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S. C. Johnson Wax Company Administration Building and Research Tower

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S. C. Johnson Wax Company Administration Building and Research Tower
1525 Howe St.
Racine, WI 53403
United States
42° 42' 55.476" N, 87° 47' 29.598" W
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Identity of Building / Site
Primary classification: Administration (ADM)
Secondary classification:
Federal, State, or Local Designation(s) and Date(s):
History of Building/Site
Original Brief:

By the spring of 1936, the Johnson and Sons Wax Company had outgrown its offices and began looking for an architect to design a new facility for the company. J. Mandor Matson was subsequently hired and designed a rather uninspired Beaux Arts building. Ground was to be broken on Matson’s building in July of 1936; however Herbert Johnson was not entirely convinced by the design so Johnson’s advertising manager William Connolley and his general manager, Jack Ramsey, drove to meet with Frank Lloyd Wright at Taliesin in Spring Green, Wisconsin. The meeting with Wright went well and Ramsey wrote to Johnson urging him to meet Wright as well which Johnson did later that month on July 20. After their meeting, Johnson was convinced enough to hand the commission for his new office building over to Wright. At the end of August, Wright presented his drawings to Johnson. He presented only eighteen to twenty drawings in order to express the overall simplicity of the project in the construction set. In October, after reviewing Wright’s designs for the new office building, Ramsey wrote to Wright asking that not all the interior walls be brick as in the Larkin building because Johnson was concerned that the effect would be jarring. Wright, however, did not concede. Throughout the design and construction process, as was the case with the interior brick façade, Wright’s concepts for the Johnson Wax Company Administration Building went unchanged even when it required that he request a change to Wisconsin’s building code in order to allow his design for the building’s infamous mushroom columns.

Dates: Commission / Completion:Wright was awarded the commission for the administration building in July, 1936. Work was begun on the administration building in October, 1936. The administration building was opened on April 21, 1939.
Architectural and other Designer(s): Architect: Frank Lloyd Wright Landscape/garden designer: Same Consulting engineer: Wesley W. Peters and Mendel Glickman Building contractor: Ben Wiltscheck
Others associated with Building/Site: Original owner: Johnson Wax Company Name: Herbert F. Johnson, President
Significant Alteration(s) with Date(s): Types of changes: The addition of the research tower, east wing expansion, and replacement of the skylights’ Pyrex tubing. Dates: Wright began designs for the research tower in November 1943, work was begun on the research tower in November, 1947 and the tower was opened on November 17, 1950. The addition of office space over the east wing of the tower carport was begun in 1960 and completed in 1961. Pyrex tubing was replaced in 1957. Circumstances/reasons for changes: The research tower was added to the administration building to accommodate the growing needs of the company’s research and development department and the east wing expansion was needed to provide more office spaces for the growing company. The Pyrex tubing was experiencing severe leakage problems which necessitated their replacement. Effects of changes: When discussing the possibility of an addition to the administration building in 1936, Wright had suggested that if there ever was one it would be tower. Thus the addition of the tower was in a sense the completion of Wright’s conceptual design for the Johnson Wax Company’s headquarters. In 1947 Herbert Johnson had asked Wright how he might expand the complex if additional office space was ever need to which Wright suggested a two-story addition to the tower carport with a light well running down the center terminating with round conference rooms. Plans were drawn up and approved by Wright, but when time came to build after his death, the light well was discarded in favor of more square footage for offices. Although the form of the addition was approved by Wright, the elimination of the light well seriously changed the character of the space which Wright had intended. The Pyrex tubing was replaced by specially molded sheets of plexiglass which visually resemble the previous tubing system. However, upon their replacement ,a layer of fiberglass was placed over the plexiglass with street lamps installed between the two layers in order to give the illusion that natural light was still penetrating through the skylights. The effect of this replacement of natural light with artificial light has severely changed the interior character of the building.
Current Use: The administration building remains the international headquarters for the Johnson Wax Company. Due to fire safety issues the research tower is no longer used and remains vacant.
Current Condition: The buildings are in excellent condition and remain unaltered since the last addition in the 1960s.
General Description:

The administration building is set back from the streets by 14 feet on each side and comprises a large open workroom surrounding with an entrance on the long side of the building to which a balcony overlooks. A rooftop penthouse of offices, which at its center is open to the workroom below, and two curved office wings are placed symmetrically over this two-story entrance lobby with office support facilities placed over the carport. The administration building is faced entirely in brick on both the exterior and interior walls. It is windowless and is lit by skylights and strips of translucent Pyrex tubing. The research tower is fifteen stories tall and comprises a series of square floors and circular mezzanine levels. The façade of the building is created through a wrapping of alternating horizontal bands of brick and Pyrex tubing.

Construction Period:

The administration building is constructed of wire mesh reinforced concrete slab and tapered mushroom columns. The research center is also of reinforced concrete with its floors cantilevered from a central hollow core.

Original Physical Context:

The Johnson Wax complex is located in the heart of Racine and is surrounded on all sides by city streets. It is situated between industrial sites and residential neighborhoods and is seven blocks west of Lake Michigan. Red brick is the prevalent material choice in this area.

Technical Evaluation:

Wright promised Johnson a building that would make him feel as if he were bathing in sunlight among pine trees, which he accomplished with the use of his “mushroom” columns. These columns taper up to support circular slabs which form the ceiling with the spaces between the circular slabs filled with translucent glass tubing thus effectively creating a man-made forest open to the sky. Additionally, by supporting the roof of the Great Workroom on the columns, clerestories of five feet in width could be included, thereby adding even more light to the space. The design of the columns themselves did not meet local building code requirements and so the Industrial Commission, being unable to decide whether or not to allow their construction, decided to have a test column built and loaded in order to observe its bearing capacity. The famous testing of the column was held in June of 1937 and after it had held the required twelve tons needed to satisfy the commissioners, Wright had the column loaded until there was no more room left to pile loads; it held sixty tons. The design of the research tower involved a coupling of a square floor and round mezzanine level. Although the vertical layout did not favor casual communication that was considered necessary for the spread of ideas, the two-story spaces provided scientists with psychological amenities as the researchers would not be confined to small two-person laboratories but rather were open to the amount of space equivalent to five smaller laboratories, as well as an abundance of light. To accomplish this, Wright conceived of the tower as a cantilevered system in which the reinforced slabs which taper from a maximum thickness at the point where the slab meets the hollow core.

The Johnson Wax Company proved to be an ideal client with ideals that paralleled Wright’s ideas that a company should not introduce products simply to gain the lead among its competitors but rather should only sell those products that were both innovative and would benefit the client. In addition to possessing these types of business principles, the company had a sense of respect for their employees with a “no layoff” policy as well as paid vacations, forty-hour workweeks (unusual at the time), and a profit-sharing system. This attitude toward the betterment of workers was clearly integrated into Wright’s design for the Great Workroom, a large space in which all clerical workers from each department were to share a common space in order to encourage cooperation. Wright considered work to have a spiritual value and designed the building to inspire work much like a cathedral might inspire worship and felt that making an environment that employees could be proud of would also inspire productivity. In the space’s multistory volume with its abundance of natural light, Wright provided this pleasant and inspiring working environment that had financial implications as the company’s office operations improved by 15 to 25 percent. Wright recalled later that the employees enjoyed the space so much that they often chose to spend their lunches in the building rather than leave to have lunch at home.

Cultural & Aesthetic:
The choice of common brick for both the exterior and interior walls of the building was made by Wright in order to make the walls as monolithic as possible responding to his ideas toward an organic design where form didn’t follow function and function didn’t follow form but rather the function and form were made to be inseparable from each other. The specific choice of dark red brick for the buildings was in response to the surrounding neighborhood’s use of a similar brick color. In removing all punctured windows from the building’s facades, Wright claimed that he was using bricks as bricks rather than glass as bricks. The interaction between the tower and the columned hall has been seen to have its precedence in ecclesiastical architecture rather than in office buildings. Japanese religious complexes bear the strongest comparisons with their emphasis on horizontality and their form of a colonnaded single story structure surrounding a quiet courtyard and the prayer pagoda.

Both the administration building and research tower were enthusiastically received by the public and the Johnson Wax Company employees alike. It was praised for both its overall quality of construction and its innovations in architectural and engineering design. In 1979, S.C. Johnson’s president, Samuel Johnson, spoke of how the company transformed the day that Wright’s building opened because it was through the building that the company gained international attention and inherited a symbol of quality that translated to their products and the working environment as well.

General Assessment:
The design and construction of the JWC allowed Wright the opportunity to explore his ideas for the ideal working environment as well as his sense that form and function should be combined into one cohesive building that imbues a desire for productivity in its occupants. The buildings also stand as a great example of Wright’s continual structural innovations throughout his career and earmark his leap to a more streamlined version of modern architecture.
Text references:

Carter, Brian, Johnson Wax Administration Building and Research Tower, London; Phaidon Press; 1998.

Lipman, Jonathon, Frank Lloyd Wright and the Johnson Wax buildings, New York; Rizzoli, 1986.

