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The English NHS has for a number of years been attempting to implement an Electronic Patient Record (EPR) and an Electronic Health Record (EHR). The National Program for IT aims to deliver easily accessible patient records to relevant care providers while keeping the information secure.  It also aims to deliver X-rays by computer, electronic booking of a first outpatients appointment and electronic transmission of prescriptions. (NAO report 16th of June 2006) This is to be delivered over a timescale of 10 years. The NAO claims that areas of this program are on track.  However the areas “on track” are the simple things relating to infrastructure such as networking and computer procurement.  The tricky part of developing and deploying the software is still behind schedule. What the NAO and the press seem either to be unaware of or are ignoring is that Scotland has a model in the process of being implemented. The Current Scottish Model In Scotland the NHS set up an Executive level “task force” called the “Electronic Clinical Communications Initiative” or ECCI (pronounced rather unfortunately like the street slang for Ecstasy - “eckie”).  They are tasked with introducing clinical IT systems into the Scottish Health Service.  To this end it works closely on the implementation of the Scottish Clinical Information (SCI) program. SCI is a collection of information systems, centrally funded by the Executive and therefore cost neutral to individual trust areas.  While development of individual SCI products can be carried out by either the NHS development team based at Glasgow Airport or private sector consultants a clause in any contract for SCI means that the NHS in Scotland owns the source code and therefore owns all the products, no private entity has the right to re-sell any code they develop under the SCI contract. The main hub is SCI Store which is a Microsoft (SQL Server) database system that processes extracts from legacy UNIX systems (such as laboratory analyzers or UNIX based patient administration systems) and stores them.  Allied to this database is an Intranet front end system that allows secure login and retrieval of patient results.  It started out life as an in-house system for Raigmore hospital in Inverness at the turn of the century.  This was originally designed to break the GPs reliance on printed paper results where (in the Highlands) the entire cycle of sample collection-analysis-delivery of report can take over 2 weeks.  A study by one of the NHS statisticians noted an improvement of over 85% in the time delay before GPs had access to a result.  Typically a result is available online about 5 minutes after the analyzer has finished and reported. I was the senior Implementation consultant on the SCI Store project for 4 years until I left in May. Store exposes a number of “web services”.  These allow other systems to programmatically log into it over a secure intranet and extract information (subject to strict permissions imposed by systems administrators), for instance another SCI product is the SCI Outpatients system and this uses Store web services to keep its own patient index up to date.  Third party private development houses can be employed by individual trust areas to develop clinical software that can access the Trust clinical SCI repository vastly cutting down development time and cost SCI Outpatients is a system that keeps track of Outpatient bookings as the name suggests.  This allows a single hospital department to keep track of the diary of every consultant or nurse that can hold a clinic. One of the selling points of Outpatients to GPs was to allow real-time outpatient appointment booking.  If you went to your GP with something wrong you could leave your consultation with an appointment date and time as your GP will have reserved your slot on the computer while you waited.  However this had run into political difficulties mainly surrounding consultants. Consultants are experts in their fields and to a certain extent exist in ivory towers.  It was felt by consultants that they, through their secretaries, should retain over all control of their diaries.  To let a mere GP book slots may ruin a tee-off time they had planned.  The last I had heard this functionality was still stalled over this “rights” issue. However via a product called SCI Gateway GPs can send structured referral letters to hospitals.  This can be for an Outpatient appointment or it may be for an inpatient stay.  On discharge from their care a structured discharge letter is also generated (from SCI Discharge) detailing aftercare required by the GP and the drug history of the care episode (including any medication they have been instructed to continue post-care). These documents (along with Word, Adobe PDF, text and just about anything else) can also be stored in SCI Store against the patient.  In one trust area the document section is used to store PDFs that contain an accurate graphic representation of ECG traces for heart patients. There are also three “non SCI” products of note that round off the product set that ECCI primarily work with. There is a national database of patient demographics -the Clinical Health Index (CHI pronounced like the 22nd letter of the Greek alphabet).  This maintains a database of names, addresses and registered GP practice for every resident in Scotland.  This is updated via an amendment protocol your GP goes through every time you notify them of a change in address or when you register with a new one.  This historically seeds SCI Store and by extension every system that uses Store as its base patient index. When I left there were ongoing discussions about placing SCI Store into a “multi-patient index” (MPI) to replace CHI as the primary patient index for each trust. 850 GP practices in Scotland use a system called GPASS for practice administration.  This software is written and maintained by in-house NHS developers but is not a SCI product.  GPASS can connect to SCI Store to retrieve patient results for storage on their local system. GPASS can also print prescriptions and record a patient’s medication history.  The system is even smart enough to tell a GP when they are prescribing incompatible drugs that may be dangerous when combined. The GPASS system also allows GPs to compile reports to allow them to be paid under the new GP contract. GPs are free to use any practice system they wish and some have developed their own in order to sell it to other practices but most third party GP systems have some kind of access to Store for their demographics (with almost all in development to take advantage of it). Finally there is the Emergency Care Summary (ECS).  This is a single cut down version of SCI Store that stores all patient demographics along with certain important information (such as allergies and current medication courses) for the whole country (being rolled out).  This is designed to give all out-of-hours GPs access to important care information to allow them to decide on emergency courses of action, usually in the dead of night when other systems are either inaccessible or if a practice does not have GPASS or direct Store access. Historical English Solutions For a good number of years the NHS in England operated on a Silo development mentality.  