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Feature Article Supplemental Data
The Role, Education, and Experience of Health Care Assistants in End-of-Life Care in Long-Term Care: A Scoping Review
Una Cronin, RGN, MSc; Joan McCarthy, PhD; Nicola Cornally, PhD
The changing age profile of the human population globally means that the requirement for residential long-term care (LTC) for older adults is escalating, with an associated increase in deaths in these facilities. Health care assistants (HCAs), whose main role is provision of direct care to residents, comprise the largest staff cohort in residential care for older adults. The purpose of this scoping review was to explore three key areas related to HCAs: their role and responsibilities, end-of-life (EOL) education, and their views and experiences of caring for residents at EOL. The literature search included five databases and 32 studies were ultimately reviewed. Key issues were as follows: HCAs feel marginalized and undervalued, they need and desire EOL education, and resident deaths impact negatively on them. The changing care needs for older adults with complex comorbidities at EOL in LTC will place an increased onus on HCAs' skills, knowledge, and personal and professional development. [Journal of Gerontological Nursing, 46(1), 21–29.]
Since the early 1990s, the average global life expectancy has risen from 64.8 years to 70 years (United Nations Population Fund, 2017). Increasing age brings challenges associated with living longer. Coping with the complexities of an aging population, many of whom have at least one chronic illness, will place particular difficulties on societies where life expectancy is escalating. In Ireland, it has been predicted that there will be a 46% increase in older adults between 2011 and 2026 (Central Statistics Office, 2017). The impact of the changing demography is that there will be an increased need for long-term care facilities (LTCFs) for older adults. Between 2015 and 2030, demand for long-term care (LTC) in Ireland is projected to increase from 29,000 to 44,600 beds, with the largest increase among adults older than 85 (Wren et al., 2017). New Zealand, with a relatively similar population to Ireland, reports similar increases from 33,006 residents in 2015–2016 to 60,080 in 2031–2032 (Technical Advisory Services as cited in Burrow, Gilmour, & Cook, 2017). Close to one quarter of the total annual deaths in Ireland occur in LTCFs (Department of Health, 2018). Several other countries, including England (Public Health England, 2018) and the United States (Temkin-Greener et al., 2013) have relatively similar death rates (21.8% and 25% deaths in LTCFs, respectively).
The changing role of nurses, due to assuming new responsibilities, combined with increased requirements for documentation of care, has reduced their bedside care provision (Drennan et al., 2018). Health care assistants (HCAs) are the primary direct caregivers in many LTCFs (Beck, Törnquist, Broström, & Edberg, 2012; Fryer, Bellamy, Morgan, & Gott, 2016). However, research related to their role in end-of-life (EOL) care is limited. The HCA role has been described as supporting the care delivery under the supervision and direction of qualified nursing personnel (Department of Health & Children, 2001; Shannon & McKenzie-Green, 2016). Other countries use a variety of titles for roles similar to HCA; therefore, for the purpose of the review, HCA is used as the generic description. For example, in the United States, the most common title is certified nursing assistant (Bureau of Labor Statistics, 2018); other titles are nursing assistant in Sweden (Åhsberg & Carlsson, 2013) and resident care aide in Canada (Waskiewich, Funk, & Stajduhar, 2012).
From an international perspective, HCA education has been reported as variable and inadequate, with a need for more consistency and standardization (Drennan et al., 2018). In Ireland, although a HCA qualification is not yet a mandatory requirement for employment purposes, many health providers seek HCA qualification when recruiting care staff. Training involves completion of a Healthcare Support Certificate of 1,200 hours of education, inclusive of classroom and work experience, normally provided on a part-time basis over 1 year (Quality and Qualifications Ireland, 2018). The EOL care module of the certificate is optional; therefore, those who undertake the latter may not have specific EOL care training. Each country has its own HCA training system. In the United States, 75 hours of initial training and at least 12 hours annually is required (U.S. Government Publishing Office, 2011), whereas in the United Kingdom, a Care Certificate (workbook of 15 standards) was introduced in 2015. Although not a statutory requirement, there is an expectation that all HCAs complete the workbook (Skills for Care, 2018). Given the primary caregiving role of HCAs at EOL, it is important that their role and responsibilities, education, views, and experiences in EOL caregiving are clear and understood by service providers and workforce planners.
The current scoping review was guided by Arksey and O'Malley's (2005) framework and the Guidance for the Conduct of JBI Scoping Reviews (Peters et al., 2015). Five stages of a scoping review are: identifying the research question (Stage 1); identifying relevant studies (Stage 2); study selection (Stage 3); charting the data (Stage 4); and collating, summarizing, and reporting the results (Stage 5). For the purposes of the review, a HCA was understood as a member of staff who supports the delivery of resident care under the direction of a RN. A LTCF was understood as any residential setting whose major focus is provision of LTC for older adults (age >65). No specific definition of EOL was deployed.
Identifying the Research Question
The aim of the review was to identify and map current research evidence on the HCA role, education, and experience in EOL care in LTCFs for older adults. Three broad questions on the topic were posed:
What are the role and responsibilities of HCAs caring for residents at EOL in LTCFs?
What EOL education do HCAs have, or need, to provide EOL care in LTCFs?
What are the views and experiences of HCAs in caring for residents at EOL in LTCFs for older adults?
Identifying Relevant Studies
Studies that included HCAs who work in LTCFs for older adults and care for residents at EOL were considered. Studies covered any aspect of the HCA's role and responsibilities, education, and experience in care provision at EOL. Excluded studies were those where HCAs were included in conjunction with other staff but were not distinguished in the analysis and therefore could not inform the review. No geographical limitation was made.
Primary research of qualitative, quantitative, and mixed method studies was included. Theses and dissertations were also considered if primary research was reported. The database searches completed on July 13, 2018, included PsycINFO, MEDLINE, CINAHL, ProQuest, and PubMed. Limits applied were: English language and 10 years. The key search words were health care assistant (24 terms), long-term care facility (16 terms), and end of life (seven terms). Boolean operators AND and OR were used, as well as parenthesis and truncation (*) to increase efficiency of the search.
Study Selection
The result from all databases was 498 articles. After a process of removing duplicates (n = 61), followed by title screen, abstract screen, full-text screen, and reference list scanning, 32 studies were reviewed. On review of the included studies, with the exception of an unpublished thesis, all were noted to have been peer reviewed. A PRISMA flow chart was created to summarize the study selection process (Figure 1).
Process for selecting studies using PRISMA guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).
Note. HCA = health care assistant; EOL = end of life; LTCF = long-term care facility.
Charting the Data
Formal methodological assessment of studies is not a criterion for scoping reviews (Arksey & O'Malley, 2005; Peters et al., 2015); therefore, it was not completed. In line with the study protocol, all charted data were aligned with the three research questions (Figure 2).
Summary of data charting.
Note. HCA = health care assistant; EOL = end-of-life; LTCF = long-term care facility.
The 32 included studies were representative of seven countries, namely the United States (n = 8), Sweden (n = 8), Canada (n = 6), United Kingdom (n = 4), Ireland (n = 3), New Zealand (n = 2), and Australia (n = 1). Seventeen studies took a qualitative approach using semi-structured interviews (n = 13) or focus groups (n = 4), 12 studies took a quantitative approach (survey questionnaires), and three studies were mixed method (combination of questionnaires and interviews). The results are presented below under the headings of the three questions asked of the literature.
Three main areas of the HCA role and responsibilities were identified in the literature and mainly emanated from 15 qualitative studies where aspects of the role were described during interviews or focus groups. Aspects of the role and responsibilities arose to a lesser extent in quantitative studies. Physical caregiving was identified as a key aspect of the role, followed by emotional support for residents and relatives. The third dimension of the role related to the physical environment.
Physical Care. It was evident from the literature that physical caregiving was the predominant element of the HCA care role at EOL (Åhsberg & Carlsson, 2014; Beck et al., 2012; Dwyer, Hansebo, Andershed, & Ternestedt, 2011; Funk, Waskiewich, & Stajduhar, 2014; Holmberg, Hellstrom, & Osterlind, 2019; Kaasalainen, Brazil, & Kelley, 2014; Kortes-Miller, Jones-Bonofiglio, Hendrickson, & Kelley, 2016; McClement, Wowchuk, & Klaasen, 2009; McDonnell, McGuigan, McElhinney, McTeggart, & McClure, 2009; Nochomovitz et al., 2010; Preshaw, 2017; Waskiewich et al., 2012). Maintaining the resident's comfort was part of EOL caring (Funk et al., 2014; Holmberg et al., 2019; McClement et al., 2009; Waskiewich et al., 2012) and was demonstrated by observing changes, identified by Sahlberg-Blom, Hårsmar, and Österlind (2013) as subtle (e.g., different smell, look, behavior) or manifest (e.g., bodily changes, self-determination), and through symptom management (Holmberg et al., 2019; Preshaw, 2017; Young, Froggatt, & Brearley, 2017), such as identifying and reporting pain (Beck et al., 2012; Cornally et al., 2016; Jansen et al., 2017; McClement, Lobchuk, Chochinov, & Dean, 2010; McClement et al., 2009; Phillips, Davidson, Jackson, & Kristjanson, 2008; Sahlberg-Blom et al., 2013; van Riesenbeck, Boerner, Barooah, & Burack, 2015).
There were conflicting findings in relation to the ability of HCAs to identify EOL symptoms when compared with nurses. One study reported that HCAs (n = 261) had significantly more difficulty recognizing EOL symptoms than nurses (χ2[2, N = 356] = 23.88, p ≤ 0.001) (Frey, Boyd, Foster, Robinson, & Gott, 2016), whereas another study reported that HCAs (n = 15) recognized significantly more symptoms than nurses (e.g., nausea [40% vs. 10%, p = 0.20]) (Cornally et al., 2016). This disparity may be impacted by the differing EOL definitions and time frame within which surveys were completed. Caring for the deceased after death was also noted as a HCA responsibility (Barooah, Boerner, van Riesenbeck, & Burack, 2015; Fryer et al., 2016; McClement et al., 2009) and included washing (Dwyer et al., 2011), dressing (Åhsberg & Carlsson, 2013), and preparing the body for the morgue (Funk et al., 2014).
Emotional Support. Emotional support for residents on the part of HCAs included alleviating anxiety (Preshaw, 2017), engaging in conversation (Holmberg et al., 2019), attending to spiritual needs (Shanagher, 2011; Waskiewich et al., 2012), and advocating on behalf of the resident (McClement et al., 2009; Young et al., 2017). Not leaving the resident alone as EOL approached was also noted as part of the HCA role (Dwyer et al., 2011; McClement et al., 2009; McClement et al., 2010; Waskiewich et al., 2012). The dying resident was also supported by non-verbal communication such as touch (Åhsberg & Carlsson, 2014; McClement et al., 2009), body language (Dwyer et al., 2011), or presence (Holmberg et al., 2019). Comforting and supporting the resident's family or relatives was another identified part of the HCA role (Åhsberg & Carlsson, 2014; Beck et al., 2012; Fryer et al., 2016; Holmberg et al., 2010; McClement et al., 2010; Shanagher, 2011; Waskiewich et al., 2012) even where "staff recognized that supporting families was not part of their job" (Vandrevala et al., 2017, p. 160).
Environment. Maintaining a calm and peaceful atmosphere (Åhsberg & Carlsson, 2014; Beck et al., 2012; Holmberg et al., 2019; Waskiewich et al., 2012) and clean physical environment (Dwyer et al., 2011; Waskiewich et al., 2012) were also described as an element of the HCA role.
HCAs have a wide range of EOL educational backgrounds. In addition, studies reported education interventions that took different approaches, all of which reported largely positive results. Three major areas for further education were identified: the process of EOL; communication; and specific clinically related skills and knowledge.
End-of-Life Education. Twenty-nine studies referred to EOL education in some form, with the prior level and type of EOL education varying across 10 studies that included specific information in this regard. Some HCAs relied on experience (Fryer et al., 2016; Holmberg et al., 2019; Shanagher, 2011), others reported HCAs as having some EOL training, which was not elaborated (Cornally et al., 2016; Frey et al., 2016; Funk et al., 2014; McClement et al., 2010) and some provided detail, for example, McDonnell et al. (2009) reported that 18% of HCAs (n = 154) had attended palliative education in the previous 2 years.
