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In fact, as you read this excellent article from Kris Gunners, who authors the website Authority Nutrition, you will see that shaming never works — it does the exact opposite. If you know someone who is frustrated with a family member or a friend’s weight and you see them shaming that person or dictating what they should eat, show them this article and ask them to really think about what it is they’re doing to that person emotionally. I would like to thank Kris for letting me re-post this here. I have given a lot of links to his website in the past, and I would encourage you to routinely check it out.
Science Confirms: “Fat Shaming” Just Makes Things Worse
By Kris Gunnars, BSc | September, 2015 |
There has been a lot of talk about “fat shaming” on the internet in the past few weeks. This was sparked by a couple of viral videos, one serious and the other a (bad) joke, that harshly criticized overweight people. Some believe that making overweight people feel ashamed of their weight or eating habits actually helps motivate them to lose weight. However, nothing could be further from the truth. Psychologists have done a lot of research on this, and the evidence is very clear. Fat shaming does NOT motivate people, but makes them feel terrible about themselves and actually causes them to eat more and gain more weight (1).
What is Fat Shaming?
Fat shaming is criticizing and harassing overweight people about their weight or eating, in order to make them feel ashamed of themselves.
Apparently, some people believe that making overweight people feel ashamed of themselves will motivate them to change their behavior so they start eating less, exercising more and finally start to lose weight.
Others are just horrible human beings, plain and simple. Horrible people often feel comfortable saying things over the internet that they would not say in real life.
In the majority of cases, the people who do this are skinny. They have never had to struggle with a weight problem themselves and don’t understand what it is like.
There are actually entire communities on the internet where people gather in order to make fun of overweight people. Often it turns into downright group harassment.
A high-profile example is reddit’s fatpeoplehate forum, which was recently closed down because their members would storm pages and videos from overweight people in order to harass them.
Research shows that a very large percentage of discussions about obesity on social media, especially Twitter and Facebook, are of a fat shaming nature. This often turns into downright harassment and cyberbullying – especially against women (2).
Whatever your opinion of fat shaming is, the research is very clear that stigma and discrimination against overweight people causes major psychological harm and makes the problem worse.
Bottom Line: Fat shaming is the act of criticizing and harassing overweight people about their weight or eating behavior. It is often justified as a means to motivate people, but research shows that it has the opposite effect.
Fat Shaming Causes Overweight People to Eat More
In the case of overweight people, this stress can drive them to eat more calories and gain even more weight (3).
In a study of 93 women, exposure to weight stigmatizing information made overweight women, but not normal weight women, eat more calories and feel less in control of their eating (4).
In another study, this time in 73 overweight women, those who watched a stigmatizing video ate 3 times as many calories (302 vs 89) afterwards compared to women who watched a non-stigmatizing video (5).
This is supported by numerous studies showing that “fat shaming” in any shape or form causes overweight people to become stressed and end up eating more calories and gaining more weight (3).
Bottom Line: Many studies show that weight discrimination (like fat shaming) causes stress and leads overweight people to eat more calories.
Weight Discrimination is Linked to Increased Risk of Obesity
Many observational studies have looked at weight discrimination and the risk of future weight gain and obesity.
In one study of 6,157 people, non-obese participants who experienced weight discrimination were 2.5 times more likely to become obese over the next few years (6).
Additionally, this study found that obese people who experienced weight discrimination were 3.2 times as likely to remain obese over the next few years (6).
This shows that fat shaming is certainly NOT likely to motivate people to lose weight.
Another study in 2,944 men people found that weight discrimination was linked to a whopping 6.67 times greater risk of becoming obese (1).
Bottom Line: Many observational studies show that weight discrimination is linked to weight gain and a drastic increase in the risk of becoming obese.
Fat Shaming Has Various Harmful Effects on Obese People
The harmful effects of fat shaming go beyond just increased weight gain, which is serious enough as it is.
- Depression: People who are discriminated against due to weight are at higher risk of depression and other mental issues (no surprise there).
- Eating disorders: Fat shaming is linked to an increased risk of eating disorders, such as binge eating disorder.
- Reduced self-esteem: Fat shaming is linked to reduced self-esteem.
- Others: By causing stress, weight gain, increased cortisol levels and mental problems, weight discrimination may raise the risk of all sorts of chronic diseases.
Looking at the literature, the research is very clear that fat shaming harms people, both psychologically and physically (8).
Bottom Line: Weight discrimination can cause depression, eating disorders, reduced self-esteem and raise the risk of all sorts of mental problems.
Can Fat Shaming Literally Kill People?
As mentioned above, studies show that weight discrimination is linked to increased risk of depression.
For example, one study found that those who had experienced weight discrimination were 2.7 times as likely to be come depressed (9).
As is common knowledge, one of the consequences of depression is suicide.
In a study of 2,436 people, extreme obesity was associated with 21 times greater risk of suicidal behavior and 12 times greater risk of suicide attempts (12).
Could fat shaming drive a vulnerable and depressed obese person to suicide? It’s a speculative leap, but it seems plausible.
Fat shamers are not only making obese people gain more weight and making them feel horrible, they may literally be killing them.
see all of Kris’ posts at authoritynutrition.com
Original post of this article: http://authoritynutrition.com/fat-shaming-makes-things-worse/
Feel you’re shaming yourself? It is common in overweight people. Read this post I wrote on body image. | <urn:uuid:87a577cc-9ec6-47a6-a78b-156be5539eed> | CC-MAIN-2020-24 | https://time2thrive.com/fat-shaming/ | 2020-05-25T09:11:10Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-24/segments/1590347388012.14/warc/CC-MAIN-20200525063708-20200525093708-00055.warc.gz | en | 0.968971 | 1,377 |
Let's Pretty-up Your Yard!
Mosaics for Outdoors
When: March 31 (10-4) + April 7 (10-3)
Where: Sacramento Fine Arts Center in Carmichael, CA
The format of this workshop is 2 sessions with a week between so you can get some homework done. In the first session you will get your substrate cut and prepped, and get started on the mosaic (adhering tesserae to substrate). In the following week, you will do some homework and finish adhering. Then you will return for class #2 to grout your piece.
In this workshop, students will learn all about lightweight, easy-to-cut, exterior-grade tile backerboard that is suitable to hang in outdoor environments. We will cut shapes, rig for hanging, mosaic, and finish off the edges in this fun class. You will also learn where to purchase this backerboard, and the other supplies needed.
First session: Info about substrates that are suitable for outdoor mosaics, cutting the board into simple shapes, and finishing off the edges. Planning a design on the board. Next, we will talk about tesserae and adhesives that are suitable for using on outdoor mosaics. And then in the afternoon you will begin cutting and adhering these materials to the piece. You will not finish by the end of the day. Our next session will be one week from today, which gives you a week to complete the mosaic.
Second session: This is our grout day. You will learn all about supplies, safety, tools, and the care and maintenance of grout. We will grout your pieces, using as many colors as you'd like. You will learn all about grout colorants, where to purchase them, and how to use them. I will then show you a few different techniques to incorporate several grout colors in your work.
Price: 150.+ 45. materials fee
To register send me an email at firstname.lastname@example.org. | <urn:uuid:c6ce5015-8b1e-48eb-9586-628f8af62f30> | CC-MAIN-2018-09 | http://scmosaics.com/artwork/3917999-Yard-Art-making-and-mosaicking-shapes-for-hanging-outside.html | 2018-02-25T07:20:33Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-09/segments/1518891816178.71/warc/CC-MAIN-20180225070925-20180225090925-00270.warc.gz | en | 0.946315 | 423 |
I never forced you to love this dragon,
But surely this dragon will always love you..
The dragon never knew how to persuade,
But surely you'll always be in this dragon's heart..
Hey,you know what..
You look too cute when you sulk,
You make me laugh with your childish attitude,
Sometimes i feel like I'm your sister,
And I have a little brother to look after.
Almost two years we've been together,
Sayang,I'm sorry for my roughness,
I'm still with my temper,
I know that you're soft hearted person,
Really soft,and it's my favorite reason why I DO LOVE YOU,
Kasarnya aku kerana lembutnya kamu,
Kerasnya aku kerana manjanya kamu...
My dear sweetheart..
Once again,I'm sorry sayang..
I LOVE YOU sweety.. | <urn:uuid:d7118a6d-b706-470d-9758-f1ebbe0108a9> | CC-MAIN-2017-17 | http://secretofnoone.blogspot.com/2012/01/soul-and-you.html | 2017-04-29T21:14:04Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-17/segments/1492917123590.89/warc/CC-MAIN-20170423031203-00103-ip-10-145-167-34.ec2.internal.warc.gz | en | 0.84815 | 203 |
JOHN C. JOHNSON. Honesty and stability of character are the foundation stone of a young man’s life, and in the formative period, when fitting himself for the battle of life, with those attributes of character, together with a fair measure of ambition, one is sure to arrive at the goal of his desires. Mr. Johnson is a native son of Madison County, Indiana, and has here resided all his life, His days here have been as an open volume to the citizens of Van Buren Township and the contiguous territory, and the people of his Township have conferred upon him the highest honor in official position in their gift,-that of Township trustee, The supervision of the schools, highways, bridges, etc,, and all pertaining to the interest and welfare of the Township have received his closest attention, and now, in the winter of 1913-14, his friends and acquaintances have solicited him to become a candidate on the Democratic ticket for the office of County clerk, and with straightforward honesty he is making the canvass, his candidacy seeming to meet the approbation of all.
