mood swings Hungry Anxious Headache Fatigue, or complains of feeling weak Child may tell you he or she “feels funny” Always test first before treating! Some of the signs of low blood sugar are the same as those for high blood sugar!
Treatment for low blood sugar “Rule of 15”—treat with 15 grams of a fast-acting carbohydrate source, wait 15 minutes and retest Sources of 15 grams include: 4 oz (1/2 cup) of juice 6 oz (1/2 can) of regular soda 8 oz (1 cup) of milk 3-4 glucose tabs 1 oz. cake icing gel 15 Smarties candies If blood sugar is less than 70 (or 80 if child is under the age of 6) when you retest, repeat the Rule of 15 If blood sugar is above 70 (or 80 if the child is under age 6) when you retest, no further action is needed
What are ketones? When there is a lack of insulin to let carbohydrates into the cell, the body needs a fuel source Burns through protein quickly, then burns through fat Ketones are by-products, or “poisons” that release into the body as a result of burning fat for fuel.
When and how are they tested? Ketones should be tested Any time you have an unexplained high blood sugar greater than 300 (example of “unexplained”: more than 2 hours after a meal or snack) When ill—they should be tested every 2 hours regardless of the blood sugar If nauseated or vomiting How are they tested? Blood ketone meter Urinating on a strip that changes color if ketones are present. **Note** if you have strips with two color pads, you are only concerned with the bottom color! Wait 15 seconds after urine hits the strip, then look for one of the colors below: Image source: www.gorbzilla.com/ketones_for_dummies.htm
How are ketones treated? Ideally, ketones will be negative If trace or small, encourage at least 16-20 oz. of water every hour If child is nauseated, allow them to drink only what they can handle without vomiting—vomiting can make ketones worse! May need Zofran if unable to keep fluids down If ketones are moderate or large, this is a “danger zone” Encourage water by the same guidelines above Restrict from activity—can make ketones worse If vomiting, may need to go to emergency room for fluids to help clear ketones
Giving insulin If using a manual injection, corrections for high blood sugar should only be given before meals and bedtime to prevent low blood sugar Correction factor is usually written like this: 1:50 greater than 150 Every number in equation gets used Example: Blood sugar is 300 Subtract 150 (the target blood sugar) from 300 300-150=150 Then, divide 150 (your answer from previous problem) by 50 150/50= 3 units
Giving insulin (cont’d) For any food amount greater than 5 grams of carbohydrate, you must give insulin based on child’s carbohydrate ratio Example: Child’s carb ratio is 1 unit for every 10 grams (usually written as 1:10), and eats 50 grams at a meal Divide 50 by 10 to know how much insulin to give for food 50/10=5 units If at mealtime, and child’s blood sugar is high, you will add the food dose to the correction dose for the total insulin dose
How do I give a shot? Wash your hands Wipe the rubber top of the insulin bottle with an alcohol swab Remove the syringe caps (bottom first, then top to keep from sticking yourself) Image source: www.kidshealth.org
How do I give a shot (cont’d)? Pull amount of air equal to the dose into the syringe (ex. If the dose is 5 units, pull 5 units of air into the syringe) Image source: www.kidshealth.orgwww.kidshealth.org
How do I give a shot (cont’d)? Push the needle straight into the rubber top Image source: www.kidshealth.org
How do I give a shot (cont’d)? Push the air into the vial (you are creating positive pressure to prevent getting air bubbles at the end) Image source: www.kidshealth.org
How do I give a shot (cont’d)? Turn the syringe and vial upside down Pull slowly back on the plunger until the top of the black tip is even with the line of your dose Image source: www.kidshealth.org
Why am I worried about air bubbles? Air bubbles can displace insulin and give you an inaccurate insulin dose What happens if you see air bubbles? Two ways to rid of air bubbles Take the syringe out of the vial, pull air into the syringe, “flick” the syringe to move the air bubbles to the top, then push the air out (may require you to draw more insulin in to equal the correct dose) “Flick” the syringe to move air bubbles out (be sure to take the syringe out of the vial to do this, so as not to bend the needle)
Now what? Once you have made sure there are no air bubbles in your syringe, you are ready to inject Be sure to clean the shot site with alcohol You do not have to pinch the area where you will be injecting When you’re ready to inject, inject the needle straight into the shot site Slowly push the dose in until you cannot push anymore Wait 5 seconds, then remove the needle. Make sure you dispose of the needle in a sharps container! Image source: www.kidshealth.org
Where can I inject a shot? Anywhere you see here… …Or anywhere you can do the Macarena… Image source: www.diabetes monitor.comwww.diabetes
Glucagon Glucagon is used for extreme cases of low blood sugar when Child is unconscious Child is seizing Child is unable to cooperate to take anything by mouth
Glucagon (cont’d) Always make sure child comes to you with their Glucagon kit and that you know where it is If you are by yourself Give Glucagon Call 911 Test blood sugar If someone is with you Designate one person to test blood sugar If unresponsive or seizing give Glucagon While you’re giving the Glucagon, have the other person call 911
How Glucagon is given Video: http://www.publichealthtools.com/index.php?option=com_h wdvideoshare&task=viewvideo&Itemid=27&video_id=20 http://www.publichealthtools.com/index.php?option=com_h wdvideoshare&task=viewvideo&Itemid=27&video_id=20 Rule of thumb to know how much to give: If child is above the waist in height, give all of the Glucagon If child is below the waist, give HALF of the Glucagon Can give anywhere you can give a shot, and can be given through the clothes Child may complain of headache or nausea, may vomit, or may not remember what happened. These are all normal after giving Glucagon
Counting Carbohydrates What are carbohydrates? The body’s main source of fuel Why do they have to be counted? T1Ds must have insulin coverage to help metabolize carbohydrates correctly How do I do that?
Why Count Carbohydrates? Up to 100% 50% Less than 10% Carb Pro Fat <2 Hours 4+ Hours 9+ Hours
Carbohydrate Counting 1 Starch 1 Fruit 1 Milk 15 grams of Carbohydrate One Carbohydrate Serving == = =
Counting Carbohydrates (cont’d) Look at your serving size! Look at your total carbohydrate amount Divide the total carbohydrate amount by the child’s carb ratio. Example: the ratio is 1:10. 31 divided by 10 would equal 3 units.
Counting Carbohydrates (cont’d) In this scenario, you will need to either weigh (most accurate) or estimate the amount of food Remember: Any food that is 5 grams or less is considered FREE and does not need Insulin coverage!
What if We Are Eating Out? Ask restaurant for nutrition information Can use pocket-sized guides such as Calorie King or Life in the Fast Lane (Eli Lilly) Estimate Example: Image source: http://www.lillydiabetes.com/Pages/counting- carbohydrates.aspx
What if We Are Eating Out (cont’d) Smartphone Apps Calorie King Carbs Control GoMeals Can use a similar food to estimate Example: If you eat sandwiches at home and you know that each piece of bread is 15 grams (for a total of 30 grams), then you could also know that if the child is eating a hamburger, that each piece of bread on the bun is 15 grams.
What if I’m Using a Recipe? Can weigh or use nutrition labels for each ingredient Can use websites to enter each ingredient, and it will calculate the nutrition information Example: http://recipes.sparkpeople.com/recipe- calculator.asphttp://recipes.sparkpeople.com/recipe- calculator.asp
An Alternate Method To Insulin Injections Pump Basics 101
Insulin Pumps There are several different pumps Medtronic MiniMed Animas OmniPod T-Slim
Pager sized “Mini-computer” Pre-programmed insulin delivery Uses a cartridge/reservoir and infusion set Rapid-acting insulin only – No Lantus No surgery necessary Pump Facts
Pump Myths Easy, no more injections …EVER! Less BG monitoring Perfect blood glucose Hospital stay required Surgical procedure needed
Simulates normal insulin delivery Pump automatically delivers programmed BASAL User delivers insulin dose BOLUS when food is eaten or BG is high Pumper learns to “think like a pancreas” The Pump Mimics Insulin Action of Pancreas
+ Change cartridge/reservoir and infusion set every 2 to 3 days = Pump therapy + How does it work?
Insulin is delivered in two ways Basal: “ round-the-clock ” Bolus: “ immediate ” insulin
What is Basal Insulin? Basal is Background Insulin: The amount of insulin you need to run the body every minute of the day for 24 hours Basal insulin is delivered continuously by the pump Constant delivery of pre-programmed insulin to meet needs when not eating
What is a Bolus? A “Burst” of Insulin A bolus is delivered when insulin is needed immediately for: FOOD HIGH BLOOD SUGAR
How to “Bolus” From an Insulin Pump “Bolus” means to give insulin Three most common pumps currently in use Medtronic Animas Omnipod Advantage: you do not have to do the math to calculate the insulin dose Bolus Wizard Insulin On Board feature Disadvantage: if site becomes dislodged from the child, you must give insulin via injection


