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Square hires talent from Yahoo, Amazon and Morgan Stanley

The payments processing startup has moved quickly to allay concerns over its CEO’s ability to run two multi-billion companies by adding heavyweight financial experience to the company leadership.

The company has hired Jackie Reses from Yahoo to lead Square Capital, the company’s business financing service that has advanced more than $225 million to Square sellers across the country since launching in May 2014.

At Yahoo Reses served as chief development officer where she focussed on revenue and product partnerships, strategic acquisitions, and operational and people transformation. She also served on the Board of Directors of Alibaba Group, co-chaired the audit committee of the Board and worked on some of their important transactions related to Alibaba and ANT Financial’s international payments operation.

“Square Capital reaches businesses that traditional financial institutions often neglect, and I’m very excited to expand that opportunity to others,” she said.

Also joining Square are Henry Domenici from Morgan Stanley and Ted Kosev from Amazon.

Henry Domenici leads Square Capital’s financing and joined from Morgan Stanley where he ran the consumer asset-backed securities business in the Global Capital Markets Division since 2009. Prior to that he spent 12 years at Lehman Brothers and Barclays Capital in various senior financing roles.

Ted Kosev leads product management and operations for Square Capital. He joined from Amazon, where he launched and grew Amazon Lending from program design to international expansion. Ted also served as head of seller marketing and acquisition for Amazon’s B2B marketplace. Before Amazon, he spent more than 10 years in small business and consumer lending.

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Video Control Board

Your Premier Audio/Visual Partner

Who We Serve

From restaurants to hotels, we can build an audio/video/lighting package to meet the needs of your guests and help you stand out.

From board rooms to reception areas to training rooms, we will design a cohesive and comprehensive system for your business-no matter how big or small.

House of Worship

From communicating your message to training the next generation, your desire to communicate effectively without breaking the budget. pdh can help.

How We Serve

Audio/Visual Systems

Our team of experts will create a system to meet your needs and provide training to ensure you are comfortable using technology

Crestron Programming

Our Crestron programmers can service existing systems, install new systems, and can train your employees on new Crestron technology.

Equipment Sales

pdh partners with the best names in technology today. Our sales team is regularly training to keep up with the most up to date products on the market to better serve you...

Equipment Repair

We have a full-time staff of service personnel to repair professional audio/visual equipment and musical instruments.

Not sure what you even need to improve your systems and integration? Let us audit your space and give you recommendations to maximize your effectiveness.

Design Installation

New for 2020 pdh has launched a new brand partner pdhhome that serves the residential community.

This is Our Why

“I can't thank you enough for the hard work...Everybody was professional, courteous, and went far beyond the extra mile to make sure our expectations were met-which actually caused them to be exceeded.”

Jon G.
Georgia Baptist Mission Board

Ready to find out more?

Contact us to learn how our decades of experience and expertise can help

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Marietta, GA

pdh Ohio

Lancaster, OH

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Isolation for Delaney Rim

Isolation Distance: 11.28 miles, 18.15 kilometers

Isolation Source PeakDelaney Rim
   Peak Elevation: 7560 ft / 2304 m
   Peak Location: USA-WY
Isolation Limit Point
The ILP for a peak is the closest point of land that is higher in elevation than the peak.
Latitude-Longitude (WGS84):
   41° 23' 33'' N, 108° 33' 18'' W
   41.3925, -108.555 (Dec Deg)
ILP Location:
Peak to ILP Bearing: 231° (SW)
ILP Source: Kirmse Auto ILP (More Info)
ILP Map LinksGeoHack Links   CalTopo   MyTopo   Bing Maps
Google Maps   Open Street Map
Isolation CircleArea: 399.6 mi², 1,034.9 km²
Nearest Higher Neighbor (NHN)
The NHN shown here is the nearest higher peak in the Peakbagger.com database to the given peak.
Sand Butte
   NHN Elevation: 8588 ft/2618 m
   NHN Location: USA-WY
Peak to NHN Bearing: 235° (SW)
NHN Distance: 18.04 mi / 29.03 km
ILP/NHN DifferencesCompared to ILP, NHN Peak is:
   6.76 mi / 10.88 km further away
   1028 ft / 314 m higher.
Isolation Circle Map:
The largest possible circle centered on Delaney Rim containing no higher ground than its summit.
Google Maps Dynamic Map

 ILP for Delaney Rim    Delaney Rim    NHN:Sand Butte    Other Peaks
Click Here for a Full Screen Map

Copyright © 1987-2021 by Peakbagger.com. All Rights Reserved. Questions/Comments/Corrections? See the Contact Page Terms of Service


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2" Diameter

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Capabilities for HR Analytics Success (Source Systems)

This week we’ll tackle the second of our four anchor capabilities required for success in analytics: Source Systems, Processes & Data Integrity. This is an excerpt from our Playbook 3 – A Practical Guide to Becoming Data Driven.

Source Systems3White.png

We'll cover the first of these topics: Source Systems.

Accessing your Data from Source Systems

Once you’ve identified your analytics project areas (3 x Do. 2 x Help. 1 x Fix.), you need to identify your overall data needs, where this data resides, and who owns it.

Given you’ll likely need to source your data from a number of systems, you will need to consolidate this data into a single data source.  Let’s quickly look at a few of the most popular:

  • Spreadsheets
  • DIY Tools
  • People Analytics PurePlay (fully managed solution)

For some this is the simplest approach to data consolidation.

You may already be very handy and experienced with this approach, but if not, this is where you may need help from your Finance friends, and possibly your IT team.

Of course, spreadsheets aren’t perfect – let’s have a look at the pros and cons of spreadsheet- based data consolidation.

  • Pros
    - You likely already have a spreadsheet tool on your computer
    - You can get going easily
    - You likely have some basic spreadsheet skills today
    - Spreadsheets can be fed with .csv data dumps/extracts from most systems
  • Cons
    - Upgrading your spreadsheet skills might be more difficult than it sounds
    - Specifically, you will need to focus on things like moving and manipulating data, cleaning and formatting data, pivot tables, developing formulas, developing charts and presenting dynamic data
    - Data security and privacy risks of spreadsheet-based reporting
    - Data and formula integrity in the reporting spreadsheet is always at risk
    - Each spreadsheet tends to be at a point in time, and can require a lot of manual manipulation every time you need a new cut on the report
    - You spend a lot of time in spreadsheet maintenance mode, as opposed to actually using your data to drive decisions and build value for your line of business

DIY BI Tools

There are also other solutions available like Tableau and Qlik - which deliver capabilities way more powerful than a spreadsheet, however you still need to have very handy-people on the ground to develop the data source, develop the algorithms for your calculations, develop the visualizations, reports and outputs, and to constantly feed-and maintain the solution.

These under-the-desk business intelligence solutions, while very capable, can present challenges with scalability (moving from an under-the-desktop tool to an enterprise accessible platform), and may actually introduce unintended risk - from a data privacy, control and security perspectives, and for ongoing sustainability given the technical hurdles when moving from under-the-desk to a fully supported, enterprise-wide production capability.

Even though the license may be on your desktop or available for a few thousand dollars, the total cost of ownership of these solutions as you scale them can be quite high – often reaching levels beyond that of a pureplay or fully managed solution.

Analytics PurePlay or Fully Managed Solution

Full disclosure – this is the space we occupy at PeopleInsight. We help HR accelerate data driven HR through our turnkey offering in people analytics.  As a pureplay, we make it very simple for our customers – all they need to do is feed us their raw, disconnected data. From that, we ensure the data is always up-to-date and available for ongoing reporting and analytics.

We’re different from some of the others in this space in that we’re focused on helping mid-market companies and our team of experts works with our customers in an ongoing fashion to be sure the analytics and reports evolve as business needs change.