A man of a jovial, kind and social nature, he makes friends easily and holds them steadfastly, and it is the expectation of many that Ike will carry the election at the head of his ticket, As one who thoroughly understands the requirements of modern education, he has already shown himself the champion of the local schools, and has used his best efforts to promote the efficiency of the local system.
John C. Johnson was born on the Joseph Johnson farm in section twenty-two on the ninth of November, 1877, His parents were Joseph and Elizabeth (Allen) Johnson, Joseph Johnson married Miss Allen in Hancock County, and then brought his young wife to Madison County in 1869, where he bought land in Van Buren Township, Successful as a farmer, he was also a man of more than ordinary local influence, He was twice elected Township trustee of Van Buren Township, and was always a willing worker in any community enterprise. His death occurred April 7, 1908, and he is buried in the cemetery of the Odd Fellows south of Summitville one and one-half miles, There were thirteen children in the family, whose names were: Manson N., Minerva J.; Jesse A.; Daniel M.; Mary E., who died May 28, 1910; Lewis W.; Etta L.; Amanda L.; John C.; Della A.; Pearl A.; James M. and Sarah C. The three last named are now deceased.
John C. Johnson spent his youthful days on the home farm of his parents in Van Buren Township, and as a boy first went to the old Zedekar schoolhouse No, 4, in Van Buren Township, For one year he was in the Summitville high school, and completed his education with one term of study in the Fairmount Academy in Grant County. It was his ambition to become a member of the legal profession, and with that end in view entered in 1896 upon a course of law studies under the able instructions of the Hon, Thomas Bagot, an honorable and successful lawyer, But ill health at that time intervened in the carrying out of this cherished desire and he returned to the farm. In the intervals of his school training Mr. Johnson worked on the farm, and was thoroughly trained for farm life and systematic business principles, Farming has been his regular vocation, and the cause of his most telling prosperity, He has a well improved eighty in section fifteen of Van Buren Township, though he does not maintain his residence on the home place for he moved into Summitville on November 7, 1907, where he has an attractive and comfortable home with his mother.
His election to the office of trustee, already referred to, came in 1908, and he has held the office up to the present time, Fraternally he is affiliated with the Benevolent and Protective Order of Elks No, 478, the Improved Order of Red Men, No, 149, and the A. F. & A. M., No, 691, His family are members and attendants of the Primitive Baptist church. | <urn:uuid:7f43fb49-1668-4467-9483-a5a0cd32ecdc> | CC-MAIN-2023-14 | https://accessgenealogy.com/texas/biography-of-john-c-johnson.htm | 2023-04-01T10:42:06Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-14/segments/1679296949958.54/warc/CC-MAIN-20230401094611-20230401124611-00581.warc.gz | en | 0.983758 | 843 |
CRNKN Takes The Throne For Best “Cool” Remix
Alesso was bound to get a serious re-work with his new track “Cool”…
Luckily for us, the best one yet was released by CRNKN. The once anthemic Alesso and Roy English track received a funky house transformation with hints of bass and trance. And although there isn’t much lyricism to this rendition, enjoy the beat and overall beautiful instrumentals.
I am sensing those midsummer feels we have all been waiting for with this one, so keep this in the vault until it’s safe to break away from your fall/winter collection. I don’t know how America is doing with this, but we are getting pretty close out here in London.
Alesso feat. Roy English – Cool (CRNKN Remix)
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- Sad Money Releases the Next “Hotline” Ring-tone - November 19, 2015 | <urn:uuid:fa9566cf-751e-4dfd-ae5b-fefcbc208900> | CC-MAIN-2017-04 | http://www.onlythebeat.com/house/2015/03/18/crnkn-takes-throne-best-cool-remix/ | 2017-01-23T08:30:14Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-04/segments/1484560282202.61/warc/CC-MAIN-20170116095122-00415-ip-10-171-10-70.ec2.internal.warc.gz | en | 0.939584 | 304 |
Beef ribs are boiled, then roasted in a tangy garlic and red wine sauce. The most unbelievable, easy to make beef ribs ever, man.
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Delicious recipes, party ideas, and cooking tips! Get a year of Allrecipes magazine for $7.99!
Read our allrecipes.com blog | <urn:uuid:78372b8e-ac84-44f5-8f14-c40b16429b4f> | CC-MAIN-2015-22 | http://allrecipes.com/recipe/insane-oven-beef-ribs/photo-gallery.aspx | 2015-06-02T14:05:33Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-22/segments/1433195035761.14/warc/CC-MAIN-20150601214355-00019-ip-10-180-206-219.ec2.internal.warc.gz | en | 0.84941 | 152 |
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My daughter turned 3, and we upgraded her nursery to a "big girl" toddler room. I wanted something that would grow with her, but yet still be fun, colorful & playful for a young child.
I didn't want to do anything with a "theme" and I wanted something clean & whimsical that would grow with my daughter.
Modern, Fresh, Contemporary, Clean Lines
Her bed is a full size - converted from her crib. Her dresser & night stand both belonged to my husband as a child (dark brown 70's with brass hardware). We just re-painted them to match her room, and bought modern nickle hardware from Lowes to clean them up. Total cost was less then $20.
Her Green & White Dresser that we repainted - I love how it turned out!
Be creative, and don't hesitate to re-use old furniture and items to give a room a loved, new look! | <urn:uuid:702fb365-c5f0-4812-a6b6-d0142bafc092> | CC-MAIN-2019-04 | https://projectnursery.com/projects/kaynas-toddler-room/ | 2019-01-16T20:09:57Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-04/segments/1547583657867.24/warc/CC-MAIN-20190116195543-20190116221543-00425.warc.gz | en | 0.975392 | 193 |
ABSTRACTPrincipal Investigator: Komlos, Janos Co-Principal Investigator: Endre SzemerediProposal Number: DMS - 0902241Institution: Rutgers University New BrunswickTitle: Some problems in Arithmetic Combinatorics and Graph TheoryThe PIs propose to investigate the structure of sets of integers without long arithmetic progressions and to extend these questions to cosets of subspaces in finite fields. They also propose to find sharp estimates for the size of sum-sets in various sets and for sum-product estimates (both 2-fold and k-fold) for integers and prime fields, as well as to describe the structure of sum-free sets. The graph theory part of the proposal contains questions about triangle-free graphs, the Burr-Erdos Conjecture, and the Komlos-Sos Conjecture.The PIs propose to develop new tools to deal with some challenging and important classical problems of Discrete Mathematics. The PIs have extensive background and experience related to these questions, some of the advanced tools used today in Discrete Mathematics were originally developed by the PIs. The proposed topics in additive numbers theory and in graph theory are applicable in mathematics and the sciences, especially in Fourier analysis and in practical algorithms, in number theory, in geometry, in graph theory and combinatorics, and in designing and analysing efficient computer algorithms (complexity theory). The subject of Discrete Mathematics is the investigation of finite mathematical objects and their structures. Discrete Mathematics is a rapidly growing area of mathematics with many theoretical and practical applications. Arithmetic Combinatorics is a field investigating the interplay between Number Theory and Discrete Mathematics, using deep combinatorial and Fourier analytic methods to understand additive structures of sets of positive integers. Graph Theory is the study of networks, modelling connection patterns in various mathematical and applied settings.
|Effective start/end date||8/1/09 → 7/31/12|
- National Science Foundation (National Science Foundation (NSF))
Explore the research topics touched on by this project. These labels are generated based on the underlying awards/grants. Together they form a unique fingerprint. | <urn:uuid:2a75230d-f4c1-4551-b406-bbd05cd2edd9> | CC-MAIN-2023-06 | https://www.researchwithrutgers.com/en/projects/some-problems-in-arithmetic-combinatorics-and-graph-theory-2 | 2023-01-27T17:30:45Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764495001.99/warc/CC-MAIN-20230127164242-20230127194242-00125.warc.gz | en | 0.900716 | 464 |
MAJOR LUCKY HEADS TO SYDNEY
Major Lucky has been withdrawn from the $150,000 Commodore Airport Hotel 2YO Harness Jewels Emerald at Ashburton on June 3 after failing to stay in touch with his former All Stars stablemates at Addington this month.
“He has gone to Robbie Morris in Sydney as he purchased him (for owner Greg Brodie). I was just looking after him,” said Overport Lodge trainer, Mark Jones.
