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Wednesday, September 4, 2013

Celebrations of Learned Men: Nibley, Schoolmen, and the Denial of Revelation

John Gee posted an interesting Hugh Nibley quote in a recent blog post.

I have discussed the supplanting of the gospel by the teaching of the schools (in ancient times, that is) in a number of studies, but to show what I mean, one example close to home will suffice. On 23 March 1955, I engaged in a public discussion in Salt Lake with my friend Sterling McMurrin. I closed my rather feeble address with the words, "At this point (i.e., after we have discovered the depths of our own ignorance) we can begin the study of the gospel; there is no further need for waiting around until 'history' can make up its mind." Immediately Sterling (for it was his turn to speak) arose and introduced his own discourse by saying, "now we will hear the real gospel." This brought a round of applause from the university crowd--did they realize what it meant? It was a frank declaration that the celebrations of the learned men and not the utterances of the prophets comprise the gospel. This has been the credo of the Christian schoolmen since the days of Clement of Alexandria: the university--Christian, Moslem, Jewish, or pagan--has its own religion, and the basic tenet of that religion is the denial of revelation." (Hugh Nibley, "Nobody to Blame," CWHN 17: 128-29.)[1]

Sterling McMurrin, of course, was an LDS philosopher often criticial of the church, but still fairly sympathetic to it.[2] Here he forms one half of a classic Nibley construct- the inherent dichothomy between the scholar and the man of god. When institutionalised, such learning becomes a counterfeit gospel, a false priesthood at odds with and fatal to the true gospel.[3]

"You see the point: The scholar and learned divine must necessarily get their knowledge from the written word, and then trouble begins. The prophet, on the other hand, who may well be illiterate, gets his knowledge by direct intercourse with heaven. The orientation of the two is entirely different."[4]

It seems a little inconsistent  for a tenured professor to have held those views, but whatever his beliefs, Nibley was nothing if not sincere. At times he even expressed a more-or-less favourable opinion of scholars.

"Lehi takes his place among the titans of the early sixth century; a seeker after righteousness, a prophet, a poet, a scholar, a man of the world, a great leader, and a founder of nations. A thoroughly typical product, we might add, of 600 B.C. and of no other period in history."[5]

While there is some truth to Nibley's claim that pneumatic authority was marginalised, I. E., that the "lights went out,"[6] I contend that his view misunderstands the medieval philosophical and scholastic traditions. Taken as a whole, each of these three religions- Judaism, Christianity, Islam- revolved around revealed tradition. Revelation was central to each, and scholars for the most part agreed that there was a limit to what could be discovered and grasped by human intellectual effort. Divine revelation bridged that gap between man and God, but the rest could, and, indeed, should, be explored to the fullest extent possible.

The 15th century Karaite authority, Elijah Bashyatchi, stressed that accepting a revealed truth or commandment ought to precede all other inquiries into it.

"The proper thing for every believer in the Law is to receive these ordinances first by tradition, and only afterward, with the help of his divine Rock, to seek the knowledge of the cause for every ordinance, according to its interpretations, particulars, and biblical examples. This is the way of him who desires and longs for moral perfection... If he were to endeavor first to learn the reasons and the biblical examples for every commandment, and accept it by tradition only afterward, he would be like a man who refuses to eat bread until he learns how it was sown, how it was harvested, how it was ground, and how it was baked, and who would consequently go hungry a long time until he shall have learned its causes and beginnings."[7]

The great scholar of esoteric Islam, Henri Corbin, pointed out that for Muslim philosophers, their Greek and Hellenistic counterparts had partaken of revelation, and thus their science was itself a facet of prophetic inspiration.

"The term hikmah is the equivalent of the Greek sophia, and the term hikmat ilahlyah is the literal equivalent of the Greek theosophia. Metaphysics is generally defined as being concerned with the ilahiyat, the Divinalia. The term 'ilm ilahi (scientia divina) cannot and should not be translated by the word theodicy. Muslim historians, from al-Shahrastani in the twelfth century to Qutb-al-Din Ashkivari in the seventeenth, take the view that the wisdom of the 'Greek sages' was itself also derived from the 'Cave of the lights of prophecy'... Philosophical enquiry (tahqiq) in Islam was most 'at home' where the object of meditation was the fundamental fact of prophecy and of the prophetic Revelation, with the hermeneutical problems and situation that this fact implies. Thus philosophy assumes the form of 'prophetic philosophy'... Correspondingly, it is not possible to speak of hikmah in Islam without speaking of mysticism—without speaking, that is to say, of Sufism both from the point of view of its spiritual experience and from that of its speculative theosophy, which has its roots in Shiite esotericism. As we shall see, al-Suhrawardi and, after him, the whole school of ishraqiyun directed their efforts to uniting philosophical enquiry with personal spiritual realization. In Islam above all, the history of philosophy and the history of spirituality are inseparable."[8]

Not only was Islamic philosophical enquiry concerned with a revealed text and tradition, gaining "knowledge by direct intercourse with heaven," was not seen as inimical to the scholastic pursuit. The ishraqi school, a highly influential school of thought in the Muslim world, even considered it the defining feature of acquiring knowledge.

In the Latin West, the attitude of the scholastics to prophecy was complex, but for the famed doctor of the Roman Catholic Church, Thomas Aquinas, revelation still stood at the basis of God's relationship to man.

"Thomas Aquinas expresses in his De ente et essentia the relationship between the Creator and the fallen creature. According to the idea of the analogia entis, an analogy will always exist between God and man. This analogy is based in man’s being created in God’s image, which is expressed primarily in man’s reason, the direct place of encounter between him and God. For Thomas and the entire Scholastic tradition, reason is seen as the umbilical cord between God and man, and yet reason in itself will never sufﬁce to fully understand and know God. Even if the analogia entis teaching expresses that there is and remains an analogy between God and man, it is far more important to acknowledge in this analogy a greater difference: while man and God can meet, this meeting can occur only on the condition that God never can be completely or fully comprehended.
This continued analogy guarantees the possibility that God can lift the veil that lies between himself and man and communicate himself to man. Although before the Fall there was continued openness, after it revelation was required whereby man might commune with God. And if the continued analogy makes continued revelation possible, God’s love makes it necessary. During the entire history of Israel, the prophets are the champions of continued openness and communication between God and man, his instruments through which he seeks to reestablish the broken unity. It is this revealing activity of God’s love that is continued in the vocation of the Christian prophets, whereby Christian prophecy may be seen as the most immediate expression of God’s revealing activity. It is immediate because not only is it a sign of God’s general revealing activity, but it is, in itself, a type of experienced revelation

Here, too, man experiences direct communication from God, and this experience is to culminate in man's ultimate goal- union with God.

"Prophecy is revealing in its mode, inasmuch the prophet considers his or her experience a form of direct communication from God through which God reveals his truths. Second, Prophecy is revealing in its scope, inasmuch as God through the prophet seeks to attain the goal of his activity, namely, to lead man back to his original union with God."[10]

Rabbi Moses ben Maimon, or more commonly in English, Maimonides, was the seminal figure of medieval Judaism. Physician, scientist, religious codifier, theologian, scholar, politician, philosopher, and benefactor of wide-flung Jewish communities, it is hard to exaggerate Maimonides' influence on both his contemporaries and subsequent generations, down to the Judaism of today. Maimonides was also widely read in a Latin translation, where his Guide for the Perplexed with its resolution of the supposed inconsistencies between the Bible and the science of the day in turn influenced the scholastics.

As Abraham Joshua Heschel noted, Maimonides (oft considered the arch-rationalist) was practically obsessed with the idea of prophecy.

"During his youth, he delved into the arcana of prophecy, and his deep thoughts about it became the nucleus of his intellectual and spiritual life. Only this personal motive offers an explanation for the extraordinary centrality of prophecy in Maimonides' philosophy, for the intellectual passion with which he asked himself these questions."[11]

A recent academic study highlighted the centrality of the Torah in Maimonides' thought.