National Park Service, National Historic Landmarks Program, http://tps.cr.nps.gov/nhl/detail.cfm?ResourceId=1521&ResourceType=Building

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S. C. Johnson Wax Company Administration Building and Research Tower
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New York, NY 10023
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Oracle Human Resources Management Systems Payroll Processing Management Guide (New Zealand)
Release 12.1
Part Number E13558-10
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Oracle Human Resources Management Systems Payroll Processing Management Guide (New Zealand)

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Payrolls Overview
Consolidation Sets
Exchange Rates
Assignment Sets
Selecting Exchange Rate Types for a Business Group
Defining Consolidation Sets
Changing Consolidation Sets
Defining an Assignment Set Using Formula Criteria
Defining an Assignment Set by Including or Excluding Assignments
Defining a Payroll
Deleting Payrolls
Setting Up Payroll Contact Information
Allocating Payroll Contacts
Adjusting a Balance

Payroll Payment and Distributions

Payroll Payment and Distributions Overview
Payroll Payment and Distributions
Payment Methods for Your Enterprise
Cash Management and Oracle Payroll
Defining a Payment Method
Viewing Statement of Earnings Information
Setting Up Payslip Information and Generating Payslips
Extracting Information to Appear on the Payslip
Running the Pay Advice Alignment Report
Running the Payments Summary Report

Payroll Statutory Deductions and Reporting

New Zealand Taxes and Social Insurance
Payroll Statutory Deductions and Reporting
PAYE: Legislative Details
PAYE in Oracle Payroll
Setting Up Child Support Protected Earnings
Setting Up Income Support Deductions
Setting Up Inland Revenue Arrears Deductions
Making Student Loan Payments
Setting Up Payroll Giving Donations
Setting up Taxation for Regular Annual Bonus

Payroll Processing and Analysis

Payroll Processing and Analysis Overview
Payroll Processing and Analysis
Process Part of a Payroll
Continuous Calculation
Event Group Qualification
Starting a Payroll Run
Setting Up Continuous Calculation
Running the Continuous Calculation Process
Running QuickPay
Running the Generate Run Balances Process
Post-Processing for a Payroll
Data Locks for Payroll Processes
Generic Upgrade Mechanism Overview
Running Post-Run Processes for QuickPay
Viewing Payroll Process Results
Printing the Payslip
Running the Direct Credit (New Zealand) Process
Running the Register BI Publisher Templates for Payroll
Running the Annual Leave Liability Process
Viewing Assignment Process Results
Viewing Assignment Process Results for a Payroll Process
Running the PrePayments Process
Running the Cheque/Check Writer (Generic) Process
Running the Cheque/Check Writer Process
Running the Void Cheque/Check Payments Process
Reissuing a Voided Cheque/Check
Running the Cheque Listing Report
Running the Void Payments Report
Running the Payroll Cheque/Check Payment Report
Voiding Magnetic Tape Payments
Making External/Manual Payments
Running the Generic Upgrade Mechanism Process
Running the Quarterly Employment Survey
Running the Payroll Reconciliation Report
Running the Payroll Reconciliation Report (XML)
Running the Leave Liability Report
Running the Pay Advice Report
Running the Inland Revenue Arrears Payment Report
Running the Employer Monthly Schedule (IR348) Report
Running the Yearly ESCT Rate Review (New Zealand) Process
Running the New Zealand CEC Contribution Report
Running the EDF/IR345 (New Zealand) Report
Overview of RetroPay Processing
RetroPay Processes Available in Oracle Payroll
When to Run the RetroPay Process
Troubleshooting RetroPay
Setting Up Retro-Notification and RetroPay
Setting Up the Retro-Notifications Report
Setting Up RetroPay by Element
Setting Up RetroPay by Run and RetroPay (by Aggregate)
Setting Up Enhanced RetroPay with Component Usages and Element Time Spans
Setting Up Overlapping RetroPay Using Balance Adjustments
Understanding the Sequence of Your RetroPay Activities
Viewing RetroPay Status and History
Running the Retro-Notifications Report
Running the Retro-Notifications Report (Enhanced and Enhanced PDF)
Running Enhanced RetroPay
Running RetroPay by Element
Running RetroPay by Run or by Aggregate
Advance Pay Process
Setting Up Advance Pay for Individual Assignments
Setting Up Advance Pay for Batch Assignments
Running the Advance Pay Listing Report
Running Advance Pay
Running the Advance Pay Process
Running Advance Pay by Element
Viewing the Results of the Advance Pay Process
Payroll Exception Reporting: Overview
Examples of Exception Report Setup
Running the Payroll Message Report
Reconciling Payments
Setting Up Exception Reports
Grouping Exception Reports
Running an Exception Report, or Exception Report Group
Correction of Run Results: Rollbacks
Correction of Run Results: Retries
Correction of Run Results: Reversals
Marking and Retrying Payroll Runs and Other Processes
Marking a Group of Employee Assignments for Retry
Correcting Run Results: Reversals
Running the Batch Reversals Process
Retrying a Payroll Run or Other Payroll Process
Rolling Back Payroll Runs and Other Processes
Rolling Back a Process from the Payroll Processes Window
Rolling Back a Process from the Submit Requests Window
Rolling Back a Process from the Assignment Processes Window
Setting Up the Payroll Purge Process
Running the Upgrade Action Contexts Process
Running the Purge Preparation Phase
Running the Purge Deletion Phase
Running the Purge Process Events Process

Payroll Event Rules

Payroll Event Rules Overview
Payroll Event Rules
Database Triggers
Process Parameters
Defining Dynamic Triggers
Grouping Dynamic Triggers into Legislative Functional Areas
Making Table Event Updates
Maintaining Parameters and Parameter Groups for Payroll Processes

HRMS Glossary

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Solaris Dynamic Tracing Guide

Use of the C Preprocessor

The C programming language used for defining Solaris system interfaces includes a preprocessor that performs a set of initial steps in C program compilation. The C preprocessor is commonly used to define macro substitutions where one token in a C program is replaced with another predefined set of tokens, or to include copies of system header files. You can use the C preprocessor in conjunction with your D programs by specifying the dtrace -C option. This option causes dtrace to first execute the cpp(1) preprocessor on your program source file and then pass the results to the D compiler. The C preprocessor is described in more detail in The C Programming Language.

The D compiler automatically loads the set of C type descriptions associated with the operating system implementation, but you can use the preprocessor to include other type definitions such as types used in your own C programs. You can also use the preprocessor to perform other tasks such as creating macros that expand to chunks of D code and other program elements. If you use the preprocessor with your D program, you may only include files that contain valid D declarations. Typical C header files include only external declarations of types and symbols, which will be correctly interpreted by the D compiler. The D compiler cannot parse C header files that include additional program elements like C function source code and will produce an appropriate error message.


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Configuration Constraints and Objectives

When making changes to a configuration, poold acts on directions that you provide. You specify these directions as a series of constraints and objectives. poold uses your specifications to determine the relative value of different configuration possibilities in relation to the existing configuration. poold then changes the resource assignments of the current configuration to generate new candidate configurations.

Configuration Constraints

Constraints affect the range of possible configurations by eliminating some of the potential changes that could be made to a configuration. The following constraints, which are specified in the libpool configuration, are available.

See the libpool(3LIB) man page and Pools Properties for more information about pools properties.

pset.min Property and pset.max Property Constraints

These two properties place limits on the number of processors that can be allocated to a processor set, both minimum and maximum. See Table 12–1 for more details about these properties.

Within these constraints, a resource partition's resources are available to be allocated to other resource partitions in the same Solaris instance. Access to the resource is obtained by binding to a pool that is associated with the resource set. Binding is performed at login or manually by an administrator who has the PRIV_SYS_RES_CONFIG privilege.

cpu.pinned Property Constraint

The cpu-pinned property indicates that a particular CPU should not be moved by DRP from the processor set in which it is located. You can set this libpool property to maximize cache utilization for a particular application that is executing within a processor set.

See Table 12–1 for more details about this property.

pool.importance Property Constraint

The pool.importance property describes the relative importance of a pool as defined by the administrator.

Configuration Objectives

Objectives are specified similarly to constraints. The full set of objectives is documented in Table 12–1.

There are two categories of objectives.

Workload dependent

A workload-dependent objective is an objective that will vary according to the nature of the workload running on the system. An example is the utilization objective. The utilization figure for a resource set will vary according to the nature of the workload that is active in the set.

Workload independent

A workload-independent objective is an objective that does not vary according to the nature of the workload running on the system. An example is the CPU locality objective. The evaluated measure of locality for a resource set does not vary with the nature of the workload that is active in the set.

You can define three types of objectives.

Valid Elements

loose | tight | none

< > ~

Objectives are stored in property strings in the libpool configuration. The property names are as follows:

Objectives have the following syntax:

All objectives take an optional importance prefix. The importance acts as a multiplier for the objective and thus increases the significance of its contribution to the objective function evaluation. The range is from 0 to INT64_MAX (9223372036854775807). If not specified, the default importance value is 1.

Some element types support more than one type of objective. An example is pset. You can specify multiple objective types for these elements. You can also specify multiple utilization objectives on a single pset element.

See How to Define Configuration Objectives for usage examples.

wt-load Objective

The wt-load objective favors configurations that match resource allocations to resource utilizations. A resource set that uses more resources will be given more resources when this objective is active. wt-load means weighted load.

Use this objective when you are satisfied with the constraints you have established using the minimum and maximum properties, and you would like the daemon to manipulate resources freely within those constraints.

The locality Objective

The locality objective influences the impact that locality, as measured by locality group (lgroup) data, has upon the selected configuration. An alternate definition for locality is latency. An lgroup describes CPU and memory resources. The lgroup is used by the Solaris system to determine the distance between resources, using time as the measurement. For more information on the locality group abstraction, see Locality Groups Overview in Programming Interfaces Guide.