This is how we operate as a people analytics pureplay:

We Make it Simple.png

Regardless of the technical approach you adopt, you will need to do the following for each Use Case:

  • Describe in a sentence or two the metric, calculation or algorithm that will give you insight
  • Start as simple as you can and over time, increase complexity
  • Identify where this data resides
  • Identify the owner of each data source and obtain their approval to use it
  • Coordinate access/ receiving a download of each data source
    • While there are always exceptions, these raw downloads can be quite simple to dump/deliver and should be something your HR Systems Administrator or HR Ops resource is already doing.
    • Take an extra 15 minutes and ask this person specifically what they need to do - or ask to see them when they actually run this data dump - and you’ll be able to see first hand the level of complexity.
  • Consolidate your data into your “tool” for data analysis
  • Build your calculations and visualizations in your “tool”
  • Play, Test, Iterate. Play, Test, Iterate.

This is going to be an iterative, or agile process - starting simple and increasing complexity as you gain momentum, trust and deliver results.

Next week, we'll move on to talk about PROCESS CONTROL & DATA INTEGRITY

Download Data Driven HR Playbook Now

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See the dashboards & analytics that HR groups at leading organizations like Splunk, Stryker and DraftKings are using for better decision making and great executive conversations

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A New Body Of Work – 400PS Audi RS 3 Saloon Debuts In Paris

September 30, 2016 By Mike Lee
Last updated on September 30, 2016

400PS Audi RS 3 Saloon Debuts In Paris
The first Audi RS saloon since 2010 features the world’s most powerful five-cylinder engine now rated at 400PS

  • First compact Audi saloon to bear an RS badge
  • 2.5 TFSI aluminium engine with 400PS and 480Nm of torque (354 lb-ft)
  • 0-62mph in just 4.1 seconds and optional 174mph top speed
  • Wider track compared to the Audi A3 and signature RS design cues
  • The most powerful five-cylinder engine on the world market

Ingolstadt/Paris, September 29, 2016 –  Now booted, and even better suited to covering ground with incredible pace and agility, the new Audi RS 3 takes to the stage in saloon form at the Paris Motor Show this week, matching blistering performance with a captivating soundtrack created by the most powerful five-cylinder engine ever to empower a series production Audi. The 400PS, 174mph RS 3 makes history as the first saloon in the brand’s history to use a transversely mounted configuration for its evocative powerplant, which has a proven track record as a seven-time winner of an ‘International Engine of the Year’ category award.

The new 2.5 TFSI delivers a phenomenal 400PS and 480 Nm (354.0 lb-ft) of torque, available at engine speeds between 1,700 and 5,850 revolutions per minute. Such firepower allows the the compact RS model to sprint from 0 to 62 mph in just 4.1 seconds. It can attain a maximum speed of 155mph and, upon request, Audi will increase the electronically limited top speed to 174mph. The unique sound of the five-cylinder unit intensifies an already emotionally charged driving experience originating from the ignition alternating between directly adjacent cylinders and widely spaced ones. The sound can be modified via Audi drive select.

With its light-alloy crankcase, the five-cylinder engine is 26 kilograms lighter than before. It employs a dual injection into the intake manifold and into the combustion chambers, as well as the Audi valvelift system for variable control of the exhaust valves.

Relentless traction, steadfast driving safety
With lightning-fast shifting, the S tronic seven-speed dual clutch transmission transmits the power of the 2.5 TFSI to the quattro permanent all-wheel drive. Its electro-hydraulic multi-plate clutch distributes the drive torque variably between the axles. The electronic control combines superior stability with a high level of driving pleasure. The more focused the driving, the faster and more often will a large share of the torque will reach the rear axle. The result is especially agile handling characteristics.

quattro management is integrated as a standard feature in the Audi drive select dynamic handling system, as are the steering, S tronic, engine management and the adjustable exhaust flaps. The driver can individually vary the operation of these components between the three modes comfort, auto and dynamic. The same is true for the optional RS sport suspension plus with adaptive damper control.

Wheel-selective torque control, an intelligent software feature of the Electronic Stabilisation Control (ESC), rounds off the work of the all-wheel drive. In fast cornering it slightly brakes the inside wheels, which are under a reduced load. In this way it can transmit greater lateral power, making handling more fluid and stable. In addition, the RS-specifically tuned ESC comes with a sport mode for controlled drifting. The ESC can also be fully deactivated for even more engaging driving characteristics.

Progressive steering, a four-link rear axle, a tight setup and lowered by 25 millimetres relative to the standard model – the chassis of the RS 3 Saloon is the perfect partner for the powerful drive system. From its stable centre position, the RS 3 Saloon deftly tackles curves and exits with superior precision.

The front brake discs have a diameter of 370 millimetres, while eight-piston calipers with large-area linings provide optimal deceleration. Alternatively, Audi supplies carbon-fibre ceramic discs upfront.

The rear axle is fitted with brake discs which are 310 millimetres in diameter. Standard on the RS 3 Saloon are 19-inch wheels and 235/35 tyres. 255/30 tyres are optionally available for the front axle.

Distinctive RS design outside and inside
The Singleframe grille with its three-dimensional honeycomb design bears the quattro logo along the bottom. Underneath, a blade extends across the entire width of the front into the side air inlets, where it forms narrow funnels for better air flow through the wheel arches. LED headlights with their distinctive daytime running light signature are standard; Audi also offers matrix LED headlights as an option.

Compared with an A3, the front track of the RS 3 Saloon is wider by 20 millimetres – the front wheel arches are accordingly flared wider as well. At the rear axle the wheels are spaced 14 millimetres further apart compared with the standard model.

A fixed spoiler lip on the luggage compartment lid improves the separation of air flow. A distinctive diffuser insert with vertical struts and the large oval tailpipes of the RS exhaust system terminate the rear. Audi exclusively offers the RS-specific paint colors Nardo grey and Catalunya red as options.

The dark-toned interior welcomes the driver and passengers with illuminated door sills bearing the RS 3 logos as a standard feature. Black fine Nappa leather sport seats with RS logos on the backrests are standard. Optionally available are more contoured RS sport seats with integrated head restraints. Their covers are also diamond patterned and colour-perforated. The RS sport leather steering wheel is flattened at the bottom. Inlays at the instrument panel and at the doors complete the customary Audi Sport touches.

Intuitive operation and high-definition displays

The flat hierarchies and intelligently linked context menus make operation of the Audi RS 3 Saloon intuitive and ergonomic. The main control element is the rotary/push-button control on the console of the centre tunnel. With the top infotainment system MMI navigation plus with MMI touch, the terminal includes a touchpad for scrolling, zooming and writing.

Additionally included is a free text search feature that automatically completes the user’s input after entering just a few letters. The voice control processes questions and commands formulated in everyday language.

As standard, a seven-inch electrically extending MMI screen is fitted. The two circular instrument dials are black with red needles and white scales. The centrally positioned driver information system includes a boost pressure indicator, an oil thermometer and a lap timer.

The fully digital Audi virtual cockpit is optionally available. On its high-resolution 12.3-inch monitor the driver can choose between three display modes. They include a special RS screen that moves the tachometer to the centre. On the left and right information appears on tyre pressure, torque and g-forces. When the transmission is operating in manual mode, a scale with a colour background prompts the driver to use the steering wheel paddle or selector lever to upshift when approaching maximum revs.

Always online with Audi connect and Audi smartphone interface

An LTE module gets the Audi RS 3 Saloon online. It brings on board the various services of Audi connect, including navigation with Google Earth and Google Street View, as well as information on fuel prices, the weather, travel and traffic. The information is displayed directly in the MMI, and operation is by way of the standard-equipped RS multifunction steering wheel, the rotary/push-button control and touchpad or by spoken command. Data is transmitted via the new Audi connect SIM, which is factory-installed in the car.