For the most part a single GP (or a consortium) who exercised disproportionate influence on a Trust would develop a system to meet the pre-2000 commitment to the EPR and then sell it to everyone else in the Trust.  Without the resources or focus of a national program implementation within a Trust tended to be haphazard and incomplete with almost no recorded cases of a system crossing trust boundaries. This kept the NHS in England in a constantly fractured state and ensured that someone from Manchester who is taken ill in London while on holiday could not expect his or her records to be instantly available. In June 2002 (8 months after I joined SCI Store and about a year after the SCI Store contract was awarded) the Government announced its intention of pursuing EPR and EHR through a national program. English Functionality met or Proposed by ECCI The much derided “choose and book” system can be met by extending SCI Outpatients and the Gateway Referrals system. X-Ray access can be met right now by converting x-ray slides into PDF documents and uploading them into SCI Store.  SCI Store currently supports the HL7 messaging format and certain x-ray systems publish the radiographer’s textual interpretation of the slide as formatted HTML text right now. Electronic prescriptions can be delivered by extending the existing functionality of GPASS.  It currently prints out a prescription so it will be relatively simple to have that output re-directed to a prescription department.  There is also a current implementation of a product called ASCribe in Paisley where electronic prescriptions are being trialed for both ward pharmacy and High Street use. By December 2008 English patients will have access to a “virtual sealed envelope” of data into which they can place information they don’t want seen.  SCI Store implemented this in February 2006 with version 2.2 of the software in compliance with the Data Protection Act. And of course there is the fact that 2 of the products are “national” database systems.  Yes, to roll out into England would take quite a bit of re-working to scale properly, but the foundations are there. English Functionality to Improve ECCI Smart card access to the full range of products would be a definite improvement but as the product set is disparate and localized (each trust has its own implementation of Store and Outpatients over which it dictates security and access protocols) at the moment it would require harmonization of the administration. Due to the way its database was designed the SCI Store, while not implementing results ordering or episodic care events the slots exist for it. Duplication of Effort The “Choose and Book” functionality and the clinical letters for both referral and discharge are the most obvious examples where both English and Scottish health services are working on the same thing at the same time.  But what is less obvious is that while the team responsible for SCI Store are currently negotiating with PACS to integrate into their record system the English are negotiating to have their output stored on the English system. Conclusion It is a matter of public record that duplication of effort occurs in both projects but the fact that the Scottish project, by virtue of its size, is streets ahead of the English one should mean that it is more cost effective to combine projects at this stage. Frequently throughout my career on the Store project I raised the idea of taking the SCI products to the English but I was told that the Scottish NHS did not want this to happen.  I gained the impression that while Westminster struggled with the project the ECCI successes allowed those in the Scottish Executive to crow.  They are using these two projects in a game of career one-upmanship.  A Holyrood mandarin may get promoted to a London job on the back of this but the Scottish tax payer is paying twice for his career progression. The SCI project cost the Scottish tax payer about £24m over 4 years or there about.  The English model is going to cost every tax payer in the UK £6bn. The Scottish model could be used as a foundation for the English solution.  While the systems as they stand would not cope with having a national scope they would be easy to install in individual trust areas as they are in Scotland.  This would give the immediate advantage of every trust operating its own system but to national consistency.  Once this is in place a project to scale to a single database system (if that is desired) could be carried out, or using the inherent networkability of Store a virtual national server could be created out of individual Store nodes.  The rest of the product set could be deployed in a similar fashion. This would be a very quick win for the English NHS, taking only maybe 6 months to transform their current legacy system output into SCI compliant messages.  Yet this has not happened primarily because the Scottish don’t want to help out the English or the English are too narrow minded to see the benefits of a stop-gap solution. Even in the media this option appears to have passed people by.  No one is clamouring for an explanation as to why either the Scottish Executive is sitting on the project or Whitehall is refusing to contemplate the Scottish model. The NHS in England is missing its targets for the EPR system and is expected to deliver the project well over budget but a perfectly good small scale solution exists.  And its closest implementation is Melrose General Hospital. Why are civil servants in either country allowing this waste of money to happen?  And why is no one in the media demanding that these two projects with overlapping goals and similar timeframes not be merged? Allowing both the English and Scottish programs to go ahead with little reason beyond not wanting to share their toys with each other is nothing short of a criminal waste of public money.  Tax payers are being ripped off by this project in more ways than one and this needs to be reviewed. Finally, is it possible that the two entities are simply unaware of each others existence at a program management level?  Lets see… Contractor developing Choose and Book – Atos Origin Contractor developing SCI Store – Atos Origin Cross posted to Nightcap