This objective can take one of the following three values:

If set, configurations that maximize resource locality are favored.

If set, configurations that minimize resource locality are favored.

If set, the favorableness of a configuration is not influenced by resource locality. This is the default value for the locality objective.

In general, the locality objective should be set to tight. However, to maximize memory bandwidth or to minimize the impact of DR operations on a resource set, you could set this objective to loose or keep it at the default setting of none.

utilization Objective

The utilization objective favors configurations that allocate resources to partitions that are not meeting the specified utilization objective.

This objective is specified by using operators and values. The operators are as follows:

The “less than” operator indicates that the specified value represents a maximum target value.

The “greater than” operator indicates that the specified value represents a minimum target value.

The “about” operator indicates that the specified value is a target value about which some fluctuation is acceptable.

A pset can only have one utilization objective set for each type of operator.

You can set both a < and a > operator together to create a range. The values will be validated to make sure that they do not overlap.

Configuration Objectives Example

In the following example, poold is to assess these objectives for the pset:

Example 12–1 poold Objectives Example

pset.poold.objectives "utilization > 30; utilization < 80; locality tight"

See How to Define Configuration Objectives for additional usage examples.

poold Properties

There are four categories of properties:

Table 12–1 Defined Property Names

Property Name

Logging level

Logging location

Monitoring sample interval

Decision history location

Maximum number of CPUs for this processor set

Minimum number of CPUs for this processor set

CPUs pinned to this processor set

Formatted string following poold's objective expression syntax

Formatted string following poold's expression syntax

Objective parameter

User-assigned importance


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The Java EE 5 Tutorial

Building, Deploying, and Running the clientsessionmdb Example Using Ant

    To build the application using Ant, do the following:

  1. Start the Application Server, if it is not already running.

  2. Go to the following directory:

  3. To compile the source files and package the application, use the following command:

The ant command creates the following:

The clientsessionmdb.ear file is created in the clientsessionmdb/dist directory.

To deploy the application and run the client, use the following command:

ant run

Ignore the message that states that the application is deployed at a URL.

The client displays these lines:

running application client container.
To view the bean output,
 check <install_dir>/domains/domain1/logs/server.log.

The output from the enterprise beans appears in the server log (domain-dir/logs/server.log), wrapped in logging information. The Publisher session bean sends two sets of 18 messages numbered 0 through 17. Because of the message selector, the message-driven bean receives only the messages whose NewsType property is Sports or Opinion.

Undeploy the application after you finish running the client. Use the following command:

ant undeploy

To remove the generated files, use the following command in the clientsessionmdb, clientsessionmdb-app-client, and clientsessionmdb-ejb directories:

ant clean


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Physician Directory

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Dr. Moen's Overview

Dr. Jon T. Moen graduated from the University of Wisconsin Medical School in 1984. He works in Fond Du Lac, WI and specializes in General Surgery. Dr. Moen is affiliated with Ripon Medical Center and Saint Agnes Hospital.

Dr. Moen's Experience

Years in Practice: 31

Dr. Moen's Specialties

General Surgery

Dr. Moen's Education & Training

Medical School: University of Wisconsin Medical School; Graduated 1984

Dr. Moen's Rating

Rate This Doctor

Overall Rating

Dr. Moen's Accepted Insurance

  • Aetna Choice POS II
  • Aetna Signature Administrators PPO
  • Anthem Blue Access PPO
  • Anthem Blue Preferred HMO
  • Anthem Blue Preferred Plus POS
  • BCBS Blue Card PPO
  • CIGNA Open Access Plus
  • First Health PPO
  • View More

Dr. Moen's Office Information & Appointments

Office Locations

Fond Du Lac Regional Clinic

420 E Division St
Fond Du Lac, WI 54935
(920) 923-7400

Office Hours and Information

Fax: (920) 926-8891

Practice Website: Not Available

Accepting New Patients: Yes

Medicare Accepted: Yes

Medicaid Accepted: Yes

Monday 8:00 AM - 5:00 PM
Tuesday 8:00 AM - 5:00 PM
Wednesday 8:00 AM - 5:00 PM
Thursday 8:00 AM - 5:00 PM
Friday 8:00 AM - 5:00 PM
Saturday 8:00 AM - 12:00 PM
Sunday Closed

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Dr. Moen's Hospital Affiliations

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Other General Surgeons Near Fond Du Lac, WI

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Physician Directory

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Ms. Raye E. Minardi

General Practice

  • (813) 745-6769

Ms. Minardi's Overview

Ms. Minardi works in Tampa, FL and specializes in General Practice. Ms. Minardi is affiliated with Moffitt Cancer Center.

Ms. Minardi's Experience

Years in Practice: Not Available

Conditions Treated by Ms. Minardi

  • Not Available

Procedures Performed by Ms. Minardi

  • Not Available

Ms. Minardi's Specialties

General Practice

Ms. Minardi's Education & Training

Medical School: Not Available

Ms. Minardi's Rating

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Overall Rating

Ms. Minardi's Accepted Insurance

  • Not Available

Ms. Minardi's Office Information & Appointments

Office Locations

Lifetime Cancer Screening

4117 E Fowler Ave
Tampa, FL 33617
(813) 745-6769

Office Hours and Information

Fax: (813) 745-6757

Practice Website: Not Available

Accepting New Patients: Yes

Medicare Accepted: Yes

Medicaid Accepted: Yes

Monday 8:00 AM - 4:30 PM
Tuesday 8:00 AM - 4:30 PM
Wednesday 8:00 AM - 4:30 PM
Thursday 8:00 AM - 4:30 PM
Friday 8:00 AM - 4:00 PM
Saturday Closed
Sunday Closed

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Physician Directory

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Dr. Vikramjeet Kumar, MD

Endocrinology, Diabetes & Metabolism

Dr. Kumar's Overview

Dr. Vikramjeet Kumar graduated from the Rajendra Med Coll, Ranchi Univ, Ranchi, Bihar, India in 1994. He works in Elyria, OH and specializes in Endocrinology, Diabetes & Metabolism and Diabetes. Dr. Kumar is affiliated with Fairview Hospital, Lakewood Hospital, St John Medical Center and University Hospitals Elyria Medical Center.

Dr. Kumar's Experience

Years in Practice: 21

Procedures Performed by Dr. Kumar

  • Not Available

Dr. Kumar's Specialties

Endocrinology, Diabetes & Metabolism, Diabetes

Dr. Kumar's Education & Training

Medical School: Rajendra Med Coll, Ranchi Univ, Ranchi, Bihar, India; Graduated 1994

Dr. Kumar's Rating

Rate This Doctor

Overall Rating

Dr. Kumar's Accepted Insurance

  • Aetna Choice POS II
  • Aetna Health Network Option Open Access
  • Aetna HMO
  • Aetna Managed Choice POS Open Access
  • Aetna Signature Administrators PPO
  • Ambetter from Buckeye Community Health Plan HIX
  • Anthem Blue Access PPO
  • Anthem Blue Preferred HMO
  • BCBS Blue Card PPO
  • View More

Dr. Kumar's Office Information & Appointments

Office Locations

Diabetes Thyroid Endocrinology Northern Ohio

673 E River St
Elyria, OH 44035
(440) 322-0872

Office Hours and Information

Fax: (440) 322-4991

Practice Website: Not Available

Accepting New Patients: Yes

Medicare Accepted: Yes

Medicaid Accepted: Yes

Monday 9:00 AM - 4:00 PM
Tuesday 9:00 AM - 4:00 PM
Wednesday 9:00 AM - 4:00 PM
Thursday 9:00 AM - 4:00 PM
Friday 9:00 AM - 4:00 PM
Saturday Closed
Sunday Closed

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Friday, January 29, 2010

Reiki at Baltimore Shock Trauma Center

The chief of anesthesiology explains the institution's scientific standard: “From what they tell us, we think they get better quicker.”

AHA policy statement on regional systems of care for out of hospital cardiac arrest

Stroke, trauma and STEMI all have their regional centers of care. Now that we have a post resuscitation bundle, why not for out of hospital cardiac arrest? It’s time.

Antimalarial use in SLE

For years the thinking regarding SLE was that one treats manifestations and complications but that there was no basic treatment for the disease itself. Over time that perception has changed with accumulating evidence that antimalarials might alter the natural history of the disease and maybe even improve survival. A new study posted ahead of print in Arthritis and Rheumatism indicates a protective effect of hydroxychloroquine against thrombovascular events:

Fifty-four cases were identified and matched to 108 controls. Univariate analyses identified age (OR, 95%CI = 1.04, 1.01-1.07) or being older than 50 years old (3.5, 1.4-8.6) and hypertension (2.5, 1.0-5.8) as being associated with an increased risk of TE while use of antimalarials (0.31, 0.13-0.71) was associated with a decreased risk of TE. Separate analyses were done for arterial and venous TE. In multivariate analysis, use of antimalarial drugs (0.32, 0.14-0.74) and age (1.04, 1.01-1.07) were the only two variables that remained significant for all TE.

We demonstrate in this nested case-control study adjusting for disease severity, duration of disease and calendar cohort that antimalarial drugs are thromboprotective with a risk reduction of thrombovascular event of 68% and of at least 26% and as high as 86%.