"The prophecy of Moses is distinguished from the prophecy of other prophets in four respects. The most significant of these differences is that “the prophets other than Moses received prophecy in an allegory or riddle, while Moses received his prophecy clearly and lucidly.”
From this description it follows, as Maimonides states, that Moses’ prophecy was rooted in the intellect alone, while the prophecy of the other prophets depended on the human imagination and the senses. Describing the prophecy of Moses in the seventh of his thirteen principles, Maimonides wrote: “There remained no veil he did not rend and penetrate, nothing physical to hold him back, no deficiency, great or small, to confuse him. All his powers of sense and imagination were suppressed, and pure reason alone remained.” Thus, the Law of Moses, the
Torah, is as close to reason, that is philosophy, as any law can be. This closeness leads Maimonides to emphasize, in his legal writings, that halakhah is based primarily on the Torah, rather than on rabbinic deductions. For the same reason, he relies on the philological considerations laid out in the Treatise on the Art of Logic for his interpretation of the Bible for the masses; it is in this way that he can bring their understanding of the biblical text, and particularly their understanding of the nature of God, closer to philosophic truth. Finally, syllogisms listed in the Treatise on the Art of Logic—again philosophic arguments—make it possible for him to show the religious person who has studied philosophy that no contradiction exists between biblical teachings, correctly interpreted, and philosophic truths."[12]

 The Torah's importance for Maimonides stemmed from it being a revealed text, and not only that, but revealed by the highest level of prophecy attainable by man. The talmuds were secondary in importance (though still authoritative) when it came to establishing legal rulings, as the reasoning was a natural, human process and thus inferior to the pure reason of revelation.

There is much more that could be said on the topic, but Nibley's sharp dichothomy between schoolmen and revelation simply does not withstand scrutiny. Not for Islam, not for Christianity, not for Judaism. The university, or the pursuit of knowledge in general, is no more in opposition to the gospel than any other human endeavour could be. It all depends on how we approach it.

[2]As an example, see

[3]Hugh Nibley, Leaders and Managers.
For a critique of another false dichothomy in Nibley's commencement speech, see

[4]Nibley, "Prophets and Scholars," in The World and the Prophets.

[5]Nibley, An Approach to the Book of Mormon, p. 39. Even this positive appraisal was qualified. "Lest we hastily conclude that Lehi was but a typical wise man of his age, and no more, we have but to set up his story and his sermons beside the stories and sermons of his great contemporaries of the East and West. What a contrast! For all their moral fervor, nothing could be less like the inspired utterances of the man from Jerusalem than the teachings of the great Greeks, with their worldly wisdom and their bleak pessimism." An Approach," p. 43-44.

[6]A representative example of Nibley's view on apostasy is found in his "The Passing of the Primitive Church: Forty Variations on an Unpopular Theme," in When the Lights Went Out: Three Studies on the Ancient Apostasy. "The call to repentance of the apostolic fathers is a last call; they labor the doctrine of the Two Ways as offering to Christian society a last chance to choose between saving its soul by dying in the faith or saving its skin by coming to terms with the world. They have no illusions as to the way things are going: the church has lost the gains it once made, the people are being led by false teachers, there is little to hinder the fulfillment of the dread (and oft-quoted) prophecy, "the Lord shall deliver the sheep of his pasture and their fold and their tower to destructions." The original tower with its perfectly cut and well-fitted stones is soon to be taken from the earth, and in its place will remain only a second-class tower of defective stones which could not pass the test... The apostolic fathers take their leave of a church not busily engaged in realizing the kingdom but fast falling asleep; the lights are going out, the Master has departed on his long journey, and until he returns all shall sleep. What lies ahead is the Wintertime of the Just, the time of mourning for the Bridegroom, when men shall seek the Lord and not find him, and "seek to do good, but no longer be able to."
The talmudic pericope on the controversy of the oven of achnay depicts the tension betwen pneumatic authority on the one hand, and the idea expressed in the talmudic dicta "a sage is greater than a prophet," and "prophecy has been taken away from the prophets and has been given to the sages," on the other. Even here, however, the question is nuanced. If God gave the law to his legislators, are they allowed to arrive at their own interpretations, conclusions, and rulings, or not?

[7]Elijah Bashyatchi, Adderet Eliyahu, as quoted in Leon Nemoy, Karaite Anthology: Excerpts from the Early Literature, p. 242.

[8]Henry Corbin, The History of Islamic Philosophy, vol. 1, p. xv-xvi. For example, even the pagan god Hermes Trismegistus was considered to be the prophet Idris, that is, Enoch. This facilitated Muslim adoption of the science in the Corpus Hermeticum. See Kevin van Bladel, The Arabic Hermes: From Pagan Sage to Prophet of Science. Following the term coined by Marsilio Ficino, this concept in Christian thought is generally termed prisca theologia. Rabbi Yosef Shelomo Delmedigo expressed one of the Jewish approaches to this. "Plato's opinions are similar to the opinions of the Sages of Israel and in a few instances it appears that he spoke as a Kabbalist. No fault can be found in his words, and why should we not accept them, for they belong to us, and were inherited by the Greeks from our ancient fathers?" For the fuller quote, and a discussion of the various prisca theories, see Moshe Idel, "Prisca Theologia in Marsilio Ficino and in Some Jewish Treatments," in Michael J. B. Allen, Valery Rees, and Martin Davies, ed., Marsilio Ficino, His Theology, His Philosophy, His Legacy, p. 137-158.

[9]Niels Christian Hvidt, Christian Prophecy: the Post Biblical Tradition, p. 124

[10]Ibid., p. 125.

[11]Abraham Joshua Heschel, Maimonides: A Biography, p. 26. See also the essay on Maimonides in Heschel's Prophetic Inspiration After the Prophets: Maimonides and Others.

[12]Arthur Hyman, "Maimonides as Biblical Exegete," in Dobbs-Weinstein, Goodman, Grady, ed., Maimonides and His Heritage, p. 10.

1 comment:

  1. Wonderful post, Calba Savua. As you know, Nibley's concept of the wide gulf between scholasticism and revelation is informed by his acceptance of the narrative of the Great Apostasy. For him, the lights must go out in order for Joseph Smith to help flip the switch on again. The present predominating skepticism of the intellectual elite (or at least the perception of such) plays into Nibley's story perfectly, and so writers like John Gee can pick up the story and declare Nibley's viewpoint QED.

    It seems to me that, however historically accurate your account may be (and I think it is), the LDS narrative of the Great Apostasy, which provides a raison d'etre for the Restoration, will probably continue for some years to obscure that history or at least demand that the revelatory experience of which these thinkers write be downgraded in significance. So, Christian mystics cannot be prophets in the minds of certain LDS thinkers, or else there would be little need for Smith to restore anything.

    What would be needed for LDS folk to give the proper due to all the great mystics would be a complete reworking of the concepts of apostasy and restoration. This is not impossible, but probably quite a hurdle. Gee, Midgley, Hamblin, and others seem adamant about the inferiority of mysticism, the minimal significance of Freemasonry, and other similar propositions that preserve the standard LDS Apostasy narrative of a vast gulf between the death of the apostles and the First Vision.

    Historical evidence, on the other hand, clearly points to the existence of a comprehensible context for Joseph Smith's religious enterprise. Newer trends in Mormon Studies, the seeds of which were sown in Arrington's Camelot period, promise to uncover that context. A fine example here is Quinn's work on magic. Again, FARMS apologists like Gee were very disturbed by Quinn's work on this topic.