Education Interventions. Six education interventions were reported, including study circles (Beck, Jakobsson, & Edberg, 2014; Beck, Törnquist, & Edberg, 2014), experiential learning in hospice (Kaasalainen et al., 2014), high fidelity simulation (Kortes-Miller et al., 2016), a series of education classes coupled with nurse support (Phillips et al., 2008), and weekly education sessions (6x) (Malik & Chapman, 2017). All reported positive results, such as HCAs being more confident (Beck, Tornquist, et al., 2014; Phillips et al., 2008) and having better communication skills (Kortes-Miller et al., 2017). However, as a result of better education, frustration with colleagues (Beck, Törnquist, et al., 2014) and lack of acceptance from nurses (Phillips et al., 2008) were perceived negatively by some participant HCAs.
Education Needs. Three core education needs were identified: (a) better understanding of the process of dying/palliative care (Beck et al., 2012; Cornally et al., 2016; Dwyer et al., 2011; McDonnell et al., 2009; Preshaw, 2017; Shanagher, 2011; van Riesenbeck et al., 2015); (b) improved communication skills (Beck et al., 2012; Dwyer et al., 2011; Frey et al., 2016; Holmberg et al., 2019; Malik & Chapman, 2017; McDonnell et al., 2009; Preshaw, 2017; Shanagher, 2013; Vandrevala et al., 2017); and (c) clinical skills and knowledge related to chronic illness (Malik & Chapman, 2017), dementia-specific EOL care (Vandrevala et al., 2017), and the use of pain assessment tools (Jansen et al., 2017; McClement et al., 2010; van Riesenbeck et al., 2015).
Overall, the studies demonstrated that HCAs feel marginalized and undervalued. Moreover, they experience a range of largely negative stresses and emotions associated with resident deaths. Caregiving for HCAs was focused mainly on comfort and they developed close bonds with the resident and family. However, they felt torn between their obligation to care for the dying resident and their other responsibilities toward other residents, which was a source of frustration for HCAs.
Feeling Marginalized and Under-valued. A major issue arising in the literature was that HCAs feel under-valued, powerless, marginalized, and/or excluded from involvement in care decisions (Beck, Törnquist, et al., 2014; Dwyer et al., 2011; Fryer et al., 2016; Jansen et al., 2017; Kaasalainen et al., 2014; McClement et al., 2010; McDonnell et al., 2009; Preshaw, 2017; Sahlberg-Blom et al., 2013; Young et al., 2017). The professional hierarchy (Fryer et al., 2016; Jansen et al., 2017) and perceived lack of leadership (Beck et al., 2012) had a negative impact on communication and relationships within the team. Support from management was viewed positively (Beck et al., 2012; Boerner, Gleason, & Jopp, 2017; Vandrevala et al., 2017); however, Shanagher (2011) noted that delegation also led to feelings of isolation. When HCAs (N = 2,636) reported better communication with other team members, directors of nursing reported better EOL assessment (p = 0.043) and care delivery processes (p = 0.098) (Zheng & Temkin-Greener, 2010).
Emotions and Coping. Being unable to relieve suffering at EOL negatively impacted HCAs' emotions (Åhsberg & Carlsson, 2014; Beck et al., 2012; Funk et al., 2014; Preshaw, 2017; Vandrevala et al., 2017; Young et al., 2017). Grief after a death was reported when the relationship was close and had developed over time (Boerner, Burack, Jopp, & Mock, 2015; Funk et al., 2014; Preshaw, 2017) and some HCAs likened their experience of grief to that of a bereaved family member (Boerner et al., 2015; Shanagher, 2011; van Riesenbeck et al., 2015). Although HCAs used a variety of strategies to cope with resident deaths (Barooah et al., 2015; Fryer et al., 2016; Funk et al., 2014; Vandrevala et al., 2017; Waskiewich et al., 2012), distress from grief was associated with higher levels of burnout (Anderson & Ewen, 2011) and complications from grief were found to be related to depersonalization (Anderson, 2008). Some HCAs were guilt-ridden when they could not give the care they wished due to lack of time and resources (Beck et al., 2012; Dwyer et al., 2011; Funk et al., 2014).
Relationships. The relationship with the resident was expressed as a close or familial bond (Beck et al., 2012; Fryer et al., 2016; Funk et al., 2014; Holmberg et al., 2019; Kortes-Miller et al., 2016; McClement et al., 2009; Shanagher, 2011; Vandrevala et al., 2017; Waskiewich et al., 2012). HCAs also developed close links described as "journeying with" family members (Shanagher, 2011, p. 43). After death, HCAs "missed all the family, too" (Funk et al., 2014, p. 29), but there were occasions when the relationship was stressful (Funk et al., 2014; Preshaw, 2017; Vandrevala et al., 2017). On the other hand, appreciation from families was affirming (Beck et al., 2012; Funk et al., 2014; Vandrevala et al., 2017). EOL care focused on resident comfort (Funk et al., 2014; McClement et al., 2009; Waskiewich et al., 2012), and HCAs were frustrated when residents were perceived to be suffering (Funk et al., 2014; Vandrevala et al., 2017). Another concern was perfunctory or passive caregiving (McClement et al., 2010; Preshaw, 2017). Respect for the deceased body was considered important (Åhsberg & Carlsson, 2014; Barooah et al., 2015; Funk et al., 2014), as was the after-death ritual (Barooah et al., 2015; Dwyer et al., 2011; McClement et al., 2009). Quick bed filling after a death was an expressed concern in four studies (Barooah et al., 2015; Beck et al., 2012; Fryer et al., 2016; Funk et al., 2014).
Resources. HCAs were conflicted between taking the time to care for the dying resident and their responsibilities to other residents and this was a source of guilt and/or frustration (Åhsberg & Carlsson, 2013; Dwyer et al., 2011; Funk et al., 2014; Holmberg et al., 2019; Kortes-Miller et al., 2016; McClement et al., 2010; Preshaw, 2017; Vandrevala et al., 2017; Waskiewich et al., 2012). Poor staffing levels were also an expressed concern (Beck et al., 2012; Beck, Törnquist, et al., 2014; Dwyer et al., 2011; McDonnell et al., 2009; Preshaw, 2017).
The aim of the current review was to identify and map current research evidence of the HCA role, responsibilities, education, and experience in EOL care in LTCFs for older adults. Methodologically, studies included qualitative, quantitative, and mixed method approaches. The key findings were that HCAs feel marginalized and undervalued, they need and desire EOL education, and resident deaths have a negative impact.
Overall, the literature strongly demonstrated that participants in the studies included in the review felt undervalued or marginalized. The reasoning behind this sense of marginalization links to other issues, such as the sense of exclusion from care decisions, inadequate communication, insufficient education, and perceived lack of support. The sense of being undervalued on the part of HCAs is not exclusive to EOL care in LTC and has been reflected in other literature (Glackin, 2016; Gray et al., 2016; Torsney, 2010).
HCAs are also vulnerable to negative emotions and stresses after a resident's death. Where HCAs reported complicated grief, which is grief that cannot be openly acknowledged (Doka, 2002), higher levels of depersonalization were evident (Anderson, 2008). Grief can lead to burnout, which presents as overwhelming exhaustion, cynicism, and detachment leading to stress (Maslach & Leiter, 2016). Guilt and frustration among HCAs were linked to resource constraints. Research on guilt among nurses concluded that when guilt becomes excessive it can have a negative psychological impact (Duarte & Pinto-Gouveia, 2017). Given the findings of the current review, the conclusion is equally applicable to HCAs. The frustrations and stresses expressed by HCAs in several studies, such as being torn between caring for dying residents versus other duties, align with features of moral distress identified in two reviewed studies (Funk et al., 2014; Young et al., 2017), which has previously been defined by Jameton (1984) as occurring when the correct course of action is known, but due to organizational constraints taking the action is impeded. The emotions and stresses of coping with resident deaths are not mutually exclusive. A HCA who is grieving the loss of a resident may also have feelings of guilt as well as experience burnout and moral distress. Thus, it is vital that employers are aware of the risks to HCAs and have clear policies, procedures, and communication mechanisms in place to support them.
A wide range of EOL education levels were reported. Lack of education implies a reliance on intuition, limited knowledge, or experience rather than having a comprehensive understanding of EOL caring. However, education interventions demonstrated that when HCAs were given the opportunity to discuss and reflect, they gained confidence in their role. International-level programs, such as the Gold Standards Framework® (2018) in the United Kingdom and the Compassionate End of Life Care Review (Irish Hospice Foundation, 2018) in Ireland, are workshop-based reflective education programs that have proved successful. An alternative means of education alluded to was that newer HCAs work with more experienced colleagues (Barooah et al., 2015; van Riesenbeck et al., 2015). This approach has worked through mentoring and modeling that helped build relationships with residents and colleagues (Tyler & Parker, 2011).
In terms of role, HCAs were most comfortable with physical care, which was not unexpected as the basis of a HCA job description internationally is supporting residents with activities of daily living (Bureau of Labor Statistics, 2018; Drennan et al., 2018; Health Careers, 2018; Health Service Executive, 2006). Physical caring included symptom management, and studies suggested that HCAs lacked education in pain assessment, so their judgments were largely subjective, with the implication that pain assessment depended on how well the HCA knew the resident and could recognize signs of pain. When formal pain assessment was completed by HCAs, it minimized conflict and provided HCAs a role in determining care (Phillips et al., 2008).
The need for communication training was reflected by the challenges reported in provision of emotional support for residents and within the care team. The challenges with residents may be due to fear of not knowing what to say and fear of having to answer difficult questions as identified by Holman, Sawkins, and Hockley (2011). Other literature has identified communication skills as a necessary part of HCA training to support the relationship with residents and facilitate teamwork and care delivery (Ryan et al., 2014; Winchester, 2003).
Resource constraints identified in the current review reflect a perception of a burdensome workload associated with perceived low staff levels. The National Standards for Residential Care Settings for Older People in Ireland state the workforce must have the required skills, experience, and competencies to respond to the needs of residents (Health Information and Quality Authority, 2016), but no staff ratios are indicated. Across Europe, there are variable levels of skill mix throughout different health care services (Drennan et al., 2018), not just in LTC. Adequate organizational resources are fundamental to ensuring the HCA workload is manageable and that HCAs can access appropriate education and support to enable them to provide the highest quality EOL care.
Strengths and Limitations
Strengths of the review were that search terms were assiduously planned and facilitated a comprehensive database search. The diverse geographical locations of studies as well as the combination of methodological approaches add strength to the results of the current review. The limitations include that the time and language limits applied may have led to omission of some earlier studies. The search did not include grey literature, which potentially could have further contributed to the results.
Five implications for practice have been identified, all of which have the potential to negatively impact on HCAs' ability to provide best quality EOL care. These are:
HCAs are confident in physical care provision, but less comfortable with emotional support.
HCAs feel undervalued and ignored within the care team.
HCAs desire and need EOL education.
HCAs need support to cope with deaths of residents.
HCAs face EOL care dilemmas due to workload pressures.
The current scoping review has explored the HCA's role, responsibilities, education, and experiences in EOL care in LTCFs and has demonstrated the complex nature of caring in this context. Three major needs that arose from the literature are (a) the better integration of HCAs into the care team, (b) appropriate EOL care education, and (c) support to cope with resident deaths. The results contribute to an increased understanding of the HCA in EOL care in LTCFs and has demonstrated that despite different health systems and role titles, nationally and internationally, HCAs have broadly similar roles and concerns. Further research of this important topic is required.
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Fryer, S., Bellamy, G., Morgan, T. & Gott, M. (2016). "Sometimes I've gone home feeling that my voice hasn't been heard": A focus group study exploring the views and experiences of health care assistants when caring for dying residents. BMC Palliative Care, 15, 1–9. https://doi.org/10.1186/s12904-016-0150-3 doi:10.1186/s12904-016-0150-3 [CrossRef]