This Medscape commentary discusses other data on protective effects of hydroxychloroquine and quotes the authors:

"The data presented, taken in conjunction with the data from the published literature, suggest that antimalarials should be used in all lupus patients regardless of their disease manifestation or disease duration," the authors conclude.

Drug induced acute liver injury

An excellent review was recently published in Seminars in Liver Disease. Free full text access is available via Medscape.

Points of interest:

Prognosis is largely determined by the presence or absence of coagulopathy and encephalopathy. Transplant free survival is poor if these are present.

Acetaminophen is the most frequent culprit.

N-acetylcysteine therapy may benefit some patients with non-acetaminophen induced injury.

Thursday, January 28, 2010

Hyperkalemia and the electrocardiogram

Another in the series by James Roberts, M.D., on at-a-glance electrocardiographic patterns that portend disaster.

MIBG imaging and heart failure prognosis

I first mentioned imaging of heart failure patients with metiodobenzylguanidine (AdreView) here. Now JACC has published a review summarizing the state of the art of MIBG imaging:

Cardiac sympathetic imaging with meta-iodobenzylguanidine (mIBG) is a noninvasive tool to risk stratify patients with heart failure (HF). In patients with ischemic and nonischemic cardiomyopathy, cardiac mIBG activity is a very powerful predictor of survival. Cardiac sympathetic imaging can help in understanding how sympathetic overactivity exerts its deleterious actions, which may result in better therapy and outcome for patients with HF.

If rapid response teams improve outcomes it takes time

In this new before and after study it took 4 years to see a reduction in mortality. Although the data were severity adjusted they did not take into account other hospital improvements that may have taken place over time. (It really gets complicated when one considers that other process improvements may have been driven by the rapid response system itself).

Internal Medicine News on You Tube

Internal Medicine News is now posting videos on You Tube which you can view here.

Microscopic colitis

An underappreciated cause of chronic diarrhea in older adults. Review in Age and Ageing.

Wednesday, January 27, 2010

Double standard for DTC advertising

Academic medical centers don’t have to (and seldom do) adhere to the same standards drug companies do. H/T to Erik DeLue.

Marketing campaign “disguised as evidence based medicine” saved lives! Who'da thunk it?

For over a decade the pharmascolds have been preaching that industry marketing is harmful to patients even though there's not a shred of evidence that it's true. Arguably the most maligned of all industry supported promotions is the Surviving Sepsis Campaign, widely criticized as being little more than marketing disguised as evidence based medicine:

Seeing in these bundles a potentially powerful vehicle for promoting their products, pharmaceutical and medical-device companies have begun to invest in influencing the adoption of guidelines that serve their own financial goals. A case in point is the development of guidelines for the treatment of sepsis, which was orchestrated as an extension of a pharmaceutical marketing campaign.1,2 Although its advocates viewed this effort as an important approach to reducing sepsis-related mortality, the campaign appears to have usurped guideline development for commercial purposes, possibly compromising highly regarded, third-party arbiters of medical quality in the process. Such intrusion into an initiative to benefit public health is of particular concern...

And on it goes. And the results of this marketing campaign disguised as EBM? Reduced mortality and better guideline adherence!

About this time last year the results were presented at the SCCM annual meeting (related post here). Now, a year later, we have formal publication of the results in the February issue of Critical Care Medicine:

Measurements and Main Results: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 yrs (p less than .0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 yrs (p = .008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37% to 30.8% over 2 yrs (p = .001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 yrs (95% confidence interval, 2.5–8.4).

The mortality was still dropping at two years indicating even better results had the campaign continued longer. Baseline mortality rates among hospitals that entered the campaign at varying points in time were similar, suggesting that the mortality reduction attributable to the campaign was real, rather than a result of other factors.

So this is one of many studies that tell us guideline adherence matters, but it's more. This is the first study ever to record patient outcomes following the introduction of an industry supported promotion. The outcomes were good. The pharmascolds were wrong.

A hospitalist’s wish list

From Robert Harrington, Jr., MD. Funny. And true.

Updated international consensus recommendations for management of patients with nonvariceal UGI bleeding

Via Annals Intermal Medicine.

Pulmonary involvement in patients with inflammatory bowel disease

Pulmonary complications of several types are emerging as important extra intestinal manifestations of Crohn’s disease and ulcerative colitis. Free full text review here.

Review of corticosteroid induced psychiatric symptoms

This may be more common we think. Via Psychiatry Online.

Tuesday, January 26, 2010

Alpha 1: the forgotten etiology

Here’s another review of alpha 1 antitrypsin deficiency, again making the point that this disorder is widely under diagnosed. Screening is recommended on all individuals with emphysema, unremitting asthma and in certain other circumstances.

The future of quackademic medicine is secure

---if this, the largest survey of its kind, is any indication:

In the largest national survey of its kind, researchers from UCLA and UC San Diego measured medical students' attitudes and beliefs about complementary and alternative medicine (CAM) and found that three-quarters of them felt conventional Western medicine would benefit by integrating more CAM therapies and ideas.

The findings will be published in the online issue of Evidence-based Complementary and Alternative Medicine (eCAM) on January 20, 2010.

"Complementary and alternative medicine is receiving increased attention in light of the global health crisis and the significant role of traditional medicine in meeting public health needs in developing countries," said study author Ryan Abbott, a researcher at the UCLA Center for East-West Medicine. "Integrating CAM into mainstream health care is now a global phenomenon, with policy makers at the highest levels endorsing the importance of a historically marginalized form of health care."

Excited delirium syndrome

Now recognized as a distinct entity. More here.

Quackademic medicine leaders head to India

---to learn more about Ayurveda:

The purpose of the U.S. delegation’s visit is to explore the possibilities of introduction of evidence-based Ayurveda, Yoga, meditation, and oil massage treatment in the United States medical education, research, and patient care areas, and also to study the possibilities of joint Indo-U.S. research under NIH funding.

Estimation of creatinine clearance in morbid obesity

American Journal of Health-System Pharmacy via Medscape.

Monday, January 25, 2010

DIC correlates with lactate levels in sepsis

---at least when the balance is shifted toward microthrombosis:

Our observations show that, in the course of human septic shock, activation of coagulation and, particularly, inhibition of activated fibrinolysis are independently associated with hyperlactatemia. This suggests a contribution of DIC resulting from a coagulation/fibrinolysis imbalance to microvascular obstruction, tissue hypoxygenation and thereby to ultimate demise.

The preoperative medical evaluation: consult, don't insult

Tips form the Perioperative Medicine Summit.

Medical textbooks available on Google Books

You can't access the entire content, but large portions. Via Clinical Cases and Images.

USMLE You Tube videos

It never hurts to review the basics even if you're long past USMLE.

Via Clinical Cases and Images.

Friday, January 22, 2010

Radical environmentalism

The new religion?

Instead of religious sins plaguing our conscience, we now have the transgressions of leaving the water running, leaving the lights on, failing to recycle, and using plastic grocery bags instead of paper. In addition, the righteous pleasures of being more orthodox than your neighbor (in this case being more green) can still be had—

Read the rest at Secondhand Smoke.

New study on rapid response teams

A systematic review and meta-analysis was just published in the Archives of Internal Medicine, concluding thusly:

Conclusion Although RRTs have broad appeal, robust evidence to support their effectiveness in reducing hospital mortality is lacking.

One curious finding was that although RRTs didn't impact mortality they reduced the number of arrests outside the ICU, which may merely mean that RRTs get people to the ICU before they code with no resulting impact on mortality.

As I said before, results such as this don't mean RRTs are useless. Your hospital may benefit if you use the process for all it's worth. Results such as this DO mean that RRTs should not be a performance standard, and no one can make the claim that RRTs save lives.

Related editorial.

Variation in interpretation of CT scans to evaluate for PE

From the American Journal of Emergency Medicine:

We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.

The present degree of confidence in CT angiography over ventilation perfusion lung scanning for the diagnosis of PE is unwarranted.

Thursday, January 21, 2010

Massachusetts election upset a sentinel event for democrats

Maybe they should do a root cause analysis. Two Medscape articles offer a perspective on how this will affect health care reform.

New York Times review of The Checklist Manifesto

From the review:

A hospital, as the saying goes, is no place for sick people. It’s filled with hazards to your health, not least of which are the myriad infections, missed diagnoses, dosage mistakes and other complications that arise from human error. And in a hospital, human error seems all but inevitable. How can any one individual, or even any one team of individuals, keep all the tasks straight and anticipate all eventualities 100 percent of the time?

You can't, but checklists may help, and that's apparently what the book is about. Why not make your own checklist to cover the areas most likely to bite you? Did you address DVT prophylaxis? Did you continue the home meds that need to be given and hold the ones that need to be held? Have you looked at today's labs and ordered tomorrow's? You can use the EMR to incorporate these into your daily rounding note.

This might be a book worth having. Now where did I put that Barnes and Noble gift card?

Via Clinical Cases and Images.

Catheter based and surgical treatments for massive DVT

Medscape has posted some presentations from the 36th Annual VEITH Symposium. This one
makes a strong pitch for catheter based and surgical treatments in patients who have extensive (iliofemoral) DVT. Although the speakers appealed to the ACCP guidelines their statement was somewhat stronger than the guideline recommendation, which suggests that in patients with extensive DVT, an anticipated survival of over a year and low bleeding risk such treatments may be used to reduce acute symptoms and post thrombotic syndrome if appropriate expertise is available.