With the corresponding data flat rate the customer can immediately use the services for up to three years free of charge – even in other European countries. In addition, the navigation systems include a Wi-Fi hotspot enabling passengers to surf the web with their tablets, smartphones and other mobile devices.

The free Audi MMI connect app offers many other features, such as transferring your smartphone’s calendar to the MMI. Through Aupeo! and Napster it affords access to countless music tracks and audio books. Destinations from Google Maps, points of interest (POIs) and the entries from the “Travel” service can be transferred from your smartphone to your car’s navigation system using the app. The Audi smartphone interface brings Apple Car Play and Android Auto into the car.

Selected apps for the phone, navigation and streaming services, for example, are then directly displayed on the MMI screen. The driver can control the apps using the various operating options in the car.

Attractive supplementary components complete the infotainment lineup. The Audi phone box inductively charges the smartphone according to the Qi standard and connects it to the car antenna via near-field coupling for optimal reception quality. The Bang & Olufsen Sound System produces an excellent sound experience with 705 watts of power and 14 speakers.

New portfolio of assistance systems
The RS 3 Saloon is also at the top of its class when it comes to driver assistance systems. They keep the car at the desired distance from the vehicle in front, assist the driver when changing lanes and staying within the given lane, detect traffic signs and help avoid rear-end collisions and pedestrian accidents.

New are the traffic jam assist, which briefly takes over the steering in slow-moving traffic up to 37mph, the emergency assist, which automatically stops the car if required, and cross traffic assist rear. The latter system looks out for crossing vehicles when pulling out of a parking space.


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Selle Italia Novus TM Flow Saddle (Black) (Manganese Rails)

Selle Italia Novus TM Flow Saddle (Black) (Manganese Rails)
Price: $119.99
Discontinued Online
This item is discontinued and no longer available for purchase. You may want to search our site for a similar item.

Light enough for the road and tough enough for mountain bikes, the Selle Italia Novus TM Flow S saddle will keep you comfortable on the longest of rides. The saddle's central Flow cutout ensures blood indeed flows to sensitive areas whilst riding ensuring hours of pedaling bliss. The saddle maestros at Selle Italia have devised their ID Match system to pair your physique with the perfect saddle. As one would expect from Selle Italia, this Italian-made saddle is exquisitely crafted and sports a durable Fibra-Tek cover as well as manganese rails to keep it slim and trim.

Selle Italia ID: S2 or L2
Width: 135mm (S2) or 145mm (L2)
Length: 278mm
Rail Size: 7 x 7mm (Standard)
Rail Material: Manganese
Cover Material: Leather
Gender: Unisex
Discipline: Road/Mountain
Color: Black
Weight: 242g (S2), 245g (L2)


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In Process.

Exhibition by Dania Chelminsky

The installation was born out of the observation of the surrounding and immediate nature, a force operating independently, according to its own rules. Out of this observation I tried to manipulate the material, and by doing so to participate in the process of its growth. The exhibition showcases the meeting point between my involvement and the natural process.

The cornerstones are Petri dishes and their image as base for experimentation. Brass circles of the dishes’ size act as framework for the intertwining between the jewel and the growing plant. These circles, laid on a damp bed, support the seed and structure an outline for its growth.

The intertwining of the jewel and the plant is forever unique: sometimes the metal is caging the plant, and sometimes supports it; other times the two are so entangled it is difficult to say which one supports the other. From the moment the seed is sparking unto life there is no way of knowing what form its relationship to the jewel will take. There is no actual regularity.

The involvement in the process of growth is in fact a link to circles of life, formed out of the expansion of the uncontrollable originating in nature. The process can now be defined by name: “Raising a Jewel”.

Brass and natural Beans

7 x 2 x .2 cm

 Ben Yehudas st 176, Tel-Aviv, Israel

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© 2017 Periscope Gallery. Designed by Tair Delia Littman & Naama Haneman


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Eyman’s paid mercenaries are set to hit the streets with I-1053 petitions

Ballot WatchdoggingEye on Money: DevelopmentsThreat Analysis

Mercenary signature gatherers hawking petitions for Tim Eyman’s Initiative 1053 will be hitting the streets over the next few days, Permanent Defense has learned.

Individuals with knowledge of Eyman’s activities have confirmed to Permanent Defense that the Mukilteo profiteer is once again hiring his pals Roy Ruffino and Eddie Agrazarm, who run “Citizen Solutions”, to orchestrate the paid signature gathering drive for Initiative 1053. Coincidentally, Eyman has issued two appeals for money to his supporters this week. Eyman wrote today:

To be successful, we need everyone — from now until July 2nd — to focus and concentrate on ways to get signatures and raise funds. Everything else is a distant, distant second.

I’m calling and meeting with supporters every day and Jack & Mike are busting their butts processing petitions and checks and credit card donations. Raising funds for signature gathering is the most important. It’s the lifeblood of this effort.

Partially-filled and fully-filled petitions are arriving every day now in our post office box in Spokane but not at a pace to ensure success. We’ve got to pick up the pace on signatures and money.

Apparently, Eyman’s patron Michael Dunmire hasn’t written his annual check yet. Last year, Dunmire paid off the loans Eyman took out for Initiative 985 and then provided several hundred thousand dollars for Initiative 1033. So far, however, he has not refilled the coffers for Eyman’s “Voters Want More Choices” committee, even though he is a co-sponsor of I-1053.

“Camano” is here: Welcome to the new Permanent Defense
Eyman files symbolic initiatives to repeal new revenue in 2010 budget

You are here:

Victory: I-976 struck down!

What we do

Permanent Defense works to protect Washington by building a first line of defense against threats to the common wealth and Constitution of the Evergreen State — like Tim Eyman's initiative factory. Learn more.

Protecting Washington Since 2002


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Persian TouringPersian Touring
mot de passe oublié?

Iran Domestic Flights

Iran Domestic Flights

Booking cheap flights between all Iranian Airports

Booking a domestic flight in Iran is one of the hardest things in arranging a trip to Iran. But this sentence is from the past. Now our flight booking system will help you to arrange a cheap domestic flight in Iran.

In this case, you can book your flight in three easy steps:

  1. Fill our flight booking form with your requested flight information. it’s required to upload your passport image.
  2. Wait for our teammate to contact with you. he will inform you about available flight time and price
  3. After you confirm the price, you will receive an online payment link for your flight. you can pay it with your Credit Cards or PayPal
  4. In just some minutes after payment was done, you will receive your flight ticket and details.

  1. The domestic flight tickets in Iran same as other countries have several classes with price and quality differences. So if you want a cheap domestic flight in Iran,  it’s better to book your flight as soon as possible.
  2. The responsibility for the validity of your tourist visa is up to you
  3. The flight price for you includes Flight ticket Price, Money Transfer Tax and Fee and our service fee.
  4. Same as other flights in all around the world, you should be at the airport at least 1 hour before your flight.

    Ouvrir le chat
    Bonjour mon cher
    Il s'agit du support Persian Touring 24/7 dans WhatsApp.
    Puis-je vous aider?


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PerthNow logo

Showground Food Guide

Showground Food Guide

Fresh produce

The IGA Fresh from WA Pavilion is packed with produce to enjoy from olives and potatoes to strawberries, honey, meat, preserves, chilli products, milk and salads. Let your nose lead the way to the sausage competition.

There are free tastings of many products and a range of just cooked and freshly prepared sample sizes to purchase.

Three times a day in the IGA Food For Life Kitchen, Cindy Sargon will be cooking from Saturday to Wednesday and Marg Johnson will be there from Thursday to Saturday. They’ll be showing off recipes from the IGA Food 4 Life Kids Cook Book featuring healthy and convenient meal solutions for breakfast, lunch, dinner, snacks and special occasions which the whole family can cook and enjoy.