    I think the effort to preserve the mystique of Joseph Smith by maintaining a shroud of historical mystery over his career will inevitably fail, and Mormonism will benefit by the history that emerges thanks to Mormon Studies. Nibley made a wonderful contribution, but this contribution strengthened the parochial idea of a desert of revelation between the apostles and Smith which, to borrow your language, cannot withstand scrutiny in anything other than chauvinistic theological terms.


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Call Center Solutions Featured Article

Appirio Allows Companies to Leverage Facebook to Manage Customer Relationships

October 23, 2008

Appirio has announced today that Facebook (News - Alert) is now ready to appeal to the business class. The company is introducing an application that allow business professionals to use their social network to get their job done.

Considering the increased use of Facebook in the office, leveraging its capability to actually drive performance rather than reduce productivity is certainly a positive thing that is likely to help drive deployment.

The new product from Appirio, MyFriends@Work, connects the sophisticated CRM capabilities of with the viral social networking capabilities enabled through Facebook Platform.

This collaboration allows users access to the powerful business tool to deepen customer relationships and assist with sales and marketing efforts. MyFriends@Work is a free application from Appirio available on Facebook
( or through

Facebook has exploded in the market to become the Internet’s leading social utility. By connecting Facebook’s 110 million users with an enterprise’s core business applications can help both organizations and individuals to capture the power of social networking to contribute to the business’ bottom line.

MyFriends@Work provides alerts to employees when their Facebook friends do business with their company. This application enables these individuals to act on their knowledge to aid sales, nurture leads and impact the customer service.
"Appirio wants to help organizations of all sizes use social networks in every area of their business to more effectively promote their brand, generate new business and even find new employees," said Ryan Nichols, vice president of product management at Appirio, in a Thursday statement.
"Introducing the 110 million users on Facebook to MyFriends@Work and giving employees an easy way to connect with friends who are doing business with their company, is a great first step in this larger vision."
Serena Software is an Appirio customer and one of the first enterprises to embrace Facebook as an effective method for improving collaboration and communication internally and with customers.
"Our ability to reach out and create communities has helped Serena lead a revolution in on-demand application development and Facebook has greatly contributed to this," said Rene Bonvanie, senior vice president of worldwide marketing, partner programs and online services at Serena, in the Thursday statement.
"Appirio's connection of Facebook to SaaS (News - Alert) business applications will allow more companies to use social networks and measure how they can impact their business."

While this platform provides an excellent way for companies to leverage the power of Facebook, there are certain dangers in relying on this capability. For one, it promotes the extended use of this platform in the workplace, which can be less than productive.

Secondly, it could easily provide the employee with a crutch where he or she is relying exclusively on their Facebook application to manage those relationships, which can be a detriment in the long run.

As with any application that is designed to make the workplace more productive, it must be properly implemented and managed in order to ensure that it delivers the benefits promised, instead of hindering productivity.

Susan J. Campbell is a contributing editor for TMCnet and has also written for To read more of Susan's articles, please visit her columnist page.

Edited by Stefania Viscusi

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CFP: Lost and Found in Virtual Reality: Women and Information Technology (9/30/04; edited book)

full name / name of organization:
Heidi Strengell
contact email:

The University Press of Lapland (Finland) will publish a book entitled Lost and Found in Virtual Reality: Women and Information Technology.

As many researchers struggle to give an account of our immersion in information and communication technology, which resonates with lived experience, there is an increasing turn to phenomenology as a way to get back to the actuality of these experiences. As Merleau-Ponty claims in his famous preface in Phenomenology of Perception: "Phenomenology is a study of essences ... But phenomenology is also a philosophy which puts essences back into existence, and does not except to arrive at an understanding of man and the world from any starting point other than of their 'facticity.'" It is with this challenge in mind that Lost and Found in Virtual reality: Women and Information Technology sees its task.

Contributors are sought for the above book (due for publication in spring 2005) which aims to analyse how women construct their identities and expertise when using information and communication technology. The monograph will aim to develop and explore not only phenomenological analysis and accounts but also a wide range of other approaches to the making of identity, such as cognition, constructivism, and consciousness studies, of phenomena such as (but not limited to):
    - Women, media, mediating and mediation
    - Women, collaboration and cooperation
    - Women, communicating and working
    - Women, information and communication
      technology use
    - Women and virtualisation of everyday life
    - Women, connecting and being connected
    - Women, ethics and mediation
    - Women, technology, learning and improvisation
    - Women, knowledge, knowing and action

Due date: September 30th, 2004

Format: 20 pages, double spaced, MLA style citations.

Additional information: 1) 200-word bio, 2) full name, and 3) contact information, including e-mail, address, and phone number.

Please, send electronic submissions (MSWord or RTF) to both editors:

Hannakaisa Isomäki, PhD
Department of Reseach methodology
University of Lapland
P.O. BOX 122
96101 Rovaniemi, Finland

Heidi Strengell, PhD, EdD
Language Center
University of Lapland
P. O. BOX 122
96101 Rovaniemi, Finland or

Requests for further information (including topics) should be directed to the editors: Hannakaisa Isomäki and Heidi Strengell.

         From the Literary Calls for Papers Mailing List
                       Full Information at
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Science, Technology, Engineering & Math | News

NASA Taps X-Hab Challenge Participants

Seven teams from six universities will take part in NASA's 2014 Exploration Habitat (X-Hab) Academic Innovation Challenge.

The teams "will work in close cooperation with members of the NASA Advanced Exploration Systems (AES) Program's Deep Space Habitat Project team" in an effort to "meet a series of milestones to design, manufacture, assemble and test systems and concepts that could be used in future deep-space habitats," according to information released by NASA.

Chosen by NASA and the National Space Grant Foundation, the winning projects are:

Designed to encourage a multidisciplinary approach and contribute to NASA's "efforts to train and develop a highly skilled scientific, engineering and technical workforce for the future," the challenge asks participating teams "to explore NASA's work on development of deep-space habitats and help the agency gather new ideas to complement its current research and development," according to an agency news release.

"The new X-Hab Academic Innovation Challenge projects reflect the great creativity and innovation of the nation's university students and faculty," said Barry Epstein, NASA's AES Habitat Systems domain lead at NASA Headquarters in Washington, in a prepared statement. "Their energy and ideas expand the reach of our project engineers and of our deep-space human exploration technology development program."

More information about X-Hab Academic Innovation Challenge is available at

About the Author

Joshua Bolkan is the multimedia editor for Campus Technology and THE Journal. He can be reached at

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Canucks Shoot Down Jets

Monday, 09.09.2013 / 5:55 PM
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Hunter Shinkaruk scored the game-winning goal with less than seven minutes remaining in the game, while Joacim Eriksson made 23 saves in net as the Vancouver Canucks skated to a 2-1 win over the Winnipeg Jets on Monday afternoon to close out the 2013 Young Stars Classic with a 3-1-0 record.

The Jets held a 1-0 lead after the first period, a period that was played mostly on special teams as the Canucks found themselves down a man on three occasions, while also having two power-plays.

Sacha Guimond knotted the score at one just over five minutes into the middle stanza, his second goal in as many games, as he banged home a slick cross-crease feed from Ludwig Blomstrand.

With 6:56 left in the third period, Bo Horvat one a key offensive zone face-off back to Ludwig Blomstrand, who found Henrik Tommernes at the point, who’s shot on goal rebound right to Shinkaruk and the Calgary, Alberta native was able to roof the puck for his first goal of the tournament, giving the Canucks the lead and eventual 2-1 victory.

The game was played in front of a standing-room only crowd at the Okanagan Hockey Academy Training Centre due to a previously scheduled concert at the South Okanagan Events Centre on Monday night.

--Shinkaruk also picked up an assist on the Canucks first goal, giving him two assists in the game.

--Although not credited on the official score sheet, Blomstrand not only set-up the first goal of the game, he also should have been credited with the second assist on the game-winner.

--Eriksson didn’t have to face a lot of shots, but made some big saves in the first period, including a few big ones while shorthanded to keep the Canucks in the game.