A well-developed Art Major half-brother to last season’s top NZ 2YO More The Better, Major Lucky was race-placed in 1:54.9 in NZ and shouldn’t be hard to place in New South Wales.
He won a maiden for the Mark Purdon and Natalie Rasmussen All Stars Stable at Invercargill on April 2.
He ran a 5.1 lengths third to The Devils Own and All U Need Is Faith in the third Garrards Sires Stakes Heat at Addington on April 21.
Major Lucky paced 2:17.7 for the 1950m, but had to settle for eighth in the $195,000 PGG Wrightson NZ Yearling Sales 2YO Open Pace, won by The Devils Own in a record 2:16.3 (1:52.4 mile rate) at Addington on May 12.
He wound up his NZ racing with a sixth to top 2YO Spankem in last Friday’s $156,400 Garrards NZ Sires Stakes 2YO Final. | <urn:uuid:eaa15bc7-37bb-4164-934e-21feb2223935> | CC-MAIN-2018-05 | http://markjonesracing.co.nz/major-lucky-nsw/ | 2018-01-17T17:50:55Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-05/segments/1516084886952.14/warc/CC-MAIN-20180117173312-20180117193312-00222.warc.gz | en | 0.957374 | 327 |
View of Lake Langas. Photo: Peter Rosén / Lappland media
Siberian jay. Photo: Erland Harberg
Reindeers in Sirges sameby. Photo: Carl Johan Utsi
Stora Sjöfallet / Stuor Muorkke National Park
Alpine nature in the high Nordic region
Imposing mountain ridges, deep sculpted valleys, high boulder fields and beautiful pine primeval forests. The mountain celebrated in the Swedish children’s classic about Nils Holgersson is here: the Akka massif, also known as “the Queen of Lapland”.
Here, you will find everything you need to know before your visit to Stora Sjöfallet / Stuor Muorkke National Park. When it is best to visit the park, how to get there and the rules you will need to follow once you are there.
Experiences and activities in Stora Sjöfallet / Stuor Muorkke National Park
Sweden’s national parks offer experiences for young and old alike. Here, you can read about the wide variety of activities and sites which you can experience in Stora Sjöfallet / Stuor Muorkke National Park. | <urn:uuid:0127a656-b706-4c2b-8864-d63e8daf89b2> | CC-MAIN-2021-43 | https://www.sverigesnationalparker.se/en/choose-park---list/stora-sjofallet--stuor-muorkke-national-park/ | 2021-10-28T21:14:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-43/segments/1634323588526.57/warc/CC-MAIN-20211028193601-20211028223601-00140.warc.gz | en | 0.848444 | 266 |
Thoughts & Intents
Grace and peace be multiplied to you in the knowledge of God and of Jesus our Lord, as His divine power has given to us all things that pertain to life and godliness, through the knowledge of Him who called us by glory and virtue, by which have been given to us exceedingly great and precious promises, that through these you may be partakers of the divine natureÖ2 Peter 1:2-4
Welcome to Thoughts & Intents, the newsletter of the Bible Basics site at BellaOnline.com.
My Latest article on Bible Basics
I love that old Saint Peter. A brash fisherman and a blustery disciple, he blurted out whatever popped into his head, he blundered and bungled things repeatedly and even denied his Savior. But he returned, brokenhearted, to serve the church in deep humility and hard-won wisdom. Peter gives me hope, because Iím really good at blurting and bungling, and often find myself brokenhearted at my own foolishness. If God could use Peter, surely He can use me, too.
From my heart to yours
The Body of Christ at our church is mourning and celebrating, laughing and weeping as weddings, funerals, and new babies crowd the calendar. Itís exhausting and exhilarating, and I donít know how anyone can grasp and navigate these giant events without the help of God and some beloved brothers and sisters in Christ.
Serving our sweet Savior,
LeeAnn Bonds, Bible Basics Editor
Read my new blog, Katalambano!. (Katalambano is a Greek word meaning ďto lay hold of so as to make oneís own, to take into oneís self, to lay hold of with the mind, to understand, perceive, learn, comprehend.Ē) Not too much on there yet, but Iím working on it.
Please visit biblebasics.bellaonline.com for a growing collection of articles exploring Bible Basics. To participate in online discussions, sign up at the Bible Basics Forum . Pick a username and password, and you can ask questions or share your opinions on my articles, and also explore the many other subject areas at BellaOnline.
You can also reply to this email to talk with me directly. Iíd be glad to know your thoughts about what Iím writing, and whether or not you find it helpful in your walk with (or toward) Christ. And please pass this newsletter along to any family and friends you think might be interested in the subject.
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Amy Dickinson is an American newspaper columnist who writes the syndicated advice column Ask Amy. In a recent column, she published a letter from a reader asking how to handle a family surprise: upon having her DNA tested, the writer discovered she had a half-sibling that she was not aware of previously. She then shared this bit of information with her family, including with both of her parents.
The information was not well received.
You can read this rather interesting letter and Amy Dickinson’s advice in a number of newspapers, including the Detroit Free Press at: http://bit.ly/2QxfdL6.
Comment by Dick Eastman: I certainly cannot compete with Amy Dickinson’s nationally-syndicated advice column but I will offer one piece of advice to genealogists: If your research finds a something that was previously not widely known within the family, you might want to stop and consider the implications before you broadcast that information to your relatives. Do you really HAVE to tell everyone? or anyone? | <urn:uuid:784443c0-f984-4346-9fd4-a301371ad77f> | CC-MAIN-2019-09 | https://blog.eogn.com/2018/12/05/if-you-dont-want-to-deal-with-family-skeletons-dont-look-in-the-dna-closet/?rel=author | 2019-02-23T19:00:37Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-09/segments/1550249530087.75/warc/CC-MAIN-20190223183059-20190223205059-00035.warc.gz | en | 0.979516 | 210 |
Curious devices, forbidden artifacts, mysterious creatures, and intriguing documents.
Ahahahaha, and I was just telling the wife we needed to hit the flea markets to look for old bottles and jars...
Whatever you do, stay away from the olive and pickle section. Your family will quickly tire of the steady diet of gherkins and banana peppers required to empty the jars you covet.
I haven't started making things in a jar yet, but I've already succumbed to buying interesting jars in the grocery store. The local Krogers is getting rid of its store brand balsamic vinegar, and I have a burning desire to use it.
Post a Comment | <urn:uuid:c5df43f0-f6a5-49d5-8bfd-c09d32f1b101> | CC-MAIN-2015-35 | http://propnomicon.blogspot.com/2009/05/spiral-of-madness.html | 2015-09-02T18:57:39Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-35/segments/1440645281325.84/warc/CC-MAIN-20150827031441-00003-ip-10-171-96-226.ec2.internal.warc.gz | en | 0.942415 | 139 |
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TRIPLETS FIND A MOM
Genre: Series, Current Series Imprints, Love Inspired
TRIPLETS FIND A MOM (4) by Annie Jones: Teacher Polly Bennett is returning to her hometown to make a fresh start. She meets Sam Goodacre, single father of triplets, whose daughters are in love with the stray dog Polly found. The girls believe he is the dog their mother wrote about before she died. Polly and the girls bond, which scares Sam, as he fears they will be hurt. A heartwarming story touching on the goodness of animals and the important message that we are never too old to become the person we were meant to be.
Reviewed By: Leslie McKee
Publisher: STEEPLE HILL
Published: March 2012 | <urn:uuid:88ada5c8-f6c0-4171-bed1-7d556c031c17> | CC-MAIN-2014-10 | http://www.rtbookreviews.com/book-review/triplets-find-mom | 2014-03-08T07:48:11Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-10/segments/1393999653980/warc/CC-MAIN-20140305060733-00012-ip-10-183-142-35.ec2.internal.warc.gz | en | 0.952613 | 238 |
As long as it’s with regards to Newton’s laws of motion and electromagnets, research shows curiosity does not kill the cat after all.
Should we be concerned or should we just keep pressing those sweet, sweet buttons?
While Japan is famous for its animation, food, pop-culture, it’s also infamous for its extremely high suicide rates. Many Japanese students and salarymen succumb to the pressures of school and work by taking their own lives. There is little knowledge about what factors increase the risk of suicide, but recent research has found that people, namely adolescents, born between January 1 and April 1, are 30 percent more likely to commit suicide.
At some point in our childhoods, most of us probably owned a few coloring books to keep us entertained on rainy days or while traveling.
Although coloring is still a great way to boost a child’s imagination and improve motor skills, as digital technology continues to develop, fewer children are turning to coloring books to pass the time.
So in order to make coloring “cool” again, Disney decided to do a little research into what they could do to breathe some life back into this old pastime favorite.
Dr. Timothy Mousseau, professor of Biological Sciences at the University of South Carolina and researcher for the Chernobyl and Fukushima Research Initiative, presented new findings to the International Ornithological Congress in Tokyo last week that suggest radiation contamination around Fukushima Daiichi, even at low levels, is negatively impacting biodiversity and wildlife populations.