Get your cookbook in the IGA Follow The Yellow Brick Road bag or purchase separately.

The IGA Kid’s Club Corner features the magical pikelet machine where kids can add their own topping.

Dairy Pavilion

For those who love dairy there are free tastings of Australia’s best cheese, yoghurt, ice cream and milk drinks at the Lou Giglia Dairy Pavilion.

Buy West Eat Best

Every day at the Department of Agriculture and Food there will be tastings of local produce to support the Buy West Eat Best program which provides consumers and the Western Australian food industry with a food-specific brand to clearly identify food products that are from Western Australia.

Healthy options

There are plenty of tempting treats available at the Show but for those of us who want healthy options it is all here.

Kebab Wraps (Ref J5) have won nutrition awards for their low-fat, low-carbohydrate products including their chicken kebabs which are 95 % fat free and the felafel kebab which is 97% fat free.

At JD’s Seafood Van (Ref G2) there are fresh salads, fruit salad packs, sandwiches on white or brown bread, vege burgers, pita bread and grilled fish. All food is cooked in vegetable oil which contains omega 3 fats (essential fats) and no cholesterol. Sushi and nori rolls are low in fat and high on protein. JD's Diner (Ref E7) has a daily selection of fresh healthy options including sandwiches, pita wraps, fresh fruit salad and garden salad trays.

Steamed corn is on the menu at The Corn Cart and The Corn Van (Ref E8 and I3). Go for salt and pepper instead of garlic, chilli and herb butter.

At the Stuffed Spud (Ref G2 and I6) everything on the menu is healthy. While Showgoers can spoil themselves with extra cheese and sour cream, yoghurt and spicy tomato are delicious alternatives, particularly for vegetarians and the weight conscious. Spuds provide Vitamin B, C, fibre, potassium, iron and vegetable protein. They are low in salt and are fat and cholesterol-free.

Fresh and nutritious Malaysian food is available at Bunga Raya Satay (Ref H2). The grilled satay chicken is cooked without fat or salt plus there are steamed rice cakes and laksa. Most Malay food is served with cucumber, lettuce, pineapple, onion and tomato.

Bottled water and 100% juices are available around the Showground.

Delicious fresh fruit mango, mango and passionfruit, pineapple and banana icy poles are available from Bare Crush Fruit (Ref I2). New to the Show is a machine which turns frozen fresh fruit into soft serve without adding a thing.

When you find the giant orange, you’ll find The Naked Orange (Ref E6 and J2) overflowing with freshly squeezed juices and juice slushies.

For those who enjoy Turkish food, the Healthy and Tasty Mobile Turkish Cuisine Van (Ref E6) offers kebabs, salad, seafood and other traditional fare.

Sometimes the simple things are the best. CWA have tea, coffee and light snacks (J6).


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Following consultation with  Dr Ivan Muscat, Consultant Microbiologist & Deputy Medical Officer of health, the Jersey Dental Association has the following recommendations.

  • Any patients contacting the Practice with symptoms of COVID-19 - cough, difficulty in breathing, fever - should be advised to self isolate & not attend for their dental treatment
  • Practices should continue with their standard cross infection procedures in surgery - sterilisation of instruments, disinfection of surfaces, hand hygiene, safe disposal of sharps, disinfection of lab work/impressions, single use instruments (where possible), safe disposal/storage of clinical waste
  • Staff should continue to use Personal Protective Equipment - gloves, masks, eye protection
  • Practices should provide hand sanitiser to allow patients to carry out there own hand cleaning
  • Practices should regularly(every 2 hours) clean areas touched by patients - reception areas, door handles, door plates, surfaces, PDQ machines
  • If a staff member has symptoms of COVID-19 they should self isolate, there is no need for other staff to self isolate unless they also exhibit symptoms

For more general & updated advice Practices should consult the gov.je website - "Advice for businesses on coronavirus (COVID-19)


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Salad Mix - Frozen

Salad Mix - Frozen

TopSail frozen Salad mix.

  • How does my Salad Mix come:

  • Refund Policy

    Peter's Sydney Fish Market prides itself on the high quality food it provides, the manner in which it is delivered and the service standards we instil in our staff.  Should a client be dissatisfied with the service, quantity or quality of food; we will address the concerns of the client and ensure that a measured approach is taken to compensate the client to ensure a positive outcome.

    We understand that mishaps, unfortunately, can sometimes  occur – if the error is due to an oversight on our behalf or you are unhappy with the product please contact us immediately upon receiving your order and our delivery personnel will visit to collect the incorrect products. The product must be in the same condition that you received them, and a refund will be provided for the affected products. Items that have been consumed may be eligible for a partial refund.

    If you are approved, then your refund will be processed, and a credit will automatically be applied to your account or original method of payment, within 7 days

We'd love to hear from you! For enquiries please fill in the contact form, or feel free to reach out through the following options:

Phone: 02 9552 2555

Shop 4 Waterfront Arcade, Sydney Fish Market

Bank St. Pyrmont, NSW 2009 Australia

© 2020 by Peter's Sydney Fish Market

ABN 83 835 862 251


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Cancer Treatment for Dogs

Cancer Treatment for Dogs

‘Palladia’ Used to Treat Mast Cell Tumors

It’s a cruel twist of fate that our beloved four-legged companions can be stricken with cancer, a seemingly humanized disease.

Up until recently, however, cancer therapy for dogs has been limited in comparison to that which people receive.

Zoetis has an oral therapy called Palladia to treat mass cell tumors in dogs that will be available through veterinarians. This is the first canine cancer therapy in the U.S. approved by the Food and Drug Administration (FDA).

How Does Palladia Work?

Palladia is a prescription-only therapy that will be used to treat grade II or III recurrent cutaneous mast cell tumors with our without regional lymph node involvement.

It works by blocking the activity of key receptors important in the development of blood vessels that supply tumors, as well as receptors vital for tumor survival.

According to Dr. Cheryl London, a board certified oncologist and associate professor at The Ohio State University College of Veterinary Medicine who helped Pfizer Animal Health develop Palladia, the therapy is an exciting, new treatment option for dogs with mast cell tumors.

“At the completion of a Palladia clinical study, approximately 60% of dogs had their tumors disappear, shrink or stop growing,” London said. “Also, we determined that dogs whose tumors responded to Palladia experienced an improved quality of life.”

Mast cell tumors are the second most common tumor type and are often seen as lumps in the skin. These tumors are classified using the Patnaik grading system: grade I, II or II, with grade III being the most severe. If not treated, they can spread to the other parts of the body including lymph nodes.

How Can Dogs Receive Palladia Therapy?

Pet owners should consult with their veterinarian about their pet’s cancer therapy options.

If your dog is a candidate for Palladia, your veterinarian will likely refer you to a veterinary specialist for treatment. The new prescription-only therapy can be administered at a veterinary clinic or given to you to administer to your dog at home, per your veterinarian’s direction.


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Common Dog Parasites – Hookworms, Heartworms and Fleas

Parasites are common in dogs and most dogs will have some at various times in their lives. They can be external or internal. They include fleas, worms, mites, and ticks. They are easy for your dog to pick up, either from other dogs or from the environment. Left untreated, most parasites can cause serious problems and lead to illness in your dog. Fortunately, most parasites are easy to prevent or treat. Here are some of the most common dog parasites your dog is likely to encounter.

Ear Mites
Ear mites are minute mites that are almost, but not quite, invisible to the human eye. They are found in your dog’s ears. They produce a brownish wax that resembles coffee grounds in the ear. They are contagious and can be passed from one dog to another.

If your dog has ear mites his ears will be inflamed and itchy. Your dog will probably scratch at them which can cause an infection as a secondary condition. Puppies are especially prone to ear mites. They can pass them to each other and they can be passed from a mother dog to her puppies.