--Cole Cassels played in his fourth game of the tournament, as he was the only non-invitee to play in all four games. Cassels was one of the top players for the Canucks all tournament long.

--Adam De Champlain was on the losing end of a first period scrap with Jets defenseman Zach Bell, while Mitch Elliot squared off with Jets forward Yasin Cisse in a quick fight less than four minutes later.

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Cape Gazette

Southern Delaware Tourism Board of Directors installs new chairperson

Jul 18, 2014
Source: Submitted Scott Thomas, executive director of  Southern Delaware Tourism, presents the tribute given by Gov. Jack Markell and Lt. Gov. Matt Denn to Marie Mayor, 2012-14 chair of the Southern Delaware Tourism Board. Nikky Fisher, right, will serve as chair for the 2014-16 cycle.

The Southern Delaware Tourism Board of Directors installed Nikky Fisher of the Lewes Chamber of Commerce as its 2014-16 chairperson at its July 8 meeting in Georgetown. The board is composed of representatives from all Sussex County chambers of commerce. At the meeting, a tribute from Gov. Jack Markell and Lt. Gov. Matt Denn was presented to Marie Mayor of Milton Chamber of Commerce in recognition of her leadership as board chairperson for 2012-14.

The mission of the board is to support and encourage sustainable, year-round tourism that contributes to the economic growth and quality of life in Sussex County. The Southern Delaware Tourism Board uses promotional campaigns including Beaches are Just the Beginning, Come to the Culinary Coast...Life Tastes Better Here, and Land, Water or Air. More reasons to get out there, as well as the Local on the Menu program and other initiatives to promote and publicize all southern Delaware has to offer potential visitors. To learn more about the work of the board, go to

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The price of liberty is eternal vigilance.


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Cape Gazette

Summer Sanity Steps for Parents and Managers

By Mike Nally | Jul 12, 2011

My wife and I have three teenage boys and a young daughter; our house is filled with the agendas, desires, and energy of kids on summer vacation.  For many parents, this can translate to chaos, frustration, and exhaustion trying to keep the family schedule straight. My wife took control early this summer and so far her leadership has produced promising results.  Here are the steps she took:

1)  She established a set of chores which need to be accomplished each morning before any TV's, computers, x-box or kid fun went on for the morning.

2) She established her intentions and expectations for the summer.

3)  She brought the boys together to divvy up the daily chores in a fair manner.

4) She set standards for getting the chores accomplished on a daily basis and gave them the responsibility for coordinating the achievement of their daily tasks if they were going to be absent in the morning.

5) She established consequences - (she would charge the boys $5.00 for every chore she had to accomplish) - if the chores went undone.

6)  She hammered home the system until the reality of a work routine sunk into the skulls of our sons.

The results?

After three weeks, the boys start their chores each morning without being asked and work together ( as much as teenage brothers can) to help their mother accomplish the thousands of tasks required to run a family on a daily basis.  Though the boys probably wouldn't admit it, I think they take pride in being part of the family work team.

My wife did what all effective managers do:

She set goals.

She clarified tasks.

She set standards of performances.

She assigned personal job descriptions.

She gave them flexibility/accountability in certain situations.

She asked for input.

She checks them each day.

She is consistent with praise and consequences for performance.

She is happy with the system and our children our proud to be part of an effective team.

Her reward - she get's just enough time to work out between shuttling children to and fro, cooking, coordinating, doctor's appointments...etc.  But she has created time for herself with a better management system.

PS:  My daughter is very comfortable being the quality control manager.

For more interesting reading, visit my blog at

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Cape Gazette

There is no 'I' in taxpayer

By Ron MacArthur | Apr 19, 2013

Each year Sussex County Council members dole out tens of thousands of dollars to worthwhile organizations in their respective districts in the form of councilmanic grants .

They receive glowing letters from the recipients thanking them personally for making donations, which range from $100 to $5,000. Sometimes photo ops are arranged, and photos of council members presenting checks appear in newspapers.

And during meetings when presentations are made, the word “I” is used frequently, as in: “I will donate $1,000.....”

During the April 9 meeting council was sternly reminded there is no “I” in taxpayer by none other than Dan Kramer of Greenwood, who has broken his vow of silence and now speaks at most council meetings.

Council – at least for one meeting – took his advice. During votes on grants at the April 16 meeting, council members used the phrase “taxpayers' account” instead of “my account.”

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‘Vintage’ Capitals Bobblehead

Posted November 26, 2013

Lets go back to a time where hockey was simpler. There weren’t all of these headshot rules, fighting restrictions, and equipment violations. However, there were still bobbleheads everywhere. The Capitals didn’t get to into the bobblehead scene until a man by the name Jaromir Jagr came to D.C. in 2001. More than ten Jagr bobbleheads were released within the next few years, kicking a craze that has yet to end. Although the whacky wobblers didn’t take off until the turn of the century doesn’t mean they didn’t exist before then. This brings us back to the year 1989 when a company name Skore began producing bobbleheads of all shapes and sizes for teams of every sport, including your Washington Capitals. Our initial discovery of this bobblehead wasn’t even until after we launched our extensive (or so we thought) database of Caps bobbleheads, when our friend Capitals Hill stumped us:

This then sent us off on a quest to find out as much information as possible on this very rare piece. Now fast forward a couple of months to the day of the Fall Caps Blood Drive (Hi Braden Holtby!). An innocent eBay seller posted a 1989 Washington Capitals bobblehead made by Skore, not knowing how rare it was.

After learning that Skore made the bobble, we took to eBay and Google to further search for information. Google returned little to nothing and eBay returned about 40-50 listings of Skore football bobbleheads, and one hockey bobble. Also, there was no trace of anything on the company itself.

After a week the auction ended, the item sold for $100, somewhat of a lower value than expected despite its rarity. Leaving you all with that I’ll now move on to what really matters is the review of this beautiful retro piece.

The bobblehead is made entirely of plastic. It isn’t of any specific player, but back in those days bobbleheads were mostly just generic players with a little grin on their face. It has a big circular stand with a sticker across the bottom that says “Washington Capitals.” The body is very smooth and looks like it has some type of a finish on it, plus a smaller sticker of the same one placed on his chest. The only issue I see is that it doesn’t really match the jerseys worn back then, as it’s more of just a generic pattern with red, white, and blue incorporated into it. He has on blue pants with two red stripes down the middle, and striped socks. He has black and white gloves hold, somewhat unorthodoxly, his hockey stick. To top in all off, he has the signature vintage grin on his face with big brown eyes and his white helmet on. The rarity of this bobble is what really takes the cake in the end. This bobble will be in the company of the Bondra Red Cross bobblehead as being one of the more difficult to find, but that just makes the hunt more exciting. If you have any information on this bobble or any other vintage Capitals bobbleheads feel free to shoot us an e-mail or tweet us with any pictures or information!

Also check out:

Caps Outsider’s Bobblehead Database

Andy Wallace

Andy Wallace

Huge Washington Capitals fan and writer for @CapsOutsider. Cover bobbleheads and special hockey events. #Caps #Bears #Royals #Medvescak #Kloten #Brynäs #Urbom
Andy Wallace
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Oneida Financial Corp. (NASDAQ:ONFC)

CAPS Rating: No stars

The Company is majority-owned by Oneida Financial, a Federally chartered mutual holding company. The Company and the mutual holding company are each subject to regulation by the Office of Thrift Supervision.

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Member Avatar liverless (20.32) Submitted: 2/8/2011 7:40:56 AM : Outperform Start Price: $7.54 ONFC Score: +101.05

Cheap NY state regional bank. Formerly a mutual holding company, converted in June 2010 and raised a bunch of cash. book value of over $12 per share. Tangible asset ratio of almost 14 means there is lots of room for growth. They have extremely low nonperforming assets.