Your fist kiss is sure to be a memorable event. It might even be the most memorable event in your life for decades if all goes well…or if it turns into a proper disaster. At least, that’s what we learned from teenage comedies–and Hollywood never lies, right? But even though it’s such a big event in any young person’s life, everyone’s first kiss seems to come at different ages.
We’ve discussed kissing in Japan before, but a new survey reveals the average first-kiss age of Japanese folks broken down by prefecture, showing which prefecture’s women were the fastest and kissiest in the country! Who do you think came in first place? And who’s bringing up the rear as the “slowest to their first kiss?” Find out below!
Thanks to the patient translation efforts of AltJapan Co., Ltd. co-founder Matt Alt, readers can now read, in English,most of the 90-page study on robot anime made available by the Japanese government. Titled “Nihon Animation Guide: Robot Anime-hen,” the original document was written by anime critic Ryusuke Hikawa, Sunrise head of cultural promotion Koichi Inoue, and writer Daisuke Sawaki, and compiled by Mori Building Co., which has previously also compiled reports on Japanese live-action special effects shows, movies, and other pop culture topics. In addition to these reports, the company also promotes media arts information, hosts symposiums, conducts surveys, and works on archive projects.
Ladies and gentlemen of the gaming world, those entire summer breaks spent parked in front of that hulking box of a rear-projection TV (but it was 60-inches!) with your N64 controller in hand were actually productive despite what your mother said. Thanks to the hard work of researchers in Berlin, we now know that playing Super Mario 64 is scientifically proven to increase your brain size. Which goes to show that a lot of things your mother told you as a kid were probably false. So go ahead, stop listening to your mom, your brain is probably bigger than hers now anyway.
Kimchi is a fermented cabbage dish from Korea that is often referred to as “Korea’s national dish.” It’s so pungent that those who enjoy eating copious amounts of kimchi have been known to purchase a separate fridge dedicated to storing it. For decades, Korean mothers have sworn by the health benefits of adding kimchi to one’s diet, but now it seems scientists agree as well. New research published in the Journal of Medicinal Food suggests that eating even a small amount of kimchi every day may help lower cholesterol, LDL (“bad cholesterol”), and fasting blood glucose levels.
Bitching about our bosses is probably one of the best things about socialising with coworkers. They’re to strict; they’re a push-over; they have coffee breath and get way too close when they talk; whatever the issue, complaining about the boss is a great stress reliever and helps us get through the day.
According to a recent survey taken across four countries, however, expectations of bosses and opinions of what makes a good one vary wildly between countries. Not only that, Japan ranks as the country with the lowest “boss satisfaction” rate of all those surveyed.
Of course, my boss is the greatest, and I would never even dream of saying a bad word about him <cough>Christmasbonus<cough>, but the difference between the opinions of those surveyed in Japan and those in other countries, most notably China, is startling.
The University of Tokyo Research Center for Advanced Science and Technology (known as “RCAST” for short、thankfully!), in conjunction with Microsoft Japan, has launched trials of new a computer program that utilise Microsoft’s Kinect for Windows technology as a way for physically disabled people to communicate and interact with computers.
For the uninitiated, Kinect is a motion-sensing camera designed for Microsoft’s Xbox 360 console and Windows PCs that tracks users’ body movements and is capable of recognising voice commands. The technology first became available for Xbox users just under two years ago, with Microsoft heralding a new age of gameplay where “you are the controller”, seeing users flapping around their living-rooms like maniacs to control their video games.
While games that utilise Kinect well have been few and far between, it would seem that the technology, once intended as a competitor to Nintendo’s popular Wii console, could soon be changing disabled people’s lives for the better.
This story probably isn’t coming to a theatre near you any time soon, but it certainly sounds like something straight out of a movie.
In the tiny village of Kamikoani, Akita prefecture, the sole medical practitioner has thrown her hands up and admitted defeat. Amid rumours of bullying and harassment, Dr. Ijiri has become the third doctor to hand in her notice in as many years. Previous GPs in the village reportedly left for similar reasons, and are quoted as saying that “the job was simply too much to bear” and that they were “slandered” by rumour and vicious talk amongst the townspeople.
But when word arrives that a 71-year-old specialist has decided to pick up the gauntlet, the tale takes an interesting turn…
The best talkers are people who keep it short with something interesting to say. It is forgivable for someone to go on at great lengths if the content is captivating. But the worst talkers are those who drone on and on concerning the most boring, mundane topics.
As adults, we all have to put up with a certain amount of polite listening, even though we would really like to run out of the room screaming from boredom. You could probably get away with that in your personal life (although you might not have any friends left afterwards), but work related meetings are particularly querulous, where you have to listen to endless reports, where nothing is decided, and where all you want to do is get out of there, or at least take a nap.
Good news! There is a way to shut people up harmlessly and with the simple aim and fire technique of a gun. Wow! Read More
Supermarkets all across Japan have been struggling to keep up with demand for that barely-tolerated gritty beverage known as tomato juice. This is the latest in an ongoing series of food fads many in the country believe to be effective in reducing weight like cabbage and bananas.
At the beginning of February one supermarket in Osaka had a well-stocked shelf of tomato juice daily, most likely catering to the odd person avoiding blood clots or making Bloody Marys. However, on the weekend of February 10, hordes of shoppers descended on their supply of juice like so many locusts on a farm. By the 14th, the staff was turning desperate dieters away as new shipments could not reach them in time. | <urn:uuid:4db97a79-dd85-4ec6-aca6-8f5215f5c623> | CC-MAIN-2016-26 | http://en.rocketnews24.com/tag/research/ | 2016-06-28T09:44:14Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-26/segments/1466783396872.10/warc/CC-MAIN-20160624154956-00162-ip-10-164-35-72.ec2.internal.warc.gz | en | 0.96553 | 1,788 |
Unilever Nigeria Plc – Welcome to Unilever, a global multinational and fast-moving consumer goods (FMCG) company with products sold in over 190 countries and more than 2 billion consumers across the world who use our amazing products everyday!
We are recruiting to fill the position below:
Job Title: Assistant HR Manager
Job ID: R-32649
- As a HR Generalist, you are at the heart of the end-to-end delivery of all people related activities and processes across Africa.
- You are hands-on and bring to the team strong operational excellence in executing best in class Employee/Industrial relations, resourcing, capability building and HR operations.
Your Key Tasks
- You are the curator of culture in your market and responsible for driving initiatives that keep employees engaged and improve the overall employee experience.
- As the first point of contact for employees in your local market, you deliver front line HR support to the business and ensure HR delivery is fully aligned to business goals.
- You act as a coach to Line managers on talent management, reward management, performance management, engagement/culture and employee relations.
- You ensure resolution of local ER/IR issues (including Payroll errors, Payroll rejects, grievances, disciplinary, dispute resolutions, absence, retirement, and redundancy).
- You support the talent management strategy and work with your regional HR team on performance management and career development plans.
- You activate and execute the performance management cycle in line with the global timelines.
- You co-create and activate the career development plans for your local market.
- You support line managers in executing reward strategy/guidelines as required as well as the development and execution of training plans to build the capacity of the talent pool.
- You ensure the employer branding strategy is implemented according to the local strategy.
- You will be required to lead/support ad hoc projects related to ekaterra’s separation from Unilever and setting up ekaterra as a successful independent organisation.
- You are responsible for the management and successful running of the monthly payroll in your market. Collaborating both internally and externally to ensure employees are paid accurately, on time.
- You ensure ekaterra’s compliance with local legislation by maintaining relationships with the relevant bodies, representing at local sessions, and maintaining relevant records.
- You ensure ekaterra’s HR data accuracy by liaising with the HR Shared service center on data management activities (Position management, data cleansing, reporting lines, etc.)
- You support line managers with their recruitment process needs (Job requisition, selection process, offer) along with pre-onboarding and onboarding activities to create a lasting experience for new joiners.
Skills and Experiences
- You have a minimum of 3 years of HR Generalist experience including employee/labour relations, recruitment, reward and benefits administration
- Good knowledge of local employment/labour laws
- Working knowledge of HRIS systems
- Good administrative, negotiation and influencing skills
- Project management experience would be advantageous.
Who we are looking for:
- Fluent in English
- Strong communication skills
- Meticulous, attention to detail
- Driven, results oriented with great passion for tea!
- Pro-active, energized, and positive
- Collaborative, team player
- Personal Mastery.
How to Apply
Interested and qualified candidates should:
Click here to apply | <urn:uuid:5a2749b1-757b-4984-95a2-5c4045f9ea71> | CC-MAIN-2022-40 | https://www.jobinformant.com/2022/02/assistant-hr-manager-at-unilever-nigeria-plc.html | 2022-10-06T19:52:27Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-40/segments/1664030337855.83/warc/CC-MAIN-20221006191305-20221006221305-00203.warc.gz | en | 0.91586 | 723 |
Just been to ASDA and this seems to be instore everywhere.