On a related note, do the guidelines recommend catheter directed or surgical treatments for upper extremity DVT? Not across the board, but if there are severe symptoms of recent onset and low bleeding risk they make similar recommendations to those for lower extremity DVT.

Tuesday, January 19, 2010

Why doesn't the American College of Physicians just merge with AAFP and get it over with?

The American College of Physicians has for some time been complicit with an agenda to eliminate Internal Medicine as a unique specialty. Retired Doc offers the latest absurd example. General Internal Medicine is on the way out. It's about pay in part, but it's mainly about loss of professional identity.

Unintentional acetaminophen overdose

A review in CCJM.

Telomeres and disease

NEJM review.

Therapeutic hypothermia made simple

Scott D. Weingart, MD, RDMS really sums up the nuts and bolts.

Management of acute decompensated heart failure

Open access review.

More acid base resources

This excellent collection from Clinical Cases and Images contains some resources I had not linked to before.

A Tale of Two MRIs

Is this what we have to look forward to under Obamacare?

Monday, January 18, 2010

The Big Five personality test and medical school success

Medical school admission candidates are evaluated for both their cognitive abilities and their personalities. The evaluation of cognitive ability is quantitative (grades, MCATs). Personality evaluation, however, is subjective, based on interviews and letters of recommendation. Is evaluation of the candidate's personality predictive of long term success? Can it be more systematic?

A large group of students in Belgium underwent psychological testing using quantitative methodology at beginning of their medical training and were then followed long term. Results were published here:

In this longitudinal investigation, an entire European country’s 1997 cohort of medical students was studied throughout their medical school career (Year 1, N = 627; Year 7, N = 306). Over time, extraversion, openness, and conscientiousness factor and facet scale scores showed increases in operational validity for predicting grade point averages. Although there may not be any advantages to being open and extraverted for early academic performance, these traits gain importance for later academic performance when applied practice increasingly plays a part in the curriculum. Conscientiousness, perhaps more than any other personality trait, appears to be an increasing asset for medical students: Operational validities of conscientiousness increased from .18 to .45. In assessing the utility of personality measures, relying on early criteria might underestimate the predictive value of personality variables.

Pauline Chen, MD, commented on the study in the New York Times:

The investigators found that the results of the personality test had a striking correlation with the students’ performance. Neuroticism, or an individual’s likelihood of becoming emotionally upset, was a constant predictor of a student’s poor academic performance and even attrition. Being conscientious, on the other hand, was a particularly important predictor of success throughout medical school. And the importance of openness and agreeableness increased over time, though neither did as significantly as extraversion. Extraverts invariably struggled early on but ended up excelling as their training entailed less time in the classroom and more time with patients.

DB's Medical Rants offered commentary here and here.

How would you have measured up? Take the test here! Think back to when you were applying to medical school and answer the questions as you would have answered them then. I took the test twice, entering “then and now” responses. My “then” responses accurately predicted that I would do much better in the basic science years than the clinical years. When I hit the wards third year I was terrified. I just wasn't ready, and didn't handle the disconnect too well. Fortunately, by the time of the last rotation of my senior year, thanks in part to some patient and understanding residents, I was beginning to hit my stride.

The stresses of training and practice, as the test also predicted, were particularly difficult for me. Fortunately I looked on life's difficulties as character building events and sought to turn stress into strength. Professional life, like my test score, is good now.

Bob Wachter resuscitates USCF medical grand rounds

Faced with dwindling attendance and the suggestion that the program be discontinued Bob Wachter decided to save the tradition, noting this:

First, in a world in which we can increasingly segment our information (i.e., watch Glenn Beck or Rachel Maddow), making a habit of attending grand rounds is one of the few ways for physicians to be exposed to information and people outside their professional silos. We are all in danger of accruing new information about only those things we already know and like.

Second, grand rounds can help build, or promote, community. Think about it: increasingly, texting, email, and Facebook mean that we can get through our days without actual human contact. Grand rounds provides a venue for all the members of a social network (in this case, a department of medicine) to schmooze and bond.

Finally, grand rounds are an opportunity for faculty to connect with their peers, letting their colleagues and trainees know what they’re up to. These interactions create the mutual respect that fuels a great department, along with many serendipitous collaborations. But for this mixing to occur, I have to attend my colleague’s lecture, and she mine. Remember Yogi Berra’s famous observation: “If you don't go to somebody's funeral, they won't come to yours.”

But aside from all that, for me and many other physicians lecture based CME is a very effective learning method. And while didactic education is currently under attack by the medical thought police, most departments of medicine have continued the format and many post the lectures on line, which I view regularly and many of which I have linked here and here.

Glorified housestaff?

The recent Today's Hospitalist piece on management of patients with intracranial hemorrhage got a lively response from readers:

The truth is that neurosurgeons are trained to manage these patients, and the bottom line is that no one wants to get out of bed. What you call a “paradigm shift” in your December 2009 cover story, I call “turf.”

I resent this shift, but I think it will be transient. With cost and reimbursement cutbacks, payers are NOT going to continue to pay two doctors when only one is needed. Hospitalists will not be paid to manage hypertension in an ICH patient when the appropriate admitting doctor (the neurosurgeon) has for years been capable of doing so.

Another response:

We are often seen as little more than glorified housestaff as we admit patients more appropriately admitted by a specialist. The only thing we accomplish is to improve specialists’ lifestyle—at the expense of providing appropriate, timely care.

Friday, January 15, 2010

Thursday, January 14, 2010

Do eICUs improve outcomes?

A study from 2004 had found that they improved mortality and resource utilization. This newer study did not. Both were before-and-after intervention studies. Given the setting and the conditions of the newer study I have to wonder what the eICU really added, given that most of the study ICUs were “closed” meaning that many patients were cared for by intensivists in the pre-intervention period. Also, utilization of the eICU by individual physicians was limited.

I suspect eICUs are like rapid response teams in that, while it is difficult to prove benefit in the aggregate, individual hospitals may benefit if they utilize them for all they're worth.

Wednesday, January 13, 2010

When woo invades hospitals

---what will hospitalists do?

Can you imagine doing comanagement with this guy?

Woo, under the guise of integrative medicine, is rapidly invading hospitals, especially academic medical centers. The Society of Hospital Medicine should take a stand against this assault on scientific medicine in hospitals and provide resources and support to help the individual hospitalist respond in an appropriately critical manner.

Unfortunately, if an article in the latest issue of The Hospitalist (an official publication of the Society) is any indication, I'm not optimistic. The article discusses a mixture of a few plausible alternative methods and some of the wooiest woo, towards which it takes a disturbingly uncritical stance.

Primary influenza pneumonia

Reviewed in Critical Care:

Primary influenza pneumonia has a high mortality rate during pandemics, not only in immunocompromised individuals and patients with underlying comorbid conditions, but also in young, healthy adults. Clinicians should maintain a high index of suspicion for this diagnosis in patients presenting with influenza-like symptoms that progress quickly (2-5 days) to respiratory distress and extensive pulmonary involvement.

...Ensuring an appropriate oxygenation and ventilation strategy, as well as prompt initiation of antiviral therapy, is essential in management.

Tuesday, January 12, 2010

Bicarb for prevention of contrast-induced nephropathy

The pendulum is swinging back. According to the latest systematic review:

The effectiveness of sodium bicarbonate treatment to prevent CIN in high-risk patients remains uncertain. Earlier reports probably overestimated the magnitude of any benefit, whereas larger, more recent trials have had neutral results. Large multicenter trials are required to clarify whether sodium bicarbonate has value for prevention of CIN before routine use can be recommended.

Another antiphospholipid syndrome review

This one is similar to the one I cited recently, but focuses more on the under appreciated association of thrombocytopenia and its management.

Monday, January 11, 2010

The role of hospitalists in stroke care

Who admits stokes? That question has been debated for decades. Now that hospital based neurologists are in short supply hospitalists are increasingly being asked to assume care. An excellent discussion and lots of great links can be found here. Something tells me this will be a major area of focus on the hospital medicine board exam.

Does simvastatin cause more myopathy than the other statins?

Recent evidence suggests that the risk of severe muscle toxicity with simvastatin may be higher than that with other statins, particularly when used in combination with cytochrome P450 isoenzyme inhibitors. However, the lack of direct comparative clinical trials assessing the risk of myotoxicity among the statins in equivalent doses precludes definitive conclusions. Data sources examining low-to-moderate doses of simvastatin suggest that myotoxicity with this agent is infrequent, with rates similar to those seen with other statins. Conversely, findings from clinical trials using the maximum daily dose (80 mg) and a clinical trials database of varying doses of simvastatin suggest a possible increase in rates of myotoxicity with the 80-mg dose compared with lower doses and a higher incidence rate when compared with maximum doses of other statins.

Friday, January 08, 2010

Should hospitalists be in charge of patients admitted with intracranial hemorrhage?

It may be a moot point because, like it or not, hospitalists are increasingly being asked to admit and be the attending physician for these patients. According to an article in Today's Hospitalist the number of head bleeds considered “surgical” is shrinking:

"Neurosurgeons are stepping further and further back from this disease because there really is not a role for surgery in ICH," points out Dr. Josephson, director of the neurohospitalist program and assistant professor of neurology at UCSF. The exceptions are cerebellar hemorrhages and those hemorrhages that are close to the surface. "Probably less than between 5% and 10% of ICH patients need surgical intervention," he says.