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The Fault in Our Stars

  • GENRE: Drama
  • RATING: PG-13
  • RUNNING TIME: 2:00
  • RELEASE DATE: 06/05/2014
  • STARRING: Shailene Woodley, Ansel Elgort, Willem Dafoe
  • DIRECTOR: Josh Boone
  • PRODUCER(S): Marty Bowen
  • WRITER(S): Scott Neustadter

Hazel and Gus are two extraordinary teenagers who share an acerbic wit, a disdain for the conventional, and a love that sweeps them - and us - on an unforgettable journey. Their relationship is all the more miraculous, given that they met and fell in love at a cancer support group. 'The Fault in Our Stars,' based upon the number-one bestselling novel by John Green, explores the funny, thrilling and tragic business of being alive and in love.

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Online Course Empowers Students to Complete HRIR Degree

October 28, 2013

The HRIR course allows students who encountered difficulty completing the program an opportunity to join the ranks of alumni

Due to a variety of unplanned circumstances, some HRIR students encounter challenges in their professional and personal lives that prevent them from completing the program. Unfortunately, some are only one capstone course or paper away from graduation.

The MA-HRIR program is encouraging those students to finish what they started and join the illustrious ranks of alumni, by offering an online capstone course that former students can take to help fulfill their graduation requirements.

"The MA-HRIR program has changed the capstone paper requirement to a capstone course instead," says Stacy Doepner-Hove, '09 MA-HRIR, director of the MA-HRIR program. "We've put together an online version of this class that can be used by people who may have been out of the program for a while, and only have this class left to complete their degree."

Once the course is complete, it is possible for students, many of whom have waited years, to complete the degree they started.

Ned Van Dellen completed his final capstone course in May of 2013, receiving his MA-HRIR degree 30 years after he began the program.

"After more than 25 years of putting 'degree in progress' on my resume, I can finally list it as completed," says Van Dellen. "It was an albatross around my neck, and it feels great to have the diploma hanging in my office."

Van Dellen was enrolled in the Full-Time MA-IR program, but began working at First Bank Systems during his final quarter. Between carrying a heavy load of work projects and later relocating, he did not finish the last part of the program.

When Van Dellen began the capstone course in 2013, he was concerned he would be "the old guy," and be bored with the course content due to his extensive experience in the human resources field. He was surprised to find that he learned new tools that he could apply to his current job.

"In all the classes I've taken, the professors kept me engaged, and added to my knowledge base," Van Dellen says.

Now that Van Dellen has finished the program, he advises others to focus on studying before finding a job.

"The best advice I never took was to 'complete your degree work before you start your new job,'" he says.

Chara Blanch was worried about balancing work, life and school when she finished her final course in the spring of 2013. She was pleased that her supervisor and coworkers understood her need for extra time to finish the program. Her advice to other students who simply need to finish the course to obtain the MA-HRIR degree is, "take the course. It feels great to be done!"

The capstone course, titled "HRIR in Practice: Strategy, Execution and Ethics," is offered online throughout the year and is taught by Professor Sid Benraouane. For more information about the course, including costs, registration and a course description, please contact Stacy Doepner-Hove at

"We hope our 'almost-completed' students will take advantage of this opportunity," says Doepner-Hove. "We look forward to welcoming them, officially, into the ranks of our alumni."


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Video: Earn 1,000XP on Halo: SA in 1 min
Date: 1/1/14 9:28 pm

Halo Spartan Assault is pretty fun. If you're like me and are neurotic about getting every gold star, you'll quickly realize the XP is hard to come by. I found a VERY easy method to earning 1,000XP every 1:05 or so. It'll allow you to stock up for the tougher missions with better weapons, AA's and boosters. Enjoy.

I'm really enjoying the game!

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A survey of 3,500 classic car owners by specialist classic car insurance company, Footman James, suggests that classics from the 1960s are the most appealing.

64% of respondents said that decade was the most interesting for classic cars, while the two most popular classics are associated with that decade: the MGB, launched in 1962 and the Morris Minor (launched earlier, but available throughout the decade).

It should be said that the result of the survey was slightly predictable in that the most common age for someone to own a classic car is 50-59 years old. Such people would have been growing up in the 1960s and would therefore naturally be nostalgic about that period now.

However, Andy Fairchild, Footman James' managing director is quite right to point out "The challenge for the industry now is to generate an enthusiasm for the future classics, cars from the 90s and noughties, ensuring the passion for classics lives on in current generations, thus securing the future of the industry for years to come."

That is a moot point. A 1960s Aston Martin DB6 Convertible in top condition is now worth £400,000. Will a DB9 convertible be worth the same amount (after taking into account inflation) in 2060? We won't be here to be proved wrong, but we suspect the more visceral appeal of a 1960s classic will always command more money than the far more competent, but less dramatic supercar of the current era. You don't need competence and sophistication from a classic, as you get that from your everyday car: you want raw thrills.


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    Marketplace User ·Over 4 weeks ago on lemonfree

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How do I change my rate plan?

We know seasons change, and so do your carshare needs. If you would like to change your rate plan, there are a few options:

  1. Use the web form on our Rates page.
  2. Send an email to
  3. Let us know through Member Feedback in your account.
  4. Call our support line at 303.720.1185.

You are allowed 2 free rate changes a year (additional changes are $25).

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 Spy photos of 2014 Cadillac CTS | Car Spy Photos

Spy photos of 2014 Cadillac CTS 15 July 2012, eagleweb @ 8:13 am

Based on the updates of the recently spotted Cadillac, it presents itself as a high performance vehicle. Though the expectations of having a coupe derivate are high, nothing has been finalized as yet. The decision will roll in anytime this year, may be in the fourth quarter part of this year. However, the news suggests that the wagon has been off for the CTS third generation.
If you wondering as to how it matters, well it does because the Cadillac’s bestselling car has always been CTS. After the end to STS and DTS, CTS was the only car that was running till the time when XTS and ATS was launched. Now that it has entered the third generation, the sales need to be pumped up in order to take the brand name on the next level, especially amongst the luxury buyers.
If we look at the platform, CTS has always faced the task of maintaining its spot with the other luxury brands on the market. Reports suggest that the 2014 model will have some changes, longer by 2 to 3 inches and some inches added to the wheelbase. It will turn out to be competing with the European and Japanese mid-size luxury based cars. At the same time, you will that there will be a breather for the small sized ATS 2013 version. Alpha Platform is being incorporated in the next gen CTS. The growth may not be as obvious and one of the reasons could be the evolution of Art and Science design language by Cadillac. You can see the sharp lines being toned down a little bit so that some resemblance. But, it seems like CTS will not be as soft looking on the overall front.
Powertrain: CTS 2014 version will offer yet again a V-6 power which comes in two flavors. The current offering of CTS’s 3.0 liter V-6 version which is the standard kind will carry only in an automatic kind. A 265 something HP base model, 3.6 liter, 318 hp V-6 will undergo some kind of changes, either in the automatic transmissions or in the manual. The 2.0 liter ATS turbocharged with four cylinders will come in the CTS performance trim model. This has 280 hp and you can find it in both gearboxes be it the manual or the automatic. The wheel drive is limited to the natural similar aspirated kinds that have an automatic kind of transmission.
Post the new CTS goes for sale, there is a high anticipation of a GM developed model with an eight speed automatics that offers six cog boxes a year.
Competition: if you look at the competition front, you can get it from cars like Mercedes Benz E-class, Infiniti M, Audi A6, Lexus GS, and BMW- 5 Series etc.
Estimated Time of Arrival and the Price: the new CTS will arrive next year with a 2014 model. You shouldn’t be surprised to see the prices reaching a $40,000 mark. As of now, the current price is around $30,000 mark and this is the price for the new model of ATS too.

