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The BIRT Team released milestone 4 of the BIRT 2.2 release a this week.The project is proceeding well. This feature along with the BIRT Web Project should help with deployment of BIRT reports.BIRT now leverages the WTP XML editor to display the XML for a report design within the Designer perspective.
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LINCOLNVILLE, MEâUniversity of Maine Cooperative Extension’s Tanglewood 4-H Camp and Learning Center, an organization that works with more than 3,000 Maine youth every year, has been granted a national accreditation from the American Camp Association. âWe strongly encourage parents to pay attention to the ACA-accredited camp status of camps during the camp search process.âTanglewood, a 4-H youth development program of University of Maine Cooperative Extension, is one of the most affordable camps in the state and has been teaching youth and adults to live harmoniously with the earth for 25 years.
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Personally I think the car was far too technical for its time, If not for the enormous amounts of free labor invested in the development, the Beetle would have been more expensive that it was.Compared to the 2CV, the VW beetle is a Lexus. Porsche used rear mounted air cooled engine constructed out of lightweight magnesium, specially treated anticorrosion steel chassis, the first use of a torsion bar suspension, acrylic paint and a very aerodynamic shape for its day.The car was thoroughly tested and engineered to standards that rival today’s cars.
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Not quite Emergency Ward 10Monday 22th JanuaryA busy, eventful day. Bill, the first patient, was waiting on the doorstep when I arrived a few minutes before 8.00 a.m. I always feel guilty when the patient is there before me in the morning even though I am not late. Bill is 61 and is a merchant banker. I dread to think what he earns. He has been in and out of atrial fibrillation. He had ablative surgery a few months ago which worked until last week when, without warning, he flipped back into fast AF. He was short of breath and in early failure. I put him on some appropriate medication and shipped him back to the cardiologist, who saw him seven days ago. Three days later, he had a cardioversion. It was successful. He is back in sinus rhythm and there are no signs of failure. The sooner you cardiovert AF, the better the chance of success. Bill had it done within four days. Of course, he has private health insurance. Most of my patients do not and so, for them, the wait for cardioversion is more like four months. So it is less successful. And do I detect a certain degree of nihilism from the cardiologists for NHS patients in AF? In the absence of BUPA, letters about âthe importance of rate controlâ seem much commoner. Or am I getting too cynical? Gayle, a 29 year old, originally from Oregon. She has one son, aged six, and has just miscarried her second pregnancy at eleven weeks. It had taken her two years to get pregnant. She had been meaning to make an appointment to discuss possible secondary infertility but did not get round to it, and then suddenly she was pregnant. The miscarriage happened abruptly and without warning. She bled heavily, was admitted late one afternoon, and had an ERPC. She was kept in overnight. The next morning, the gynaecology SHO and an anaesthetist came to see her to talk about the anaesthetic and the operation. The conversation seemed bizarre, until she realised that neither of them knew that she had already had the operation. When she had been admitted the previous night, the original plan had been to do it the next morning, but she was bleeding so heavily that in the end they had to do it immediately. Then the shifts changed. No one took her off the morning list. It is as well that Gayle is intelligent and articulate. A lot of people in hospital do as they are told without questioning. So Gayle was sent home. Without a letter. Without follow up and, worst of all, without any attempt to provide her with support or counselling. And she needs it. All women need support after a miscarriage. Gayle particularly needs it as one of her close friends said to her, âNever mind, maybe it was because you did too much exercise. You will know next time.