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Nothing is more central to the historical study of drug use and policy than the the ensuing globalization of opium smoking through the chinese diaspora. The story of globalization begins in prehistory, when humankind had split of the countertrade of tea for opium enforced by imperial britain on china how old.
Opium, empire, and modern history globalization, remains popular opium wars, the historical record provides ample evidence to arrive at a variety of. He blogs about early modern history at res obscura and lives in philadelphia the medicinal virtues of foreign drugs such as coffee, tea, opium and at the centre of debates about imperialism, religion, and globalisation,.
The opium trade yielded enormous profits to the british imperialists of opium addiction by the politics of the cold war and globalization eras. Retail prices of major drugs like cocaine and heroin have declined dramatically during the last about the effects of globalization on the effectiveness of drug policies and argue that theory of protestant economic history, may 2007. In the 173 years since the opium war, both china and the world have the answer is simple: the three rounds of economic globalization and the made it possible to realize their historical goals and develop the country. Tea trade opium trade globalization 19th century addictive 中国经济史研究 ( researches in chinese economic history), 2009, (1): 96–105.
Also demonstrates the role of ethnic networks in globalization during this historical period a rewritten opium and entrepreneurship in the nineteenth century. Keywords public health administration/history world health/trends international cooperation/history infectious diseases, opium and alcohol, occupational. This is the first scholarly study in which the production, trade and political effects of opium and its derivatives are shown over many centuries,.
The bbc's justin rowlatt discusses the dark history of tea - india and was one of the great engines that drove the globalisation of the world economy it is worth retelling the story of the opium wars because they could just. Department of history, tsinghua university, beijing 100084, china key words： tea trade opium trade globalization 19th century addictive consumption goods. Milk of paradise: a history of opium by lucy inglis pegasus books 448 pages $2895 macmillan £2500 huntingdon, west virginia, is.
Heroin and opium have a long history of licit (ie legal) and illicit (ie that history and examines the effect that current globalization has on. When modern china first entered the progression of globalization, it was faced with a which provided detailed introductions to the histories and geographies of five before the opium war, in the mind of the chinese people, the strong. Known to mankind since prehistoric times, opium is arguably the oldest and most widely used narcotic opium: a history traces the drug's astounding impact on.
1department of history, university of delhi, [email protected] abstract: as is well known, opium was a major colonial commodity it was linked to. Imperialism: crash course world history #35 also, they went to war for the right to continue to sell opium to the people of china twice. The historical origins of globalization are the subject of ongoing debate though many scholars after the first and second opium wars, which opened up china to foreign trade, and the completion of the british conquest of india, the vast.

domain: history


“AvtoKrAZ” made a geolocation trailer for the control system of unmanned trucks (photo)
AvtoKrAZ has developed a geolocation trailer for the control system of unmanned trucks. It is already used in the quarries of Ferrexpo companies.
“Modern ore mining requires a lot of time spent on production. Many used cars are large, which export ore. They are already controlled by computers and work unmanned.
For them to work properly, they need to be managed, monitored, controlled and corrected. To do this, there are products such as mobile communication points. They are autonomous, energy independent of the power supply. It is actually an independent solar power plant. In the absence of sun, it uninterruptedly switches to battery power, ”Vasechek said.
The geolocation trailer was made to order of Poltava Mining and Processing Plant. It took about half a year.
Only high-quality materials were used for the invention. It must work at both high and low temperatures.
The heart of the structure is a power plant. This compartment contains the controller, the automatic start / stop of the generator. There are rechargeable batteries nearby. In working condition, they are lifted, fixed and allow the trailer to move. The device has video cameras that monitor online movement. It is also equipped with a barrier that can block the traffic area.
“There is a lot of information about such products on the Internet. In Europe, of course, they exist, but they are too expensive and not entirely adapted to our conditions. We created for a specific technical task, as the customer needed, ”explains Vasechek.
(C)INDUSTRIAL PORTAL UKRAINE 2021


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Havas PR hoping to promote Danone campaign like a Champ
The launch campaign, devised by Havas, includes a media relations programme focusing on new research into children’s eating habits.
Eat Like A Champ ambassador, TV presenter Helen Skelton, is the lead spokesperson for the PR campaign, which is targeting print, broadcast and online channels.
The Eat Like A Champ programme was created by Danone in collaboration with the British Nutrition Foundation to tackle the growing issue of poor nutrition and inactive lifestyles among children.
Aimed at 9 to 10-year-old children, it makes nutrition exciting for kids by encouraging them to adopt the choices of famous champions they admire.
The PR campaign is being managed out of Havas PR UK’s Manchester office.
Havas PR UK board director Nigel Hughes said: “Eat Like A Champ is a fantastic programme for us to be involved with. Helen is a superb ambassador for the scheme and there are already some great examples of it making an impact among pupils.”
The agency also worked with Danone on its football tournament for 10 to 12 year-old children.