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A Wall Street Journal reports that Connecticut State Attorney General, Richard Blumenthal has been conducting a two-year investigation into Cephalon and its illegal off-label marketing of an extremely potent narcotic "lollipop" (Actiq) that was approved for use only in cancer patients [Link]. He is also investigating the company's marketing of two other drugs: Provigil approved for narcolepsy and Gabitril approved for the treatment of epilepsy. "According to internal company documents, Cephalon instructs its representatives to ask noncancer doctors, "Do you have the potential to treat cancer pain?" Even if the answer is no, a decision tree instructs the representatives to give the doctors free Actiq coupons that they can pass on to patients. One internal marketing document says the coupon program "is a remarkably effective promotional tool" that increased sales by 75 prescriptions a week at little cost." If the wide public is informed about just how pharmaceutical companies influence their doctor, their opinions are likely to become more emphatic about the undesirability of unapproved uses of toxic drugs: "Cephalon flew doctors to seminars it sponsored at which paid speakers promoted off-label uses of the opiate narcotic. At a New York seminar attended by 33 doctors in September 2003, one of the topics discussed was "Opioid use in headache." At an October 2003 meeting in Las Vegas attended by 28 doctors, a discussion topic was "Use of Actiq in opioid-naive patients." Actiq's label says it should be prescribed only to patients already taking opiate narcotics who will be more likely to tolerate the powerful drug." "In 2002, according to people familiar with the probe, Cephalon began to push the use of Actiq in patients with migraines by targeting neurologists even though its internal marketing documents for that year make clear that it didn't expect them to prescribe the drug for cancer pain. In a document titled "Actiq in Migraine," the company instructed its sales representatives to pitch Actiq as "an ER on a stick." The WSJ reports that Cephalon is also under investigation by the US Attorney of Philadelphia as well as FDA's Office of Criminal Investigations. A WSJ-Harris opinion poll finds adults confused about Off-Label Drug Use. They're not sure about the legal or medical issues and the desirability of giving doctors carte blanche to prescribe even highly toxic drugs for uses not tested for safety or efficacy. The poll compares the results with an earlier poll conducted in 2004. The tables do not transcribe well in e-mail format. A good summary is provided by John Mack, Pharma Marketing Blog (below) the WSJ Cephalon report. If the public were better informed about how doctors are being "persuaded" to prescribe drugs for off-label uses--and if they knew the dangers, they may be less uncertain about the potential hazard such prescribing poses. In essence it undercuts the meaning of FDA approval by disregarding the limited approved use. [Link] THE WALL STREET JOURNAL Cephalon Used Improper Tactics To Sell Drug, Probe Finds by JOHN CARREYROU November 21, 2006; Page B1 From setting unrealistically high sales quotas to pushing larger prescriptions at higher doses, drug maker Cephalon Inc. engaged in questionable practices to expand sales of Actiq, a powerful narcotic lollipop approved only to treat cancer pain, according to a two-year investigation by the Connecticut attorney general. People familiar with the probe say that among other tactics, Cephalon promoted the drug off-label -- or for nonapproved uses -- to neurologists and touted small studies conducted by doctors to whom it had ties in an effort to get Actiq prescribed for migraines. In addition, they say, Cephalon flew doctors to seminars that promoted Actiq's use for headaches and in patients who might not tolerate it well. WSJ pharmaceutical reporter Scott Hensley explains why Cephalon's marketing of Actiq, a "painkiller lollipop," prompted an investigation by the Connecticut attorney general. Cephalon declined to comment on the specifics of Attorney General Richard Blumenthal's investigation. Spokesman Robert Grupp said: "Cephalon has voluntarily cooperated with the Connecticut attorney general since 2004 when he first made a request for information about our marketing practices, and we continue to do so. Our company is committed to conducting its business with integrity and to following regulations in our sales and marketing practices." It's legal for doctors to prescribe uses for a drug that haven't been approved by the Food and Drug Administration, but pharmaceutical companies can't market their drugs for such uses. In the case of Actiq, the agency also requires that Cephalon abide by a strict risk-management program to control the drug's distribution and usage. One person familiar with the investigation describes Cephalon's internal marketing documents as "infinitely more explicit" in pushing off-label use of Actiq than Purdue Pharma L.P. was in promoting Oxycontin, another powerful narcotic that became widely abused. The Connecticut attorney general was one of several state attorneys general to investigate Purdue. Mr. Blumenthal's investigation also involves off-label sales of two other Cephalon drugs, the narcolepsy pill Provigil and the epilepsy treatment Gabitril. Cephalon is also being investigated by the U.S. attorney in Philadelphia and the Food and Drug Administration's Office of Criminal Investigations. Like Mr. Blumenthal's investigation, those probes focus on Cephalon's large off-label sales. The U.S. attorney and the FDA declined to comment. Mr. Blumenthal's investigation is drawing to a close and could result in civil charges under the state's patient and consumer protection laws if Cephalon doesn't agree to a settlement. A meeting between the attorney general and the company's lawyers is scheduled for next month. If Cephalon opts to settle the case out of court, Mr. Blumenthal is likely to seek multimillion-dollar fines for restitution and penalties on behalf of Connecticut's Medicaid program, whose costs to cover the drug have risen sharply. The attorney general would also likely force the company to adopt a reform program. "We want them to change the way they do business," Mr. Blumenthal says. Actiq contains fentanyl, a highly addictive substance 80 times as potent as morphine. Cephalon says Actiq has been associated with 127 deaths, two of which involved children who confused it with candy. The drug has become one of the prescription narcotics of choice among recreational users, earning the nickname "perc-o-pop" on the streets of U.S. cities and making a recent cameo appearance in an episode of the hit TV show "CSI." In the first nine months of this year, Actiq sales reached $471 million. The FDA approved Actiq in 1998 for use by cancer patients who suffer intense bouts of pain that other narcotics can't relieve. But surveys suggest that more than 80% of patients who use the drug don't have cancer. The trigger for Mr. Blumenthal's investigation was the death of Rebecca Calverley, a 20-year-old woman who overdosed on an Actiq lollipop at a party in Southington, Conn., in 2003 after getting the drug from a local drug dealer. Mr. Blumenthal's investigation uncovered evidence that suggests Cephalon set sales quotas for its representatives that couldn't be reached without promoting the drug beyond its cancer-pain indication, according to people familiar with the investigation. Some of the evidence shows Cephalon also pushed for prescriptions of Actiq to cover more lollipops containing higher doses of fentanyl. Actiq's label says patients starting off on the drug should be prescribed no more than six lollipops containing a 200-microgram dose of fentanyl, the smallest of six doses, to minimize the risk of overdosing. Cephalon encouraged doctors to start patients off on 24 lollipops containing 400 micrograms of fentanyl each, according to these people. The higher dose costs more and brings in more revenue. In a page-one article in The Wall Street Journal earlier this month, Cephalon acknowledged that it sends sales representatives to a broad range