â Albert, who is 79, presented a few weeks ago feeling well, but complaining of having to get out of bed to pass urine twice a night. He had got up once a night for years and found that manageable, but twice was too much. To be honest, many men of his age put up with worse, but it is a subjective matter. Examining him, his prostate gland was huge, but did not feel malignant. I arranged an ultrasound, which confirmed the large prostate and showed, rather surprisingly, that he was able to empty his bladder almost completely. His PSA however came back at 17.97 which is significantly raised. So off to the urologists, with all the reservations that I have about this sort of thing. The inevitable biopsy was not entirely benign, despite the clinical findings. For the technically minded, he had Gleason 3 3 in 3/10 cores. A CT scan showed no evidence of spread outside the prostate.So what do you do?You have an MDT meeting in which every specialist within a hundred miles sits down to discuss the best treatment. The surgeon felt he was too old for radical surgery. The radiotherapist was not keen on radical radiotherapy. Albert was disappointed not to be offered surgery. He is fit for his age, and if he had been 20 years younger he would have been offered it. The MDT meeting conclusion was to treat him with casodex followed by zoladex. Albert looked it all up on the internet and decided that he did not like the possible side effects of this treatment. He fancied âradical radiotherapy.â The radiologist still was not keen and said, âWell, in the end it is up to you. Think about it and have a chat with your doctor.âI am glad that, when I have my car serviced, the garage does not ask me to think about what kind of camshaft I want fitting.Albert has been round the houses. He has recovered from the biopsy and is back, where he started, sitting opposite me. He is still feeling well, still getting up twice a night to pass urine, and still not liking it. There is one difference, however. Now he knows that he has cancer. Like most people he would like to get rid it. âWatch and waitâ and hormone treatment is not the radical solution for which he was hoping.What do I feel about it? I feel that I would hate to have radical radiotherapy to my pelvis. I see the side effects from this treatment. Radiation cystitis and radiation proctitis can give you unbearably painful urinary frequency and diarrhoea day and night for weeks or even months. And it is difficult to treat. Quite literally, the patient has to sit it out. Family doctors see the reality of these conditions far more often than the radiotherapists and the surgeons. So I steer David away from radiotherapy, and he accepts my advice. He will persevere with the hormonal treatment.What do I really feel about it?I wish I had never done the PSA in the first place. I will not have one done at that age unless I am seriously symptomatic. I have a couple of retired doctors on my list, both in their seventies, to whom I have offered PSA screening. Both said, âNot bloody likely.âMind you, we doctors are a law unto ourselves. Tuesday 23 January Charlene is nearly 18 now, and is close to term in her first pregnancy. She came today for what will likely be her last ante-natal check. She was with her mother. Boyfriend disappeared some months ago. She has coped well with the pregnancy but today was fidgety and on edge. I did all the routine checks, which were normal. Then I asked her if she was frightened. She nodded and her eyes watered. She is frightened that it is going to be painful having the baby. She is correct. It is going to be painful. Charlene wants to have an epidural. Charleneâs mother, who is in her late thirties, had an epidural when she gave birth to Charlene. At the hospital last week, Charlene saw one of the older midwives who told her that âyoung girls like you should be able to âmanageâ without an epidural. âWeâ well see how you go.â âManageâ? âWeâ? Charlene is not stupid. A friend of hers had a baby and had a bad time. She wanted an epidural, but the midwives delayed and delayed and when they finally seemed to agree, suddenly it was âtoo lateâl. So they gave her some pethidine, which did not help the pain and did make her feel nauseous. There is a danger that, because Charlene is so young, she will have difficulty standing up for her rights. Mother will be there and will do her best. I wrote âepidural at the onset of labour pleaseâ in large letters all over her birth plan. We shall see what happens. When I was a medical student I was conditioned to believe that asthma was woefully under diagnosed in small children and that antibiotics were woefully and inappropriately over-prescribed for children who had either asthma or viral infections. My cohort of doctors remains keen on spotting the iceberg of undiagnosed asthma in children. At this time of year the cross-over and confusion between viral upper respiratory infections, bronchiolitis and asthma is as difficult as ever. I was trained never to use the expression âchest infectionâ. What do you mean by that, Crippen? Bronchitis? Pneumonia? Be precise. Or are you missing another asthmatic? For many, âasthmaâ remains a bogey word. I saw Joley today. She is two years old. I send her into hospital a few days ago, because she was having a severe asthma attack. Well, that was my diagnosis. Mum was not keen on it. âWe donât have asthma in our family, doctor.