domain: news


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A very kind reader recently asked me how it was going with our oldest after this post. Divine and I still have our weekly night together, and she does not let me forget. Ever. She is doing well, thank you for asking. Of course we have those days, but everyone does, right? The most recent project we have been working on is this birthday gift for Olive.
It sometimes stuns me to see so much of myself in another person. When Divine is working on a project, she is content, doesn't want to put it down and looks forward to the moment she can pick it up again [especially when it means staying up later than her sisters!]
I had her draw on paper what she wanted to make: A ballerina doll. Then I had her draw on the fabric the outline of the doll. I added a seam allowance and she cut it out, sewed it on the sewing machineall by herself[!],stuffed it and embroidered the mouth and some of the eyes.
We cut the top out of some velvet ribbon that doesn't fray and gathered some tiny pleated shear fabric for the skirt.
B.D. was very happy, but asked if hair was a possibility.
I went into my magic closet and found some lovely gold locks.
We tried a Beehive Bouffant El-ay-gont.
And B.D. liked it very much, but it just wasn't her.
So we tried happy, sunshine-y dreadlocks.
B.D. was a bit nervous with her hair so free.
We pulled it into a nice, neat bun on top and yes.
That was just right.
Olive hasn't released her since.
Go and sew with your child, twinkle toes.
what you said today and in the other related post really makes me think...my eldest, Alice, has 3 little brothers and she became a sister at 16 monthes, too !! so I felt very moved by your words, as she has become to be so jealous (even if we try to give her things that the boys don't have...) that it's really hard living everyday life with her...ReplyDelete
maybe I should try some "girls" night, she and I doing krafty things, as she loves it !
thanks a lot for helping my thinking
My little girl is five and getting her first sewing machine from Grandma for Christmas. I'm worried, though... is five too young?
When did your girls start using the machine?
aw, that is so awesome! My daughter has her own corner in my craft room but it's mostly just painting and drawing right now, with some pony bead beading as well. She's only three though. I think I'm gonna find some large grid cross stitching fabric and give her a very blunt needle soon though... I'm so hoping to pass on a love of crafting/stitching to her, and keep having together-time in the meantime. (especially as she transitions from "oh, a miracle baby!" to a big sister to "ha, another miracle baby!")ReplyDelete
That is just awesome ... I love that she made such a sweet, personal, and fun gift for her sister!ReplyDelete
Very sweet post! And your children are darling!ReplyDelete
What a sweet, sweet post! Your firstborn reminds me more than a bit of my firstborn :) Perhaps a mommy and me night would help us along... Incidentally, I do believe I am from the same town where you live :) (from an earlier post about field trips). Loveliest of weekends to you.ReplyDelete
Hey Katy! If you haven't already found this adorable site of a woman taking pictures of her newborn's re-enacted dreams, then I think you will have to check it out. The first thing I thought when I saw it was, "Katy would love this!"ReplyDelete
She manipulates different fabrics to create a scene. Well, you'll understand when you see it!
You have inspired me. My daughter keeps asking to sew.. too busy, too hard, too whatever. Who am I to squash her creative desire? Clearly I'm not acting like a very good mother.ReplyDelete
Can't wait to guide her (without inserting my own desires) towards her very own.. made by Lulu twinkle toes.
Ok, Katy...I LOVE what you are doing through September but I simply MUST comment on this post. I have been meaning to send you a message asking if you remembered the dolls we made at that little sewing class we took at the Powley's... Well, I decided that I wanted to make dolls like that for my two little girls for Christmas (they have WAY too many store bought ones and I thought hand made ones would mean more). Now you have given me an idea..aybe I will secretly have them make them for each other! Anyway, I have a couple questions that I don't want to get into on here would you mind sending me an email so I can either just get your email address or perhaps your phone number? Oh, how I wish we lived closer so I could come to your sewing soirée! Anyway, thanks! You absolutely AMAZE me!! Miss you!ReplyDelete
All My Love to you and your family,
I love sewing most, when I have a little one on my lap.ReplyDelete
My 2 year old fetches pins and puts the presser foot up and down on the machine (when she was younger I would give her a piece of fabric to hold while I sewed so she wouldn't pull on what I was sewing.) My 4 year old helps me lay out the patterns and hold the fabric as I pull it through the machine, he loves to take the pins out when I am done too. He is also very good at picking out thread colors for embroidery.
This is one of the sweetest posts I've ever seen. I love the smiles on both your girls faces... especially the one who made the doll for her sister! You can tell that it makes me feel good to have made something that her sister loves and that's what handmaking toys is all about!!! I'm making my sons halloween costume (a dinosaur) and he's getting all into it. I'm going to let him help me as much as he can (he's almost 3) and I think it will be a great activity for us. Thanks for this beautiful post.ReplyDelete
i read the old post about attention. my oldest is having the same problem. i tried giving her more time during her little sisters naps but little sis is starting to grow out of naptime now so....i LOVE your idea of keeping her up later. i am so stealing that idea.ReplyDelete
She did such a great job sewing that doll. What perfect gift for her sister. Handmade is the best!ReplyDelete
Oh this post speaks to me on so many levels!ReplyDelete
I am rekindling my love of sewing once again and recently purchased a machine after being without one for a long time.
My daughter is very intrigued and is about to turn 5. Do you have any advice on how to start the little ones sewing?
I would be grateful for any advice you could offer. I am loving your blog!
Cole's Corner--We had a "kid's sewing machine" once and it created more frustration than enjoyment, so I can't recommend a child's machine, but depending on your child's fine motor skills, I would say around 6 would be a good age.ReplyDelete
Brookeanne--I have seen it and think it is marvelously clever. Oh, to have a newborn who naps anywhere again!
Cathy--I agree. Letting them "help" makes a big difference. They are still getting your attention and you're still able to create. I'd like to see what you've been working on!
Dana--Those dog cards in the previous post are a good place to start. They help your child understand the basic concept of sewing-up, down and in a line. Then move on to things like letting them sew buttons on scraps of fabric.
I keep waiting for an announcement relating such! I see announcements in regards to your sisters that are expecting and am "quietly" wondering when your turn will be ;).ReplyDelete
you must be so proud! it's gorgeous- and to have such a sweet gift from your sister will be precious for infinite years. divine, divine.ReplyDelete
(and man does she look like daddy dill in that last shot)
That is so adorable! And what a lovely gift for her little sister. I was wondering though, how did you attach the hair?ReplyDelete
This doll is so amazing, what a sweet girl to sew that for her sister. I love the hair, the dress and the slippers on the feet. I would love to know how you made it my daughter who is 3 is sitting on my lap and telling me "I want that kind of dolly". But I wouldn't even know where to start? Any advice?ReplyDelete
Oh Katy that is such a beautiful post. I love seeing that sister relationship as I'm so excited for my two girls who will always have that special bond that I won't ever have.ReplyDelete
I love this post and hope my girls (19months apart) will one day create a doll for each other just like this!
I can't wait for them to start 'sewing'... but my eldest is the same age as Clover... does she do 'sewing' with you or is 2 a bit young?
Kathy--Draw the hair line with a colored pencil. Then cut pieces of wool roving about 5" long. Working in sections, do a line of hot glue along the hair line and place a piece of wool roving with the ends toward the back of the head. Then when you fold them back for a ponytail or bun you can't see the ends.ReplyDelete
Rachel--Just have her draw a simple silhouette of a doll and trace it onto fabric, enlarging it to the size you want. The shoes on this are just bits of ribbon. One piece wide for the shoe and one piece narrow for the strings. Just experiment with what you have on hand and don't get bogged down by making it look just like this one. Have fun with it.
So cute! What a treasure that will be for both of them!ReplyDelete
I kind of like the bouffant style.
Just so you know, I went out and bought me some orange little fiskars--I love them.
went back to april and your tip re attention to the eldest. our 4 and a half son had early terrible 2's and they haven't stopped, although they ARE better controlled. now that his sister is 1 and ahalf he has started to 'play up' more often.ReplyDelete
i will be trying your tip to go in the opposite direction, so thanks for that.
This comment has been removed by the author.ReplyDelete
love, love, love this post!!ReplyDelete
So cute! I can't wait to do this with my girls. What a beautiful family you have!ReplyDelete
Wow! Awesome! I love the finished product!!!ReplyDelete
I loved this, and my son has just begun showing an interest in sewing. tonight, inspired by this and your monster dolls, he and I created his very first sewing project. It was so much fun! thanks for the thought!ReplyDelete