The article offers opinions and links to primary sources on the medical management of such patients, particularly hypertension management. Included is a section on blood pressure management in ischemic stroke in which the guideline recommended cut off of 220/120 is advocated.

Concerning ICH the larger question is whether hospitalists should be managing them in the first place, either as attending physicians or under some vaguely defined comanagement arrangement. Hospitalists are increasingly being maneuvered into managing patients outside the scope of their training and experience. This may emerge as a liability issue for the field.

Thursday, January 07, 2010

Drug induced torsades: a forme furste of LQTS

A new study published in Circulation: Arrhythmia and Electrophysiology found LQTS mutations as frequently in drug induced cases as in congenital cases:

Conclusions— dLQTS had a similar positive mutation rate compared with cLQTS, whereas the functional changes of these mutations identified in dLQTS were mild. When IKr-blocking agents produce excessive QT prolongation (dLQTS), the underlying genetic background of the dLQTS subject should also be taken into consideration, as would be the case with cLQTS; dLQTS can be regarded as a latent form of long-QT syndrome.

We've suspected this for a long time to explain the fact that drug induced TDP appears to be idiosyncratic.

Which home medications should be continued perioperatively?

Here's a very helpful article from The Hospitalist.

Risk stratification in pulmonary embolism: lessons from the EMPEROR registry

A great deal has recently been written about the use of biomarkers and echocardiography for risk stratification of patients presenting with pulmonary embolism (PE). Data from the EMPEROR study, presented recently at the annual meeting of the Society for Academic Emergency Medicine, compared biomarkers and clinical scores. The presentation was reported in Hospitalist News:

None of the predictors displayed good sensitivity for predicting adverse events. However, a PESI greater than 100 had outstanding specificity and conferred an 8.7-fold increased likelihood of adverse outcome. The shock index performed second best. The two vital signs proved to be slightly better predictors than the two biomarkers.

PESI is the pulmonary embolism severity index and is explained here. The shock index is the ratio of heart rate to systolic blood pressure. A value of over 1 was an adverse sign in EMPEROR.

In patients with pulmonary embolism, routinely calculate the pulmonary embolism severity index (PESI) and shock index, and strongly consider admission to an ICU for patients with elevated values, Dr. Jeffrey A. Kline advised at the annual meeting of the Society for Academic Emergency Medicine.

Although there has been considerable interest in use of biomarkers, echocardiography and clinical assessment to predict good outcomes and select patients for early discharge that was not evaluated in EMPEROR. However, PESI and the Geneva score were evaluated in a 2007 study published in Chest with this conclusion:

The PESI quantified the prognosis of patients with PE better than the Geneva score. This study demonstrated that PESI can select patients with very low adverse event rates during the initial days of acute PE therapy and assist in selecting patients for treatment in the outpatient setting.

Now that prasugrel is approved which thienopyridine should we use? Is new better?

According to this CCJM review greater efficacy must be balanced against increased bleeding risk, and the decision depends on individual patient characteristics:

Compared with clopidogrel, prasugrel is more potent, faster in onset, and more consistent in inhibiting platelets.

Prasugrel should be avoided in patients at higher risk of bleeding, including those with a history of stroke or transient ischemic attack, those age 75 or older, or those who weigh less than 60 kg.

Wednesday, January 06, 2010

Effectiveness of vaccination against pandemic 2009 H1N1 influenza

From Annals of Internal Medicine. Yes, Jeanne, the vaccine matters.

NEJM Sounding Board piece on industry supported CME

Like many other articles this one, written by authors from the Office of Inspector General, cites plenty of opinion but offers no evidence to the effect that industry support of CME is harmful.

Activated protein C in sepsis

This NEJM case presentation and review makes the same point I did last year about paying attention to the PROWESS exclusion criteria in selecting patients for treatment, and notes the trial now in progress which restricts enrollment to patients in septic shock.

Tuesday, January 05, 2010

Perioperative management of diabetes

Multiple practical aspects are covered in an article from the Perioperative Medicine Summit.

The disconnect between performance and quality

Two years ago, when I reported about the lack of effectiveness of heart failure performance measures in the OPTIMIZE study, I noted this concerning heart failure instructions as a performance measure:

The first quality measure was the provision of discharge instructions on medications, diet and other aspects of heart failure care. In one study on which this recommendation was based the instructions included a full hour of one-on-one verbal counseling. The intervention was associated with improved outcomes. The “core quality” measure, in contrast, required only that written instructions be given to the patient. It’s one thing to hand patients a ream of paper as they are rushed out the door and quite another to provide detailed counseling. Nominal compliance may earn the hospital a perfect report card while doing little of substance to help patients.

In my recent top 10 post on quality I examined individual performance measures and again noted, concerning heart failure instructions:

Discharge instructions: Same as for smoking cessation above. In the studies which showed discharge instructions to improve outcomes a specialty nurse sat down and spent an hour or two with the patient and family. Hospitals, concerned about bed control and early discharge, don't feel they have time to do this and don't have to to play for the report card.

Now the NEJM reports a disconnect between quality and performance in heart failure instructions:

Methods We examined hospital performance on the basis of two measures of discharge planning: the adequacy of documentation in the chart that discharge instructions were provided to patients with congestive heart failure, and patient-reported experiences with discharge planning. We examined the association between performance on these measures and rates of readmission for congestive heart failure and pneumonia.

Results We found a weak correlation in performance between the two discharge measures (r=0.05, P less than 0.001). Although larger hospitals performed better on the chart-based measure, smaller hospitals and those with higher nurse-staffing levels performed better on the patient-reported measure. We found no association between performance on the chart-based measure and readmission rates among patients with congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 23.7% vs. 23.5%; P=0.54) and only a very modest association between performance on the patient-reported measure and readmission rates for congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 22.4% vs. 24.7%; P less than 0.001) and pneumonia (17.5% vs. 19.5%, P less than 0.001).

Although the authors considered both measures as performance measures, the real performance measure was the chart based measure (what the hospitals said they did) whereas the patient's reported experiences were closer to real quality. The correlation between what the institution said it did and what the patient reported was very weak, at r=0.05. Although the patient reported measure was associated with a highly statistically significant reduction in readmission rate the magnitude of the reduction was modest. This may be because the patient questionnaire itself was weak, making it easy to pass the measure (see appendix to the article).

More expensive care sometimes really is better

At least in this study, greater resource expenditure was associated with better outcomes in heart failure.

H/T to Retired Doc. More counterpoints to the Dartmouth Atlas data.

Monday, January 04, 2010

Performance measurement has doctors adrift on Lake Wobegon

In the last JAMA issue of 2009 Donald Berwick mused about quality performance measurement. Doctors' skills vary. Measurement uncovers variation. Variation is considered the enemy of quality. Quality Performance “improvement” initiatives seek to eliminate variation. All doctors would become average. That would never do for most doctors, who need to be above average. What are they to do? Game the system, criticize the methods and indulge in self deception. And so, we remain adrift.

How will Medicare's elimination of consult codes affect hospitalists?

In two ways, most likely. First, it will decrease your own RVUs since much of what you did under the various and ubiquitous comanagement scenarios was, in the past, eligible for consult coding. Now you'll have to use the ordinary admission H&P codes which pay less. Secondly, if you've been having trouble getting subspecialists to do anything other than procedures that will probably get worse, as these physicians will get even less for their cognitive services.

Info from Medscape here and here.

Medullary sponge kidney

Brief discussion in CCJM. A key point is that ultrasound and CT may miss it. You need an IVP. Think if it in a patient with recurrent attacks of pyelonephritis.

Antibiotics for all patients with necrotizing pancreatitis?

This systematic review suggests it may not be warranted:

Based on all available data, antibiotic prophylaxis should not be used in patients with necrotizing pancreatitis. Instead, a more measured, on-demand use of antibiotics is preferred. Antibiotics should be added if signs and symptoms of infection are present (eg, fever, leukocytosis, positive results of cultures). Given improvements in intensive care and nutritional support, recent trials have found a lower incidence of infected necrotizing pancreatitis than before. Therefore, future trials are likely to need higher numbers of patients.

Sunday, January 03, 2010

A spike in narcotic deaths in Canada after shift in prescribing from short to long acting opioids

CMAJ reports:

From January 1991 to May 2007, the prescribing of opioid analgesics in Ontario increased by 29%, from 458 to 591 prescriptions per 1000 individuals annually (Figure 1). Codeine was the most frequently prescribed agent, although the number of prescriptions for the drug declined gradually during the study period. In contrast, the number of oxycodone prescriptions rose more than 850% during the same period, from 23 per 1000 individuals in 1991 to 197 per 1000 in 2007. The prescribing of hydromorphone, fentanyl and morphine also increased considerably over the same period,....

The prescribing change actually took place after 2000 when long acting oxycodone was introduced to the formulary.

We observed a substantial increase in overall opioid-related mortality following the addition of long-acting oxycodone tothe provincial drug formulary in January 2000. Between 1999 and 2004, the annual number of opioid-related deaths increased by 41% (p = 0.02), from 19.4 to 27.2 per million annually (Figure 2, top panel). The number of oxycodone-related deaths increased by 416% (p less than 0.01) during the same period, from 1.39 per million to 7.17 per million annually (Figure 2, bottom panel). The rise in opioid-related deaths was due in large part to inadvertent toxicity; there was no significant increase in the number of deaths from suicide involving opioids over the study period (Figure 3).