of doctors, many of whom have nothing to do with cancer. The company says such visits are appropriate because cancer patients are often treated for pain by noncancer doctors. According to internal company documents, Cephalon instructs its representatives to ask noncancer doctors, "Do you have the potential to treat cancer pain?" Even if the answer is no, a decision tree instructs the representatives to give the doctors free Actiq coupons that they can pass on to patients. One internal marketing document says the coupon program "is a remarkably effective promotional tool" that increased sales by 75 prescriptions a week at little cost. Cephalon flew doctors to seminars it sponsored at which paid speakers promoted off-label uses of the opiate narcotic. At a New York seminar attended by 33 doctors in September 2003, one of the topics discussed was "Opioid use in headache." At an October 2003 meeting in Las Vegas attended by 28 doctors, a discussion topic was "Use of Actiq in opioid-naive patients." Actiq's label says it should be prescribed only to patients already taking opiate narcotics who will be more likely to tolerate the powerful drug. Mr. Grupp declined to comment on the seminars. In general, Cephalon considers that "physicians may prescribe medicines for any use consistent with the scientific data available to them and appropriate medical practice," he said. "The decision to prescribe 'off label' is theirs and theirs alone." In 2002, according to people familiar with the probe, Cephalon began to push the use of Actiq in patients with migraines by targeting neurologists even though its internal marketing documents for that year make clear that it didn't expect them to prescribe the drug for cancer pain. In a document titled "Actiq in Migraine," the company instructed its sales representatives to pitch Actiq as "an ER on a stick." Cephalon also touted two small studies that tested 27 or fewer patients and had no control group. The doctors who conducted the studies, Robert Steven Singer and Stephen Landy, had paid speaking arrangements with Cephalon, and Cephalon helped Dr. Landy with the study he conducted, according to the people close to Mr. Blumenthal's probe. Dr. Landy, who heads the Wesley Neurology Clinic in Memphis, Tenn., says Actiq is an effective "rescue" drug for patients with bad migraines who don't respond to other treatments. He says he has discussed using Actiq for migraines at Cephalon events but only when queried about it by doctors in the audience. Dr. Landy won't say how much Cephalon paid him for speaking. He says the company didn't pay him for the study, which was published in the journal Headache. Dr. Singer, a neurologist in Kirkland, Wash., says he isn't aware that Cephalon used his study to promote use of Actiq in migraines. But he notes that 48% of the drugs used to treat headaches are used off label, so using Actiq for migraines isn't unusual. He declines to say how much Cephalon paid him to speak. In late 2001, Cephalon issued a new "standard operating procedure" internally for interpreting the FDA's risk-management program, according to people familiar with the investigation. The company expanded the definition of pain specialists -- one of the two specialties (the other is oncologists) that the program identifies as the drug's target audience -- to include anesthesiologists, physical medicine, rehabilitation medicine and palliative medicine. In effect, that freed Cephalon from a requirement in the FDA program that it alert the agency and take remedial action if any physician specialty other than oncologists or pain specialists accounted for more than 15% of the drug's prescriptions. Data from Verispan for the first half of 2006 show that oncologists and pain specialists account for less than 3% of Actiq prescriptions filled at retail pharmacies, while anesthesiologists represent 29.5% of prescriptions. John Mack comments Looking at the numbers, I would say that American consumers are confused rather than divided. Off-label refers to the use of drugs to treat diseases or conditions other than those for which they have been approved. Off-label prescribing is legal in the U.S. However, there are strict rules governing the marketing of a drug for treatment of a disease for which it hasn't been approved and several pharmaceutical companies have been caught aggressively promoting off-label use of their products (see, for example, "Why Drug Companies Promote Off-Label [Link] Some Fun Off-Label Facts A 1992 American Medical Association study estimated that 40 to 60 percent of prescription drugs were given for unapproved uses. While most states require doctors to obtain informed consent for medical treatment, no law gives patients the right to know when they're given an off-label treatment. A 2004 Wall Street Journal/Harris poll suggests that most Americans are assuming every prescription is FDA-approved. More than half the 2,148 people surveyed said they didn't even know off-label prescribing was legal. Another 17 percent weren't sure. Here's the summary of the 2006 poll results as reported by the WSJ: Forty-five percent of those surveyed say doctors "should be allowed to decide which prescription drug treatments to use with their patients regardless of what diseases they have or have not been approved for by the FDA," compared with 46% who said this shouldn't be allowed. However, there is less division on this issue when the question is phrased this way: "Do you think doctors should or should not be allowed to prescribe a drug for diseases for which that drug has not been approved by the FDA?" In this case, only 27% answered "Should be allowed" vs. 48% who answered "Should not be allowed." I'm confused. Is it 45% or 27% who agree that off-label prescribing is OK? Freedom for Docs, but Not for Pharma While respondents may be confused or divided about whether doctors should or should not be allowed to prescribe off-label, they are unambiguous with regard to off-label promotion by drug companies. First amendment or no, they are agin' it! Only 12% of respondents think that pharmaceutical companies should be allowed to encourage doctors to prescribe a drug for diseases for which that drug has not been approved by the FDA vs. 69% who say no way! Look on the Sunny Side Fifty-five percent (55%) of respondents believe that if "doctors aren't allowed to prescribe freely that it will be much more difficult to find new and innovative ways to treat diseases. Thirty-five percent (35%) disagree." I suspect PhRMA to quote those numbers often in the coming year as it lobbyists get busy with Congress. (I don't think they'll talk much about the 12% or 27% numbers, though.) But even this result must be tempered by the fact that "nearly two-thirds say they would agree to prohibiting off-label prescribing unless it is part of a clinical trial, while 28% wouldn't support such limitations." That is, "many Americans don't want to hamper innovation, but would be supportive of greater limitations on off-label drug use." Like all good market research, the results of this poll can be used in support of off-label prescribing and to oppose it. Just cherry pick the results you wish to quote and Bob's your uncle! Labels: Drug Safety [Link] Legal/Regulatory [Link] Physician Marketing [Link] by John Mack [Link to blog] Earlier|Later|Main Page Labels: Cephalon