Funk, L. M., Waskiewich, S. & Stajduhar, K. I. (2014). Meaning-making and managing difficult feelings: Providing front-line end-of-life care. Omega, 68(1), 23–43. https://doi.org/10.2190/OM.68.1.b PMID: doi:10.2190/OM.68.1.b [CrossRef]24547663
Glackin, P. (2016). The evolving role of the healthcare assistant and its implications for regulation in the Republic of Ireland: A case study approach [PhD thesis]. University of Northumbria, Newcastle.
Gold Standards Framework®. (2018) Care homes training programme. Retrieved from http://www.goldstandardsframework.org.uk/care-homes-training-programme
Gray, M., Shadden, B., Henry, J., Di Brezzo, R., Ferguson, A. & Fort, I. (2016). Meaning making in long-term care: What do certified nursing assistants think?Nursing Inquiry, 23(3), 244–252. https://doi.org/10.1111/nin.12137 doi:10.1111/nin.12137 [CrossRef]27044593
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Health Information and Quality Authority. (2016). National standards for residential care settings for older people in Ireland. Retrieved from https://www.hiqa.ie/reports-and-publications/standard/current-national-standards-residential-care-settings-older-people
Health Service Executive. (2006). Report of the high level group on health care assistants regarding the implementation of the health care assistants programme. Retrieved from https://www.hse.ie/eng/staff/resources/hrstrategies-reports/report%20of%20the%20high%20level%20group%20on%20health%20care%20assistants%20regarding%20the%20implementation%20of%20the%20hca%20programme.pdf
Holman, D., Sawkins, N. & Hockley, J. (2011) Experience of use of advance care planning in care homes. In Thomas, K. & Lobo, B. (Eds.), Advance care planning in end of life care (pp. 132–145). Oxford, UK: Oxford University Press.
Holmberg, B., Hellstrom, I. & Osterlind, J. (2019). End-of-life care in a nursing home: Assistant nurses' perspectives. Nursing Ethics, 26(6), 1721–1733. https://doi.org/10.1177/0969733018779199 doi:10.1177/0969733018779199 [CrossRef]
Irish Hospice Foundation. (2018). Enhancing compassionate end-of-life care in residential care centre. Retrieved from https://hospicefoundation.ie/healthcareprogrammes/ceol
Jameton, A. (1984). Nursing practice the ethical issues. Upper Saddle River, NJ: Prentice Hall.
Jansen, B. W., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfatrick, S. J. & Parsons, C. (2017). Exploring health-care assistants' role and experience in pain assessment and management for people with advanced dementia towards the end of life: A qualitative study. BMC Palliative Care, 16(1), 6. https://doi.org/10.1186/s12904-017-0184-1 PMID: doi:10.1186/s12904-017-0184-1 [CrossRef]
Kaasalainen, S., Brazil, K. & Kelley, M. L. (2014). Building capacity in palliative care for personal support workers in long-term care through experiential learning. International Journal of Older People Nursing, 9(2), 151–158. https://doi.org/10.1111/opn.12008 PMID: doi:10.1111/opn.12008 [CrossRef]
Kortes-Miller, K., Jones-Bonofiglio, K., Hendrickson, S. & Kelley, M. L. (2016). Dying with Carolyn: Using simulation to improve communication skills of unregulated care providers working in long-term care. Journal of Applied Ger-ontology, 35(12), 1259–1278. https://doi.org/10.1177/0733464815577139 PMID: doi:10.1177/0733464815577139 [CrossRef]
Malik, M. & Chapman, W. (2017). Education and training in end-of-life care for certified nursing assistants in long-term care. Journal of Continuing Education in Nursing, 48(2), 81–85. https://doi.org/10.3928/00220124-20170119-09 PMID: doi:10.3928/00220124-20170119-09 [CrossRef]28135382
Maslach, C. & Leiter, M. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry, 15(2), 103–111. https://doi.org/10.1002/wps.20311 doi:10.1002/wps.20311 [CrossRef]27265691
McClement, S., Lobchuk, M., Chochinov, H. & Dean, R. (2010). "Broken covenant": Healthcare aides' "experience of the ethical" in caring for dying seniors in a personal care home. Journal of Clinical Ethics, 21(3), 201–211.21089989
McClement, S., Wowchuk, S. & Klaasen, K. (2009). Caring as if it were my family: Health care aides' perspectives about expert care of the dying resident in a personal care home. Palliative & Supportive Care, 7, 449–457. https://doi.org/10.1017/S1478951509990459 doi:10.1017/S1478951509990459 [CrossRef]
McDonnell, M. M., McGuigan, E., McElhinney, J., McTeggart, M. & McClure, D. (2009). An analysis of the palliative care education needs of RGNs and HCAs in nursing homes in Ireland. International Journal of Palliative Nursing, 15(9), 446–455. https://doi.org/10.12968/ijpn.2009.15.9.44257 PMID: doi:10.12968/ijpn.2009.15.9.44257 [CrossRef]19957455
Moher, D., Liberati, A., Tetzlaff, J. & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta analyses: The PRISMA statement. PLoS Medicine, 6, e1000097. https://doi.org/10.1371/journal.pmed1000097 doi:10.1371/journal.pmed.1000097 [CrossRef]
Nochomovitz, E., Prince-Paul, M., Dolansky, M., Singer, M., DeGolia, P. & Frank, S. (2010). State tested nursing aides' provision of end-of-life care in nursing homes: Implications for quality improvement. Journal of Hospice & Palliative Nursing, 12(4), 255–262. doi:10.1097/NJH.0b013e3181dfd012 [CrossRef]
Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D. & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews. International Journal of Evidence-Based Healthcare, 13(3), 141–146. doi:10.1097/XEB.0000000000000050 [CrossRef]26134548
Phillips, J. L., Davidson, P. M., Jackson, D. & Kristjanson, L. J. (2008). Multi-faceted palliative care intervention: Aged care nurses' and care assistants' perceptions and experiences. Journal of Advanced Nursing, 62(2), 216–227. https://doi.org/10.1111/j.1365-2648.2008.04600.x doi:10.1111/j.1365-2648.2008.04600.x [CrossRef]18394034
Preshaw, D. H. L. (2017). Ethical issues experienced by healthcare workers providing palliative care in nursing homes: A mixed methods study [doctoral thesis]. Queen's University Belfast, United Kingdom.
Public Health England. (2018). Statistical commentary: End of life profiles, February 2018 update. Retrieved from https://www.gov.uk/government/publications/end-of-life-care-profiles-february-2018-update/statistical-commentary-end-of-life-care-profiles-february-2018-update
Quality and Qualifications Ireland. (2018). Qualification details: Healthcare support 5M4339. Retrieved from https://qsearch.qqi.ie/WebPart/AwardDetails?awardCode=5M4339
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Sahlberg-Blom, E., Hårsmar, A. & Österlind, J. (2013). Assistant nurses' descriptions of signs of dying among older people in nursing homes. Nordic Journal of Nursing Research, 33(3), 20–24. https://doi.org/10.1177/010740831303300305 doi:10.1177/010740831303300305 [CrossRef]
Shanagher, D. (2011).The experience of health-care assistants in end-of-life care in a continuing care unit [unpublished dissertation]. University of Dublin Trinity College, Dublin, Ireland.
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Temkin-Greener, H., Zheng, N. T., Xing, J. & Mukamel, D. B. (2013). Site of death among nursing home residents in the United States: Changing patterns, 2003–2007. Journal of the American Medical Directors Association, 14(10), 741–748. https://doi.org/10.1016/j.jamda.2013.03.009 PMID: doi:10.1016/j.jamda.2013.03.009 [CrossRef]23664483
Torsney, K. (2010). Impact of participation in team meetings on the stress and coping of lower status nursing employees in long-term care. Stress and Health, 27(3), 256–262. https://doi.org/10.1002/smi.1344 doi:10.1002/smi.1344 [CrossRef]
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Vandrevala, T., Samsi, K., Rose, C., Adenrele, C., Barnes, C. & Manthorpe, J. (2017). Perceived needs for support among care home staff providing end of life care for people with dementia: A qualitative study. International Journal of Geriatric Psychiatry, 32(2), 155–163. https://doi.org/10.1002/gps.4451 PMID: doi:10.1002/gps.4451 [CrossRef]
van Riesenbeck, I., Boerner, K., Barooah, A. & Burack, O. (2015). Preparedness for resident death in long-term care: The experience of front-line staff. Journal of Pain and Symptom Management, 50(1), 9–16. https://doi.org/10.1016/j.jpainsymman.2015.02.008 doi:10.1016/j.jpainsymman.2015.02.008 [CrossRef]25701690
Waskiewich, S., Funk, L. M. & Stajduhar, K. I. (2012). End of life in residential care from the perspective of care aides. Canadian Journal on Aging, 31(4), 411–421. https://doi.org/10.1017/S0714980812000360 doi:10.1017/S0714980812000360 [CrossRef]23088799
Winchester, T. A. (2003). Teaching communication skills to nursing home certified nursing assistants. Geriatric Nursing, 24(3), 178–181. https://doi.org/10.1067/mgn.2003.47 PMID: doi:10.1067/mgn.2003.47 [CrossRef]12813433
Wren, M. A., Keegan, C., Walsh, B., Bergin, A., Eighan, J., Brick, A. & Watson, D. (2017). Projections of demand for healthcare in Ireland, 2015–2030: First report from the Hippocrates Model. Retrieved from https://www.esri.ie/publications/projections-of-demand-for-healthcare-in-ireland-2015-2030-first-report-from-the
Young, A., Froggatt, K. & Brearley, S. G. (2017). 'Powerlessness' or 'doing the right thing': Moral distress among nursing home staff caring for residents at the end of life: An interpretive descriptive study. Palliative Medicine, 31(9), 853–860. https://doi.org/10.1177/0269216316682894 PMID: doi:10.1177/0269216316682894 [CrossRef]28659023
Zheng, N. T. & Temkin-Greener, H. (2010). End-of-life care in nursing homes: The importance of CNA staff communication. Journal of the American Medical Directors Association, 11(7), 494–499. https://doi.org/10.1016/j.jamda.2010.01.006 PMID: doi:10.1016/j.jamda.2010.01.006 [CrossRef]20816337
Ms. Cronin is Lecturer and PhD Student, Dr. McCarthy is Senior Lecturer, Healthcare Ethics, and Dr. Cornally is Senior Lecturer, Catherine McAuley School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Una Cronin, RGN, MSc, Lecturer and PhD Student, Catherine McAuley School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Cork, T12AK54, Ireland; e-mail: unacro96@gmail.com.
Received: May 03, 2019
Accepted: August 09, 2019
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Website: As well as providing downloadable practitioner and parent resources (session plans, parent handouts etc), our practitioner log-in areas contain guidance on getting going with Peep delivery in a range of contexts. We also share case studies on our 'public' webpages, illustrating different ways that the Programme is being used.
We have two e-newsletters, sent alternately every few weeks. We automatically add Peep-trained practitioners and managers to both lists, as part of our post-course support, but you can unsubscribe at any time from the bottom of the newsletter.
Peep Postings is for Peep-trained practitioners and their managers, focusing mainly on ideas and updates that support your Peep delivery. Our Peeple Newsletter focuses more generally on working with families to support the home learning environment, and anyone can sign up.
Access to both the log-in website and the newsletters is included in the price of LTP and Antenatal training.
The experience of our own practitioners and the many we've trained around the UK and beyond – not to mention thousands of Peep families – tells us that the LTP is engaging, easy to use and makes a real difference to parents' understanding about how to help their child's development.
However, when people get back to work they'll have additional questions, which will vary depending on their level of experience, confidence and knowledge in working with parents and children together, the sector they work in, the families they work with, etc. You're welcome to phone us with quick questions.
You can also book implementation/ delivery support session/s with one of our trainers/mentors, which we'll tailor to the needs of your staff. These can be held via skype or in person. They can be useful soon after training, to help practitioners get going, or as a follow-up/ refresher a few months later. Either way, they contribute to practitioners' CPD and help quality assure programme delivery.
Delivery support sessions fast-track and can extend what practitioners would learn for themselves, drawing on the trainers' in-depth Peep knowledge and experience to help deal with any challenges or questions. You might have a question about recruiting or engaging families, or managing a session with parents and children together - especially if you're used to working with just parents or just children, and are suddenly faced with a bunch of roaming two year olds and very quiet or very talkative parents...! Whatever your questions, there's a very good chance we will have come across them before, and will be able to discuss some useful approaches with you.
Contact us on 01865 397976 or training@peeple.org.uk to discuss potential content and costs.
Some organisations and local authorities have their own Peep co-ordinators or 'champions' who can provide on-going support to colleagues as part of their role. In our log-in Members Area we've provided some tips on establishing this, drawing on the experience of those already doing it.
We share regular tips, ideas, links and updates (for parents as well as practitioners) via Twitter, Instagram and Facebook - and have started using the hashtag #PeepIdeas, to make them easier to find. We also love to hear about what parents and practitioners are doing. There's absolutely no pressure to include identifiable photos of children. Social media gets a (deservedly) bad press sometimes – but it also has lots of supportive communities - such as our @PeepleCentre pages - especially helpful for anyone who is feeling isolated.