Ear mites are easy to treat with a miticide liquid. These products are sold in pet stores or you can consult your veterinarian for advice in choosing one. You should check your dog’s ears often for signs of mites.

Fleas are the most common of all dog parasites. They are most common in warm, humid areas but they can be found virtually anywhere. They are a special problem in summer months. Fleas can be passed from dog to dog, or from other animals to dogs. They also spend much of their time off their host animal in the surrounding environment so a dog who visits an area where fleas are found can easily pick up fleas. Dogs who go to dog parks, vet offices, animal shelters, or other places frequented by lots of dogs can easily pick up fleas.

A dog who has fleas will typically become itchy and he will scratch a lot. You will probably find flea dirt, or flea excrement on your dog. This is a black or red-brown grit on your dog’s skin. It is essentially dried blood from your dog that has been excreted by the fleas. If you go over your dog with a flea comb you will be able to find the fleas. In severe cases or if the dog has a flea allergy, the dog may scratch so much that he removes patches of hair and he becomes bald in places. He may have red, inflamed skin.

Fortunately, there are now some good products that prevent flea infestations or kill fleas on contact. Topical spot-on flea products such as Frontline and Advantage II are easy to apply on a monthly basis to your dog’s skin and will kill fleas very quickly. They also keep fleas away for a month or more. Other products can be given orally such as CapStar to kill fleas immediately. There are also good flea sprays, powders, and shampoos to get rid of fleas.

When you treat your dog for fleas it is always advisable to treat your home and yard for fleas to get rid of fleas in the environment, too. Use products with an insect growth regulator whenever possible to keep flea eggs from hatching and starting the cycle all over again.

Left untreated, heartworms can be fatal to dogs. Heartworms are spread by mosquitoes. Mosquitoes bite an infected animal and eventually bite your dog. They deposit immature heartworm larvae in your dog’s bloodstream. In a few months these microfilariae migrate to your dog’s heart and lungs where they can grow for years, eventually reaching over a foot in length. There can be dozens of these large worms in your dog’s heart and lungs, choking off blood supply. They will eventually kill your dog. Your dog may not show any symptoms at first but he will slowly show signs such as becoming tired easily, coughing, and shortness of breath.

Again, heartworms are easy to prevent. Most people give a monthly heartworm preventive such as Heartgard or one of the other Ivermectin products. Collies, Shetland Sheepdogs, some other herding breeds, and some sighthounds are sensitive to ivermectin. You should talk to your vet about how to prevent heartworms if you have one of these breeds. If your dog already has heartworms they can be treated and killed, but it is easier and less expensive to prevent them than to treat them.

Other Worms
Dogs are subject to a variety of other common worms, too, including hookworms, roundworms, tapeworms, and whipworms.

Hookworms are nasty little intestinal parasites that live in your dog’s digestive tract. They feed on your dog’s blood. They pass their eggs through the digestive tract and in to the environment where the hookworm larvae hatch. Dogs ingest them in this form or the larvae enter dogs through contact with their skin.

Hookworms pose a special danger to puppies and elderly dogs because they do cause a loss of blood to the dog. Puppies should be checked for worms when they are young and wormed if necessary. Older dogs should be checked for worms periodically. Some heartworm medications also kill hookworms and roundworms.

Roundworms are the most common worm found in dogs. Nearly all dogs have them at some point, especially when they are puppies. The worms can be passed from the mother dog to the puppies through the milk, for example, or passed from the mother before birth if she has worms. If a dog eats an animal it catches, such as a mouse, and the animal has roundworms, the dog can get the worms.

The worms live in the dog’s intestines. Most dogs don’t show signs of infestation but if your dog has a heavy infestation he will show symptoms such as diarrhea, vomiting, weight loss, and loss of hair. This is especially true of puppies who may also have a pot-bellied appearance. You may see roundworms when your dog coughs or vomits or in the diarrhea. They look like long strands of spaghetti.

Young puppies should be checked for worms and wormed if necessary. Breeding females should be wormed prior to breeding or when they are pregnant using a wormer that is safe for the embryos. Some heartworm medications also kill roundworms and other worms on a monthly basis.

Tapeworms are long, flat, segmented worms that attach themselves to your dog’s intestines. Each of the tapeworm segments has its own reproductive organs. As the tapeworm grows, the end segments break off and are passed through your dog’s intestines with your dog’s feces. You may find the segments attached to your dog’s rear or in his feces looking like grains of rice. When a dog comes in contact with these tapeworm segment, the cycle starts all over again.

Fleas are one of the intermediate hosts for tapeworms which means that if your dog has fleas, chews on his body to get the flea and stop the itching, it can lead to a tapeworm infection in his intestines. Good flea control is one way to avoid tapeworms.

Have your vet check your dog for worms during your visit for vaccinations. Occasional worming may be needed. Many heartworm products will also kill tapeworms and other worms.

Whipworms are one of the most common worms found in dogs. They live in the cecum which is the area where the large and small intestines intersect. Dogs get whipworms by eating and swallowing whipworm eggs found in the soil or eating dog feces that may contain whipworm eggs.

If your dog just has a few whipworms he probably won’t show any symptoms but more severe infestations can result in bloody diarrhea. Left untreated whipworms can cause severe gastrointestinal issues and even death.

Whipworms can be more difficult to diagnose than the other worms discussed here. It’s best to have your dog wormed when you take him for his regular vaccinations in order to make sure he is not carrying a worm infestation. A simple worming will usually take care of all the worms mentioned here. Many heartworm medications will also kill whipworms and other worms.

Ticks are found in many parts of North America these days. You don’t have to live in the woods. If you simply have brush or a woodpile in your yard, you could have ticks lurking in them.

Ticks attach themselves to a dog with their mouth parts and start consuming your dog’s blood. Some ticks excrete a glue-like substance to help them hang on. In some cases tick bites can result in anemia to your dog. Ticks can also spread disease such as Lyme Disease and Rocky Mountain Spotted Tick Fever.

It’s hard to prevent ticks from getting on your dog but you can use tick prevention products to deter them. Many of the flea control products also have a tick control element such as Frontline Plus and Advantage II. Ticks who come in contact with these ticks will quickly die after biting your dog. Even though they bite your dog, your dog should be safe. It usually takes about 48 hours for a tick to transfer any disease to your dog and they will be dead much faster than that.

If you live in an area where ticks are common, you should treat your yard for ticks to deter them. You can use a product such as diatomaceous earth which will dry out the ticks and kill them. You should also check your dog often for any ticks that could be attached to his body and remove them.

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 gold mining companies in rwanda

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gold mining companies in rwanda

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with an agrarian subsistence economy, rwanda remains one of the poorest countries in africa. the primary mineral resources of rwanda include: arable land, hydropower, methane, gold, tin ore, and tungsten ore. some 90% of the rwandan population is involved in agricultural work, and 75% of the land is suitable for growth of crops.inquire now

top 10 largest gold mining companies by revenue as of 2018

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gold mining and conflict: how effective are regulations

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barrick gold corp. is the country's largest gold mining company by several measures of size. after growing 3.35% on the year, on november 8, 2012 goldcorp leapfrogs barrick gold in capitalizationbarrick lost 25% of its market value that year.inquire now

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in october 2012, rwandas ministry of natural resources suspended mining activities in the countrys western province on the basis that they were endangering the river sebeya. the decision was met with negativity due to the affected mining companies loss of production and the loss of thousands of jobs for workers at the mines.inquire now

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bcm international is a private company that bought its nzema mine from endeavor mining tsx:edv in 2017. the mine is located at the south end of the ashanti gold belt. the mine is 90percent owned by the company, and 10percent owned by the government of ghana.inquire now

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hometrimetals mining inc.