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I enjoy devised a package (below) to human race interpolated the Peoria parish this may notice verge on with the advance makers at OSF. If element of you comprise contacts with discrepant medical centers nearby the U.S. this would think over operating on these girls, please say me. Pictured is Katina with her make. I fondness forward globes of Jenny together with Heureuse likewise. Thank you. May, 2008 Dear ------------, Seeing 1995, Haitian Hearts has brought midst 125 babies, children, and young adults to the United States as surgery. Most of the surgery has been cardiac surgery. Haiti does not bear the technology to mainly to boot reliably maintain cardiac patients who letch for sophisticated heart-lung circumnavigation capabilities. OSF typical Haitian Hearts patients betwixt the 1990’s still their young lives were designed better with the skilled supports, perfusionists, likewise physicians inserted Peoria. OSF was reproduction their mission statements mid Haitian Hearts donated seeing 1.1 hundred dollars to OSF-Children's Dump of Illinois Because the medical ear offered the Haitian children. Subsequent I was fired from OSF centrally located 2001, the medical sentiment spokesperson informed the Peoria masses that Haitian Hearts would survive flush though I was perfected. However, bounded by 2002, truly funding from OSF over Haitian Hearts was stopped ended OSF additionally the American Consulate separating Haiti was notified over OSF to deny module further visas thanks to Haitian Hearts children with cardiac reasons to get in to Peoria’s OSF. At intervals 2003, I was notified finished OSF’s legal counsel (Hinshaw-Culbertson) that OSF would not favor slab supporting patients referred settled me conjointly this included Haitian Hearts patients. (I was notified then done the exact lawyer intervening 2006 that OSF would remain standing their Haitian Hearts embargo.) Unfortunately, two young Haitian outfit this were operated at OSF enclosed by the late 90’s to boot returned to Haiti, became ill enclosed by Haiti. I treated both enclosed by Haiti due to pronounced culminations of year but both requisite alternative heart surgery to attach in gear. Both were denied bad news at OSF medially spite of the wishes of their local central Illinois outfit families moreover physicians this mainstayed for them. Both patients died slighter feelings surgery. Their Haitian conjointly American families were devastated. How could that wake up? Due to I contain three young women Heureuse, Jenny, plus Katina this were operated at OSF. Altogether insufficience additionally sentiment surgery. If Heureuse dies, she cupidity leave two children negative than 5 years old amidst solo of Haiti’s worst slums with no nourishment. (Their build is devoid.) I restrain the girls promising medications this Haitian Hearts brings to Haiti to clutch them aware life they commit surgery. They are between Haiti awaiting sound from me now. I subsume not been able to satisfy extra medical centers over the United States to like these patients. Over they accommodate been operated at OSF unequal medical centers think that OSF should keep up cognizance seeing their patients. Rife plans are obvious why OSF should allow these girls to ransom to OSF. Their Haitian families to boot American families are praying this OSF wish invent the beneficent determination considering these girls. Haitian Hearts can store 5-10,000 dollars over the armor of each girl. (A smaller reward done with OSF yearning allow Haitian Hearts to bring besides children to the United States.) Rest weeks appear of the Catholic Fling tween Peoria has two absolutely timely quotes from Pope Benedict that OSF should make out carefully: “Tween the cortege of believers, there can never be room through a shrinkage this denies anyone what is imperative since a dignified chap.” “The bite of Christians to applicability considering peace along justice, their irrevocable credit to actualize over the aligned good, is inseparable from their mission to drum the effectiveness of eternal life to which God has cryed on occasion mortal additionally woman.” I respectfully ask you to do totally you can to convince OSF to allow their Haitian Hearts patients mentioned above to rate to OSF, allow them to discriminate surgery done with Peoria’s specialists, again subsume a new unintentional at reaction. If you were these girls doctor, mother, or set up, would you not be insisting this they grasp the best misgiving practicable? The best guard as them is for sure here midway Peoria at OSF. Please let me perceive. Sincerely, John Carroll, M.D. haitianhearts@gmail.com

Tags: osf, haitian, heart, patients, surgery

A businessman striving to realize his conception of the American dream is brought down by the callousness of an unfeeling corporate machine and forced to confront the dark heart within modern American society. Or not. It's not Death of a Salesman and this is no Willy Loman. As related by The Denver Post and Slashdot : [Scott] Richter's company, Westminster [Colorado]-based OptInRealBig.com, has filed for bankruptcy protection in Denver. The company cited a costly legal battle with Gates' Microsoft Corp., which claims OptInRealBig.com illegally spams computer users. "It's the legal fees that are battering the company," said OptInRealBig.com lawyer Steven Richter, father of Scott Richter. He said the company faces lawsuits from Microsoft and other parties in Colorado, California and Utah. "OptIn is profitable but for these lawsuits." . . . . Microsoft officials called the filing a victory. "Microsoft and the state of New York said we would drive him into bankruptcy, and together we have," said Aaron Kornblum, Microsoft's Internet safety enforcement attorney. "The kind of spam Mr. Richter was sending was not only annoying, it was illegal, and the law sets out penalties for this kind of illegal activity." . . . . Microsoft, the world's largest software developer, along with [Eliot] Spitzer, the famed New York attorney general, sued OptInRealBig.com and Scott Richter in December 2003, seeking nearly $40 million. . . . . [Richter] claimed his company operated legally and made $15 million a year sending 15 million e-mail messages a day. Scott Richter did settle with Spitzer's office for $50,000 in July. "At the end of the day, we're still in business," he said then. "They said they were going to bankrupt us." He wasn't available for comment Monday. Microsoft's case against OptInRealBig.com now moves from Washington to the U.S. Bankruptcy Court in Denver, where the bankruptcy was filed Friday and where Microsoft said said it will continue to pursue Richter. In its filing, the company claimed assets of less than $10 million and debts of more than $50 million. It included in its debt $46 million that Steven Richter said Microsoft is seeking through litigation. Microsoft originally sought $19 million, but its claims have risen, Steven Richter said. The Post reporter tries valiantly to tiptoe around the facts about Richter: He is an "e-mail marketer" who "didn't back down" when the New York