McCoys BIG Value pack Classic 18 (Actual Price is £4.37). ASDA is selling 2 for £4
6 x Salt & Malt Vinegar
6 x Salted
6 x Cheddar & Onion
Also chances to win Fantastic Football Trips contest along with pack.
So 36 Packs for £4 wich is 9 Packs for just a pound. Seems to be Fantastic deal. | <urn:uuid:317402fe-3072-4c78-9ccc-04319f6821bd> | CC-MAIN-2016-50 | http://www.hotukdeals.com/deals/mccoys-big-value-pack-2-for-4-at-asda-686553 | 2016-12-06T20:10:10Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-50/segments/1480698541995.74/warc/CC-MAIN-20161202170901-00461-ip-10-31-129-80.ec2.internal.warc.gz | en | 0.916048 | 97 |
A donation form may be accessed for printing by clicking here. Forms are also available in the LearningQUEST office.
Make your check payable to “LearningQUEST” and mail to:
P.O. Box 693
Huntsville AL 35804
LearningQUEST is a 501(c)(3) organization; all contributions are tax deductible to the extent allowed by law. | <urn:uuid:4a8f288c-664c-4cac-bc15-cfe0e5a6101d> | CC-MAIN-2017-26 | http://lquest.org/forms/donation-form/ | 2017-06-24T08:45:25Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-26/segments/1498128320243.11/warc/CC-MAIN-20170624082900-20170624102900-00114.warc.gz | en | 0.909942 | 78 |
Friday, November 6, 2009
Once one is over the fascination and glamour of the martial arts, whatever they are, one can then begin real work and study of them. Clearing the mind of fantastic notions, theories,ideas, and attempts to accomplish marvelous,extraordinary and stupendous feats abandoned, one can perhaps learn and perceive what martial arts are really all about. The commercial trappings that seem to surround these ancient and modern martial arts,wherever found, distract many from the true and real path but cannot always be avoided but have to be recognized CONSCIOUSLY for what they are in any case.
Wednesday, October 7, 2009
Many people have seen various martial arts feats,performances, tournaments, demonstrations, exhibitions, or lessons and classes involving martial arts, BUT HAVE THEY EVER OBSERVED SUCH? oBSERVATION IS NOT SIMPLY SEEING SUCH. True observation requires you be there, that you OBSERVE and are AWARE,not passively letting things flow in front of you. Yes, people have seen much,especially via media and confuse that with actuality/reality and believe they 'know all about' whatever it is being presented,etc. This is why when all the people watching such things, as martial arts, leqave the scene, they cannot do anything they have witnessed! This is because they have not observed, at least to the degree necessary to take away certain impressions and influences based on a truly conscious presence. FOR THOSE WHO ARE AWAKE, this is why the old masters never allowed people to merely attend or witness or 'observe' their methods and practices except on rare exceptions, like when defending themselves or others. In today's electronic universe, everything is hanging out, ready like hanging grapes to pick off U-TUBE and elsewhere or DVD's books,etc. which is good if you can grab things that way and really make them your own. Whenever I go anywhere I try to come away with something that others will leave behind, because,as has been said, 'their cups are full when they arrive'! Whatever masters, instructors, experts,etc. I have been fortunate to meet, to know, to befriend, I have always been privileged to obtain something from them,whether tangible or intangible, and without OBLIGATING MYSELF as much as possible,that is, owing them great debts of gratitude,etc. If they want to show me personally something, I do not refuse,let alone attempt to do what so many others do(show them my ways,unless they really insist and ask). In this way, I had many valuable lessons and am still learning,not teaching. If you understand this, then perhaps you will b egin to really observe while others merely see and watch and applaud,etc.
Tuesday, September 15, 2009
HOW you die is as important as when you die or where you die, if not more so. That everyone and everything dies is a truism everyone seems to accept. The goal of many is to live a long life and to die peacefully, but few really achieve this, and many end up in a drugged stupor surrounded by strangers and not family or friends. Their machine(s) are kept alive as long as possible by 'scientific' apparatus and other methodologies. Eventually all the systems shut down and someone tries to determine the time of actual death,etc. Then the body is given some procedures to either bury or burn it and then comes various rites and rituals, ceremonies and so forth for either remembrance(s), accolades and tribute and testimonies, or to whisk the 'soul' onits way to Heaven or Hell, Paradise, or Eternal Slumber and so forth. This happens only in countries where such can take place,but the truth is that many people simply die in the streets or wilds and GREAT NATURE consumes them. In fact, GREAT NATURE and THE GREAT UNIVERSE absorb all the released energies of life which GREAT NATURE & THE GREAT UNIVERSE utilize in many ways, mostly hidden, obscure, etc. to us! What has any of this to do with MARTIAL ARTS? Martial arts in their esoteric aspects are designed to prepare us for death as well as to assist GREAT NATURE in absorbing energies released when we kill or destroy,as martial artists,who lhave great responsibilties in this regard.
Tuesday, September 8, 2009
Although all martial arts practice invoke risk of injury as well as death, it is my observation that nearlyall of them as shown on Dvd,U-tube,MMA,and at tournaments,etc. with perhaps some rare exceptions, all lack what can be termed 'lethality'. It is obvious that most demos and bouts,though sometimes multiples are involved, which usually involve two persons facing each other, that no one is going to really killed or severely crippled,injured,etc. as a result. If you know this then you are really only going to evaluate it as such on the basis of certain factors(to be considered another time) and you cannot really state if they are truly 'lethal' tactics,deadly, or capable of killing. Do we need to prove such lethality? Laws and regulations,etc. are against such proofs and on today's battlefileds hand-to-hand,traditional, classical methods are seldom employed because of high-tech weaponry and the like. More to be said on this war/combat aspect another time. The point is that nearly all those taking up martial arts ahve not and probably won't ever kill anyone with their bare hands,unarmed,though some may kill with knives, sticks,etc. either accidentally or on purpose.
In nearly all martial arts and various practices related to martial arts, there is always the risk of danger, injury, as well as the possibility of death, it might seem, just as there is in nearlyevery human activity. Martial arts are assumed to be somewhat lethal and are to be used with caution and discretion, as most experts and masters tend to assert and insist. HOWEVER, I notice among all the various demos and matches and antics in and out of the ring,etc. a complete lack of LETHALITY. Few persons enter such with the exact notion of killing or crippling their opponents, all in the name of sport and competition, and we are all advised to save such for what are considered 'rare',life threatening, and dangerous situations, but clearly a 'kill or be killed' attitude and effort are lacking no matter how many injuries are sustained or how 'brutal,. such instances appear. A great fear of legal implications,even in wartime, hangs over the real warrior who usually these days uses guns and other weapons. This concept of LETHALITY is difficult to explain, let alone demonstrate, in any seminar or workshop or training program and is completely ignored for the most part for all kinds of reason. The Japanese during WWII had little hesitation in showing how sharp theair swords were on the necks of Chinese, Americans, British,Dutch, Filipinos, Indonesians,and other captives. There would be little doubt in the minds of those witnessing such that lethality exists and such weapons can and are lethal. NO THEORY THAT! The same also applied to ju-jutsu, arnis, karate,etc. because they can be very lethal when this concept is fully understood(and it never is for a number of reasons) and is not necessarily the same as 'cruelty',barbarism' 'torture' or the like when you have to call upon this LETHALITY to survive. There is always more to be said on such but I think we can safely say that most practitoners and students of martial arts as undergoing training today have not intentionally killed anyone using these martial arts. There are exceptions,no doubt.
Tuesday, September 1, 2009
The word 'esoteric' means 'inner' whereas the word 'occult' has come to mean 'hidden'. There are three forms of knowledge, that is, esoteric/occult. Which means also there are three forms of existence among humans who pursue these things: THE ESOTERIC;THE MESOTERIC; and THE EXOTERIC-but the outermost circle, if we conceive of humanity being divided or,rather, framed within circles of existence, is the OUTER CIRCLE OF HUMANITY to which most of humanity belongs in and in which they live. The Law Of Accident operates very strongly in the Outer Circle and GREAT NATURE tends to rule over things on the earth.