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nov 11, 20150183;32;gold production in uganda has radically increased in the recent past. today gold sales contribute about 30% of ugandas export revenue. with gold deposits spread across the country, uganda offers companies a great opportunity to invest in gold mining. ugandas gold mining regions so far, exploitation of gold in the country has been []inquire now

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rwanda's mining sector decries inadequate financing

jul 16, 20190183;32;francis gatare, the chief executive officer of rwanda mines, petroleum and gas board rmb admits that the financing gap is indeed big, disclosing that less than 30 percent of the companies operating in the countrys mining sector are doing professional exploration activities.inquire now

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sep 02, 20170183;32;excelent mining company limited, kigalirwanda. this video is the contents of rwanda gold supplier. excelent mining company limited, kigalirwandainquire now

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new kush exploration & mining limited

new kush exploration & mining company ltd nkem is a first mover gold exploration company focused on east africa, particularly south sudan, northern uganda and ethiopia, with a vision to discover new frontier mineral deposits hosting in excess of 3 million ounces of gold.inquire now

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the price of gold broke a threeyear losing streak in 2016, but the focus of the worlds top gold mining companies in terms of output continued to be on costcutting and divestment with varying inquire now

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may 11, 20160183;32;gold in rwanda. after the end of the civil war and the genocide in rwanda in 1994, the new government has put efforts in reviving its mining industry. gold mining was a major focus in this revival. the government took control of most of the subsurface gold mines.inquire now

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sep 02, 20190183;32;rwanda could miss revenue targets for mineral exports. by ivan r. mugisha more by this author rwanda is staring at the possibility of missing its $600 million revenue target for mining exports this year, and investors are worried about missing the $800 million target for 2020.inquire now

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mining in rwanda presents un exploited opportunities in ores, processing and diversification; rwandas main mineral exports are ores processed to extract tin, tantalum and tungsten and few gold and gemstones; mining is the second largest export in the rwandan economy. in 2017, the sector generated about $373.4 million of foreign exchange.inquire now

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nov 07, 20150183;32;rwanda produces cassiterite, wolframite, tantalite and gold. the country enforces a minerals traceability programme that requires all ores to be tagged from the mining sites until they are exported. rwanda's ministry of natural resources has granted mining licences to inquire now

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Degenerative neurological disorders

Motor neurone disease: management of common symptoms

There is no cure for motor neurone disease, but symptom control is achievable and can improve quality of life.

Person with motor neurone disease in a wheelchair

A multidisciplinary team approach is paramount in achieving optimum quality of life for people with motor neurone disease

Motor neurone disease (MND) is a neurodegenerative condition that affects the brain and spinal cord. It is thought that there are around 5,000 adults in the UK living with MND, the majority of whom are aged between 55 and 79 years[1]. MND has unknown aetiology and is subdivided depending on the class of motor neurones affected (i.e. upper motor neurones [UMN] and lower motor neurones [LMN]) and the variety of symptoms present[2] (see Table). As the disease progresses, the signs and symptoms become similar, irrespective of the initial MND type diagnosed. These symptoms include limb and torso muscle weakness, difficulty swallowing and speaking, and respiratory muscle weakness that leads to respiratory failure and death[3].

MND cannot be cured and ethical debates around assisted suicide, as the course and outcome of this disease can be extremely difficult for the patient and their relatives, have put a spotlight on the disease[2]. However, symptom control is achievable to ensure optimum quality of life (QOL)[4]. A multidisciplinary team (MDT) approach is paramount in achieving this and the involvement of palliative care specialists is recommended from initial diagnosis[2] in order to offer a holistic management approach, where the needs of the patient and relatives are met throughout the trajectory of the disease.

As part of a MDT, pharmacists can advise on the administration of medicines prescribed for the control of symptoms associated with MND. This article describes the holistic management of the most common symptoms encountered in MND and provides examples of how this is applied locally in the UK.

 Amyotrophic lateral sclerosis (ALS)Progressive bulbar palsy (PBP)Progressive muscular atrophy (PMA)Primary lateral sclerosis (PLS)
Table: The four main types of motor neurone disease
Motor neurones affectedUpper motor neurones and lower motor neuronesUpper motor neurones and lower motor neuronesLower motor neuronesUpper motor neurones
Common signs and symptoms
  • Limb and torso muscle atrophy
  • Bulbar muscle weakness (e.g. loss of speech, ability to swallow, ability to chew)
  • Respiratory muscle decline
  • Mainly affects bulbar muscles with less prominent limb weakness
  • Emotional lability
  • Muscle weakness and wasting, first of hands then rest of lower body
  • Fasciculation (twitching)
  • Muscle cramps
  • Stiff and slow movements, first of legs, then torso, arms, hands and eventually bulbar muscles
Percentage of patients with motor neurone disease (%)8555–101
Life expectancy from time of onset2–5 years6 months–3 years5 years or longer, but often progresses into ALS5–15 years
Sources: [2],[5],[6]

Common symptoms and their management

Problems with muscles and movement

Muscle weakness, muscle twitching, cramps and stiffness are all commonly experienced by people with MND.

First-line treatment is quinine bisulphate 300mg tablets at night[3]. Since no formal trials have studied the nature of cramps in MND or the effect of medicine on cramps in this disease[7], evidence is based on quinine bisulphate use in muscle cramps regardless of cause. A meta-analysis of 23 trials demonstrated low-quality evidence that quinine (most commonly used dose of 300mg/day) reduced the number and days of muscle cramps, while moderate-quality evidence demonstrated that it reduced the intensity of cramps[8]. The Medicines and Healthcare products Regulatory Agency advises that quinine should only be used when cramps are painful and persistent, and that use is periodically reviewed for side effects (e.g. abdominal pain and hearing impairment)[9].

If quinine is ineffective or contraindicated, second-line treatment is baclofen 5mg twice or three times per day[3]. If baclofen is not effective, not tolerated or contraindicated, consider tizanidine, dantrolene or gabapentin[3].

Baclofen, tizanidine, dantrolene or gabapentin can be considered to treat muscle stiffness, spasticity or increased tone in people with MND[3].

Physical exercise, such as stretching, which is adapted to the patient’s ability, can also help reduce stiffness and discomfort. Exercises will not strengthen the patient’s muscles, but will help to keep them as active as possible[3].

Decreased mobility

Physiotherapists can recommend exercises that help the patient maintain their posture and flexibility at initial stages of the disease, as well as exercises that focus on breathing as the patient approaches end of life. Occupational therapists can assess patients for wheelchair use, arm and neck supports, rise and recliner chairs, commodes and other equipment to aid activities around the house[10],[11].

RB teaser

Difficulty in swallowing and weight loss

When prescribing medicines it is important to consider if the patient has dysphagia and is unable to swallow[12]. Speech and language therapists (SALTs) will be able to provide advice on food and drink consistency, as well as appropriate body positioning during meals. Dietitians can help determine calorific intake and optimise nutritional supplements.

Surgically, a percutaneous endoscopic gastrostomy (PEG) is indicated when the patient is considered to be at high risk of aspiration, choking, malnutrition and dehydration[10]. MND nutritional guidelines recommend PEG insertion once the patient experiences >10% weight loss and has a forced vital capacity (FVC) of >50% predicted for the patient’s age and height[13]. A retrospective study of 150 dysphagic amyotrophic lateral sclerosis (ALS) patients demonstrated that PEG insertion increased overall survival by at least 6 months. A proportion of the patients studied who had successful PEG insertion had FVC <50% with short-term mortality (at one month) similar to that of patients with FVC >50%. They showed marginally higher medium-term mortality (at six months), but this was non-significant[14]. In practice, a MDT approach is instrumental to assess and advise the patient on whether PEG insertion is appropriate and beneficial[11].