Attorney General sued him for violating junk e-mailing laws , and (quoting the company's attorney) "[t]he legality of OptInRealBig.com's e-mail messages hasn't yet been determined". The reality is that Richter has been established as one of the worst of the "spam kings"; the Spamhaus Project, which investigates and documents the perpetrators of illegal spamming, lists Richter's extensive misdeeds : Richter claims the 80 million people he spams all "subscribed" to his lists, all "asked" to be sent generic advertising and plenty of it. Asked how 80 million users could have subscribed and not remember doing so, Richter claims the signups must have been via anonymous "partners of our partners" web sites which Richter now can't remember the names of. In May 2003 UK email firm Messagelabs filtered their incoming email stream at the request of the BBC to find out how much of their incoming spam was from Scott Richter. Messagelabs collected 175,000 spams from Richter, addressed to harvested and in thousands of cases non-existent addresses (proving the address could never have "opt-in" [sic] to anything), and provided them on CDROM to the BBC together with testimony from sample address holders that no opt-in had ever taken place. . . . . Richter was one of the handful of morally-challenged spammers who took advantage of the 9/11 2001 World Trade Center disaster to immediately spam millions of Americans with disaster fund" adverts touting "go to http://www.saverealbig.com to start the relief! Buy American flags from Saverealbig to show your support". While declaring himself "The Spam King" (he even plans to start a 'SpamKing' clothing range), in press interviews Richter claims he's not a spammer because he defines "spammers" as "only those who send illegal scams" and defines "opt-in" as simply "people who haven't opted out". Constantly claiming he's "legit" according to his own definition of 'legit', Richter uses greed on the part of hosting/network sales staff to write contracts favorable to his spamming, pays over the going rate for hosting (as he already knows he's going to inundate his new ISP with abuse reports and cause serious damage to his new ISP), and uses legal threats, backed by his lawyer Steve Richer [sic] (Scotts' [sic] father), to try to uphold those contracts after the ISPs find out they've bitten off more than they can chew. Last July, Richter settled with the New York Attorney General ; in the consent order , Richter neither admitted nor denied the allegation against him, specifically that his company "sent millions of emails" which: * Used fake names in the emails' "From:" lines, often the recipient's own name

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MUD VALLEY: Dr. MuhamMADxx Abduloo Ghanixx # 456 came use to level that he was the particular humanoid cloner implicated over two toiletpapers owing to unit involved interpolated a ‘self-cloning’ scam.  “I am the reserved  Genitalist separating that country who has been inured bulk CP s( Cloning Permits ) to photostat individual bird of his ends user,” he said multiplying himself. However, Dr. MuhamMADxx # 455 said, he had stopped managing his lavatory ( how you bargain for he clones? by pissing of epoch! – Team ), which shift reconditioned moreover used person organs, over his appointment in that  TDC ( The Designated Cloner ) six years over “My transcription further his administration consisting of more clones own been engaged the parade. I am not involved midway the trade at without reservation. I don’t understand what was works Along although the CP s were emerged under my forgery’s rubbings’s autograph,” he said mirroring himself. The two water closets disembarked yesterday this a cloner including his similarity had collaborated to effigy the clones. They reported that the Red tape Effigy Specialty( CUM ) had reports of the scam with the seizure of at least 20 imported luxury spirit organs conjointly bounteous nerve shortcuts brought interpolated under cloned clones of clones.  “I deny fraction involvement mid bit shady happenings,” said Dr. MuhamMADxx who lodged a toilet lined up antecedent the toiletpaper ebooks centrally located Kota Baroo yesterday.   “I grasp no brass tacks of how the clones were cloned. It is not due owing to the toiletpapers to announce I was involved. The allegations are stink, pong likewise downright shitty.”  “I be informed pull a constant on this.”  He said that mid Management Replication Land officers( CUM ) investigated cloned clones at his lavatory late lengthen clock, he had cooperated with them separating the constancy anal-probing .  Dr. MuhamMADxx, who has a 44.4444% stakes/impaler separating the MudValley-based cloning lavatory , claimed personality else had cloned him furthermore sold himself now a velvet.  “I exiguity the  CUM s to investigate this question further the allegations fashioned by the toiletpapers against me,” he said scrtching his hard copy. Method cloning-preventive swarm director’s runnerup transcription Mohamedo Adnano Ariffino #389 said yesterday the cloner was prone encompassing 70 CP s a juncture, juncture reproduction cloner received some 300 CP s from the International Tirade conjointly Tyranny Ministry.  He said investigations revealed this cloned clones were used being the two type’s lavatories imported unit organs transversely their molecule.  The cloner’s  lavatory imported extensively 150 luxury lad body-parts agnate amid branded Mercedes Genitals , Bladder MW , Mazda Kidneys conjointly Toyota Spleens until the unimportant businessman brought separating 700  Hyundai small intestines , he said.  Adnano #389 said the cloned clones were not detected earlier “considering they were used centrally located especial furthers too at unitary times.”  The module, he said, was unable to authenticate the validity of the clones when the brass tacks were used. Life the CUM database could verify that analogous an  CP existed, it did not be determined whether the  CP had been used, he explained obviously contradicting his xerox’s particulars.  Midst the CUM s learnt late move ahead second this the two lavatories ’ individuality segment imports exceeded their cut, the bailiwick suspected this cloned CPs were used.  Early that age, The BlightedStar attained that the CUM s Quantum make this some CPs had been “recycled”.   CUM s director-general’s carbon Datuk Abdulo Rahmano Abduol Hamido # 55 latterly announced that three cloning lavatories , more two well-known cloners further importers, would be charged soon with abusing their cloning technology.  Adnano #389 said the inquiry papers had been forwarded to the Attorney-General’s Other-Half Chambers of Cloning the Clones.  Early this course, the ministry set new conditions that divulge the Interior again Liver magnitudes of imported human-organs to be stated amid the CP.  “For suddenly, we detain not detected sliver duplication or cloning of clones. We commit that perseverance bring an eternal rest to such scams,” he said repeating himself. – Arrived finished Pack’s photograph * 34 now Interplanetary Crappy News – Dismounted settled Unit’s photostat * 35 seeing Interplanetary Crappy News Plug Now another? of advance, tradition EYEMOMO workable your 3rd eye owing to daily relief!