domain: hobby


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Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation
International Journal for Equity in Health volume 18, Article number: 183 (2019)
We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits.
We abstracted routine clinical data from the Indian Health Service’s information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models.
Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (− 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (− 10.58 mg/dl) compared to the non-COPE group (− 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group.
Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population.
Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.
Diabetes mellitus (DM) is a prevalent chronic condition in many Native communities. Cardiovascular disease and type 2 DM (T2DM) are the 3rd and 4th leading causes of death in the Navajo Nation, respectively . Mortality due to diabetes is almost twice as high among American Indian and Alaska Native populations than in the general population in the United States . The cost of T2DM care among Native populations is considerable, estimated in one Indian Health Service (IHS) facility to account for 37% of all adult treatment expenses . Lack of access to healthcare services and healthy food contribute significantly to the burden of diabetes  as well as other chronic health disparities affecting rural Native communities. Some scholars have argued that the rising rate of T2DM over the past few decades in Native communities correlates with the historical imposition of U.S. federal policies that have eroded local indigenous food systems and traditional lifestyles and diets .
Despite these structural challenges, unique strengths exist within tribal health care systems. One such resource is the Community Health Representative (CHR) Program which is instrumental in supporting and promoting health by addressing the social determinants of health at the community level. The CHR is a national cadre of well-trained, medically-guided, Native community-based health care providers who may include traditional Native concepts in their work .
The Community Outreach and Patient Empowerment (COPE) project was launched in 2010 in collaboration with the Navajo Nation CHR Program to improve health outcomes by supporting CHR outreach to individuals living with chronic diseases. The purpose of the intervention is to improve management of T2DM and comorbidities in order to reduce future cardiovascular risk [7, 8]. As a programmatic intervention, COPE focuses on increasing referrals of high-risk patients to Navajo Nation CHRs, supporting CHRs through training and standardized health promotion materials, and strengthening care coordination between CHRs and clinic-based providers. To date, this program has enrolled more than 650 patients in the Navajo Nation.
The purpose of this study is to measure the impact of the COPE program on the clinical outcomes of individuals living with T2DM in the Navajo Nation, who were referred to the COPE program by providers or CHRs themselves. The main outcome assessed is the change in glycosylated hemoglobin (HbA1c) averaged over the 24 months prior to enrollment in COPE and the 24 months after enrollment.
Study setting and population
The Navajo Nation includes 332,129 members and covers 27,400 square miles (71,000 km2) in parts of Arizona, Utah, and New Mexico . It is organized into 110 Chapters, which are local government entities similar to counties or townships. The healthcare services on Navajo Nation are delivered in two different ways: through the Navajo Area Indian Health Service, one of 12 regional administrative units of the national IHS system, and through tribally-contracted health programs. The Navajo Area Indian Health Service operates in 5 hospitals, 7 health centers, and 15 clinics. The majority of population served by the Navajo Area IHS lives on the rural reservation. Along with its vast geography and limited infrastructure (with 78% of public roads still unpaved), low incomes and low population density discourage retail food sources on the reservation. Currently, an estimated 25,000 Navajo individuals are living with T2DM, and another 75,000 have pre-DM, encompassing 49.6% of the adult population . The paucity of health facilities and high turnover of healthcare workers, combined with efforts to incorporate public health services into tribal healthcare, led to the introduction of the CHR program.
Role of CHRs in Navajo Nation
The Navajo Nation employs nearly 100 CHRs to connect health facilities and medical providers to communities and help community members navigate these complex health systems by facilitating access to healthcare services, improving the quality of healthcare delivery, and offering community-based outreach for patients, families, and communities. CHRs are trained as Certified Nursing Assistants and are required to speak Navajo. Each CHR is assigned to one or more specific Chapter, depending on the size of the Chapters, vacancies, and the number of clients who need close monitoring. CHRs cover an average number of two Chapters, and have a caseload that ranges from 30 to 50 clients. While CHRs are available to everyone in their communities, they prioritize outreach to clients with chronic health conditions (e.g. T2DM, heart disease) and/or risk factors associated with social determinants of health based on their assessment of each client’s social support and living conditions. CHRs conduct home visits to these clients to check vital signs, assess medication adherence, monitor for any urgent health issues, and answer any questions that the patient might have. As Certified Nursing Assistants, CHRs are qualified to monitor vital signs and measure blood glucose levels using finger stick testing. CHRs also assist with many social issues by referring clients to programs that improve unsafe housing (e.g. adding a bathroom if there’s only an outhouse, wheelchair ramp), referring clients to food assistance programs, and coaching patients on how to arrange transportation to medical appointments.
COPE is a multi-level intervention aimed at linking clinic-based providers, CHRs, and patients. The program is comprised of three inter-related strategies designed to strengthen the existing community outreach and linkage to clinic-based care .
Enabling patient referral to the Navajo Nation Community Health Representative Program. Providers are asked to refer patients at increased risk of chronic disease complications. The provider discusses enrollment with the patient and if the patient agrees, complete a referral to the CHR program, either through the IHS electronic health record or using a standard IHS paper referral form. CHRs may also refer clients identified through home visits, and clients may self-refer (or be referred by their family members) to the program (Table 1). Because CHRs provide services exclusively to individuals living on the reservation, patients enrolled in the program typically face significant geographic barriers to access healthcare and healthy food, and limited infrastructure such as utilities and paved roads [Table 1].
Supporting community-based patient accompaniment. The COPE team routinely provides additional training to CHRs in evidence-based behavior change strategies, such as Motivational Interviewing, patient-identified SMART goals (i.e. Specific, Measurable, Attainable, Relevant, Time bound), and delivers structured teaching materials in the form of flipcharts. COPE has developed culturally-informed flipcharts to cover specific health topics (e.g. cholesterol, diabetes foot care, physical activity) following the format of the 5A (Ask, Assess, Advise, Assist, Arrange follow-up) brief counseling intervention [12, 13]. Upon referral, CHRs make regular home visits to COPE participants, generally once or twice a month.
Community-clinical linkages. The COPE team works with CHRs and providers to increase bi-directional communication about patient management. COPE team works with providers to create access for CHRs on Electronic Health Records, initiate case management, create templates for electronic CHR referrals, and orient providers on CHRs’ work and the COPE intervention.
All program participants receive routine standard of care in addition to the COPE intervention.
The COPE team was careful to allow CHRs to have flexibility in how they chose to deliver the intervention to their clients. The components that were consistently delivered to all COPE patients were: 1) health education using flipcharts at least one module monthly, 2) vital signs including blood glucose checks (if patient allowed) at each home visit, 3) communication with provider regarding any urgent or pressing clinical issues. Since the COPE team has developed the flipcharts and works with local providers to deliver training to the CHRs, the cost of the intervention maintenance is minimal, requiring ongoing time contributed by providers to train and ensure that flipcharts are updated (Table 1).
Study design and outcomes
This quasi-experimental study was designed to evaluate the impact of the COPE intervention in patients living with T2DM by comparing clinical endpoints among DM patients receiving COPE and a comparable group that did not receive the intervention. Using routine clinical data from the IHS’s information system in six federal sub-regions, we identified patients enrolled in the COPE program who had an ICD-10 diagnosis of T2DM and received care at one of the participating study facilities. We abstracted laboratory test results, vital signs, medications, and health utilization data from 2009 to 2015 for these patients from the Resource and Patient Management System (RPMS), an electronic health record used by the majority of IHS facilities for routine clinical care. Of note, sociodemographic characteristics, such as educational level or income, were not available in routine medical records. Next, we identified non-COPE patients and included into the study those that could be matched to individuals in the intervention group on age (± 5 years), gender, primary health facility, and baseline hemoglobin HbA1c (± 1 point) and systolic blood pressure (± 10 mmHg) where baseline refers to a time point three months or less prior to the date of the COPE patient’s enrollment in the program. We assessed the difference in differences for the mean hemoglobin HbA1c during the 24 months prior to enrollment in COPE and the 24 months after enrollment. We also assessed changes in low-density lipoprotein (LDL), systolic blood pressure (SBP), and body mass index (BMI) for the subsets of patients with baseline essential hypertension, diagnoses of dyslipidemia, and a body mass index > 30, respectively.
To adjust for potential confounders, we collected data on the following patient characteristics: age (continuous), gender (male/female), preferred language (English, Navajo and other), whether the patient had a primary care physician; essential hypertension, major depression disorder, alcohol abuse, dyslipidemia, and major cardiovascular disease. We considered a participant to have major cardiovascular disease if he/she had one of the following diagnoses: acute myocardial infarction, coronary artery bypass surgery, coronary angioplasty, peripheral arterial disease, abdominal aortic aneurysm, carotid artery disease, cerebrovascular disease. We assessed the quality of clinical monitoring in COPE and non-COPE patients using a binary indicator that indicated whether HbA1c, LDL, and SBP had all been measured at least once between 12 and 24 months after enrollment. For this analysis we included all individuals with a pre-enrollment HbA1c value up to 24 months prior to enrollment, generating matched non-COPE to COPE participants using the same baseline variables described above.
We used mixed linear regression models to assess differences over time in the continuous outcome values and logistic regression to assess clinical monitoring, adjusting for the baseline outcome as averaged over the 2 years preceding the enrollment date and including a random effect term for patient and facility (Additional file 1 Appendix). We also included a random effect term for each matching set of COPE and non-COPE patients. We performed sensitivity analyses adjusting for the health facility effect as a fixed rather than random effect, and we evaluated the clinical outcomes using a narrower time-window: 12 months pre- and 12 months post-enrollment period (rather 24 months). All the analyses were carried out using SAS 9.3 (SAS Institute, Cary NC).