A little background. The beginning of this past decade marked a groundswell of activism for more aggressive pain management. It spread to the regulatory agencies (remember Joint Commission's roll out of pain management standards?), the courts, medical journals and even our CME courses. It was based almost entirely on opinion and dogma with very little science. Typical of the preaching of the day was this WJM editorial from 2001:

...there is a standard of care for pain management, a significant departure from which constitutes not merely malpractice but gross negligence. Even if professional boards might not hold their licensees to that standard, juries will. With the implementation of the new pain standards by the Joint Commission for the Accreditation of Healthcare Organizations, which recognize the right of patients to the appropriate assessment and management of their pain, public expectations will likely increase exponentially.

Public expectations did increase. So did the deaths, according to reports from all over, even in hospitalized patients:

The current emphasis on pain assessment as the fifth vital sign and the use of unscientific pain scales is causing serious injury and death from overmedication...

Overmedication with sedatives/narcotics, during the two periods, clearly contributed to deaths in 13 and 32 patients and probably contributed to deaths in 5 and 14 patients, respectively. This occurred in 17 and 43 patients, respectively, after blunt injury and in 1 and 3 patients, respectively, after penetrating injury. Two clinical scenarios predominated, ie, overmedication in preparation for an imaging study and overmedication after discharge from ICU to the floor. The sequel of hypotension and compromised airway requiring intubation initiated a cascade of negative events that led to death.

Purdue Pharma's illegal and non-evidence based promotion of Oxycontin, described in this NYT article from 2007, has some interesting parallels with what doctors were taught in CME courses and by Joint Commission leaders:

Federal officials said that internal Purdue Pharma documents showed that company officers recognized that, even before the drug was marketed, they would face stiff resistance from doctors concerned about the potential of a narcotic like OxyContin to be abused by patients.

As a result, prosecutors charged, the company effectively started a fraudulent and deceptive marketing campaign aimed at convincing doctors that OxyContin, because of its time-release formula, was less prone to abuse, and that it was less likely to cause addiction or to produce other narcotic side effects than competing drugs. In its plea agreement, the company acknowledged doing so.

It reminds me of some of the dogma they were shoving down doctors' throats at the time, including pain management talks at a couple of hospital medicine courses I attended. Our thought leaders told us that because short acting pain medications tended to be used “prn”, thus encouraging patients to repeatedly ask for more doses as analgesic effects wore off, they encouraged a form of “pseudoaddiction” which was really a symptom of inadequate pain control. Although this concern, as well as the concern about patients getting too much tylenol, had some merit, we were also told that addiction and abuse were rare when patients' pain control was adequate.

Industry promotion may have had a role but didn't explain most of the trend. In the U.S., alongside the spike in Oxycontin use was a spike in its generic, non-promoted but equally dangerous competitor methadone which, among narcotics, has been reported to be associated with the greatest number of deaths.

Friday, January 01, 2010

Will hospital medicine “arrive” in 2010?

Well, it is gradually gaining status as a specialty. We have our own professional organization, an official journal, our own textbooks and now even board certification. So how will we really know hospital medicine has arrived? When our word processors finally recognize the word hospitalist!


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Samoyed Facts

by Kea Grace
    Samoyeds are members of the working dog group.

    Samoyeds are members of the working dog group.

    samoyed image by Vladimir Klein from

    The samoyed is an ancient breed of dog that is currently recognized by all major kennel clubs. Highly active and intelligent, the samoyed needs an experienced, energetic owner. Samoyeds are known for their gentle, happy-go-lucky personalities, full, long, flowing coat and being hardy, capable workers.

    The samoyed is a primitive, ancient breed that originated in Siberia over 3,000 years ago. It was bred by the Samoyedic people. This nomadic group used the fluffy, white, beautiful dog as a herder, sled dog, and a source of heat. The dog's instincts to gather, pull, and cuddle were carefully cultivated. The samoyed has never had fox or wolf blood introduced into the breed's bloodline.

    The samoyed is known for his beautiful, long, thick, light-colored coat. This breed possesses a double coat, meaning it has a very dense, thick, nearly weatherproof undercoat that is short, and the outercoat grows straight through the undercoat. The outercoat is much longer and weatherproof. The samoyed's coat is very fluffy and is thicker and longer on males than females. The coat is shiny and must be white or biscuit colored.

    The samoyed has a typical spitz head. It's wedge-shaped and broad with a clearly defined muzzle. The ears are pricked and well-furred, and the eyes must be almond shaped. While every eye color can occur, only dark colored eyes are allowed in show dogs. The samoyed is known for the "samoyed smile," which is made by the black colored lips curling up slightly at the ends of the muzzle. This gives him a jovial, intelligent look.

    As a draft dog, the samoyed must be solidly built and muscular. His chest is deep with a well-rounded rib cage. He is squarely built with a strong back. His tail is fluffy and slightly curved. The samoyed's back slopes slightly and is gracefully curved from the neck.

    The samoyed is extremely dedicated, driven, gentle, and intelligent. They adore playing and need constant stimulation to avoid getting in trouble due to boredom. They're very good-natured, yet independent. They need a firm hand and consistent guidance from an early age.

    Photo Credits

    About the Author

    Since 2001, Kea Grace has published in "Dog Fancy," "Clean Run," "Front and Finish" and an international Czechoslovakian agility enthusiast magazine. Grace is the head trainer for Gimme Grace Dog Training and holds her CPDT-KA and CTDI certifications. She is a member of the APDT and is a recognized CLASS instructor. She's seeking German certification from the Goethe Institut.

    Trending Dog Behavior Articles

    Have a question? Get an answer from a Vet now!


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Ivaylo Gotzev; “This was the fight that needed to happen”
INTERVIEW By Gabriel Montoya  (April 5, 2007) Doghouse Boxing (Photo © German Villasenor)
It was announced on K-FSN TV that the fight for the right to face WBC champion Oleg Maskaev is officially over and Samuel “The Nigerian Nightmare” Peter has won what every clear head in Boxing considered what was already rightfully his. After Peter had won his second title eliminator over James Toney, WBC “ Champion Emeritus” Vitali Klitschko decided to come out his two-year retirement and go directly into a fight for his old title with Maskaev. However, negotiations to pay step aside monies to Peter’s camp (as well as secure a future date with the winner of the proposed match up) went on too long for the Klitschko camp and now the “whole issue is resolved “ according to Ivaylo Gotzev”, Sam Peter’s manager.”No deal has been set but negotiations for the fight are under way.” The road is now paved for the true number one heavyweight contender to fight for his place among the heavyweight division titlists. The following is a transcript of the interview between Mr. Gotzev and myself regarding the negotiations for the potential bout.

Gabriel Montoya: First off congratulations.

Ivaylo Gotzev.
Thank you.

GM: What does it mean to your company that you were able to basically stand your ground and get justice done in Boxing?

It’s great for Boxing and the heavyweight division in general because this was the fight that needed to happen. This was the fight that was advertised. For various reasons [it was postponed in favor of the Klitschko fight]. Now that that fight is off and the right is on we are just looking forward to a very positive promotion of the fight and I believe it is going to be an explosive fight and match up between these two great punchers. We want to focus on all the positive stuff that going to happen in the near future rather than go back over on what could have been. Because we really did lose 3 months [of Peter’s career] in the process unfortunately.

GM: Has Sam been in the gym during this period?

Sam has been training every day for the past month and a half. He’s in great spirits now and is already in good shape. So we are looking forward to the showdown with Oleg Maskaev.

GM: When do you think the fight will take place?

We’re working right now for a June date. We have some things will happen within that time frame. June would be a perfect date for this heavyweight battle to happen.

GM: Well, thank you, Ivaylo. I look forward to future updates.

Thank you for keeping in touch.

GM: Best of luck.

Gabriel at: Coyotefeather@gmail.com
© Copyright / All Rights reserved: Doghouse Boxing 1998-2007


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  ETA Home   ETA_News_Releases>

News Release

ETA News Release: [02/24/2011]
Contact Name: Mike Trupo or Lina Garcia
Phone Number: (202) 693-3414 or x4661
Release Number: 11-0210-BOS

US Department of Labor announces grant to help New Hampshire workers with health insurance payments

Funds also will allow state to upgrade existing benefit payment system

WASHINGTON —The U.S. Department of Labor today announced a $744,000 grant to provide partial premium payments for health insurance coverage to about 150 jobless workers in New Hampshire. Funds also will be used to upgrade the state's existing benefit payment system.

"Being without health care coverage can be one of the most stressful aspects of losing one's job," said Secretary of Labor Hilda L. Solis. "When workers have some assurance that their coverage will continue beyond a layoff, they can better focus on the task at hand: finding another good job that leads to long-term career opportunities."

The grant, awarded to the New Hampshire Department of Resources and Economic Development, will be used to provide "gap filler" payments for unemployed individuals who are receiving Trade Adjustment Assistance benefits and are eligible for the Health Coverage Tax Credit program. Under the program, eligible individuals can receive 80 percent of premium costs for qualified health insurance programs.

The payments provided through this grant cover the gap period, that is, the time it takes to complete Internal Revenue Service enrollment, processing and first payments under the HCTC program. The state of New Hampshire will provide two to three months of gap filler payments for each participant. New Hampshire also will use part of these funds to upgrade the state's existing benefits payment system.