Tuesday, July 28, 2009
In recent years yoga has gained a great popularity in the world for many reasons. When I was younger and first learned about yoga and its existence, you could not find anything much on it except in books, magazines, and occasionally a movie or two. I learned about yoga around the age of 8,9,or 10 years and I shall relate some of that in later blogs or comments. Nowadays, yoiu can find a 'yoga studio' or session in even the smallest US towns and villages, along with other Eastern practices,such as Tai Chi or Qi Gong or Acupuncture,etc. as well as other similar things of a mystical/occult nature. Magazines and DVD's or videos as well as books and seminars, and yoga camps have all contributed to the spread and growth of yoga. All this may seem rather obvious to sophisticated and uptodate people, who follow all the trends, but at one time, the search for yoga was difficult and as mentioned previously in this section, The Way of The Yogi is not for everyone if it is truly followed. Most people are concentrated on the so-called basics of HATHA YOGA and are content to twist themselves up into pretzels and complicated, intricate poses and postures, of which they seldom, but occasionally, have any idea as to why these are done,save for supposed physical benefits,etc. I find a complete ignorance of the traditional Yoga Classics, and literature often existing,except if one has come under the sway or influence of specific groups and teachers or masters and swamis,etc. who tend to keep tabs on their devotees and followers for reasons of their own,usually. Of the three traditional ways: THE WAY OF THE YOGI tends in its higher forms to be MENTAL or even intellectual,involving the mind, the brain and the nervous system as well as logic and positive thinking, but not the kind most think of or about. Where systems of Yoga are heavily coated with the religious notions and speculations and rituals and rites of TRADITIONAL HINDUISM, one will encounter a number of obstacles and contradictions and problems on this path,especially without a true, real, initiated teacher or teachers. Entering ashrams and other yoga areas can prove interesting, disappointing,exciting, and laborious. To really understand yoga, and,indeed, any religion or martial arts or such similar area, I always say for others to visit the lands where these things originated if possible and not rely on just readings, second-hand observations and comments and teachers who have not trod the hot,dusty trails or the high perilous mountains,etc. in search of these things.
Tuesday, July 14, 2009
The Way of the Monk includes the Priest, the Lama, the Hermit, the Wiseman, and a number of others who follow a religious orientation and system or practice, whether organized or not,but, like the Way of the Fakir or the Way of the Yogi, everything has to be accepted from the beginning and followed to the end, without knowing where you will actually end up: whether HEAVEN OR NIRVANA, HELL OR HADES, OR PARADISE OR THE NEW EDEN,etc.etc. You will have to embrace ritual and rite, kneeling in prayer and also allow devotional attitudes to emerge. Emotion and 'LOVE' and other things will be the focus. Then,in some cases, obedience, chastity, and poverty will be your burdens. The Way of the Sufi is sometimes along this path as is the way of the Fakir. They sometimes share certain aspects of their respective paths,but few of us will give up our present state and embrace these paths. It is most informative to read the biographies and autobiographies of Westerners who have gone to Indis, Tibet,Egypt, Thailand, China, Japan,etc. to embrace the religions and practices of these lands,especially Zen, Yoga, Vedanta,Sufism, etc. The caution is NOT TO LET YOUR IMAGINATION SWAY YOU INTO EMBRACING ALL THESE THINGS.
This traditional Path is one of the most misunderstood of the three classic paths. The other paths, that of the monk and the yogi, sometimes employ a few of the methods and techniques from this path. Essentially, the path is physical, intensely so, and the more familiar examples of the practitioners can be found in RIPLEY'S BELIEVE IT OR NOT, in either photos or drawings,etc. FAKIRISM does not mean faking though some Fakirs are 'tricksters',con-men, and utilize various techniques. They can also be soothsayers, magicians(the street variety) and even astologers, but various schools exist. More needs to be said on this aspect of THE WAY OF THE FAKIR, but you can see some examples in 'body-builders', Hatha yogis, and side-show performers,etc. Mastery of the body is the key to being a Fakir. Often this involves intense pain and suffering to achieve a goal few would care to try and reach in the modern, indulgent world. Some of the practices tend to masochism and even sadism, torture and physical extremism. However, the notion of 'INTENTIONAL SUFFERING' is a much higher format to follow than most realize. Aspects of this can be found in BUDDHISM and CHRISTIANITY, of course. For most religions, life itself is suffering and all life suffers. People in the West tend to try to evade and escape from pain at all costs, especially through drugs,etc. and do not really try to understand certain forms of pain or to control such,etc. The Way of the Fakir is one way to do this and perhaps to achieve liberation and enlightenment but you have to accept everything from the beginning without knowing where you will end up!
Although most of us look at sensing as being the same as the 'senses' it is not really the case as anyone who undertakes the process and activity of 'sensing' will soon discover. Several systems of sensing exist and many of them have merit for particular persons and more especially for specific body types. If you look at the nerve patterns and pathways in the body as well as the meridians and channels, and other types of a similar nature, you will see that much is involved. However, you have to also learn some things about relaxation and tension, which are not 'sensing' per se but they can also assist in your understanding and possible mastery of this process. The better way to learn what sensing is about is to have an actual teacher guide you.
Tuesday, June 30, 2009
Remembrance is a periodic process whereby one remembers or recalls certain images, events,circumstances,happenings,experiences, people, relatives and other things from the past, that are essentially one's own.! Ponder this a bit. It is an important aspect of life to remember and to remember one's self most of all. There is a certain duty, an almost ceremonia laspectto all fothis and perhaps that is why on certain days of the year certain memories are best recalled and remembered.
There is avast body of FALSE KNOWLEDGE that plagues the modern world and it has a great allurement,seducing the minds of both young and old, while it masquerades as 'DIVINE' OR 'SCIENTIFIC' or'HEALTHY'! Advocates of these systems ofFALSE KNOWLEDGE arise daily and establish trends that appeal enough to form an addiction to their various stimuli. The DANGERS of FALSE KNOWLDEGE are not to be ignored or denied as any excursions taken along THE PATH OF FALSE KNOWLEDGE will prove.
Tuesday, June 9, 2009
Ask any sniper or hunter and you will find that the concept of CONCEALMENT is very important. Concealment can be called a blending in with your environment or surroundings so that you appear to be part of the landscape but at a much higher level, INVISIBLE, not present on any level. Playing the idiot,the fool, the clown, can also do this in certain places and certain times. What this means is that your intentions are concealed, not read in any 'body language' terms or gestures or subconcious movements discernible by astute observers of mannerisms and the like. On a mental level it means not betraying or revealing your mindset, your beliefs and thoughts,etc. On an emotional level it means not showing pain or joy or other emotions even though you may well feel them. This includes signs of thirst, pain, anger,etc. All this, as you might well know, is what is necessary to survive,should you be subjugated to them, the modern methods of interrogation and torture, as well as others, should you, as a warrior,be captured! There is much more to this as you might well imagine and for now this is perhaps too much for you to swallow.
Thursday, June 4, 2009
The usual list of THE FIVE SENSES: seeing,hearing, feeling, tasting and smelling are supposedly well-known to everyone who has them,though some people are deprived of one or two or more of them by nature and other circumstances,of course. Then there is the notion of a 'SIXTH SENSE' sometimes equated with ESP! Anyone know who first came up with this notion of Extra-sensory Perception? Will give you the answer sometime later after you wade through these posts of mine. Technically, there are more senses than the traditional five. One is the kinesthetic sense which is important for martial artists and yogis, and occultists. It also involves the principle of leverage when it comes to performing 'tricks',stunts''feats' and 'miracles'. There is a difference, however, between the senses and 'SENSING' which few persons know how to do and this will be a first focus for those who seek to know more about such intangibles as "KI','CHI','QI' or 'GHI' and even that elusive KUNDALINI.
Wednesday, June 3, 2009
The concept of SILENCE is not merely being quiet but that is a start,especially in most forms of meditation,whether yogic or zenist,etc. Most people are far too talkative, verbose, and given to noise of all kinds. Their favorite subject is usually themselves and their doings and interests,etc. I am no exception as you will see, no doubt,but my goal in expounding things is to leave them for others to mull over and ponder as they see fit, rejecting or accepting, affirming or denying. In some cases this sort of silence means being rather unknown or anonymous but there is a deeper meaning which is expressed in this term: TAKIYAYAH OR TAQIYA which runs the risk of being misunderstood by those who are no versed in this. Many so-called MASTERS of various disciplines,whether martial arts or meditation or occult areas are both flamboyant and verbal and even literate, publishing volumes of things for a variety of reasons. The Silent Masters, difficult to locate, let alone understand, seldom come with the ordinary person's scrutiny or social sphere. The old saying, 'WHEN THE PUPIL IS READY, THE TEACHER WILL APPEAR' applies here,no doubt, but many who pin their hopes on this sort of passive approach, may end their lives with no teacher at all.
Saturday, May 30, 2009
Hand-in-hand with stealth is the concept of EVASION which means eluding your enemies or those 'hunting' or 'stalking' you and involves the other important concept, often discussed in martial arts, but seldom practiced or understood: NON CONFRONTATION or DIRECT ASSAULT. In future posts, I will try to discuss without compromising those who know of such, the principles and concepts and some applications for those interested in expanding their martial arts background
One of the most important and least understood of martial arts concepts and applicatons is that of STEALTH. Very few dojo-trained martial artists understand stealth and its applications for several reasons that will be discussed at another time. While military men, warriors, and hunters, and others may know about stealth needed to conduct certain operations, especially at night, which is another entire subject that needs elaborate and practical treatment, ordinary persons usually relegate the concept of stealth to 'walking on tip-toes' or 'sneaking about' much like a cat or a stalker(hunters and snipers are actually stalkers but by another name). It can also be described as 'walking through the world silently', leaving no trail or footprints(either literally or figuratively). If any trace of presence is left, the marks, nearly invisible and unnoticed, can only be read and discovered by those who know!