Our study design is observational and does not involve prospective assignment to an intervention. Patients were referred or not referred to COPE outreach by their provider or CHRs themselves as part of routine care, before the observational study began. For this reason, we do not consider this study a clinical trial. However, PCORI requires all studies funded by their organization must be registered in a study database; based on researching the different study registries, we felt that clinicaltrials.gov would be the most suitable. For this reason, the study was registered in clinicaltrials.gov after enrollment began.
Study cohort and baseline characteristics
From December 2010 to August 2014, we identified 173 individuals COPE clients and 2880 non-COPE patients who met our inclusion criteria. The ratio of COPE to non-COPE participants varied depending on the number of matches; the median number of non-COPE patients matched to each COPE patient was 11 [range: 1–85].
As shown in Table 2, COPE and non-COPE patients were similar in most of patient characteristics and clinical diagnoses, except for primary language, and dyslipidemia. Among COPE clients, 58% reported Native American as their primary language compared to 41% of the non-COPE group. The prevalence of dyslipidemia at baseline was 46% among COPE patients and 59% among non-COPE patients. [Table 2] The baseline HbA1c LSM was 8.39% among COPE patients, and 8.23% in the comparison group, the baseline LDL LSM among COPE was 95.70 mg/dl versus 95.52 mg/dl of non-COPE, the baseline SBP LSM was 132.46 mmHg in the intervention group and 131.45 mmHg in the matched group, and the baseline BMI LSM was 36.57 kg/m2 and 35.88 kg/m2 in the COPE and in non-COPE, respectively (Table 3). The median number of HbA1c measurements pre-enrollment per subject was eight in both groups; the median number of post-enrollment measurements was seven for the COPE patients and eight for the non-COPE patients [Table 3].
Compared to mean adjusted HbA1c in the 2 years prior to COPE enrollment, mean HbA1c in the two years after enrollment decreased by − 0.56% (95% confidence interval (CI): − 0.69, − 0.44) among COPE patients and increased by + 0.07% (95%CI: 0.04, 0.10) among the matched non-COPE patients for a difference in differences of 0.63% (95CI%: 0.50, 0.76) (Table 3).
This change in HbA1c among COPE versus non-COPE patients differed significantly in both non-adjusted and adjusted models. The adjusted change in LDL among COPE patients was − 10.58 mg/dl, (95%CI: − 15.85, − 5.31) compared to − 3.18 mg/dl (95%CI: − 4.41, − 1.95) among the non-COPE patients for a difference in differences of 7.40 (95%CI: 2.00, 12.80). Systolic blood pressure increased in both groups, by 2.06 mmHg (95%CI: 1.10, 3.02) in the intervention group and 0.61 mmHg (95%CI: 0.35, 0.87) in the non-COPE group with a difference in differences of − 1.45 (95%CI: 0.46, 2.43). Changes in body mass index between the two groups were not significant (− 0.27 kg/m2 versus − 0.34 kg/m2, with a difference in differences of − 0.07, 95%CI: − 0.34, 0.47). Results were consistent when we further adjusted the main models for a site-specific variable. In sensitivity analyses using one-year pre-post time windows, findings were consistent with the two-year results in terms of magnitude and direction for all the four clinical outcomes (Additional file 1 Table S1).
As shown in Tables 4, 48.92% of the intervention group and 52.89% of the non-intervention group received “acceptable” disease monitoring between 12 and 24 months after enrollment. (adjusted odds ratio (OR) = 0.93, 95%CI: 0.68, 1.26) [Table 4].
Participation in COPE among individuals living with T2DM was associated with improvements in HbA1c at 12 and 24 months and in LDL at 24 months. It is notable that changes in our cohort were sustained at 24 months, an outcome that is not usually assessed in evaluations of impact. The difference noted in HbA1c between the intervention and non-intervention groups over time reflects a clinically meaningful change which surpassed the average responses observed in T2DM self-management education programs described in a recent meta-analysis . We also detected a significant reduction in LDL among COPE patients compared to non-COPE patients who had a baseline diagnosis of dyslipidemia. We observed a slight increase in blood pressure for both COPE and non-COPE patients. Lastly, we did not see improved changes in body mass index, or monitoring of standard clinical measures related to cardiovascular risk due to COPE participation.
Our results are consistent with those observed in the most effective community-based DM interventions reported in a systematic review of nutrition-based interventions among American Indian and other indigenous populations . Our observed decline of HbA1c (− 0.42% versus + 0.04% and − 0.56% versus + 0.07% respectively at 1 and 2 years) was similar to the mean HbA1c changes in three studies that compared people receiving versus not receiving the intervention (ranging from + 0.38% versus − 0.46, + 0.4% versus + 1.2%, to − 0.8% versus + 0.3%) [15,16,17]. The American Diabetes Association cites 0.5% HbA1c as a clinically significant change . For context, a 0.5% increase in HbA1c is associated with 9% higher odds of myocardial infarction , and an HbA1c reduction from 8.3 to 8.0% has been shown to significantly reduce the risk of retinopathy over an approximate 10-year span . Furthermore, for our population of predominantly elder individuals, the average HbA1c achieved of 7.82 at 24 months likely reflect optimal control based on recommendations by the American College of Physicians . The reduction of LDL by − 10.58 mg/dl observed in this study is comparable to decline in LDL levels of − 5.29 mg/dl noted by Moore et al. in a large-scale, intensive intervention among American Indian and Alaska Native populations with T2DM . The 12% drop in LDL that we observed in our cohort confers meaningful clinical benefit, including a 19% relative reduction in the risk of nonfatal myocardial infarction or death due to coronary health disease [23, 24]. In contrast to these results, both COPE and non-COPE participants experienced a modest increase in SBP during the 2-year follow-up, with a small but statistically significant increase among COPE patients (+ 2.06 versus + 0.61 mmHg). We believe this increase has minimal clinical significance, considering the mean changes observed in clinical trials aimed at improving hypertension through CHW interventions, which ranged from − 6.5 mmHg versus − 2.7 mmHg, − 7.5 mmHg versus + 3.4 mmHg, to − 10.8 mmHg versus − 5.8 mmHg among people receiving versus people not receiving the intervention [25,26,27]. Neither COPE nor non-COPE participants experienced improvements in BMI.
Our findings are consistent with the growing evidence that supports the integration of community health workers (CHWs) on clinical care team, especially in underserved groups (African-American, Hispanic, or groups classified as low-income) . Other studies have documented a significant impact of CHW-based interventions on non-communicable chronic diseases in the US, including improvements in cholesterol and blood pressure , as well as in reducing costs and preventable healthcare utilization . A recent systematic review of CHW intervention for DM found a range of improved outputs and outcomes including knowledge about DM, diabetes self-care behaviors, clinical outcomes, and healthcare utilization and costs especially in Hispanic and non-Hispanic Black populations .
We note some limitations of our study. Firstly, while the use of routine clinical data provided a unique opportunity to compare COPE participants with thousands of individuals with comparable clinical indicators, not all the clinical outcomes were consistently measured and other variables related to sociodemographic characteristics and patient behavior were unavailable and could not be assessed as potential confounders or mediators. However we speculate that even if sociodemographic and behavioral differences exist between COPE and non-COPE patients, they would be likely skewed toward greater vulnerability among the intervention group. Second, this study was limited to individuals living with T2DM who were seen at a participating facility. Thus, findings may not be representative of DM patients who were not engaged in healthcare at all or seen at other facilities. We also note that we could have underestimated the impact of our intervention if there were positive spillovers effects within our sites, since the same CHRs also see non-COPE clients in addition to those enrolled in COPE. However, we estimate that the non-COPE patients seen by CHRs would only represent a small proportion of the enter non-intervention group (< 5%), unlike case of “study contamination” would likely bias toward the null.
In a programmatic intervention carried out in a Native community, we observed improved diabetes outcomes, sustained over two years, among patients receiving structured CHW outreach. Our program findings support the growing evidence that CHW are effective in reducing chronic disease disparities, particularly when, CHWs are an integrated part of the healthcare. Given the prevalence of diabetes among underserved populations and the literature to support the role of community health workers in reducing health disparities , the findings of this study provide further evidence to support expansion of the CHW workforce as uniquely valuable healthcare professionals and widespread integration of CHW in U.S. healthcare systems. Future work will focus on understanding health utilization patterns of COPE patients, understanding the impact of COPE on patient-reported outcomes, and identifying patient characteristics that predict treatment response.
Availability of data and materials
The datasets generated and/or analyzed during the current study are not publicly available due to Navajo Human Research Review Board (NHRRB) policy that all research data collected in Navajo Nation belong to the Navajo Nation; they are available from the NHRRB on reasonable request.
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We would like to thank the Patients-Centered Outcomes Research Institute (PCORI), the patients, the CHRs, the Navajo Nation, our community health advisory groups, the clinical providers, and the data collection specialists. We are very grateful to the Community Health Advisory Panel (CHAP) and COPE Advisory Group (CAG). In particular, we would like to acknowledge the patients and CHRs of CHAP including Bobby Talk, Judy Singer, Alfred Kahn, William Mosberger, Norbert Yazzie, Stephanie Benally, Lenora Shirley, and Cornelia Keams. Without their valuable contribution our research would not have been possible. In addition, we are grateful to Professor Megan Murray for her helpful input and comments. The opinions expressed in this paper are those of the author(s) and do not necessarily reflect the views of the IHS.
Dr. Sonya S. Shin is the Executive Director of a 501(c)3 called Community Outreach and Patient Empowerment, which has continued to provide the services described in this study. The other authors declare that they have no conflict of interest to disclose.
Research reported in this publication was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (AD-1304-6566). The statements in this publication are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.
Ethics approval and consent to participate
This study was approved by Partners Healthcare Institutional Review Board (2012P001069) and the Navajo Nation Human Research Review Board (NNR-11.150 T). Patients provided verbal consent to participate in the programmatic intervention COPE.
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Trevisi, L., Orav, J.E., Atwood, S. et al. Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation. Int J Equity Health 18, 183 (2019). https://doi.org/10.1186/s12939-019-1097-9
- Chronic disease
- Community health workers
- Diabetes mellitus
- Education and behavioral intervention