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Castle Rock's White Construction wins on weight loss

Tim White and his partner Doug Decker made good on a promise to employees, who exceeded a company-wide challenge to lose weight. In exchange, the head honchos of White Construction took their side of the bet … to their heads.

With insight gained from his experience as a board member for Parker Adventist Hospital, White challenged his employees to lose weight, setting a cumulative goal of 100 pounds. His employees responded with a campaign that in six weeks resulted in a loss of nearly 154 pounds.

As a reward to employees, White shaved his head and Decker dyed his black hair blue during an April 3 celebration at the company’s Castle Rock headquarters.

The challenge was the latest effort in the company’s internal wellness program, which White Construction Group launched in 2009 to improve employee health. It was about that time that White joined the board of directors of Parker Adventist, gaining new awareness about the benefits of healthy living.

“It became apparent to me that the health crisis solution has to be a grassroots effort,” White said. “If we can become healthier people and model it with our practices, we can show you can have a healthier lifestyle.”

White Construction holds pedometer competitions, measuring the number of steps among employees or the number of miles walked. The company uses a software application provided by its health-care provider to track progress.

Lyssa Franckowiak, 35, used that software as motivation during the competition, which she won as the top weight loser in the company. Franckowiak, who lives in Highlands Ranch, lost 16 pounds in the six-week challenge, making small diet adjustments along the way.

Franckowiak cut soda and most of the dairy from her diet, added a healthy breakfast to her daily routine and stopped eating late at night. She also checked in daily to see who might be homing in on her first-place spot — a habit that upped the motivation element.

“I’m very competitive, so I tried to stay ahead of people if they started to gain on me,” Franckowiak said. “It was a lot of fun. I feel a lot better and I have a lot more energy.”

Despite his newfound baldness, White sees the competition as a win-win situation. His attitude is that healthy employees are more productive employees.

“You’re probably a better mom, dad, volunteer,” he said. “Whatever you’re doing in life, you’re probably much better at it when you’re leading a healthy lifestyle."

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3 Little Witches Theme - Printable Party Tags - Circles -Cupcake Toppers - Halloween Printable Party Tags - Halloween Witch

JW Illustrations By JW Illustrations

Product Info

This listing is for Printable Party Circle Tags featuring cute 3 Little Witches theme! Your printable file will come in PDF and JPG formats.

Print as many as you need from home or from a shop with print services such as Staples or OfficeMax.

Cut these out in Squares, Punch out Circles or use a 2" craft flower punch to create labels, cupcake toppers and more!

Formats Included:

-High Resolution JPG with White Background
-PDF Printable File (Opens with Adobe Reader)

Uses Allowed:

-Any Personal or Non-Profit Projects Only

Artwork is NOT available for Resale, Reproduction, or Redistribution of any kind.

All Original Artwork and Rights are © 2014 Jessica Weible Illustrations LLC.

keywords: halloween, witches, witch, printable, party printables, craft, print, diy, cupcake, topper, birthday, party, crafty, do it yourself, print from home

Close Follow Catch My Party


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Contributor biographical information for Born to run : a hidden tribe, superathletes, and the greatest race the world has never seen / Christopher McDougall.

Bibliographic record and links to related information available from the Library of Congress catalog

Biographical text provided by the publisher (may be incomplete or contain other coding). The Library of Congress makes no claims as to the accuracy of the information provided, and will not maintain or otherwise edit/update the information supplied by the publisher.

Christopher McDougall is a former war correspondent for the Associated Press and is now a contributing editor for Men’s Health. A three-time National Magazine Award finalist, he has written for Esquire, The New York Times Magazine, Outside, Men’s Journal, and New York. He does his own running among the Amish farms around his home in rural Pennsylvania.]]

Library of Congress subject headings for this publication:
Running races -- Mexico -- Copper Canyon Region.
Tarahumara Indians -- Mexico -- Copper Canyon Region.
Long-distance running -- Mexico -- Copper Canyon Region.
Long-distance runners -- Mexico -- Copper Canyon Region.
Long-distance runners -- United States -- Biography.
Running -- Mexico -- Copper Canyon Region.
Athletes -- United States.


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Custom Engraving by Catharine Kennedy
Let me make your plane into a fancy!
Why should gun & knife owners have all the pretty tools?

A beautiful tool is so inviting that it makes you want to use it, and custom engraving is a wonderful way to to make a favorite tool uniquely beautiful, with crisp monograms, Fine English scrolls, acanthus leaves and other classic engraving details and motifs, all executed by hand in the finest traditions of metal working. If you find pleasure in making and using hand tools, embellishing them with custom engraving is a logical extension of that appreciation for beautiful tools.
Catharine Kennedy
After graduating from college in 1970 with a liberal arts degree, I became a carpenter and graduated the Union Carpenter apprenticeship program in 1982. Eventually I found that my professional niche and personal delight were in the field of hand tools, their decoration and use. My passion was reinforced when I became the lead woodworker at Hancock Shaker Village museum in Pittsfield, Massachusetts in 1994, demonstrating 19th-Century hand-tool joinery and woodworking tools in general. I have studied hand engraving with Sam Alfano and Marcus Hunt, both masters in the field.
...Catharine Kennedy
Chatham Center, NY

CLICK HERE to inquire about my engraving services
for your particular tool or project.

Prices vary on the size and complexity of the work, but for a #2 or #3 bench plane, engraved on both sides as shown in the photo above, with a monogram on the left side, the price will be in the $250 - $350 range. Knives and block planes will be somewhat less depending on the size and the complexity of the design. I also am available for other types of engraving work, such as signage, commemorative plaques and decorative objects.

See more of my work at!

Belt Buckles

© 2009 by Catharine Kennedy.
Images may not be reproduced or copied by any means
without the express written permission of the owner.


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Archive | Disney World 2011

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How Would You Like to be in Cathe’s Cycle Max Video?

If you’ve ever dreamed or wanted to be in a Cathe video, this is your best chance and opportunity… and you don’t want to miss it! We’re looking for eight fit and enthusiastic Cathletes for Cathe’s zero impact Cycle Max video shoot. Casting calls are limited to those attending the Disney and/or Glassboro Road trips. […]

Join Our Lucky Group of Cathletes for a Fitness Vacation of a Lifetime!

You can still sign up for our 2011 Cathe Road Trip at Walt Disney World® Resort that will be held Friday July 1st through Monday July 4th, 2011, but time is running out. This will truly be the most unique and magical tour event we have ever held and you don’t want to miss it! […]

Sign Up for Our Next Road Trip

Registration will begin at 1pm (eastern) on Friday, Feb 25, 2011. Space is limited! Registration for our next Road Trip that will be  Walt Disney World® Resort in Florida has now started. Just go to and click on the Register button. Space is limited and registrations are on a first come first serve basis. $179 […]

Get Ready to Sign Up

We’re getting ready to start taking deposits and registrations for our next two scheduled road trips: Disney World – July 1 – 4th, 2011 Glassboro – July 29 – 31st, 2011 We will provide further sign up details shortly. A non-refundable deposit is required to secure your position and space is limited for each event, […]


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IV.C.1. (XIII.D.1.)

Compare vibrational frequencies in CCCBDB for LiOH (lithium hydroxide)

Frequency in cm-1
  Calculated   Experimental
Mode Number Symmetry Frequency diff Symmetry Frequency Comment
1 Σ 3547 -141 Σ 3688
2 Σ 1083 212 Σ 871
3 Π 408 151 Π 257
The calculated vibrational frequencies were scaled by 0.962

See section XIII.C.3 List or set vibrational scaling factors to change the scale factors used here.
See section III.B.3.c Calculate a vibrational scaling factor for a set of molecules to determine the least squares best scaling factor.
See section III.B.3.b List of vibrational scaling factors and their uncertainties for information on where the above scaling factor is from.


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Email updates

Keep up to date with the latest news and content from Critical Care and BioMed Central.