Chronic drooling

Also known as sialorrhoea, drooling occurs owing to poor handling of saliva and not necessarily owing to excess saliva production.

The anticholinergic treatment, hyoscine hydrobromide patch 1.5mg every 72 hours, as well as amitriptyline 10mg three times per day or atropine eye drops 0.5% or 1% two to four times per day sublingually, are recommended by national and European guidelines as first-line treatment options[3],[15].

For patients with cognitive impairment, glycopyrronium is an alternative[3] as its poor lipophilicity prevents its passage through the blood–brain barrier, resulting in minimal medication-induced drowsiness[16].

If first-line treatment for sialorrhoea is not effective, not tolerated or contraindicated, the National Institute for Health and Care Excellence (NICE) recommends botulinum toxin A administration in a specialist setting[3]. In a systematic review, 7 out of 12 studies reported a statistically significant reduction in drooling after treatment with botulinum toxin A or B; however, none of the trials were specifically related to MND patients. The neurotoxin, which is used as an unlicensed drug, is injected into the salivary glands[17].

Non-pharmacological management involves encouraging good oral hygiene, using suction methods as necessary and ensuring appropriate hydration.

Respiratory symptoms

MND affects involuntary respiratory muscles, resulting in shortness of breath on exertion and poor cough reflex, leading to increased risk of respiratory tract infections and carbon dioxide retention. Patients will experience difficulty in lying flat, night-time waking, morning headaches and daytime fatigue.

Physiotherapists and respiratory medical teams advise on positioning and breathing exercises to regularly assess spirometry[10], appropriately manage sialorrhoea and treat respiratory tract infections that may arise[3], as respiratory failure with bronchopneumonia is a major cause of death in patients with MND[18].

Non-invasive intermittent positive pressure ventilation via a nasal mask may be used initially at night only to help control night-time symptoms. A ‘just in case’ kit, including an opioid and benzodiazepine can be offered, particularly when assisted ventilation is withdrawn.

Evidence demonstrates the benefit of morphine in the treatment of dyspnoea for patients with cancer, COPD and heart failure; however, there are no studies evaluating its use in patients with MND[13]. Based on palliative care practice, data are extrapolated to conditions such as MND, whereby opioids have resulted in the reduction of patients’ sensation of breathlessness. In opioid-naive cancer patients, 1–2.5mg of morphine immediate release 4-hourly pro re nata (PRN) is used, titrated to response. For non-malignant conditions, smaller doses and less frequent administration may be adequate[19].

In MND, parenteral options must be considered if the patient is unable to swallow[3],[13]. In breathlessness associated with anxiety, 2–10mg diazepam daily with additional sublingual lorazepam PRN may be indicated. Likewise, the route of administration must be taken into account[3], with parenteral midazolam or levomepromazine being alternative options[19].

Invasive mechanical ventilation can prolong survival of patients with MND; however, there is no evidence showing improvement in QOL. It has high implications in terms of cost, carers and emotional strain[13] and is, therefore, rarely used[10].

Effect on speech

SALTs can carry out a review of the patient’s speech and different forms of communication, while neuropsychologists can formally assess and support the patient as language capacity deteriorates[13]. Communication aids, such as pen and paper, tablets and other speech-generating devices can perpetuate the patient’s ability to communicate for as long as possible. Dexterity will require continual assessment as patients become unable to write and need further technological input, such as computerised speech synthesisers.

Other symptoms

Patients with MND may also experience:

  • Emotional lability;
  • Cognitive and behavioural changes;
  • Frontotemporal dementia;
  • Anxiety;
  • Depression.

Patients with anxiety and depression may benefit from interaction with support groups, online forums and counselling, as well as from pharmacological management as per guidelines for non-MND patients[3].

As the patient approaches the end of their life, the palliative care team must consider the proper timing to discuss this event with them and their family. The patient’s cognition and mental capacity should be taken into account and psychological support sought, if beneficial[3].

Slowing progression

Riluzole is currently the only drug licensed for the treatment of individuals with ALS and has been shown to slow down the progression of the disease[15]. It should be initiated by a neurological specialist with expertise in the management of MND[20].

Box 1 provides an example of how MND is managed by a MDT in Dorset, while Box 2 provides a patient perspective on the condition.

Box 1: Multidisciplinary team management of motor neurone disease in Dorset, UK

A patient with confirmed or likely motor neurone disease (MND) is promptly referred to a neurologist specialised in MND. Upon confirmation of diagnosis, the joint MND and palliative care multidisciplinary team (MDT) takes a proactive approach to management with early and advanced care planning whereby patient cognition, respiratory function, nutrition requirements and palliative care needs are continually considered and assessed[21].

A single healthcare professional expert in MND will contact the patient within two weeks of initial diagnosis to arrange a follow-up appointment[21], where the nomination of a ‘single point-of-contact’ or keyworker is arranged to facilitate patient support[3].

The following is covered during the appointment:

  • Advice on symptom management;
  • Discussion about patient’s, their family’s and carers’ concerns;
  • Support contact numbers;
  • What action should be taken during an emergency.

The National Institute for Health and Care Excellence (NICE) guideline on MND advises that this follow-up appointment occurs within four weeks of diagnosis[3], which is a target achieved within Dorset[22]. The ideal interval between subsequent appointments is not stated in national guidelines. In Dorset, the reviews are timed according to patient need and, therefore, adjusted on an individual basis with a maximum interval of three months for all patients[21].

Some patients may have no available care at home or are caring for others[3]. Locally, the family support team, children’s support team and social services can provide help[21].

The patient’s wishes for treatments or interventions, ‘do not attempt resuscitation’ orders and lasting power of attorney[21] are discussed with the keyworker and relevant members of the MDT[3].

Nutrition pathway

In Dorset, MND patients have access to a registered dietitian for nutritional assessment[23]. Dietary advice is sought if >5% weight loss is noted, which is more cautious than the European guidance of >10% weight loss[13].

If a patient agrees to percutaneous endoscopic gastrostomy (PEG) tube insertion, their forced vital capacity (FVC) is assessed. If their FVC is >60%, the patient is referred directly to the gastroenterology team, but if it is <60%, then respiratory specialists are involved[23]. This practice was discussed with the local neurologist expert in MND who stated that patients with <60% FVC can go on to have a PEG insertion, but are monitored more carefully to minimise any undue harm.

Sialorrhoea pathway

In Dorset, anticholinergics are first-line therapy, as per the NICE guidance[3],[24]. Many patients present with cognitive impairment, resulting in glycopyrronium bromide 1mg/mL orally/PEG at a dose of 1–2mg twice daily to be used and titrated according to response[22]. This dose is based on evidence from a trial specifically studying patients with amyotrophic lateral sclerosis[25].

Botulinum toxin A is not funded by the clinical commissioning group and, therefore, cannot be offered in Dorset[24]. In thick tenacious secretions, carbocisteine 1.5–2.25g daily in divided doses is tried, as per BNF recommendations[26].

Respiratory pathway

Baseline spirometry and symptoms are obtained, physiotherapy referral is made and a ‘just in case’ kit is offered if appropriate[3]. Symptoms of dyspnoea, orthopnoea, early morning headaches and daytime fatigue are continually assessed and non-invasive positive pressure ventilation is offered as symptoms worsen[27].

If the patient requests invasive ventilation, the relevant commissioning body is contacted for NHS Continuing Healthcare Panel approval. A ceiling of care must be established with the patient, including when ventilation will be withdrawn[27]. In Dorset, this route is rarely followed[22].

End of life

The Dorset pathway identifies symptoms, such as recurrent infections and increasing shortness of breath, as an indication that the palliative care team need to have sensitive end-of-life discussions with the patient, using communication aids if needed, at the proper timing[28]. An individualised end-of-life plan is communicated to all MDT or out-of-hours carers. When the patient dies, bereavement support is provided to the family and carers by the palliative care team[28], as per the NICE guideline[3].