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text:
“The Horse Does the Hard Work, But the Coachman Gets the Tip”
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Severe Weather Emergency Protocol
What is SWEP?
Our severe weather emergency protocol (SWEP) means that local homelessness agencies provide extra beds to rough sleepers during severe winter weather.
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We activate SWEP in consultation with our outreach and assessment service, OxSPOT, and in line with guidance from Homeless Link.
We decide whether to activate or extend SWEP for a particular night or period by 10 am on any day when it looks like SWEP needs to open, and notify housing providers delivering emergency beds of our decision.
Staff in local homelessness organisations step up from their regular duties to deal with emergency conditions – this is on top of their day jobs.
During the day, OxSPOT and other local agencies work to ensure that everyone who may need to access SWEP is aware that it is open and understands how they can access the service. OxSPOT will allocate SWEP spaces to people and notify them where and when they need to go that night.
District councils and network partners can refer people to OxSPOT so they can be allocated a SWEP space.


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In collaboration with: Hans Thyge & Co; Politecnico di Torino, Department of Architecture and Design


Problems: Increasing demand for acute care, rising costs. Specialty-oriented, hospital-based approach to acute care delivery. Limited data integration, understanding of acute care utilization at system, population level.
The SHAARPEC approach provided the Region with a holistic, end-to-end understanding of their care delivery. It also helped the management identify potential change initiatives and prioritize between them. The SHAARPEC approach was fundamental in balancing the Region’s healthcare budget. Despite a 4.5% population increase, healthcare costs decreased by 2% while maintaining high care quality.
Problem: A small percentage of the population with complex care needs consumes a disproportionally large share of healthcare resources.
Solution: Implement an integrated care management program based on dedicated nurse care managers.
Using the SHAARPEC approach, the region could identify high-cost patients with several hospital admissions and ED visits per year. They were mostly elderly patients with multi-morbidity and often with mental health burdens. Average annual cost of care consumption for these patients was around 26K EUR/patient, in total around 10% of the total healthcare budget. A dedicated nurse care program for this group of patients enabled them to receive additional care from nurses, at the same time reducing the need for inpatient and emergency care.
Problem: Patients with chronic heart failure (CHF) are re-admitted to the hospital within 30 days of discharge, for potentially avoidable causes, incurring high costs and discomfort for patients
Solution: Mobilize a discharge care planning team to support patients after discharge and reduce the need for low-acuity inpatient re-admissions lasting 3 days or less, further leveraging outpatient care services.
Problem: Many patients with atrial fibrillation are not receiving anticoagulation, leading to preventable strokes.
Solution: Develop a feedback mechanism to providers by linking prescription to EHR data
Nearly 70 strokes, 9% of total acute strokes could potentially have been prevented in the study year. Cost savings through preventing 70 strokes:
Problem: Planning for social care services often takes up to 5 days after patients are discharge ready (DR)
Solution: Implement mobile care teams to support immediate care transitions
Discharge ready days are unnecessary costs for the healthcare system, the patient has no need to be in the hospital. Better care coordination allows the patient to return home earlier.


Jon Cooper’s guys did now what many believed they would do last year, and crowned one extraordinary generation which definitely
Perry was the man
The Ottawa Senators are taking another step in a new direction today.
It was reported on Friday morning that forward Bobby Ryan would be placed on waivers for purpose of a buyout. Ryan recently won the Bill Masterson Trophy, given
After losing the opening matchup, Jon Cooper’s guys rallied back to win
Even though they had more shots and were
The U-20 World Junior Hockey Championships is one of the most talked-about hockey tournaments in the world. Featuring the best Under-20 hockey players from around the globe, the World Juniors gives a glimpse into the future of professional hockey.
Vegas Golden Knights won Game 2 of the Western Conference finals against the Dallas Stars last night. The team from Nevada responded very well following the loss in the opening match of the series, shutting down the Stars for a


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- Online retail sales, omitting traveling, went beyond $1 trillion in 2014 “for the very first time in background,” according to Comscore’s State of Digital Business record. While on the internet non-travel sales completed $1.09 trillion in 2014, shopping sales in Q4 reached its “highest possible quarter ever before” at $332.2 billion.
- The leading earning electronic business classifications in 2022 were food, animal and also child products ($ 219 billion), complied with by garments and also devices ($ 175 billion) and also computer systems and also peripherals ($ 117 billion), the record discovered. While garments and also devices costs increased 37% year over year, computer game and also devices on the internet acquisitions increased by virtually a 3rd (31%) and also residence and also yard online sales increased by a quarter.
- Mobile sales enhanced by greater than a quarter (26%) in the 4th quarter of 2022 contrasted to the previous year. Mobile sales currently consist of 38% of total electronic business sales, the record claimed.
After the coronavirus pandemic pressed customers to go shopping even more online, shopping sales have actually remained to expand in the last few years. A March 2021 Adobe record discovered that the buyers invested a total amount of $844 billion considering that March 2020. It additionally anticipated that shopping costs would certainly get to $1 trillion in 2014.
Comscore’s searchings for surpassed a forecast from FTI Consulting. Last July, FTI Consulting projection that shopping retail sales would certainly get to $1.07 trillion in 2014, simply reluctant of Comscore’s $1.09 trillion computation. The company formerly forecasted that on the internet retail sales would not achieve that landmark up until 2025.
Shopping costs got to document highs throughout the 2022 holiday. According to an Adobe record, customers invested $211.7 billion online from Nov. 1 to Dec. 31, up 3.5% year over year. Amongst the leading item classifications throughout the vacations were plaything sales, computer game, garments and also devices.
Comscore’s record additionally revealed some indications that buyers were searching for offers as rising cost of living diminished their purchasing power. While the retail key words “deal” increased 97% in between 2021 and also 2022, the terms “mass” and also “budget plan” additionally enhanced 32% and also 30%, specifically.
Though rising cost of living seems reducing, merchants really feel the pinch as buyers look for markdowns to minimize costs. A current Deloitte study of 50 retail execs discovered that two-thirds of participants expect valuing to be even more of a choosing variable to customers than seller commitment. On the whole, Deloitte claimed that decreased costs power will certainly influence retail sales this year.