â They do not have broken legs in their family either, but who knows what is round the corner. The hospital kept her in for three days and treated her with nebulisers, steroids and antibiotics (just in case). She is much better now. Back to normal. Mum is delightful, really, but said to me, slightly triumphantly, âand the specialist said it wasnât asthmaâ. I looked at the discharge summary. âBronchial hyper-reactivity, mucus plugging and post-viral wheeze.âI must look up the definition of âasthmaâ again. Thursday 25th JanuaryA lengthy diary entry to give but a small insight into what it is like living on the crumbling edges of the NHS.We have an excellent rheumatologist locally, to whom we refer all our patients with rheumatological problems. I will call him Dr Grumpy, because he often is. He is grumpy because he is stressed. He is stressed because he is a single consultant running a department that really needs three, possibly four, consultants. He is also grumpy because, as he freely admits, he went into rheumatology because he has a interest in connective tissue diseases such as lupus. Unfortunately, he has to spend most of his working life seeing a rag-bag of poly-symptomatic middle aged worriers who have a variety of aches and pains, but no serious underlying illness. It is wearing him down.Dr Grumpy is also, like Dr Crippen, a high-emotive doctor and so Dr Crippen and Dr Grumpy occasionally clash. Dr Grumpy does not let off steam by writing about the stresses and strains of the NHS. Unless he is Dr Grumble, but I do not think he is.Kate is 42 and has severe Rheumatoid Arthritis. She used to be a county standard tennis player and was still playing a formidable game when her arthritis came on ten years ago. I referred her to Dr Grumpy, and she has been under his care ever since.Except she hasnât really been under his care for, although she attends his clinic every three months, she has not seen him for two years, and then it was only for thirty seconds when he stuck his head round the door and said âhelloâ.Kate is currently on methotrexate. This is a drug that should only be initiated by rheumatology specialists. Get it right and you can dramatically improve the patientâs quality of life. Get it wrong, and you can kill the patient. So, because she is on methotrexate, and because her arthritis is severe, Kate goes to a specialist clinic. And sees one of Dr Grumpyâs two ânurse-specialistsâ. She used to see the senior registrar, or occasionally the SHO, but they have long gone. The nurse-specialist asks Kate how she is. If Kate is feeling bad, the nurse says she will âgo and have a word with Dr Grumpyâ and leaves the room. Maybe she does speak to Dr Grumpy and maybe she does not, but when she comes back, she gives Kate a depot steroid injection, and Kate feels better for a few weeks.Because there is a pretense that Kate is going to specialist clinic, she does not come to see me, because that is not ânecessaryâ. My job is merely to prescribe the methotrexate. Many years ago, the hospital dumped their prescribing on us to âsave moneyâ. It saves money from their budget, and takes it off mine. I do not care about that. What I do care about is more expensive for me to prescribe the methotrexate because when I issue a prescription, she has to take it to a high street pharmacist, who bulk buy methotrexate.There is a shared care protocol for prescribing methotrexate. I need to see that the up to date blood tests are normal, and I need to see the shared care card. Dr Grumpy’s nurses are busy, and often too busy to bother to get this information to the GP. So then I decline to prescribe and the patient gets cross, and thinks I am being awkward. Today I saw Kelly for the first time in ages because she has not got any methotrexate and I have not got any blood tests.Before she came in, I phoned Dr Grumpy and told him that I was fed up with this, and also fed up with the fact that he had not seen the patient for two years. This is not specialist care. Dr Grumpy wasâ¦grumpy. He is too busy for this kind of phone call, but he promised to get the nurse to fax the results through.By the time Kate came in, I had the results, and she had the co-operation card, though it had not been filled in for three months. âThe nurse was too busyâ. Kate is in fact delightful, and intelligent, and we talked about the issues, and her temper disappeared. I showed her the red-alert âskull and cross bonesâ type decal that comes up on my computer screen when I try to prescribe methotrexate, and she laughed. Then we talked about her arthritis. When she goes to the clinic, the nurse looks at her hands, and asks her âhow she isâ and that is about it. Kelly has trained her, like Pavlovâs dogs, to produce a steroid injection on demand. âI try not to have more than three or four a year, but when I want one, I just say I feel bad. She said that she wished she could see Dr Grumpy again but she knows that is not going to happen.Then I took an arthritis history. What can she do, what canât she do. She cannot comb her hairlink
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