I am not sure what you are saying ! But if you have a problem with your transaction submit a message with your transaction details(TXID) at: support@ark.io and someone from our technical staff will help you !
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As a parting gift at the end of one of my projects, I wanted everybody to walk away with their list of personal strengths.
Not just a list that I made up, or their own list, but a list of strengths through the eyes of the team.
I wanted everybody to know exactly how the other team members valued them.
I wanted each person to have a new lens on their strengths that they could carry forward for their future adventures.
I'm a fan of focusing on strengths, but part of that means knowing what your strengths are, as you see them, and as others see them. I know too many people with hidden talents, simply because they just don't know how valuable their skills and strengths are to the situation or to other people.
I kept the process simple. I sent an email to my distributed team around the world, and then compiled the results, and shared with the team. It was nothing fancy, but it meant a lot to each person on the team because it was real.
… send me 3 unique strengths for each person, you've seen demonstrated during the project.
Framing out new areas, new chapters, guide structure, etc. So that the team can follow behind.
Always knows what he wants. Driven by a vision.
Does a good job with the tasks assigned to him.
Starting documents. Getting something going.
Knows how to express practice in words.
Frames crispier sentences from long-running paragraphs.
More or less knows/expects a given outcome from a task.
Gets stuff done one way or another.
Precise. Doesn't like beating around the bush.
Wants to be involved in everything.
Some people were surprised by the strengths that others saw in them. Some were deeply touched. Everyone felt stronger with a clear picture of what they brought to the table and how they were valued for their contribution.
Would you take your strengths listed there and compare that to another list somewhere of strengths found through other means? I'm just wondering if you'd aggregate the data rather than leave things in separate piles. I could see it being useful to have that feel good moment of thinking of how members of the team see each other and can know what kinds of things to either keep those traits that resonate with them or work on areas that weren't as noticed.
For example, I've often been called a smart person, someone that is almost always thinking. For me, this is just as natural as breathing to have my mind be fed whatever is around and process away. I enjoy being that knowledgeable person but my next challenge is working on how to influence people which is a bit more challenging for me but does seem to be a logical step.
We sometimes fail to see our own strength. Others can pick them up more easily and it makes our day brighter when someone inform us about our own strengths.
That's a wonderful gift to give to your team. We all need to know how we are viewed in other people's eyes. It helps us get a better understanding of our selves. I like how someone called you visionary. I can see that very much in how you run this blog.
@ JB — The short answer is, I leave things in separate piles, but I look for patterns and trends. Personally, I treat it as another source of input and I look for surprises or reminders or blind spots. For example, the fact that somebody valued me for "Making decisions quickly and efficiently" tells me that might be an important distinction compared to other project leaders they've worked with.
@ Vincent — You're right. In fact, it took one of my close friends to point out a strength that I completely over-looked and undervalued, that turned out to be one of my most important assets.
@ Karl — It's the gift that keeps on giving. It's priceless and yet, it costs nothing more than a brief exercise. Thank you for your kind words.
Powerful exercise, I can imagine how empowered everyone felt after getting their results.
"Always knows what he wants. Driven by a vision." I can so see that in you too, JD.
Good insight to find the strengths amongst the team members. A Project manager should know this to make the project successful. As each individual is different and is perfect in it's own way. Sometimes team members are not aware about their hidden talents and such exercise helps to find hidden talents.
I love the quote…that by itself is outstanding. The exercise reminds me of an exercise I did years ago at a church workshop. One person sat in the middle of a circle, the others in the circle expressed out loud the strenghts of that individual, the leader wrote the strengths down on a big sheet of paper and gave it to the person. Each person in the circle took a turn being in the middle. I'll never forget that day.
Being one of 10 kids I didn't get a lot of attention. I believe I was affirmed more in that one day than I had been in my 30 years.
This is very powerful when done with a family as well.
@ Lana — Powerful indeed. Thank you!
Hi JD .. we hear what others say, but receive a different message .. the message we think we hear .. and that must be true for our strengths and weaknesses .. because weaknesses can be strong sometimes.
I love your 'very vocal' strength .. I can hear you leading the conversation and discussion along – as you have a very clear vision of the areas of your life as seen via this blog.
Tess' experience must have truly impressed .. and working together -we do so much better as a team and helping each other.
@ Hilary — It's a beautiful reminder that value is in the eye of the beholder. It's also a reality check that the context or situation can really change what's a strength vs. weakness. Have a great weekend, too!
So true. For many people it's a revelation to hear that they have strenghths. And we all have them. It is sad though that frequently we don't know, or what's more usual, we don't believe in our own strenghths. I wonder whether this is due to some conditioning in early childhood. We seem to be so critical of ourselves that we lose sight of what's good about us. Let's celebrate what we are.