Box 2: Patient perspective — Jack, a 56-year-old man living with motor neurone disease

January 2017

Jack* was diagnosed with amyotrophic lateral sclerosis (ALS) — the most common type of MND. Initial signs of disease presented as occasional stumbling while out walking the dog (limb muscle weakness) and speech impediment (bulbar muscle weakness).

Upon diagnosis, Jack’s wife, Clarissa*, remembers reading up on the disease and learning that life expectancy was a matter of a few years. She states: “I didn’t understand what I was reading. ALS had come out of nowhere, but it changed so much of our lives.”

September 2017

Jack lost the ability to eat orally. He and his wife had already had discussions with the local palliative care team and were aware that this would happen during the progression of the disease. “We were prepared and we knew that a [percutaneous endoscopic gastrostomy] tube was the necessary and right thing to do,” says Jack.

October 2017

Walking became more difficult for Jack, who had been using a cane up until this point. Through one of his regular therapy assessments with the physiotherapist and occupational therapist, Jack was able to obtain a wheelchair. He was encouraged to still undertake ongoing daily exercises to maintain as much muscle strength as possible for as long as possible.

November 2017

Further bulbar muscle weakness became apparent as Jack lost the ability to speak and salivation became more of a problem.

To aid communication, Jack says ‘yes’ by lifting his eyebrows and ‘no’ by closing his eyes. “Tools and techniques become very important for simple daily tasks,” says Jack through his voice synchroniser. “The patch (hyoscine hydrobromide) he was prescribed has helped to control excess saliva and we have a little suction machine thing as well,” explains his wife.

December 2017

Jack lost all ability to walk. Strength in both legs and arms failed first, followed by torso muscle weakness. “I remember when he could no longer type with his hands, he used his nose. Now that he cannot use his nose, he types with his eyes — amazing technology,” affirms Clarissa.

Since diagnosis, Clarissa has been Jack’s full-time carer. The local palliative care nurse specialising in MND, along with other specialists in the multidisciplinary team, provide ongoing support and help the couple adapt to Jack’s deterioration. Both Jack and Clarissa appreciate the expertise and care provided by the healthcare team, and have good relationships with their GP and local pharmacist who they go to for advice on medicine’s administration.

“I appreciate the good things, the small daily senses and experiences I used to take for granted. I think about death daily, but I don’t feel like I’m dying. For now, there is a life force that just won’t give up,” declares Jack.

*All names have been changed for confidentiality.

Future perspective

Further research is necessary to elucidate the cause of MND, to develop and improve current treatment strategies, and to slow disease progression. Current NICE guidance recommends further research into the ALS Prognostic Index and whether this is an accurate predictor of survival in people with MND, as well as how to manage sialorrhoea[3].

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2019.20205952

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Natural Areas Management

You’ve invested considerably in plants, seed, mulch and labor to install your native planting…now what? Success in sustainable landscaping and ecosystem restoration projects depends, not only on quality installation, but equally on the maintenance they receive post installation.

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News and Stories - Climate Change - 10th December 2015

A welcome change: Paris Agreement 2015

A welcome change: Paris Agreement 2015

Plan International welcomes many aspects of the Paris Agreement, signed by the governments of 195 countries at COP21. However, we are concerned over issues around financing adaptation and the importance of human rights in the response to climate change.

We are encouraged to see countries agreeing to limit the global temperature rise to well below 2 °C, aiming to limit temperature increase to 1.5°C. This represents a clear acknowledgement that global action on climate change must safeguard the futures of the most vulnerable people and countries.  It is now essential that concrete action be taken to ensure that warming is kept as low as possible.

We are pleased to see that countries have agreed that greenhouse gas emissions must peak soon and net emissions must fall to zero. All countries now need to step up efforts to reduce their own emissions to make good on this global goal.

The impacts of climate change threaten to undermine a range of human rights. Children’s rights are being particularly affected and the poorest children will be the hardest hit.

The inequity of climate change impacts will also be felt across generations. Children and future generations, who have not contributed to the current problem of climate change, will bear the brunt of future impacts.

We are encouraged to see that the preamble to the agreement acknowledges the importance of protecting and respecting all human rights in countries’ responses to climate change. The recognition of children’s rights is also an important inclusion. However, this could have gone further and we were very disappointed that references to human rights throughout the rest of the agreement were removed. We are also disappointed to see weak references to intergenerational equity.

Tackling climate change relies on protecting the rights of the most vulnerable groups, including children, women, those living in poverty, migrants, indigenous peoples and more. We urge all countries to adopt rights based approaches in their responses to climate change.

Adaptation and building resilience are critical components of the response to climate change. We are pleased to see that adaptation is included as a goal of the agreement, and that the urgent and immediate needs of the most vulnerable are recognised.

Adaptation must be done in a gender-responsive, participatory and transparent way with a specific focus on the most vulnerable. We call on all countries to ensure that the specific needs and rights of children are a key focus of their adaptation efforts and that children and young people are able to participate in climate change adaptation.

Climate change adaptation imposes a large financial burden, particularly on the poorest countries. It is disappointing that the agreement does not provide enough clarity on how climate finance will be scaled up to meet the scale of the challenge, or include specific commitments on finance for climate change adaptation.

Climate change education, as part of education for sustainable development, increases the adaptive capacity of children and their communities, helps to foster environmental stewardship and thus contribute to climate change mitigation, and develops children’s capacity to be agents of change and active citizens. Plan International is pleased to see that the new agreement reaffirms the important role of climate change education.

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  • About my display
  1. No problem, I think that it is kinda funny actualy. I havent heard anything anway.

  2. I'm sorry, but I accidentally hit the "report" button next to your name on the private message you sent. I have immediately written trying to correct my error. So just in case you get anything, I wanted you to know what happened. If you have any problems because of it, please let me know and I will do whatever I can to fix it. personal email is [email protected] Again, I'm sorry for the goof up. My vision plays tricks on me sometimes. darlene pino

  3. Thanks....... for reminding me

  4. Happy Birthday from Albany

  5. My memeory stick was flaking out, but I did get a few pics saved to my camera.
  6. Thank you Lori,Glen and everone at Lori's, we really appreciate the hospitality that you extended to us today. I look forward to talking and doing business with you in the future!! To Michael B. and Bill V. thank you for helping to plan and assemble everyone, I am sure it was quite a job to do so well. Thanks also needs to go out to the presenters, all the info about the DIY, LEDS, Wireframes and different softwares has really opened possibilites for me. Again Thanks!!!! Steve and Chase
  7. Janet and I will be there. I am glad that yall are doing this, hated missing the Ga meeting. Steve
  8. Are you going to the Georgia Mini in April? John and I are plannig to go. Darlene (Pino) &John Antoniewicz

  9. ssaunders

    I remember seeing the sequence on lorsequences.com, not sure where to find the yellow snow audio though.
  10. I am keeping it small again this year, Just not enough time to go around. I will try to get you some pics later today.

  11. Got any photos of your display this year? All is well here. Getting a nice group of visitors to our light show, but not too many to make it uncomfortable. Made it in the newspaper last week too. I entered the PC contest. don't know if we'll get the judge's attention, but we'll try it. I hope all is well there and you don't get too cold this morning! Darlene Pino

  12. Decided at the last minute to replace the slices in my mini mega tree and am still working on sequences. The rain has kept me from working in the yard much:(, I know we need it. It will be small again this year, which is ok seeing that we are away from any larger cities. Steve
  13. My display will definitely be small again this year. I will me rewiring most of my mini-mega due to the color coming off of the bulbs while in storage but it will be in Crosland Ga.
  14. I am so glad you reminded me to do a backup. Think I will check this out now.
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