Tuesday, May 5, 2009
Ordinary life is often seen as monotonous and with little way to accomplish things beyond the humdrum. We often ignore the ordinary and hope for the sensational as well as the complex. But the truth is that ordinary life is the best path to be on though it is the most difficult to follow! Yes, you can give everything in ordinary life, as so many have, to become a priest, a monk, a minister, a warrior, a yogi or a fakir,etc. but the overall characteristic of your life, will not be certain and actually be what you really should be. In future blogs if I am able to do so, I shall discuss why ordinary life offers more than all the other pathways put together. Let us first look at LIFE, which is all that we have at the moment. Never mind so-called 'immortal souls' or Heavens or Hells or Afterlife or any of this NON-SENSE(meaning, of course, not easily apprehended by the five or more senses we possess). Without LIFE where are you? Who are you? Why are you? How are you? These questions have always been asked and the answers vary from teacher to teacher and group to group. You have to find your own answers to such and this is why ordinary life is so difficult. Ordinary life does not offer you a quick and easy solution. Whereas all these other paths offer you ready-made, seemingly logical, emotional or physical answers to all of life's great questions only if you accept everything, right off, and follow that path. Life's ordinary demands are often enough for most of us but we don't realize it until our life is no longer and that is why life is so important, and,of course, right now.
There are three traditional paths: THE WAY OF THE FAKIR; THE WAY OF THE MONK; and THE WAY OF THE YOGI. The main problem of embarking on these path, which may be both occult and esoteric as well as involving other things too numerous to mention here now, is that you cannot be sure of reaching the goal or the aim that you may have in your life! If you decide to embrace any or all of these paths you will be unable to decide things for yourself because all is set up for you and you cannot know where you will actually end up. How many have embarked on these and found, nearly at the end of their lives, they had made a great mistake or else succumbed to the delusions that such has brought them great gains, either in happiness, prosperity, health, accomplishment, and even Paradise! Also, the members of these Paths usually attempt to persuade others to follow these paths and pursuits and that they are generally absolutely right and correct in their assumptions, beliefs and so forth,sometimes making it appear others are in error and delusion. This might well be the case, of course, but one has to live one's life, however, long or short. | <urn:uuid:cf5f9b87-afc0-48c9-86d0-6b438f08f806> | CC-MAIN-2017-34 | http://esotericmartialarts.blogspot.com/2009/ | 2017-08-16T14:53:29Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-34/segments/1502886102307.32/warc/CC-MAIN-20170816144701-20170816164701-00011.warc.gz | en | 0.962206 | 5,094 |
The median line
of the modified schiff
and its sliding parallel create a descending channel
which works phenomelly well with price finding support and resistance
everytime it reaches them. It is now approaching the upper parallel into a corrective structure, so keep a closer eye for a sell setup completion. Stops should be placed above 0.99400 and profit targets at 0.98500.
I wish you Merry Xmas!
All the best to you and your families,
p.s: Spot your FREE seat in my four weeks training course on median line
analysis (January Class). Info in the signature box below..! | <urn:uuid:7c314965-0b2f-4f4f-93ee-fb37ce3a9f73> | CC-MAIN-2019-04 | https://www.tradingview.com/chart/USDCHF/DdEjUKBU-USDCHF-Sell-Opportunity/ | 2019-01-17T01:14:18Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-04/segments/1547583658662.31/warc/CC-MAIN-20190117000104-20190117022104-00606.warc.gz | en | 0.883409 | 130 |
Hi VIPs! We love Wednesdays. don’t you? We’re half way through the week and on a downward momentum as starting off is always the hardest. So let’s have a mini celebration about the fact that it’s Wednesday. Why not? We deserve some breaks.
So take time out and turn the volume up to listen to these top 5 tracks of the week:
Florence and The Machine -Too Much Is Never Enough
Bon Jovi – This House Is Not For Sale
Young Thug, Travis Scott – Pick Up The Phone
Tinashe – Superlove
Green Day – Bang Bang
Sabrina Carpenter – On Purpose
What did you think?
Have a fab day and we’ll be back tomorrow with a round-up of the week’s top celeb goss so far. | <urn:uuid:a291bc8f-0d7e-4c18-b363-c6348adfdbb1> | CC-MAIN-2019-47 | http://livelikeavip.com/2016/08/17/midweek-music-top-5-new-videos-15/ | 2019-11-15T09:57:54Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-47/segments/1573496668618.8/warc/CC-MAIN-20191115093159-20191115121159-00014.warc.gz | en | 0.848639 | 179 |
Trick or Goat-Ginger Pumpkin Goat Milk Soap
Trick or Goat
Ginger Pumpkin Goat Milk Soap
Homemade goat milk soap, milk from hand milked goats. I have a small diary mix herd along with an endangered species of goat called the San Clemente Island Goat. I am selling soap and other farm products to help people be aware of the awesome goat!
Ingredients and information-Weighs 3oz.
Ingredients are-Olive oil, coconut oil, shea butter, goat milk, lye, bentonite clay, black cocoa powder, ginger pumpkin fragrance oil. | <urn:uuid:2ffeaa37-6275-4d5f-b826-9a14793d9ffd> | CC-MAIN-2020-29 | https://www.ebranchllc.com/store/p105/trickorgoatgingerpumpkingoatmilksoap.html | 2020-07-10T07:47:43Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-29/segments/1593655906214.53/warc/CC-MAIN-20200710050953-20200710080953-00263.warc.gz | en | 0.867866 | 124 |
Tell us about your entrepreneurial product or service.
KidMastermind is cloud platform creating awesome educational tools for parents on mobile devices with idea: “Spend quality time with your child through playful education.”
As platform we provide opportunities to different professionals to create educational tools. It could be teachers, moms or dads photographers, moderators and developers. Being passioned about their job and having for example some circumstances in life, they could join us, work from home and create quality products.
All these different products transform for parent into ready-to-fly programs, that are based on parent's possibilities (like time) and goals (educational approach. for example, like montessori) and also on child's age and current educational level.
One more feature – it is all on mobile devices and could be used everywhere and anytime. And it is so valuable to get certificate teacher feedback from the cloud.
What we have now:
– iPhone app KidMastermind University for Parents with step-by-step educational programs (developing skills, progress included) for child (1-5) with educational coach support.
– iPad games for children age 1-5 that develop exact skills and have inner progress.
What inspired you to launch your business idea?
When my son was born I realised that I have no instructions what to do with him. I started to read books, chat on blogs, hired educator for me to develop my son. All these researches took ton of time. But I wanted to spend time with my son, than just reading.
Actually it pushed me to start doing something easy to use for modern busy parents, tailored just for their needs and on mobile devices. It grows to KidMastermind.
What problem does your business or organization solve?
Nowadays active busy parents have luck of possibility to spend perceived time with their little children. But they want to spend quality time together, to tighten family bonds and to achieve high results. What they get mostly from the market – parenting books as source of information (books are not personalised and request lots of time for search); TV (child mostly waist time alone) and educational apps for tablet (not obvious what skills does it develop).
We propose solution that saves their time, help them spend quality time with children together and achieve high educational results for children.
What has been your biggest challenge as an entrepreneur and how are you working to overcome it?
First to stop dreaming and start doing. And be responsible for quality of the products you are developing.
Also to manage big team including mobile developers. So I even tried make code to understand details. But the most challenge for me now to make idea of playing with kids trendy!
Give us one word that people might use to describe you.
How has Project Eve helped you and/or your business?
To let more people know about my business and challenge, believe in their potential and left their fears.
Give us an insider tip that relates to your industry or startup story.
Not IQ tests impact on child success in future, but parent-child connection. Only parents role and involvement in communication and play with child forms self-confidence. And it is straight way to success!
Follow my organization on social media here:
Please submit your story to the largest archive of entrepreneurial startup stories in the world so, together, we can motivate women in business to think beyond traditional boundaries, support one another, embrace change and view challenges as opportunities. Whether you are a small business owner, a freelancer, a serial entrepreneur, own an online business, operate a storefront on Main Street, or even moonlight with an amateur blog our 500,000+ community would like to hear your Startup Story! Answer seven short questions to create a blog of your story today! | <urn:uuid:f863350f-b18b-4e3e-bc62-6f9839d3b3d3> | CC-MAIN-2017-39 | http://projecteve.com/startup-stories-kidmastermind/ | 2017-09-25T23:58:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-39/segments/1505818693866.86/warc/CC-MAIN-20170925235144-20170926015144-00671.warc.gz | en | 0.951884 | 771 |
Award-winning author, D.L. Young, was born and raised in Texas -- which is why it wasn't a weird thing for his imagination to create a sci-fi series set in the dystopian Republic of Texas. With a kick-ass female lead with special abilities, you just can't go wrong and Soledad: Dark Republic Book One has been very well received. Today, Young chats to us about how he is an obsessive planner, why his book contains so many moral dilemmas and why he made Texas an independent nation.