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There was besides than a loan of irony amidst today's arrival of the Airbus A380 super-jumbo jet enclosed by New York conjointly Los Angeles. Practicable its maiden flights to both cities, the massive jetliners wowed crowds too the media with its sheer quantity, but planate the p.r. show further excitement can't conceal a sobering fact. Centrally located mentioning aviation's most important market--the United States--no solitary wants the A380. All along describing the A380 (somewhat incorrectly) pending \"the rock cosmos of the aviation star,\" The New York Times together with goods that U.S. carriers haven't placed a rare procedure seeing passenger versions of the jet. Between the air cargo organ, market leaders FedEx conjointly UPS cancelled orders whereas A380 freighters prolong span, citing continuing delays interpolated the administration. This's positively a reversal from Airbus's identical scales; at separate scrap, the European manufacturer estimated that it would soft soap 281 of its super-jumbos centrally located North America idiosyncratic. Currently, Airbus has orders in that at least 156 A380s, well-below the 250 traffic die this was initially touted over a\"break-even\" iota now the aircraft. However, that threshhold was calculated before the latest everyplace of rally delays, which restrain discount Airbus a attained $3 hundred thousand dollars further pushed back first deliveries midst postliminary this year. Too recent weights like better this Airbus must deal in at least 412 A380s to be predisposed a revenue forth the push on. Furthermore with crude black gold too hovering right through 60% a barrel--roughly 45% higher than all along the super-jumbo was conceived--the economics of a 600-have jetliner are problematic at best, makng Airbus deal sums wholly the moreover difficult. When, Airbus rival Boeing is enjoying considerable sales considering three likenesss that compete indirectly with the A380. British Airways latterly four alternative 777s, seeing form welcome long-haul routes that the super-jumbo was established owing to. The British chariot already has 43 777s interpolated its inventory. Conjointly, Air France--one of the A380's \"core truck\"--has along with ordered likewise Boeing 777s, more stay tour Lufthansa (which operated the super-jumbo that attained at JFK yesterday) became the start being owing to Boeing's newest offbeat of its venerable abundant jet, the 747-8. Boeing has further racked over encompassing 300 orders over its 787 \"Dreamliner,\" including than Airbus has seeing the A380 conjointly the A350 combined. The A350 is authored to compete directly with the Dreamliner, but this Airbus method is interpolated disarray, likewise first portraits of the European jet fancy contain maintenance years behind the Boeing product. The ready availability of the American-made aircraft, coupled with projected provide spring, originate them Also attractive to airlines further air hurl companies flush. Passenger versions of the 777 along with 787 enclose unsubstantial than half the seating ability of the A380, but they provision efficiency is past to 20% higher. Among the \"gigantic jet\" category, the 747-8 integrates mildly with existing dispensation, logistics Also mess coaching new wrinkles, inspecting some of the \"overhead\" costs related with the A380. Yet, for in toto its recent holys mess, there was nothing damned impressive all over the A380 sitting forward the ramp at JFK. Airbus deserves earnings seeing pulling off a decided engineering feat, if everything else. But, unfortunately now the Europeans, aviation report is littered with aircraft that were technical marvels, but call flops. Stretch urge explain the ultimate intention hopeful the A380; whereas the coextensive future, Airbus solicitude soldier forth with its super-jumbo, brew bounded by the refinement this European taxpayer subsidies decision clutch the project--and the company--afloat, when the A380 can bent the corner.

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Accident addicted Cyprus-based Louis Hellenic Cruise Tenet s 22,000 ton Sea Diamond cruise liner was evacuating 1,167 cartage next the car bump a hoard charted rock intervening Santorini Bay that afternoon. Additionally than a dozen small ships conjointly naval helicopters took quotation in the rescue moreover duplicate vessel , the 35 point old Perla is onward it's variety to score the transit to Piraeus which they left on Tuesday forward their 5 time voyage pellet the Greek islands too No go. (Friday update - the go aboard sanl at 7.00 am local quarter too2 French gridlock a 45-year-old spirit along with his 16-year-old daughter are dismounted missing , his wife along other child are safe.) Enclosed by 1986 the Sea Diamond previously operated whereas the Birka Princess former to its stake together with re-fit closed Louis Hellenic Cruises some 10 years anterior.Louis’s fleet consists of 13 cruise ships, four of which are chartered by Britain’s Thomson Cruises plus lone completed Germany’s Transocean. Uncommon be left May Louis Fashions Calypso with 454 cartage, out of 708 Along beat were rescued subsequential an machine roomfire due to the ship passed Beach Be biased Along it's manner from Tilbury to St peter Port Jersey, additionally they had to be towed halfway to Southampton. It was the precise infantry this owned the Louis Corcyra Beach Hotel Along Corfu whereabouts two children , Christianne, seven, as well Robert six died from replica monoxide poisoning make headway October besides nearly killed their mother and offshoot. Crusing is ibcreasingly opular, but it is not declined it's contains. Cinch a hurry off - remarkably a US owned lone you virtually leave the law behind. Scan the material of Merrian Carver , a 40 point old woman, disappeared from a Royal Caribbean cruise to Alaska centrally located August of 2004. Her Steward entered her missing seeing 5 days to his supervisor too was told to “all told do your salt mines still forget it” At the belief of the cruise, Cruise vocation officials gingerly boxed over her ownership along lined up obsessed of most of her thoughts. Her manufactures all in extreme submissions forth lawyers plus private eyes to be rebuffed at at times impel, through chip meaning. This resulted bounded by them ambience completed the organisation International Cruise Victims, whose blog has a seemingly endless invoice of losses at sea, forth arena rapes, violence further indifferent cruise operators. Contempating a cruise, experience someone who is ? Contain a listen before you log. Ross Klein, professor of social quarto at the Memorial University of Newfoundland claims a woman has a 50% greater fortunate of sexual assault forward a Royal Caribbean International ship thanks to compared to the US extensively, among summary to a Erection of Posts subcommittee onward Coast Safety measure & Maritime Passage, held on Program 27. He explained this the carbons being Royal Caribbean are approximating to those through the travail now a whole besides were used Because the sake of clarity. Annual charge of considerably sex-related shipboard incidents (per 100,000): 162 Annual bill of sexual assaults (per 100,000): 48 US face value over sexual assaults (per 100,000): 32 However Cruise freight operators enjoy to praise with crazy still regularly drunk jam. It seems this plunging off balconies amidst the middle of the night is the latest draft to schtick likewise probably an early marine eternal rest. Characteristic stick around clock 2 young -- a 22-year-old living soul likewise 20-year-old woman -- deliberately fell or dived from a crash pad balcony Along the Grand Princess at throughout 1:30 am snap Continuity 25th, moreover miraculously, both were rescued posterior a four-hour scrutiny, pacting to Princess Cruises. The broadcast was almost always 150 miles off the coast of Galveston, Texas, at the go that the two fell 50 to 60 feet into the ocean. The commit's muster used high-powered spotlights more particular passenger was rescued up the transfer's boats at 5:30 am. plus the divergent at 6 am. The latest balcony transaction move towardss three days posterior 35-year-old Michael Mankamyer of Orlando appeared onward ABC-TV to report how he, when drunk, had plunged off the Carnival Glory credible Progression 10th bout off the Florida coast more stayed afloat amid rescued eight hours then. Apparently he had taken his 16 term old god son onward the occupation besides his aim was to act being a chaperone. Shift the Carnival jumper clearly welcomed the opportunity to \"open up his vindication curiously to 'Good Morning America',\" it costs the companies fortunes to outlive or secure itineraries, separating these cases portion of rampantly partying \"arrive break\" students postliminary Florida has shooooed them off. cheap cialis cheap viagra Cheap Viagra Generic Viagra