text:
USA-Iran Men's World Cup Player Ratings
by Mike Woitalla on Nov 29, 7:43 PM
The USA celebrated its first victory of the 2022 World Cup and is headed to the knockout stage.
USA-England Men's World Cup Player Ratings
by Mike Woitalla on Nov 26, 12:32 AM
The USA remained undefeated at the 2022 World Cup with a scoreless tie against the Group B's top seed.
USA-Wales Men's World Cup Player Ratings
The USA scored wonderfully and conceded foolishly in its World Cup opener -- a 1-1 tie with Wales.
USA-Germany Women's Friendly Player Ratings
by Mike Woitalla on Nov 13, 10:34 PM
The USA recovered from a 1-0 deficit and a miserable first-half performance to beat Germany, 2-1, in New Jersey on Sunday.
USA-Germany Women's Friendly Game Report
A tactically savvy German team beat the energetic but imprecise USA, which is now on a three-game losing streak.
Watch: Sydney FC keeper Andrew Redmayne beat from way out twice in a week

redpajama_set_name: RedPajamaCommonCrawl


There is a price to pay to have the media run investigations, seek the truth and speak freely and England is here to prove it after a failed bid to host the 2018 World Cup. While the loss was mostly blamed on a poor communications strategy, the ongoing investigations and published pieces on FIFA by local publications have played a strong part in the decision.
England lost in the very first round yesterday after getting only two of the 22 FIFA executive committee votes and watched Russia win instead. Eulogy chief executive Adrian Brady criticised the England 2018 bid's PR strategy, saying it should have thought about a 'longer-term campaign based on the power of the collective voices of the football-mad English public'.
'A campaign which emphasised the rewards for the average member of the public and in which they were seen as true spokespeople – with a real personality marshalling and leading them throughout the process – may have resulted in better communication on the factual side and better leeway with delegates on the emotional side,' said Brady.
But he also added that the BBC's Panorama programme on FIFA corruption broadcast on Monday and the Sunday Times investigation into the ethics of FIFA members were 'undoubtedly related' to the defeat.
While this is bad news for England, it is also quite a PR problem for FIFA as well. They have just proven the world they discourage any impartial analysis of how they do things, retaliating harshly after any sign of criticism or accusation.


text:
Q: How to reach the desired Non functional requirements im new to perf testing,i have to run some performance tests and have already created the scripts and infra- running distributed testing with gcp Vms
i have been given the the nfrs buti should use minute wise data (transactions done in a minute ) for the load
e.g  this are the active users and bets placed per minute,i have minute data for about 2 hrs

how can one configure jmeter to the minute-wise data,i did the conversion to get the hourly and then distribute the load concurrently  but been told that is incorrect.

A: Take a look at Constant Throughput Timer it allows specifying the desired load in terms of number of requests per minute

Be informed of the following:

*

*Constant Throughput Timer can only pause the threads in order to limit JMeter's Samplers execution rate to the desired number of requests per minute

*Despite word Constant it its name it doesn't have to be "Constant", you can put a JMeter Variable or Property into the "Target Throughput" field and amend it according to your workload model as required in the runtime.

redpajama_set_name: RedPajamaStackExchange


Fitball or gymnastic ball has long been a special place in fitness training. It is easy to use, and exercises with a gymnastic ball effectively affect all muscle groups. Pregnant women, people who want to adjust their figure, just sports fans can use fitball in their training. After all, the ways of using it and the set of exercises directly depend on the purpose of training.
Great slimming shell In the process of training on fitbole it is necessary not only to work out the necessary group of muscles, but also to keep the balance. And this means using other muscles, respectively, to load the body more and burn more calories.
Effective work of the muscles of the cortex Muscles of the abdomen, back, waist and buttocks work here like a clock.At the same time, not only the visible muscles of the eye are being studied, but also deep ones that did not participate in the standard training.
Development of many abilities of the organism Coordination of movements, the vestibular apparatus, flexibility and plasticity – lessons on the ball develop all these skills. Even simple elements develop a sense of balance and balance.
Delicate work of the back Exercises on the gymnastic ball for the back safely strengthen her muscles.The loin is not loaded, the traumatic stress on the back is minimal. Fitbol is even recommended as a set of exercises that can relieve pain in the spine: the spinal column is unloaded, the posture is improved, the intervertebral discs are regenerated.
Soft load on the legs Gymnastic ball is suitable for recovery after injuries of the lower limbs, it does not hurt with varicose veins and injured knee and ankle joints.
Availability Children and adults, elderly and pregnant, overweight and far from sports – a gymnastic ball is available to absolutely everyone.
In addition, exercises on the gym ball diversify training, improve mood, relieve stress. Only this shell contributes to the harmonious work of the vestibular, motor, tactile and visual apparatus.
As a set of exercises with a weight-loss fitball designed to reduce body weight, circular training is perfect. The elements here are constructed in such a way that they allow one to work through all the muscle groups aimed at getting rid of excess calories. The effect of training is also that there is no rest between the elements.
Lifting of the pelvis. Lie down on your back and put your feet on the ball. Raising the pelvis, slowly roll the ball to yourself. At the maximum point, we linger for a few seconds. We do ten repetitions. Here the buttocks, legs, waist and press work.
Slopes. Clutching the ball between the legs, we lay on our backs. We lift feet together with fitball. Alternately, we tilt the legs in different directions. The top of the body should remain on the floor. Twelve repetitions will be enough. The same muscle groups are involved as in the first element.
Twisting lying. We kick our feet on the ball and pinch it with them. Put your hands under your head. Holding the fitball, we pull the knees to the stomach. By the end of the twelfth repetition, the press should literally burn.
Push ups. We do usual push-ups from a floor, legs thus having laid on a ball. A dozen replays will work perfectly hands.
Push-ups sitting. Continue the load on the hands – connects the triceps. Squatting on the edge of the fitball, leaning behind him with his hands. We begin slow squats. Also need 10-12 repetitions.
Tip # 1! To avoid rolling back the ball, you can lean it against the wall.
Raising the legs. We pass to the buttocks and legs. Lay down face to the floor, the palm rest on the floor, and put our ankles on the ball. We begin the slow alternate lifting of the legs. Each limb should be divided into fifteen repetitions.
Twisting lying with his back on the ball. We lay down on the ball, arms crossed on the chest. We begin the slow ascents to the sitting position. For ten repetitions will have time to work press and a loin.
Tip # 2! To keep the balance, you can roll back slightly when lifting.
Such circles it is desirable to make three, resting between them at a minimum. This set of exercises on the gym ball will strengthen all the muscles necessary to maintain the flawless shape of the skeleton.
Exercises with a gymnastic ball for the spine are aimed at aligning the spinal column, increasing its flexibility, strengthening the dorsal muscles and preventing curvature. The complex will not only relieve tension and strengthen muscles, but also increase the mobility of the joints.
Movable hip joints. Sit down with a flat back on the ball. We roll on the fitball in different directions and back and forth, describe the hips circles in different directions and begin to gently jump on the ball. For everything about everything – five minutes.
Stabilization. Remain sitting on the ball with arms spread apart. We lift the left leg and begin to jump on the ball and roll on it in different directions. The right leg will act as a stabilizer. We change the leg.
Extensors of the spine. We lie down on the ball, stretching our arms at the chest level. Straight feet rest against the wall. On inhaling, lifting the thorax, we open. At the same time we squeeze the blades and we raise the arms back. On exhalation we lower hands in front of us. The legs remain straight throughout the exercise. Ten repetitions will suffice.
Alignment. We squat down, putting our hands on the ball. Doing an exhalation, we roll the ball away from ourselves. The spine is stretched with the ball as much as possible. With an inspiration we return to the starting position. Also ten times.
Lateral exhaust. We sit down on the fitball. Leaning to the left, stretch out your elongated right arm over your head. Do the same in the other direction. It is important to maximally stretch the lateral muscles. For each side, ten replicates are required.
Training will not only restore the mobility of the back muscles, but also alleviate the pain. In this case, in the early stages of back disease with the help of fitball it is possible to prevent their further development.
Rifts. We take a position as for push-ups: hands rest on the floor with the palms of our hands, we lay our ankles on the ball. Carefully stepping hands, we move on the ball back so that it is under the belly. Always keep your feet straight and do not lower them to the floor. Walking forward, we return to the starting position. Repeat until easy fatigue.
Twisting, sitting on the ball. Sit down on the ball with a straight back. We make small steps with our feet forward so that we lie on the fitball with the blades. Hold your hands behind your head. Twenty repetitions are enough.
Twisting in the bend. Here the work of the oblique muscles is going on. We lay down on the ball with our shoulder blades, bending our knees. The arms are widely spread apart, the feet stand evenly on the floor. We make turns of the whole body first into one, then to the other side. We connect hands at turns. We do fifteen turns in each direction.
Twisting, lifting your legs. We lay down on the back, we throw our feet on the fitball. Putting your hands behind your head, we start to swing the press. Half of the training is done with the legs bent, the other half with the straight ones, since different abdominal muscles work.
Hyperactivity. We train the lumbar department. We lay down on the ball with our belly, clasping our hands behind our head. The body is stretched in a line, our toes rest on the floor. Tilt the body forward down, and then maximally back up. We return to the starting position in one line. We do three approaches ten times.
Fitball is an excellent projectile for pumping the press. The main thing is systematic, and the result will not take long. The gymnastic ball is also good because, working on the muscles of the press, we also connect the buttocks, hips, back and legs to the training.
at a curvature of a backbone.
For all the rest, classes are not only shown, but also useful.
Stitches. They should not be obvious, otherwise during training they can rub the skin and, accordingly, reduce the effect of training.
Material. To avoid allergic reactions necessarily in the product should be present antistatics.
The size. As a rule, balls can be 55 cm, 65 cm and 75 cm. You need to select the size, based on the growth of the person involved. The first fit for growth of 149-164 cm, the second – 164-171 cm, the third – above 180 centimeters.
Tip # 3! When choosing a ball, sit on it from above. Hips with knees should form a right angle with the floor surface.
Function "anti-break". When buying, pay attention to the abbreviations: ABS, BRQ and "anti-break system." This indicates that the ball can not suddenly tear.
The weight. Pay attention to the maximum possible weight that a gymnastic ball can withstand. This is true for the full people and athletes who want to engage in fitball with large weights.
Pump. The presence of the pump in the kit greatly simplifies the procedure for applying the ball. Otherwise, we will have to look for it, because you need to inflate the ball yourself. When inflating, pay attention to the air being distributed evenly.
Exercises on the gym ball can replace any workout. Competently having made a complex of elements, it is possible to pump the necessary groups of muscles, to grow thin or to recover after traumas. Fitball is a universal simulator that will suit any person. And you can study on it at home and at any time. The ball can also be easily taken with you – it is enough to blow it off and put it in a box.