Health technology assessment review: Computerized glucose regulation in the intensive care unit - how to create artificial control

Miriam Hoekstra1*, Mathijs Vogelzang23, Evgeny Verbitskiy45 and Maarten WN Nijsten6

Author Affiliations

1 Departments of Anesthesiology and Cardiology, University Medical Center Groningen, 9700 RB Groningen, the Netherlands

2 Department of Cardiology, University Medical Center Groningen, 9700 RB Groningen, the Netherlands

3 Google, CH-8002 Zurich, Switzerland

4 Department of Dynamical Systems and Mathematical Physics, Research Institute for Mathematics and Computing Science, University of Groningen, 9700 AK Groningen, the Netherlands

5 Information and System Security, Philips Research, 5621 BA Windhaven, the Netherlands

6 Department of Intensive Care, University Medical Center Groningen, 9700 RB Groningen, the Netherlands

For all author emails, please log on.

Critical Care 2009, 13:223  doi:10.1186/cc8023

The electronic version of this article is the complete one and can be found online at:

Published:16 October 2009

© 2009 Biomed Central Ltd

Current care guidelines recommend glucose control (GC) in critically ill patients. To achieve GC, many ICUs have implemented a (nurse-based) protocol on paper. However, such protocols are often complex, time-consuming, and can cause iatrogenic hypoglycemia. Computerized glucose regulation protocols may improve patient safety, efficiency, and nurse compliance. Such computerized clinical decision support systems (Cuss) use more complex logic to provide an insulin infusion rate based on previous blood glucose levels and other parameters. A computerized CDSS for glucose control has the potential to reduce overall workload, reduce the chance of human cognitive failure, and improve glucose control. Several computer-assisted glucose regulation programs have been published recently. In order of increasing complexity, the three main types of algorithms used are computerized flowcharts, Proportional-Integral-Derivative (PID), and Model Predictive Control (MPC). PID is essentially a closed-loop feedback system, whereas MPC models the behavior of glucose and insulin in ICU patients. Although the best approach has not yet been determined, it should be noted that PID controllers are generally thought to be more robust than MPC systems. The computerized Cuss that are most likely to emerge are those that are fully a part of the routine workflow, use patient-specific characteristics and apply variable sampling intervals.

There is widespread consensus [1] that hyperglycemia should be treated with insulin in patients in the ICU, although appropriate glucose levels achieved through glucose control (GC) are still under debate. Insulin therapy in ICU patients, even with a moderate glucose target range, is complex and time consuming, particularly since insulin-induced severe hypoglycemia should be avoided. In most ICUs, protocols for GC are paper-based and nurse-driven. However, even with this form of standardization medication errors frequently occur and play a major part in overall patient safety, which is a key issue in all healthcare systems. For safety and efficiency, computerized clinical decision support systems (Cuss) appear to be superior to standard paper protocols. Patient data management systems and computerized physician order entries are increasingly being used in the ICU, both with and without decision support. This review focuses on the progressively more complex approaches that have recently been introduced to achieve GC. Successful implementation of computer-guided GC is of relevance to other ICU domains, since the basic titration principle behind GC (for example, increase insulin infusion if glucose is high) holds for numerous other clinical ICU problems. Although this is not a formal exhaustive review, this paper discusses several important studies on paper protocols and development of computer assisted methods, including flowcharts, Proportional-Integral-Derivative (PID) and Model Predictive Controllers (MPC).

Glucose control with paper protocols

Hyperglycemia frequently occurs in critically ill patients and is strongly associated with adverse outcome in patients with acute myocardial infarction [2], stroke [3], and trauma [4,5]. Also in a heterogeneous ICU population hyperglycemia was associated with increased hospital mortality [6,7]. This observation raised the interesting question of whether normalizing blood glucose (BG) improves outcome. In 2001 van den Bergh and colleagues [8] showed a one-third mortality reduction in surgical ICU patients treated with intensive insulin therapy (using a paper protocol for insulin infusion). However, subsequent high-quality controlled trials [9-11] and a large cohort study [12] in both medical and surgical ICU patients could not replicate this mortality benefit. The recently published international NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation - Survival Using Algorithm Regulation) trial [13] demonstrated in 6,104 patients that 'tight' GC with a target of 4.5 to 6.0 mmol/L was associated with a higher mortality. The investigators used a computer-assisted glucose regulation protocol. In the meta-analysis that followed (including the NICE-SUGAR study data), no mortality benefit was demonstrated in the tight glycemic control group [14]. However, because there is consensus about avoiding serious hyperglycaemia, GC in ICU patients is still recommended so that glucose levels should be kept at approximately <8.0 mmol/L [1,13].

To achieve desired glucose levels, insulin therapy is required in most ICU patients. GC requires intensive monitoring of glucose levels with frequent adjustments of insulin therapy. A first step in managing GC is the use of protocols that allow physicians and nurses to decide unambiguously how much insulin should be administered. The recommendations of these protocols are generally based on previous glucose levels and insulin dosing according to a 'sliding scale' protocol (a predetermined amount of insulin is administered according to the actual BG) or 'dynamic' protocol (the dosage of insulin is changed by a certain amount, according to the actual BG) [15]. Given the frequency of BG sampling, it rapidly became apparent that the nurses who care for the patient should have a central role in executing GC. Standardizing GC by a nurse-managed protocol has been found to improve safety and efficiency of GC [16].

One of the main challenges in achieving glycaemic control is minimizing the risk of hypoglycaemia. Hypoglycaemia can cause serious complications and should be prevented in critically ill patients [17]. In several studies an increased occurrence of severe hypoglycaemia was strongly associated with tight glycemic control. Two large trials investigating the clinical effects of strict GC that were prematurely ended showed high rates of iatrogenic hypoglycaemia [10,11]. Although the overall evidence suggests that the beneficial effects of insulin therapy may outweigh the possible negative effects of hypoglycaemia [18], fatalities occurring due to iatrogenic hypoglycaemia are not acceptable. A balance must be struck between the preferred level of control and the number of measurements. To achieve GC with a low incidence of hypoglycaemia without excessive BG sampling, more complex computer supported algorithms are required that manage the patients with an increased risk for hypoglycemia.

Introduction of computerized glucose control

For many years, computer software has been recognized as a promising tool to improve clinical practice as many adverse events can be traced back to preventable human errors. These so-called CDSSs are information systems designed to improve clinical decision making using characteristics of the individual patient. Implementations of these systems have been shown to reduce serious medication errors [19] and improve adherence to recommended care [20]. In the past few years several computer directed glucose regulation programs have been investigated for their effectiveness and safety in critically ill patients. We performed a literature search (PubMed, Cochrane and Medline) to find published computer-based intravenous insulin protocols that were designed for critically ill patients and tested in an ICU setting (in at least 15 patients). Table 1 summarizes the 19 identified studies [13,21-38].

Table 1. Summary of published computer-assisted glucose regulation protocols, designed for critically ill patients

How to create artificial control?

Devising an algorithm for controlling blood glucose is a challenging task. The algorithm should be evaluated to be safe, robust and efficient for a population of patients with a wide range of clinical conditions. To date, three types of algorithms have been considered for BG regulation: (heuristic) paper-based or equivalent computerized flowcharts, PID and MPC.