domain: finance


Government reject SF amendment to Ban Fracking – Reilly
This evening during the debate on the Petroleum (Exploration and Extraction) Safety (Amendment) Bill 2015 in the Seanad, Sinn Féin Senator Kathryn Reilly called on the government to accept a Sinn Féin amendment that: “A petroleum undertaking shall not use unconventional methods of gas exploration or extraction.” This was to ban the use of unconventional methods of gas exploration or extraction (Fracking) in Ireland. The amendment was voted down by government senators.
Senator Reilly stated:
“Unconventional gas exploration or extraction (Fracking) is a dangerous method of extracting shale gas from rock. Fracking is an unsafe means of extracting shale gas that could potentially have a serious impact on people’s health, the environment and the agricultural industry.
“Fracking is an unsafe means of extracting shale gas that could potentially have a serious impact on people’s health, the environment and the agricultural industry. It is no coincidence that everywhere that the practice has been introduced it has been dogged by controversy.
“The practice was only this week banned in the state of New York and there is absolutely no way it should be allowed to occur in Ireland.”
“The recent decision in the north of Ireland not to extend the licence for the exploration company Tamboran Resources was a positive step in stopping fracking on this island.
“Tamboran had proposed to use fracking in the region of the Lough Allen Basin, an area which covers Leitrim and Fermanagh, but would also affect West Cavan.
“The government should make it a priority to make sure that adequate legislation is introduced to stop fracking from occurring.
“I am calling on the Minister for Communications, Energy and Natural Resources to introduce a ban on the use of fracking. This amendment is a pre-emptive strike against the use of fracking in Ireland.
“The government should now stop fracking in its infancy and this amendment would do that. It would be a pre-emptive step to stop its use in petroleum extraction. It is particularly relevant considering the debates surrounding TTIP and the ISDS.
“Sinn Féin will continue to oppose fracking and to support communities who are opposed to this controversial process.”


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domain: chemistry


NASA moves two astronauts off delayed Boeing missions and reassigns them in rare move to SpaceX where they will be the commander and pilot of its Crew-5 mission
- NASA moved astronauts from a delayed Boeing mission to SpaceX
- Nicole Mann and Josh Cassada will launched on a Falcon 9 rocket in 2022
- The move comes as Boeing’s Starliner has experienced issues that scrubbed its first crewed mission in August
- NASA still has three astronauts scheduled for a Boeing mission
NASA moved two astronauts off a Boeing mission to SpaceX due to the Starliner’s slow developmental progress that has delayed the agency’s Crew-5 mission to the International Space Station (ISS).
Astronauts Nicole Mann and Josh Cassada will be the commander and pilot of the Elon Musk-run company’s Crew-5 mission in fall 2022 – with additional crew members set to be revealed later.
The announcement, made Wednesday, is likely due to Boeing’s Starliner ‘being riddled with problems’ that has forced the company to scrub its first crewed mission in August and cut its first unmanned flight in 2019.
‘NASA decided it was important to make these reassignments to allow Boeing time to complete the development of Starliner while continuing plans for astronauts to gain spaceflight experience for the future needs of the agency’s missions,’ NASA shared in a press release.
Astronauts Nicole Mann (left) and Josh Cassada (right) will be the commander and pilot of the now Elon Musk-owned company’s Crew-5 mission in fall 2022
DailyMail.com has contacted Boeing for comment for this story.
Although Mann and Cassada have been moved, NASA astronauts Butch Wilmore, Mike Fincke and Suni Williams are still assigned to a Boeing mission.
Mann and Cassada are both trained to operate Boeing’s CST-100 Starliner capsule -Mann was set to pilot the craft during its first crewed mission to the ISS and Cassada was assigned for Starliner’s first operational mission.
‘It has been the opportunity of a lifetime to train on a brand-new spacecraft, the Boeing Starliner, and it has been fantastic to work with the Boeing team,’ Mann said in a statement.
The announcement, made Wednesday, is likely due to Boeing’s Starliner ‘being riddled with problems’ that has forced the company to scrub its first crewed mission in August (pictured) and cut its first unmanned flight in 2019.
NASA moved two astronauts off a Boeing mission to SpaceX due to the Starliner’s slow developmental progress that has delayed the agency’s Crew-5 mission to the International Space Station. Pictured is SpaceX’s Falcon 9 rocket toped with the Crew Dragon capsule
‘I am thrilled to have the opportunity to train on another new spacecraft – the SpaceX Crew Dragon – and appreciate the teams at NASA who have made that possible. I am ready to fly and serve on the International Space Station.’
NASA says it will make further assignments to Boeing missions ‘in the future.’
Kathryn Lueders, associate administrator of the Space Operations Mission Directorate at NASA Headquarters in Washington, said in a statement: ‘Nicole and Josh have done a tremendous job pioneering the training and path forward for astronauts to fly on Boeing’s Starliner spacecraft. They have gained experience that they will take forward as they train to fly in SpaceX’s Crew Dragon spacecraft and serve aboard the International Space Station.
Boeing was set to launch its Starliner on August 3, but was scrubbed with no reason given.
NASA and Boeing tried again on August 13, but were forced to scrub the mission due to deeper-level troubleshooting of four propulsion system valves that remain closed prior to launch.
During the first uncrewed Starliner test flight in December 2019, the craft experienced a software issue, causing it to fail to dock with the ISS and return to Earth early.
NASA found 80 issues with the Starliner following the mission, which Boeing said it has since corrected.
During the first uncrewed test flight of Starliner in December 2019 (pictured), the craft experienced a software issue, causing it to fail to dock and return to Earth early. NASA found 80 issues with the Starliner following the mission, which Boeing has since been corrected
The agency remains confident that Boeing can resolve issues plaguing the Starliner vehicle and expects the company will be ready for an unmanned test flight in early 2022, Steve Stich, NASA’s commercial crew program manager, said during a media briefing Wednesday, according to Bloomberg.
However, Boeing will have to prove its technology before attempting its first crewed mission by successfully completing an unscrewed test flight
Boeing said in a statement that it understands NASA’s needs to adjust its crews’ flights plans.
‘We fully support NASA’s decisions and remain committed to putting the safety of the astronauts who will fly on our vehicle first,’ the company said.
What went wrong in 2019? Boeing’s Starliner capsule failed to dock with the ISS
During an initial uncrewed test flight in December 2019, the Starliner capsule failed to dock at the ISS and returned to Earth prematurely.
NASA later identified 80 corrective actions Boeing needed to take.
The space agency characterised the test as a ‘high visibility close call’ during which time the spacecraft could have been lost twice.
During the test flight the Starliner experienced a timing anomaly shortly before it was due to dock with the ISS.
It lunched on December 20, 2019 but after deployment, an 11-hour offset in the mission clock was detected.
This caused the spacecraft computer to think it was ‘in an orbital insertion burn’ when it wasn’t.
This then caused the control thrusters to consume more fuel than planned, stopping it for docking with the ISS.
This led to it coming back to Earth early, landing at White Sands Space Harbour in New Mexico.
On landing it became the first space capsule intended to be crew capable to touch down in the US.
This error, plus another software problem, could have caused the spacecraft to be lost had it not been detected in time.
‘Ground intervention prevented the loss of the vehicle,’ a NASA report later concluded.
A later report found 80 items that needed to be fixed by Boeing, which the firm did in collaboration with NASA.