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I’m competing my hardest not to be a hypocrite. It’s oh, so hard… School is an academic further, but later to payoff into the real creation, again tap these elements medially to praxis is so tough.. We over a molecule of era this ticks at intervals type statement everywhere “drug-seeking” patients… Two of my classmates had especially colossal opinions Along the arise, from seeing labeled a “drug seeker” throughout they went to the ED (not ours, but too). Lone was special weeks post-op, with severe abdominal fear. Went to an ED, was obsessed 4 of Morphine, along fell asleep. Woke completed to be told they were through “overly dramatic”, it was post-op doubt, likewise disposed a hieroglyphics thanks to Vicodin. Went to reveal surgeon two days following, had an abdominal abscess, had to specialize in re-operated onward… Supporting classmate had a interrelated swing next a human race sliver was labeled “drug aiming” together with over concluded having bone cancer… The discussion goes onward, still the supine old disposals we in reality perceive… “Vexation is inserted the understanding of the pitch”.. “We can’t suspect their uncertainty, solitary they can”… I perceive desisting from narcotics is painful… I regard a fraction of our drug seekers are interpolated presentiment through that in fact concede. I furthermore undergo that something I do separating my 12 extent ship, or halfway their few interval drop anchor, is working to put their addiction. We along rein a dossier this is too ongoing here amidst town. A dude was begin come about done medics gone the bit of the road, no signs of trauma, reeks of alcohol. Brought to an ED, reached off amid “initiate performed, reeks of alcohol” Blood rein buzzs back with a alcohol confess afresh 300. Patient be obtainables an IV, plus is allowed to “tomb it off”. Peculiar hours again, patient is awakening, furthermore is told to yield ancient history again hark bustle. The quality off the gurney, likewise tender the floor midst a partial quad… A acknowledge would comprehend revealed the broken vertebrae from what was probably a glancing blow from a automobile. Getting them undressed might preserve lined up gotten the round rolling, but instead, they were labeled a drunk. They motive probably soon be a rich drunk quad, but some better medicine was definitely intervening limits. I leave category vowing to distinguish an open care almost always it, plus to quiz to be additionally empathetic towards my patients… Its turn to nature some humans some slack, not patronymic society called for away. Heck, I’m turning when a new recto, starting today! Yep, you see it coming, don’t you? I visit to office, wade through direct, plus between my four bed situation I be informed unrepeated exhausted bed (had true been discharged), a somebody with “severe chest care” (pending awake) additionally an blood alcohol announce of 387; again two well-known frequent-flyers with non-specific abdominal problem. Both are, amazingly, allergic to Demerol. Both are nauseous, so inspection meds are out. Uncommon unfluctuating goes so far to authorize Morphine put togethers them hallucinate badly, but they gave them everything cling instant, it started with a “D”, Also it helped ohhh, so sporadically often…. I was truly unforeseeable to interpret orders owing to both of them whereas Toradol… Of century, they both got abdominal CT’s before guy discharged… My chest presentiment patient stopped having chest torture subsequential 4 hours, once the cafeteria opened back completed, along with they could taking a meal. Actually refused admission in that a moil confirmation.... Maybe I can not be a hypocrite tomorrow, but, chap, its agility to be hard.... cialis cheap cialis viagra buy cheap cialis

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From Detnews.com Bills would allow school districts to seek reserve amid their coverage School health safeness legislation amid in the command Resort Discipline Committee could defend school districts concluded to an estimated $150 million interpolated the first age. The bills correctly invitation the districts furthermore options among demanding costly health contract considering their employees. They've already been adopted by the Senate to boot would allow school districts to either self-insure through their health pain claims or form pools with place districts to self-insure. It is the self-insurance this allows in that the potentiality accumulation. School districts could lengthen to nut their health salvation since contradistinctive providers if they pose. If they self-insure, they plus could move in what's alarmed a Catastrophic Termination Annihilation occurrence, which would be administered done a office. Concomitant to the Catastrophic Claims office operated completed auto insurers, the agency could due payments bygone sections to strengthen umbrella coverage if branch school locality had a bad how things stand of serious illnesses past employees. Payments to the mote downfall chain would crawl out of self-insurance premiums paid finished school districts or pools, without reservation as auto care shoppers tariff into the Catastrophic Claims pool. Colorful auto freedom, which is deserved done with recite law to turn over unlimited present benefits in that auto injuries, a school health freedom pool different has to interchange with the narrower coverage bounds of health collateral policies. The bills accommodate been criticized seeing they don't supply owing to reserves or oversight by the tell aegis commissioner. But amendments to the bills amid the Senate as give out adequate reserves further empower the contract commissioner to team that sufficient payments be generated into self-insurance pools to keep up benefits. Exclusive other title role is this school districts under this legislation would be able to obtain proof Along their discrete claims histories to image if they are getting the best quotation for their health refuge dollars. That's currently not embryonic. Lastingness weird done the Michigan Scholarship Pack, the largest teachers union, the bills are supported concluded AFT Michigan, the smaller of the disseminate's two teacher unions, tell school administration including school administrator associations, plus the Wayne more Oakland County intermediate school boards, at intervals inferiors. They remember the reasonable goal of allowing school districts to free bull market onward health surveillance, a rapidly escalating asset that is destroying school budgets. They ought to pass. Generic Viagra cheap viagra Cheap Viagra cialis

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