text:
LGBT Trump Supporters Dismayed Over Pride Marches Becoming 'Resist' Events
The month of June, which is celebrated as gay pride month, has been particularly fraught for one subset of the LGBT community: Trump supporters. In Los Angeles the Pride Parade morphed into a Resist March to stand against the administration's policies.
In more than 50 marches across the states, LGBT people and their allies gathered to stand in solidarity against the Trump administration over the weekend.
In Washington, D.C., people gathered in droves. Troy King, a 47-year-old gay man from Atlanta, marched to continue to pressure politicians to stand up for his community's rights.
"I'm not proud; I'm just gay," he said.
Corey Williams, a lesbian woman from D.C., smiled on the sidelines with her dog, Boogie. She said she was happy to see Pride returning to its roots in protest.
But the month of June, which is celebrated as gay pride month, can be fraught for one subset of the LGBT community: Trump supporters. That is particularly true this year, as many marches are billed as "resistance" protests against the administration.
'Political' Vs. 'Partisan' Protest
Matthew Craffey, a member of the conservative LGBT group Log Cabin Republicans, lives in Los Angeles, where he leads the local chapter. There, the Pride Parade has morphed into a Resist March to stand against the ideologies of a Trump presidency and how some of the members of the LGBT community fear his potential policies impact their lives.
"I'm not discrediting people who have issues with the Trump administration, but my problem is that the Pride parade has always been political, but it's never been partisan," he said. "So it's a missed opportunity for all of us to have a break from the division and the anger."
Gina Roberts, a transgender woman from Los Angeles who served as a delegate at the 2016 Republican convention, said she was disappointed in the change to the Pride parade.
"There's no way in heck that I would attend LA pride because it's a Resist march," said Roberts. "Instead of celebrating diversity, it's the opposite of what Pride stands for."
But supporters of the Resist movement, like David Stacy, the government affairs director of the Human Rights Campaign advocacy group, said he was frustrated at the thought that this march shouldn't be partisan.
"Pride has always been a protest movement and a Resist movement and a challenge to the status quo," Stacy said.
Other LGBT activists on the left, like GLAAD CEO Sarah Kate Ellis, agree. She said the plans for over 50 "resistance and equality marches ... symbolizes a community that feels under attack. Pride started as a resistance march back in the '70s. We're going back to our legacy: When we're being targeted, when we're being attacked, we're going to go to the streets and speak out."
So what does that mean for the members of the LGBT community who voted Trump and don't want to resist his administration?
'We Exist'
Exit polls from NBC News and elsewhere showed that Trump received 14 percent of the LGBT vote against Hillary Clinton's 78 percent. Compare that with Romney's 22 percent in 2012, McCain's 27 percent in 2008, and George Bush's 23 percent in 2004.
According to the Pew Research Center, nearly 9 in 10 LGBT voters rated Trump as "cold" on a "feeling thermometer," and 9 percent found him "warm" or "somewhat warm."
But LGBT supporters of the president find this hard to believe. They cite the difficulty of not only coming out as LGBT but also coming out as a Republican.
"The beauty of a secret ballot is no one is going to know who you vote for except you," said Charles Moran, a gay Republican who voted for Trump. He added, "[LGBT] people are shamed into lying that they didn't vote for Donald Trump [when they did]."
Other Trump-supporting members of the LGBT community have echoed Moran's opinions, including Gays for Trump President Peter Boykin, who suspects that Trump got closer to 25 percent of the LGBT vote.
"We exist. ... We're not some little small minority," he said. "I'm pretty damn sure there are more gays who voted for Trump but won't admit it."
Some supporters say they feel they're openly shamed for their political opinions — at times more than they're shamed for their sexual orientation.
"Generally, in 2017, it's a lot easier to be openly gay than to be openly Republican," said Vincent Foster, president of the Miami chapter of Log Cabin Republicans.
'LGBTQ Is Not A One-Lane Highway'
One theme echoed across Trump-supporting members of the LGBT community who spoke with NPR: They define themselves by other identities and values before their sexual orientation. And they don't think the members of their community on the Democratic side feel the same way.
"First of all, one of the distinctions I make about a lot of Republican LGBT members is that we tend to identify ourselves as Americans ... and then we're patriots. And we happen to have this feature where we're gay," Gina Roberts of Los Angeles said. "That's kind of the biggest difference I can see between the two sides."
Roberts said LGBT people voted for Trump for the same reason straight people did: He was their favorite candidate, not in spite of his stances of social issues, but because of them.
But GLAAD's Ellis doesn't think voters can parse out stances of social issues and separate them from any of the other issues. She said no issues can be isolated from the LGBT community.
"If you care about employment, and you could get fired because you're LGBT, it's an employment issue," Ellis said. "At every intersection being LGBTQ is not a one-lane highway."
And many conservative members of the LGBT community have similar lines of thoughts. They just don't see it as a black-and-white issue.
"Being a gay Republican, I have to ask, 'How much I am going to have to sacrifice my equality agenda with backing up my candidate?' And the good thing about Trump is that I didn't have to do that," Moran said. "I realized that he was the type of candidate the Republican Party needs, and his record was quite good."
Moran was referring to Trump's business record with hiring members of the LGBT community when he first bought Mar-a-Lago; Trump was believed to be the first club owner in Palm Beach to admit an openly gay couple, as the New York Times has reported.
Tracking forward, some LGBT voters, like Vincent Foster, weren't positive if that was enough to sway them to his side — until the Pulse night club shooting in Orlando one year ago.
"In the aftermath of the Orlando radical terrorist events, his words of acceptance to the LGBT community as a candidate, was when I knew I was going to vote for him," Foster said. "We need better vetting, and we need to increase our FBI abilities and resources. Especially to the LGBT community ... we were specifically targeted. We can't afford to let in everyone. If you want to help a refugee, help LGBT homeless youth."
The Pulse shooting shook the entire community. And for a few members, it made them wish the U.S. was more aggressive in the war against terrorism.
"The Orlando Pulse night club killing opened a lot of things," said George Gramer, Colorado's Log Cabin president.
On the anniversary on Monday, Trump tweeted in remembrance of the victims.
'A Disservice To This Movement'
Overall, many of these voters say they aren't ignoring their identity in the LGBT community as a trade for conservative values. Rather, they say, they align.
"LGBT people should have a real choice in being able to vote for either party and feel good about it," Craffey of Los Angeles said. "We should each be fighting to make our side better. We're just doing it in different ways and from different perspectives. I think in my opinion, you get a lot more accomplished from engaging than resisting. So I'm going to engage the administration who has been willing to engage with us."
But Craffey doesn't think the other side of politics necessarily agrees with him. He said he feels ostracized by the rest of the LGBT community, and that makes it more difficult to work together on the policies they do agree on.
"I knew I was a Republican before I knew I was gay," Craffey said. But he said he never felt uncomfortable with the Republican Party after coming out as gay. "If we are a community who celebrates diversity, that has to include political diversity as well. I'm fighting as much for my friends on the left ... as I am for the people in my group and myself."
Trump-supporting members of the LGBT community said they're trying to be part of both groups, but the partisanship that has taken over politics and the politicization of their identities has made that rather difficult.
"We have values that promote equality," Moran said. "I believe in traditional family values, but that includes my LGBT family. There is no gay perspective on the environment or education. ... Just because I sleep with a man and have a different family doesn't mean I'm any less of a conservative. And now I have to convince the left that I'm gay. For the community on the left to sit there and not treat us equality and not respect our belief is a disservice to this movement."
What does the community on the left think?
"The president has made a handful of statements saying he's going to be good for LGBT people, but there's been nothing to back that up," Stacy of the Human Rights Campaign said. "I understand people ... saying, 'I'm glad he's not going out and bashing us,' but that's an incredibly low bar to set in 2017. ... If you're continuing to think the president will be good on LGBT rights, you really have your blinders up."
Christianna Silva is an NPR Digital News intern.
Christianna Silva
See stories by Christianna Silva