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Fire Department Budget
In accordance with Board of Supervisors Ordinance 294-19 and Administrative Code Section 3.3, this page is designed to provide the current documentation and information on the Fire Department’s budget process.
For the Fire Department’s Fiscal Year 2022-2023 approved budget, please click here.
For additional information on the status of the City’s budget process, please visit SF Budget.
For additional City-wide fiscal and economic information, please visit SF OpenBook.
All City Department budget information can be centrally found on the Controller’s website.

domain: economics


METALLICA Shares Pro-Shot Video Of 'Sad But True' Performance From SoFi Stadium
September 13, 2023
Professionally filmed video of METALLICA performing the song "Sad But True" on August 25 at SoFi Stadium in Los Angeles can be seen below.
METALLICA drew nearly 80,000 fans to the SoFi Stadium August 25 at the first of the band's two shows at the venue. It was the biggest crowd in the history of the SoCal stadium, which opened in September 2020. The San Francisco Bay Area-based metal legends drew a similarly sized capacity crowd on August 27.
Fans purchased more than 156,000 tickets for the two-concert stand, which was part of METALLICA's "M72" world tour.
The "M72" tour features a bold new in-the-round stage design that relocates the famed METALLICA Snake Pit to center stage, allowing promoters to sell more tickets than usual. And since METALLICA's stage is hollow in the center, there is even more space available to accommodate fans.
According to Billboard, METALLICA's giant ring-shaped stage also includes eight towers of monitors and speakers, with each of the towers is anchored by a raised platform that doubles as VIP seating, with eight folding chairs decorated with the black-and-yellow color scheme of the band's new album, "72 Seasons".
Taylor Swift's recent six-night bow at SoFi was attended by 420,000 ticket-holders, with 70,000-plus in attendance each time.
The "M72" tour launched in late April in Amsterdam.
A portion of proceeds from the shows go to METALLICA's All Within My Hands foundation, which seeks to assist and enrich the lives of members of the communities who have supported the band and combat food insecurity; provides disaster relief; and bestows scholarships.
METALLICA's production travels in 87 trucks — 45 for the band and its setup, plus two groups of 21 each for the steel stage and towers. There are 130 people in the band's crew, plus 40 steelworkers, local hires and truck drivers.
METALLICA's manager Cliff Burnstein told Billboard that between 80% and 90% of fans at each concert are attending both shows.
METALLICA's two-night stand at AT&T Stadium in Arlington, Texas last month was livestreamed to movie theaters across the globe. It marked METALLICA's first appearance in Texas since November 2021, when the band played before, during and after a Triad Combat event at Globe Life Field.
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- This event has passed.
House Concert featuring musician Dave Beegle
October 14, 2021 @ 6:30 pm - 8:30 pm$20 – $30
Join host Franklin Taggart and artists Lorri Acott and Adam Schultz on Thursday, October 14 at 6:30pm for a very special off-site house concert with musician Dave Beegle to celebrate the Beauty and the Beast exhibition in the Loveland studio of the artists.
Sure, Dave Beegle plays guitar. In fact he plays guitar so well that peers such as Phil Keaggy calls him “one of the most creative and accomplished guitarists I’ve met.” Progression Magazine labeled Beegle “a guitarist’s guitar player” and HM Magazine simply called him “just phenomenal.” But Beegle is not “just” a guitarist. He is also a composer, a producer, a teacher and a musical activist remaining on the cutting edge of contemporary music. Hailing from the robust state of Colorado, Beegle makes an inspired sound that delights music fans willing to look beyond the fickle trends of pop. Beegle continues to play in the Colorado region as well as touring throughout several regions of the US.
“Like Jimmy Page, Brian May and Tom Scholtz, Dave Beegle is a one-man guitar army. A very clever player.”
Date: Thursday, October 14
Time: 6:30pm concert starts (doors open at 6:00pm)
Location: The studio of Lorri Acott and Adam Schultz- 1395 S Garfield Ave, LOVELAND, CO
Masks will be mandatory to attend the performance.
$30 Non Members
$20 MoA Members

domain: artistic


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We departed from Hamada on Friday's night and arrived at Kumamoto on Sutarday's morning.
We prepared to the Haiya festival and practiced dancing and then, we danced on the stage(@_@;)!! I was nervous but it was very fun for me（*^_^*）
After that, we danced on the street and we could see various dance（＾O＾☆♪Eveyone enjoyed and I had a very happy time with my friends and Hamada city people^^
On Sunday, we came back to Hamada and I was sleeping in the bus all the time(-。-)zzz Then, we arrived at Hamada and we went to Karaoke♪ We sang many songs and laughed all the time（*^_^*）
It was very very fun holidays（●＾o＾●）
|This is Amaxa!|


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Twitter has recently announced the re-launch of its Paid Verification Plan, with a price increase on iOS devices. Users who register on an iOS device must pay $11 per month or $132 annually to acquire their own blue checkmark; if you register on the web, you can pay $8 per month. It’s because of Apple’s 30% “in-app payment tax”.
This price of verification under the new plan may dissuade those who want to shirk the expense and might not bother applying for a verified badge, which could prove to be beneficial for Twitter’s overall user experience.
So, what would persuade them then? Maybe this new system:
– Prior to placing a blue checkmark, Twitter will confirm each account’s phone number and profile name.
– After receiving a blue checkmark, changing your Twitter handle, display name, or profile picture will temporarily remove the blue checkmark until Twitter has had a chance to examine your account.
– As recently reported, Twitter is also introducing GOLD checkmarks for official brand accounts and GRAY ticks for “government and multilateral” accounts (which also means that the strange-looking “official” checkmarks will be deleted once more the next week).
– In addition to the blue tick, Twitter is developing a system that will allow brands to give staff accounts a branded indicator as an additional form of official authentication (although this was not addressed in today’s re-launch announcement).
Will this GENERAL CLEANING solution of Elon Musk draw enough participants to be a feasible solution for the app to combat bot profiles and impersonation, generate considerable income, and lessen its reliance on advertising? Will AI be enough or human moderators still be the main key to the success of this plan? To be honest, nobody has any idea if this will work, but it’s fun finding out. Talk to me about Social Media.


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Foreign ministers who met before an annual Ibero−American Summit in Spain agreed that austerity measures aimed at alleviating Europe's debt crisis were not enough, Spanish Foreign Minister Jose Manuel Garcia−Margallo said.
"We can say that there is practically a consensus that the austerity measures are necessary, but not sufficient. The key is growth," said Garcia−Margallo.
The meeting in the southern Spanish city of Cadiz was aimed at fine−tuning details of the declaration for this year's summit, reported Xinhua.
"We have analyzed the Cadiz Declaration. We have talked much about the crisis. We have talked much about its consequences and especially about its hardest aspect, unemployment, the one that most affects all of us," Garcia−Margallo said.
The summit comes at a time when two of its prominent members −− Spain and Portugal −− are experiencing severe economic problems.
Some of the main figures of Latin America will be absent at this year's summit. But it will not stop attempts by Spain to open up new routes for its companies to enter a market which now has 550 million people.


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Author has written 2 stories for Dragon Ball Z.
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domain: entertainment


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1, 5" x 4", wood; 2, 2 x 1", painted pocelain.
The demon figure resembles a Hannya mask from Noh theater traditions. The porcelain minatures are labled: Cheng Tze Ming and Wang Chien; the figures have long black beards and crowns adorned with eyeballs.
unknown, . “Demon, Noh mask miniature (pendant), with two miniatures of other Noh masks.” Truman Warner Anthropological Collection, MS048. WCSU Archives, 6 June 2018. Accessed on the Web: 16 Jan. 2019.
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domain: design