Computerized flowcharts

The first flow-chart protocol was based on studies by van den Berghe and colleagues [8,9]. It allows nurses to determine (at the bedside) the necessary adjustment of the insulin pump based on the most recent BG value and the trend (using the number and levels of past BG values to determine the trend). In case of extremely low BG or other exceptional cases, special actions are planned. The paper-based flow-chart protocol can easily be converted into a computerized form (see, for example, Thomas and colleagues [36] and Laha and colleagues [28]). Furthermore, the use of computers allows an increase in the sensitivity (resolution) of the titration part, for example, in the Vanderbilt protocol [21]. The formula uses a simple multiplier, which is determined and adjusted according to previous BGs (BG in mmol/L; multiply multiplier by 18 for BG in mg/dl):

(Equation 1)

where the multiplier is adjusted by 0.01 up or down when two consecutive BGs are above 6.1 or below 4.4 mmol/L, respectively; in the case of extreme values (<3.3 or >11 mmol/L) the multiplier is adjusted by 0.02, and in the case of BG <3.3, the insulin dose becomes zero. Boord and colleagues [21], and later Dortch and colleagues [24], demonstrated an improvement in overall GC compared to a previous manual protocol. At the same time, a glucose sample was required approximately 18 times per day.

PID control

A titration formula like Equation 1 puts the control algorithm in the class of the so-called PID controllers. These are the most widely used controllers in industrial applications. Typical examples are the kitchen furnace and automotive cruise control. The basic idea of PID control is easy to explain: deviation of the controlled quantity (BG in our case) from the target is corrected by adapting the control parameter (insulin) using a linear combination of absolute deviation, trend, and the sum of past deviations. In fact, a PID controller has already been used in the BioStator, the first device for 'glucose clamping', developed in the late 1970s [39]. Equation 1 utilizes only the proportional (P) part of the PID control. Vogelzang and colleagues [38,40] also use the derivative (D) component. For the rationale behind the application of the integral (I) part, see Wintergerst and colleagues [41].

Model predictive controllers

A great deal of work has been invested in mathematical modelling of glucose regulation. Models of various complexities have been constructed in the past 50 years, as recently comprehensively reviewed by Chee and Fernando [42]. Deterministic mathematical models can also serve as a basis for the development of control algorithms. Given the model equations and the values of all model parameters, one is able, in principle, to precisely compute the glucose evolution in response to any insulin infusion strategy. In theory, this allows a selection of an optimal insulin infusion scenario. In practice, however, mathematical models rarely exactly describe reality, and a large number of parameters need to be estimated, which will inevitably lead to errors in prediction of glucose response.

An example of such complex MPC was developed by the CLINICIP (Closed Loop Insulin Infusion in Critically Ill Patients) group. The ultimate goal is a closed loop system for glycemic control. Plank and colleagues [32] describe, in a multicenter randomized controlled trial, glucose management with the MPC program in 30 patients after cardiac surgery. Compared with routine protocols for glucose regulation, the time within target range improved significantly (19% to 52%) during the first 24 hours postoperatively. However, an hourly glucose sample was necessary, which substantially increased the workload of the ICU nursing staff. Thereafter, the algorithm was enhanced with a variable sampling interval based on the accuracy of the glucose prediction. The improved protocol (eMPC) resulted in a 50% drop in sampling frequency [31] and maintained effective glucose control in different ICUs, with different (nutritional) protocols and during cardiac surgery [22,26]. The authors report that the program was safe in 30 patients. It should be noted, however, that the published incidence of hypoglycaemia, a key safety indicator, varies from less than 1% to a few percent, thus rendering a sample size too small to assess such a safety parameter.

PID versus MPC

The following might serve as a caricature explanation of the difference between PID and MPC. Suppose a person wants to drive a car on a mountain road. The control (equivalent to the art of driving) consists of two continuous inputs: steering and throttle. The PID approach would be analogous to a driver negotiating the road by continuously adjusting the input parameters, correcting deviation from the ideal line, proceeding along as the new corners or obstacles appear in front. The MPC strategy would be analogous to studying the whole road and selecting the driving strategy before the departure. Note that even the MPC approach does not guarantee 100% success as the strategy might have to be adjusted to changing conditions like rain, other road users, and so on. This example is illustrated in Figure 1.

thumbnailFigure 1. Model Predictive Control (MPC) versus Proportional-Integrate-Derivative (PID) control. When using MPC control, the driver determines ('calculates') his driving strategy before departure after careful investigation of the road. When he uses the correct information (input variables), he stays on the road (yellow car), but small errors in input variables can lead the car in the wrong direction (red and blue cars). The drivers using PID control readjust their driving strategy often by frequently calculating the difference with the 'ideal' track.

The theoretical advantage of the MPC over the PID approach is that the 'intelligent' control algorithm could be able to minimize glucose oscillations and keep glucose within the target range better than PID controllers. This, however, would require further improvement of not only the mathematical models and the parameter estimation procedures, but the control algorithms as well, since the current results of in silico (that is, with a virtual electronic patient) testing exhibit rather dramatic oscillatory behavior [43].

Finally, some believe that with the envisioned introduction of continuous glucose monitoring systems (CGMSs) in the ICU setting, the current problem - high workload for nurses resulting from frequent glucose measurements - will reduce considerably. Results reported in the literature strongly suggest that, with the frequent sampling of BG, the more transparent PID controllers are fully capable of regulating glucose successfully. However, application of CGMSs in the ICU setting is still hampered by a relative inaccuracy of the existing sensors. Moreover, it must be noted that regardless of the algorithm employed, CGMSs may not come so easily or cheaply as originally envisioned, since the devices are expensive and may require quite frequent BG samples as well, albeit only for calibration purposes. For more discussion on the combination of CGMSs and PID controllers or PID control versus MPC control see [44-48].

Computer versus paper-based insulin infusion protocols

Whether computer-based or paper-based, the underlying algorithm is the crucial 'know-how' responsible for overall performance. The same algorithm in paper or computer form should have the same overall performance, provided that nurses are easily able to use both versions and comply with recommendations in the same way. Computer implementations probably offer higher comfort to the nursing staff. The chance of human error grows dramatically with the complexity of the protocol when it is implemented on paper. Therefore, the class of all protocols potentially implementable by humans is strictly smaller than the class of protocols implementable on the computer.

Successful implementation of decision support systems

To make the implementation of a computerized CDSS successful, the algorithm used is not the only element that must be taken into account. Kawamoto [49] performed a systematic review to identify features critical to the success of a CDSS and concluded that to make a program likely to succeed, it must be fully part of the caregivers' routine workflow and provide the decision support at the time and location of the actual decision making. Also transparency, such as documentation of the reasons behind the decision making, and a feedback mechanism (for example, an alarm as a reminder for when a glucose sample is required) were features leading to success. Before implementation, adequate training of the nursing staff and physicians is important. To date, no systematic studies on the costs of computerized protocols have been published, but it is likely that a program that requires 18 measurements per day will turn out to be more expensive than one that requires 6 measurements per day.

Future perspectives

To improve patient safety, more and more technology will arise in healthcare, especially in the ICU, where the complexity of patient care is high. A system that is effective, safe, transparent and easy to work with has a chance to become routine practice. An advantage of computerized regulation is that improvements of the internal algorithm may enable a higher level of control and safety while maintaining a simple user interface. To date there have been no direct comparisons made between different algorithms, so the best approach has not been determined yet. Development of a closed-loop system using continuous BG measurements has been ongoing for many years. For the near future, the method of choice for insulin therapy will still be based on intermittent glucose sampling because the continuous techniques are not yet reliable enough (mainly in the hypoglycaemic area) and are expensive.

Computer-assisted glycemic control has proven to be more safe and effective than paper protocols in ICU patients. A successful system is nurse-centered, fully integrated into the routine workflow, transparent, and uses patient-specific information with intermittent glucose measurements and variant sampling intervals.

BG: blood glucose; CDSS: clinical decision support system; CGMS: continuous glucose monitoring system; GC: glucose control; MPC: Model Predictive Control; PID: Proportional-Integral-Derivative.

Competing interests

The work of EV on glucose regulation in the ICU is supported by the Netherlands Science Organization through the national cluster 'Non-linear dynamics of natural systems'. MH, MV and MN declare that they have no competing interests.

The authors would like to acknowledge Felix Zijlstra and Iwan van der Horst for critical reading of the manuscript.

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