What Is the Difference between a LG Washer Dryer Combo and a Regular Model?
One question people have when shopping for new laundry appliances for their home is the difference between an LG washer dryer combo and an LG conventional side-by-side or stackable model. The primary difference is a combination model includes both the washing and drying features in a single appliance. It also combines optimal capacity and energy-saving efficiency to provide you with clean clothes with an appliance that takes up less space.
LG washer dryer combo appliances are fairly new to the United States market, but have been readily available for years in international markets. This is due to the fact they use half the water, energy and space of conventional appliances. There are other advantages besides these. Not only are you able to have in-home laundry without taking up much space, but also to have a machine that is easier to maintain because there are fewer parts. Further, the LoDecibel™ Quiet Operation found in LG combination models keeps your laundry area from sounding like you are at a laundromat. Additionally, you have the flexibility to customize your wash cycles based on the size and weight of each load, with the LG SenseClean technology for optimal energy-efficient performance.
One of the best features of a combination model is it does not require any dryer venting in your home. Thanks to advances in drying technologies, dryer vents are no longer required. As a result, you are able to place your new LG combination appliance in any area of your home, as long as you have access to hot and cold water lines, a discharge drain, and a 110 V three-prong outlet, like in your kitchen.


Unforgettable experiences in unforgettable places.
Promoting tourism in Peru by innovative ways of offering tourism activities, accommodation for the national and international tourists.
Providing the best customer service and being part of your memories.
Contributing to improving the Peruvian business in hosting services, promoting respect for men, nature and respect for a dignified life.
Helping people with financial resources, especially for the children in the urban areas of Cuzco, focused on education, health. With your staying you are making the lives of these children better.
In our Hostel in Cusco it is to give the best service to all our guests as a specialist in the good service, and therefore consider Peru as the best tourist destination in the world, thanks to the attractions that this has.
We are people who want people !
These two commitments are the reasons that inspire and strengthen us because we believe that there is nothing greater than being helpful for the most needy.


Propagation is an important part of a growing operation. Healthy, strong 'propagated' plant material grow into strong plants whether by seed, cutting or Tissue Culture. Propagation involves significant climate control and manipulation with bottom heat, misting and humidification and cooling of the environment.
The growing media requires quite precise formulation for air porosity and waterholding to minimise damping off. Supplying seedling mixes, misting and specialised formulations for propagation houses has become an integral part of Grower Technology business and expertise.


Click here to view catalog of options that can be applied to most door styles.
This picture shows details of the design options you can choose on a standard raised panel cabinet door, such as our CRP-10. The various choices that you can make are shown below.
On many cabinet door styles, you may choose how you want the outside edge to look. These profiles are some of our popular selections. If you don't see an edge profile that you want, please contact us.
The framing bead is the term used to describe the inside edge of the frame. For cabinet doors that don't have a pre-defined framing bead, these are the options.
The panel raise determines the slope used from the edge of the panel (that fits in the frame) to the center of the panel. For cabinet doors that don't have a pre-defined panel raise, these are some of the options. If you don't see an edge profile that you want, please contact us.
The Cabinet Authority is among the most respected cabinet door and RTA cabinet stores on the web, designed as the best place to learn about cabinet doors and RTA cabinets, shop for cabinet doors and RTA cabinets, and buy cabinet doors and RTA cabinets. While providing the best quality of any provider of discount RTA kitchen cabinets and cbinet doors, The Cabinet Authority also provides the best service before, during and after your cabinet door or RTA cabinet purchase. Visit www.cabinetauthority.com to get high quality, ready to assemble kitchen cabinets (sometimes called discount kitchen cabinets or wholesale kitchen cabinets or DIY kitchen cabinets) along with custom cabinet doors and drawer fronts -- all made in the USA. The Cabinet Authority provides unbeatable customer service, friendly and knowledgeable sales support staff for all your cabinet door and ready to assemble (RTA) cabinet needs. The Cabinet Authority is the place to go if you are looking for discount, high-quality, ready to assemble (RTA) products online. Along with being the best place to shop for cabinet doors and RTA Kitchen Cabinets, The Cabinet Authority offers great quality wood mouldings, refacing materials and accents to go with your new RTA cabinets or your existing cabinets. No other RTA cabinet provider has a better selection of RTA cabinets and accessories than The Cabinet Authority. Contact The Cabinet Authority anytime to work with a knowledgeable RTA Cabinet account manager.


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Q: Connecting to the JMX Agent Programmatically in Java 9 I need to connect to JMX agent programmatically using Attach API (loading agent at runtime if necessary) as shown in example here. This worked fine in Java 8 but doesn't work in Java 9 since there is no management-agent.jar in the lib folder anymore:
String agent = vm.getSystemProperties().getProperty("java.home") +
   File.separator + "lib" + File.separator + "management-agent.jar";

Could you please advice what is the right way to do that in Java 9?
Thanks in advance,
Vadim

A: Yes, management-agent.jar has been removed (see release note). If you looking to start the management agent then look at the new startManagementAgent and startLocalManagementAgent methods in com.sun.tools.attach.VirtualMachine.
The "Setting Up Monitoring and Management Programmatically" section in the JDK 9 docs needs to be updated.


That is a very cool shot. I love those intense colours and the beautiful balanced composition.
I love it, it appeals to the biker in me.
A beautiful minimalist picture composition and a good colour contrast. Like it!
Very good abstract composition. Colors too.
what a pleasant blast of colors.. :) great shot!
Not really taking away from the quality of the shot but just fyi...Those 2's are not actually the number of the car. They mean it is second class seating on both the top and bottom levels.


Sarah Lianne Lewis is a Welsh composer whose music often explores instrumental textures and aural architecture of performance spaces. Her main focus is on vocal and chamber music, having worked with juice vocal ensemble through Sound and Music's 'Portfolio' scheme, participating in the Jerwood Opera Writing Programme 2014-15, and working with Silbersee opera and LOD MusikTheatre in Ghent through the European Network of Opera Academies.
She has received commissions from Making Music (2012-13), the Royal Philharmonic Society (2014), Herne Hill Festival (2014), Aix-en-Provence Festival (2015), and Heidelberg Music Festival (2016).
The beginning of 2016 saw her new work for symphony orchestra, Is there no seeker of dreams that were?, premiered by the BBC National Orchestra of Wales in March, and subsequently broadcast on BBC Radio 3 and BBC Radio Wales. She attended the Heidelberg Music Festival as a Composition Fellow in April 2016, and is currently writing a work for Piano 4-Hands, based on the 62 moons of Saturn, extracts from which were premiered at the Cheltenham Music Festival in July 2016 by Mantras Piano Duo.


text:
'Norwegian Prima' – a high-end hotel
david 2022-09-12T13:32:38+00:00 September 12th, 2022|Interior Design|
Recently delivered 'Norwegian Prima's' interior spaces offer a break from traditional cruise ship aesthetics to create an ambience more reminiscent of a modern, high-end hotel, Oslo-based architecture and design company, YSA Design claimed.
Recently christened in Reykjavik, Iceland following her completion at Italy's Fincantieri Marghera Shipyard, 'Norwegian Prima' is the first of Norwegian Cruise Lines' (NCL) new 'Prima' class cruise vessels.
The 294 m long cruise ship can accommodate up to 3,099 guests.
YSA Design was responsible for the design of several spaces on board, including two dining areas, the forward and aft public stairs and lift lobbies, plus the public toilets.
"For this first-in-class vessel, we departed from the conventions of the cruise-ship aesthetic to create a fresher look and feel based on the flair of a modern, luxury hotel," explained YSA Design senior interior architect and project lead, Fabiana Vale Dornelas. "Our design approach is characterised by elegant and contemporary elements, including clean lines, reflective surfaces, stone finishes and metal detailing."
An example of this approach is the New York-style restaurant located on Deck 7 aft. Named after the river that separates Jersey City from Manhattan, Hudson's is an upmarket venue offering 280-deg views from the stern of the ship.
Described as an open, airy space, the venue is decorated in contrasting bright and deep-blue tones, with golden finishes reflecting the natural light that enters through sloping floor-to-ceiling windows. Adding colour and texture are the velvet upholstery and the organic, abstract motif of the carpet, while crystal-embedded gold-leaf chandeliers cast intricate patterns of light on the ceiling.
Aft of the back stairs on Deck 8 is The Local, a casual venue comprising a starboard bar and a restaurant on the port side. In the bar, cool blue lighting from behind the counter contrasts with the warm, earthy tones of the seating area, and multi-coloured mosaic tiling and wood-panel flooring converge at straight and diagonal angles in the centre.
Sharing the warm palette of the bar seating area, the restaurant brings together boldly coloured upholstery with subdued wood and brick finishes. The entire venue is unified by a dark, semi-open ceiling partially illuminated by contemporary string lights.
"The idea with The Local was to offer a relaxed environment for informal dining and socialising," Dornelas explained. "The space is vibrant and quirky with a multi-cultural twist – the perfect setting for sharing a bite to eat and a drink with friends."
Comprising three lobbies, four lift towers and 14 lifts, the forward and aft public stairs share a consistent look and feel, featuring straight lines, marble flooring, stylish stone finishes with metal detailing and deep-blue tones reflected in the mirror elements and chandeliers.
Spanning lift to lift, the chandeliers form a fluid, wavy shape that appears to change depending on the angle from which it is viewed.
Adjacent to the lobbies are the public toilets, which maintain the modern hotel style. The aesthetic is described as sophisticated and clean, with wooden and stone finishing.
Contributing to the elegant look are a reflective wall with metal inserts, slate floor tiles arranged in an irregular pattern and crystal pendants that produce fascinating reflections. In line with post-pandemic hygiene standards, the integrated sinks include touchless taps, soap dispensers and dryers.