National Emergency Grants are part of the secretary of labor's discretionary fund and are awarded based on a state's ability to meet specific guidelines. For more information, visit


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Get Ready For Family Adventure In The 2015 Mitsubishi Outlander

NOTE:Mitsubishi gave me the privilege of test driving 2015 Outlander for a week. They did not compensate me for this post. Who’s ready to the hit the road? You will be after I introduce you to the 2015 Mitsubishi Outlander! It the highest rate crossover for safety and has the capability of 28 mpg gallon on the highway. […]

Back To College Tech That Makes The Grade

This post sponsored by Best Buy. How did time go by so fast? I’m not one of those weepy, helicopter moms that have to know every step of my child’s day. I’m definitely not. It does really feel like yesterday I was dropping her off for her first day of preschool. In a few days […]

Upgrade Your Photos To Awesome With The LG G4

This post sponsored by Best Buy. I take a ton of photos. I thought I just loved to take them. Recently, I figured out I was taking so many because I was trying to get the right shot. I was trying to to get more light in the photo, the right angle and so many […]

How To Make The Best Ever Strawberry Shortcake

How To Make Strawberry Shortcake in a

It’s summer. That means its time to enjoy some strawberry shortcake! Ingredients: Strawberries-2 quarts, washed and sliced Biscuit bowls-6 (SEE BELOW FOR BISCUIT BOWL RECIPE) Whipped cream   Watch the video. Directions: Place biscuit bowl in small dish. Add strawberries. Top with whipped cream. ENJOY! Biscuit bowls: Ingredients: 2 cups Bisquick 1/2 milk 1/2 cup […]

Let’s Get Crafty With Cricut!

Getting Crafty with Cricut

**This post contains affiliate links and I will be compensated if you make a purchase after clicking through my links. If you’re reading this post, chances are, you’re a creative type. You like to craft, explore your creativity, and share your creations with others. And it’s for people like you that Cricut created their line […]

Mark Your Calendar: Simon Premium Outlets SideWalk Sales!

Chicago PO July 4 Summer Sale Flyer

Let’s Go Shopping!! As American as apple pie and baseball (but even more fashionable), Simon Premium Outlets’ July 4 Weekend Sidewalk Sale is one of the biggest and most popular sales events of the season. For four days, July 2-5, shoppers at Chicago Premium Outlets in Aurora, Illinois, Lighthouse Place Premium Outlets in Michigan City, […]

It’s Time To Get Your Drone On!

This is a sponsored post in partnership with Best Buy. Have you ever considered getting your own drone? Solo, the Smart Drone is arriving in over 400 Best Buy stores this June! If you didn’t get Dad something he loved, I’m sure getting him this, even late, would make up for it!  It’s the first-ever […]

3 Reasons You Need A SWASH In Your Life #SwashAtBestBuy

This is a sponsored post as part of a partnership with Best Buy. Unless they’re on a Sharpei or on a chubby baby, nobody likes wrinkles. Nobody. We don’t like them on our faces and we definitely don’t like them on our clothes. When our best friends at Best Buy gave us the opportunity to […]

Love Doing The Laundry With The Samsung Activewash Laundry Pair #MasterYourHome

Note: This post about our love of laundry is sponsored by Best Buy. Thank you for stopping by! I used to loathe laundry. Seriously. Every step of it. But now I’m back on the happy train to laundry town! I know, I know, you’re probably like, “yeah, right.” I could not be more honest with […]

Best Buy Education: Your Education Technology Partner

Schoolkids Working on Laptops

This is a sponsored post. Best Buy Education: Your Education Technology Partner! Best Buy Education will help your school every step of the way! Their Account Managers and Education Specialists are eager to listen and understand your technology needs, then use that knowledge to provide unbiased advice. They’ll assist you with product purchasing, installation, service […]


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(atlanta) 770.623.1530

Phone sales until 8:00pm M-TH, 5:30pm F
A+ BBB Rating Free Shipping over $199, Discounts on Door Hardware, Baldwin Hardware, Emtek, Rocky Mountain Door Hardware
0 items ($0.00)
Free Shipping Over $199
Need Assistance? 770.623.1530
Credit Card Processing
BBB Acredited Business
A+ Rating
DoorHardwareUSA Accepts Visa, MasterCard, AMEX, and Discover

Acceptance Mark
Products Details
click to enlarge
Baldwin 2357

2540 PULL x 2124 PULL PLATE - 4" x 16"

- Shipped with fasteners for 1.75" thick doors

starting at


text:
(atlanta) 770.623.1530

Phone sales until 8:00pm M-TH, 5:30pm F
A+ BBB Rating Free Shipping over $199, Discounts on Door Hardware, Baldwin Hardware, Emtek, Rocky Mountain Door Hardware
0 items ($0.00)
Free Shipping Over $199
Need Assistance? 770.623.1530
Credit Card Processing
BBB Acredited Business
A+ Rating
DoorHardwareUSA Accepts Visa, MasterCard, AMEX, and Discover

Acceptance Mark
Products Details
click to enlarge
Alno - Cabinet A240-38-AEM

1 1/2" KNOB

A240-38-AEM 1 1/2" KNOB


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Dorit Sessions New York, New York

This site is for my session reel. For original music and info please email Doritworld@aol.com
I can sing various genres with Rock being my strongest and most fun to do. My fav track here is the Zeppelin standard "Whole Lotta Love."

contact / help

Contact Dorit Sessions

Streaming and
Download help


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Tag Archive for end of the world

Ragnarok approaches!

The children of Loki by Willy Pogany

Oh terrific, another APOCALYPSE. I have plans this weekend! Ragnarok Viking apocalypse due to occur over the weekend. In advance of the predicted Ragnarok Viking apocalypse over the weekend, “Norsemen” have started to arrive in York in anticipation of the bloody battle that is supposed to happen on Feb. 22 and end the world. Attendees…

Jeffs messes up again

Oops, another false prophet. Twice unlucky for Mormon cult leader – 3 News. The leader of a breakaway Mormon sect has incorrectly prophesied the end of the world for the second time in as many months. Warren Jeffs, head of the Fundamentalist Church of Jesus Christ of Latter-Day Saints (FLDS), issued his latest edict last…

Happy unapocalypse!

…and I feel fine. I’m very glad to report that no supernatural or man-made disaster befell us today. You never know about those who take “prophecies” into their own hands. Actually, the REAL interpretation was that this was not doomsday but a spiritual rebirth. Sadly, I’m not feeling that. Maybe tomorrow. Or maybe there was…

Countdown: 5 days until the un-apocalypse

Oh, geez, 5 Days. Time to read those books you never got to and watch those classic movies… Survival pods. Yeah. Chinese Farmer Creates Apocalypse Survival Pods | Mayan Apocalypse Survival | LiveScience. There’s always zombies. CofC professor weighs in on the never-ending end of the world | Doomed | Charleston City Paper.

Countdown: 6 days until the un-apocalypse

December 21: nothing to worry about. It’s just another day: du du du du du… They have this cult in China. That doesn’t go over well. Doomsday Sect Clashes With Police. China perhaps misinterpreted the joke from Australia. China reacts to PM’s apocalypse message. Great page from NASA NASA – Beyond 2012: Why the World…

Countdown: 8 days until the un-apocalypse

It’s getting closer. Time to send best wishes to those distant relatives for the last time. Nonsense debunking nonsense. Does it cancel out or produce a null set? Santa Cruz psychic debunks Mayan doomsday predictions Another one of those “safe” places? Rumors of an alien-built pyramid in the mountain have apparently driven doomsday-fearers to seek…

Countdown: 9 days until the un-apocalypse

Only 9 days left including today. Better start eating the perishable food in the fridge. 😛 LiveScience has a countdown clock. Yep, the myth of the Mayan Apocalypse is all a big sham. But you knew that. ‘Mayan Apocalypse’ Started With A Bad 70s Mushroom Trip, Not Ancient Civilization. A Turkish village has become the…

Jeffs delivers prophecies from jail, scaring locals

Jeffs FLDS doomsday prophecy and business closures cause concern | Deseret News. There’s mystery, worry, and new indications of turmoil among followers of imprisoned polygamist leader Warren Jeffs. At least three of his followers’ most prominent businesses were suddenly closed in the Fundamentalist LDS Church’s twin towns of Colorado City, Ariz., and Hildale, Utah. The…

Cult mass suicide averted in Brazil

"Prophet" Luis dos Santos

Last week, police received information that a cult was preparing for a mass suicide by poisoning, including their children holed up inside a house near Teresina, Piaui, Brazil. The story unfolded… Fears of Mass Suicide in Brazil as Doomsday Cult Barricades Itself Awaiting the End of the World Today Brazilian police fear a mass suicide…

Duct tape: Keeps demons out. Do not use on children.

Parents Duct Tape “Demon Possessed” Children | FOX2now.com. Two parents who admittedly duct taped their children inside an SUV in a Walmart parking lot said they did so because they were “demon possessed.” During Tuesday’s court hearing, the judge dropped five felony counts of aggravated child endangerment against both parents. The couple still faces three…

Australian doomsday ministry in ruins

Agape doomsday cult’s financial empire dismantled, ordered to pay taxman $3 million. This morning, the District Court ordered the controversial group and its fugitive founder, Rocco Leo, settle their debts with the Australian Taxation Office. For two years, the ATO has pursued Agape, Leo and his confidante, Joe Veneziano, for amounts left unpaid since 2009.…