We're all proud desi aren't we ? Lets find out your awesome favorite reasons for being desi ! Make others go crazy with your SWAG.Upload a photo of your desi lifestyle and tell us how much desi you are and Win Ustraa Products.


text:
Sixteen weeks of exercise reduces C-reactive protein levels in young women
Andrea Y. Arikawa, William Thomas, Kathryn Schmitz, Mindy S. Kurzer
Department of Public Health Sciences
Department of Physical Medicine and Rehabilitation
Penn State Cancer Institute
Cancer Institute, Cancer Control
Division of Health Services and Behavioral Research
Purpose: Regular exercise has been shown to protect against breast cancer risk, and one possible mechanism is through a reduction in inflammation. The purpose of this study was to examine the effects of 16 wk of aerobic exercise training on adipokines and inflammatory markers in healthy young women. Methods: Participants were 319 sedentary women aged 18-30 yr, with body mass index of 18-40 kg•m, randomized to an exercise intervention or no exercise for approximately 16 wk. Adiponectin, leptin, C-reactive protein (CRP), and amyloid A (AA) were measured at baseline and after 16 wk. Adiponectin was measured by enzyme-linked immunosorbent assay, and AA, CRP, and leptin were measured by multiplex bead array assays. Results: Exercise significantly decreased CRP levels in the exercise group compared with the control group (-1.41 mg•L in exercisers vs -0.005 mg•L in controls, P = 0.040), and this effect was largely driven by changes in CRP that occurred in the obese exercisers. There was no effect of exercise on levels of SAA, adiponectin, or leptin. There was also no effect of exercise on stress and depression scores. Neither change in percent body fat nor change in fitness influenced the effects of exercise on these inflammatory markers. Conclusions: This study demonstrated that a 16-wk aerobic exercise program significantly decreased levels of CRP in young women, especially in those who were obese. There was no evidence that this effect was mediated by changes in perceived stress, percent body fat, or fitness. These findings suggest that adopting an exercise routine early in life may decrease future risk of breast cancer and other chronic diseases in obese women.
Medicine and science in sports and exercise
https://doi.org/10.1249/MSS.0b013e3182059eda
10.1249/MSS.0b013e3182059eda
Fingerprint Dive into the research topics of 'Sixteen weeks of exercise reduces C-reactive protein levels in young women'. Together they form a unique fingerprint.
C-Reactive Protein Medicine & Life Sciences
Exercise Medicine & Life Sciences
Adiponectin Medicine & Life Sciences
Leptin Medicine & Life Sciences
Amyloid Medicine & Life Sciences
Adipose Tissue Medicine & Life Sciences
Breast Neoplasms Medicine & Life Sciences
Adipokines Medicine & Life Sciences
Arikawa, A. Y., Thomas, W., Schmitz, K., & Kurzer, M. S. (2011). Sixteen weeks of exercise reduces C-reactive protein levels in young women. Medicine and science in sports and exercise, 43(6), 1002-1009. https://doi.org/10.1249/MSS.0b013e3182059eda
Arikawa, Andrea Y. ; Thomas, William ; Schmitz, Kathryn ; Kurzer, Mindy S. / Sixteen weeks of exercise reduces C-reactive protein levels in young women. In: Medicine and science in sports and exercise. 2011 ; Vol. 43, No. 6. pp. 1002-1009.
@article{dabd4a18c7d24183aadbc007a7b3d8dd,
title = "Sixteen weeks of exercise reduces C-reactive protein levels in young women",
abstract = "Purpose: Regular exercise has been shown to protect against breast cancer risk, and one possible mechanism is through a reduction in inflammation. The purpose of this study was to examine the effects of 16 wk of aerobic exercise training on adipokines and inflammatory markers in healthy young women. Methods: Participants were 319 sedentary women aged 18-30 yr, with body mass index of 18-40 kg•m, randomized to an exercise intervention or no exercise for approximately 16 wk. Adiponectin, leptin, C-reactive protein (CRP), and amyloid A (AA) were measured at baseline and after 16 wk. Adiponectin was measured by enzyme-linked immunosorbent assay, and AA, CRP, and leptin were measured by multiplex bead array assays. Results: Exercise significantly decreased CRP levels in the exercise group compared with the control group (-1.41 mg•L in exercisers vs -0.005 mg•L in controls, P = 0.040), and this effect was largely driven by changes in CRP that occurred in the obese exercisers. There was no effect of exercise on levels of SAA, adiponectin, or leptin. There was also no effect of exercise on stress and depression scores. Neither change in percent body fat nor change in fitness influenced the effects of exercise on these inflammatory markers. Conclusions: This study demonstrated that a 16-wk aerobic exercise program significantly decreased levels of CRP in young women, especially in those who were obese. There was no evidence that this effect was mediated by changes in perceived stress, percent body fat, or fitness. These findings suggest that adopting an exercise routine early in life may decrease future risk of breast cancer and other chronic diseases in obese women.",
author = "Arikawa, {Andrea Y.} and William Thomas and Kathryn Schmitz and Kurzer, {Mindy S.}",
doi = "10.1249/MSS.0b013e3182059eda",
journal = "Medicine and Science in Sports and Exercise",
Arikawa, AY, Thomas, W, Schmitz, K & Kurzer, MS 2011, 'Sixteen weeks of exercise reduces C-reactive protein levels in young women', Medicine and science in sports and exercise, vol. 43, no. 6, pp. 1002-1009. https://doi.org/10.1249/MSS.0b013e3182059eda
Sixteen weeks of exercise reduces C-reactive protein levels in young women. / Arikawa, Andrea Y.; Thomas, William; Schmitz, Kathryn; Kurzer, Mindy S.
In: Medicine and science in sports and exercise, Vol. 43, No. 6, 06.2011, p. 1002-1009.
T1 - Sixteen weeks of exercise reduces C-reactive protein levels in young women
AU - Arikawa, Andrea Y.
AU - Thomas, William
AU - Schmitz, Kathryn
AU - Kurzer, Mindy S.
N2 - Purpose: Regular exercise has been shown to protect against breast cancer risk, and one possible mechanism is through a reduction in inflammation. The purpose of this study was to examine the effects of 16 wk of aerobic exercise training on adipokines and inflammatory markers in healthy young women. Methods: Participants were 319 sedentary women aged 18-30 yr, with body mass index of 18-40 kg•m, randomized to an exercise intervention or no exercise for approximately 16 wk. Adiponectin, leptin, C-reactive protein (CRP), and amyloid A (AA) were measured at baseline and after 16 wk. Adiponectin was measured by enzyme-linked immunosorbent assay, and AA, CRP, and leptin were measured by multiplex bead array assays. Results: Exercise significantly decreased CRP levels in the exercise group compared with the control group (-1.41 mg•L in exercisers vs -0.005 mg•L in controls, P = 0.040), and this effect was largely driven by changes in CRP that occurred in the obese exercisers. There was no effect of exercise on levels of SAA, adiponectin, or leptin. There was also no effect of exercise on stress and depression scores. Neither change in percent body fat nor change in fitness influenced the effects of exercise on these inflammatory markers. Conclusions: This study demonstrated that a 16-wk aerobic exercise program significantly decreased levels of CRP in young women, especially in those who were obese. There was no evidence that this effect was mediated by changes in perceived stress, percent body fat, or fitness. These findings suggest that adopting an exercise routine early in life may decrease future risk of breast cancer and other chronic diseases in obese women.
AB - Purpose: Regular exercise has been shown to protect against breast cancer risk, and one possible mechanism is through a reduction in inflammation. The purpose of this study was to examine the effects of 16 wk of aerobic exercise training on adipokines and inflammatory markers in healthy young women. Methods: Participants were 319 sedentary women aged 18-30 yr, with body mass index of 18-40 kg•m, randomized to an exercise intervention or no exercise for approximately 16 wk. Adiponectin, leptin, C-reactive protein (CRP), and amyloid A (AA) were measured at baseline and after 16 wk. Adiponectin was measured by enzyme-linked immunosorbent assay, and AA, CRP, and leptin were measured by multiplex bead array assays. Results: Exercise significantly decreased CRP levels in the exercise group compared with the control group (-1.41 mg•L in exercisers vs -0.005 mg•L in controls, P = 0.040), and this effect was largely driven by changes in CRP that occurred in the obese exercisers. There was no effect of exercise on levels of SAA, adiponectin, or leptin. There was also no effect of exercise on stress and depression scores. Neither change in percent body fat nor change in fitness influenced the effects of exercise on these inflammatory markers. Conclusions: This study demonstrated that a 16-wk aerobic exercise program significantly decreased levels of CRP in young women, especially in those who were obese. There was no evidence that this effect was mediated by changes in perceived stress, percent body fat, or fitness. These findings suggest that adopting an exercise routine early in life may decrease future risk of breast cancer and other chronic diseases in obese women.
U2 - 10.1249/MSS.0b013e3182059eda
DO - 10.1249/MSS.0b013e3182059eda
JO - Medicine and Science in Sports and Exercise
JF - Medicine and Science in Sports and Exercise
Arikawa AY, Thomas W, Schmitz K, Kurzer MS. Sixteen weeks of exercise reduces C-reactive protein levels in young women. Medicine and science in sports and exercise. 2011 Jun;43(6):1002-1009. https://doi.org/10.1249/MSS.0b013e3182059eda