Please give us a short introduction to Soledad: Dark Republic Book One
The story takes place several generations after a failed Texas secession, where the economy and society have totally collapsed into chaos. Regional factions fight over control of territory and resources, and in the midst of all this a young woman with special powers, Soledad Paz, has to make a dangerous journey across the Texas wastelands to find out the truth about her past.
What inspired Soledad Paz's character?
Probably who rather than what. And the who is just about every kick-ass female lead you can name. Ripley from Alien, Furiosa from Mad Max, Lisbeth Salander, Tank Girl, you name it. Soledad has a little bit of DNA from a lot of awesome female protagonists.
Why did you decide to use Texas as the backdrop and make it a republic in your book?
I was born and raised in Texas. For a writer, there's TONS of fodder (both good and bad) for books and stories to be found in my home state. And there's a fringe element in Texas (well, maybe not so fringe) that has always wanted to see Texas as an independent nation. One of the questions my novel asks is: so what if Texas DOES secede and everything goes completely wrong? The story basically takes place in a worst-case scenario of an independent Texas.
What is it about dystopian worlds that fascinates you?
If we're defining "dystopian" in its broad, commercial sense (i.e., everything from Blade Runner to 1984 to Mad Max), for me the appeal is the breakdown of traditional societal structures. How do people adapt to new, often dangerous and anarchic, worlds? Do they maintain their value systems and morality when there are no legal structures to enforce "lawful" behavior or constrain their choices? There's a whole Hobbesian aspect to dystopian fiction that as an author I find interesting to explore.
Your book starts in the middle of the action, several generations after the crisis, without explaining to the reader the "how" and "why" right away. Why did you pick this approach?
Well, hopefully I dropped enough facts early on that the setting isn't a total mystery, but yes, it's not until nearly the halfway point of the book that you get the backstory of why this world is the way it is. As a reader, I like to be dropped into richly detailed worlds and figure things out as I go along. I don't want or need a ton of explanation. Some of my favorite writers do this. Ian McDonald comes to mind. Patrick O'Brian was a master of this kind of thing. I try to emulate this in my own work.
Even though the story is set in a very different world than we are used to, you managed to make it very plausible. How did you pull that off?
I think a big part of plausibility of any future world is understanding how economics drive behavior. When you think about our world today, whether it's the cutthroat economies of failed states in Africa or the (relatively) stable economies of Western Europe and North America, prosperity and scarcity are the catalysts that drive so much of human behavior. In speculative fiction, you have to envision a world where the economy intrinsically "makes sense" to the reader, where the relationship between the haves and have-nots rings true. It doesn't have to be fair necessarily (and usually isn't), it just needs to have some alignment to our own reality. I think this is an aspect of speculative fiction a lot of authors get wrong, and (for me, at least) it's a huge part of making a world plausible or not.
Soledad: Dark Republic contains a lot of twists. Did you plot them all out before you started writing?
Lord, yes. I'm an obsessive planner. We're talking pages and pages of character sketches, back story, outlines, etc. By the time I actually finish the pre-work and sit down to write, I've managed to work out all the plot points and twists and turns. My level of outlining isn't for everyone, but it works for me.
You worked a lot of moral dilemmas into the book. Was that intentional?
Totally. For me, the most interesting characters in books and movies are ones that aren't 100% bad or good, but somewhere in between. I try to make sure all the major characters--even a few of the minor ones--have some moral dilemma they need to confront.
What was the most challenging aspect of writing this book?
Getting up at 5AM Monday through Friday for four months straight. I have a pretty crowded life, and 5AM to 7AM during the week is the only time I can carve out for novel writing.
Soledad seems to have spawned from a short story of yours, The Reader. Are you planning on turning more of your short stories into full-length novels?
I haven't thought about that, but I suppose it's possible. I don't have any plans at the moment, though, other than getting the second Dark Republic book out.
How does Book Two tie in with Dark Republic?
I'm in the throes of writing book two right now (the Dark Republic series will be a trilogy set in the same world), so I don't want to give away too much. I can tell you, though, of all the people who've read Soledad, only a couple have guessed the direction book two is going. Stay tuned!
Where can our readers discover more of your work or interact with you?
My amazon page is probably the best place to find my work. My website always has updates on my events and activities. I'm also fairly active on social media. You can find me on Facebook and Twitter and Instagram. | <urn:uuid:3f5f75eb-992d-4a0a-8cc6-4042bd05a936> | CC-MAIN-2018-30 | http://manybooks.net/featured-authors/dl-young-the-republic-of-texas-in-a-dystopian-world | 2018-07-19T11:56:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-30/segments/1531676590866.65/warc/CC-MAIN-20180719105750-20180719125750-00511.warc.gz | en | 0.966451 | 1,326 |
2 bedroom apartment for rent in Ponte Vecchio area
For rent area Ponte Vecchio
PONTE VECCHIO AREA. First floor apartment located a stone's throw from the Ponte Vecchio. The apartment is composed as follows: entrance into the living room with sofa and TV, open kitchen with 4 burners, oven, dishwasher and fridge. Bedroom with a double bed and ensuite bathroom with shower.
75 Sq. mt. - 3 Rooms € 1.200
2 Bathrooms2 Bedrooms | <urn:uuid:5e94d0b7-1edc-44cb-b8e4-600c384a626a> | CC-MAIN-2021-39 | https://www.milligansales.com/web/immobili.asp?tipo_contratto=A&language=eng | 2021-09-29T02:48:03Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-39/segments/1631780061350.42/warc/CC-MAIN-20210929004757-20210929034757-00524.warc.gz | en | 0.905821 | 110 |
A UNIQUE INFORMATION COMPANY THAT'S PASSIONATE ABOUT SOUTH AFRICA'S DEVELOPMENT
GeoScope provides decision makers with strategic information for market and socio-economic development of South Africa.
GeoScope conducts research surveys and geospatial services to make information available for strategic decision making. The company was established in 2007 to focus on access to finance in African countries. GeoScope has broadened its focus to include surveys on Micro, Small and Medium Enterprises (MSME), perception surveys, social surveys, facility audits, business enterprise surveys as well as staff and customer satisfaction surveys.
Using geospatial methods GeoScope provides geospatial data for South Africa. Geospatial data is used to enable the optimum provision of government facilities and retail outlets. Our team of researchers and associates use innovative methods in conducting surveys and developing geospatial datasets. Our web mapping viewers provide unique information for use by individual and corporate clients.
Our sister company AfricaScope focuses exclusively on the African market. Geoscope Europe focuses on the Irish and European markets. | <urn:uuid:e43bb653-b7fd-4cbd-8560-f08b812d49dd> | CC-MAIN-2022-40 | https://geoscope-sa.com/latest-news/ | 2022-09-30T09:36:48Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-40/segments/1664030335448.34/warc/CC-MAIN-20220930082656-20220930112656-00298.warc.gz | en | 0.90836 | 221 |
Chris Drury is an environmental artist, who creates site-specific nature based sculpture, often referred to as Land Art. His body of work includes ephemeral assemblies of natural materials that he finds around him, as well as more-permanent landscape art, works on paper, and indoor installations. On paper, he uses a variety of unusual media—notably mushroom spore prints, dung, and peat—as a source of color and patterns, which he might overlay with text or fingerprints, or underlay with maps or other geographic images.
Drury’s work is an excellent example of artworks that promote green awareness by connecting nature and people. “Chris Drury concentrates on the interaction between nature and people, fungus and the human body” (Gooding & Furlong, 2002).
In Drury’s Portrayal of Poison Pie (featured here), he has created a hidden meaning. When you look at the artwork from a distance, it looks like the underside of a mushroom with carefully drawn lines in white ink. However when you look closely, the radiating lines in white ink are in fact a handwritten list of all the poisonous fungi in Britain and their effect on the human body. The fungi names are written in Latin and their biologically correct names. Drury says himself that, “mushrooms are the great recyclers of our ecosystems” (Gooding & Furlong, 2002). Poison Pie is about promoting mushrooms and their ability to recycle and clean the environment that humans have degraded, and about how humans and nature are connected.
Drury says “there is nowhere you can go that hasn’t been touched by man, and I think you shouldn’t start from the premise of cutting man out because we are nature, and that’s what interests me” (Gooding & Furlong, 2002).
Chris Drury talks about the process of making the piece Time Capsule, where nature will complete his creation as time continues. Watch the project from start to finish as students help create a natural masterpiece. | <urn:uuid:9a0851af-3036-4657-bab4-e8de81b46c64> | CC-MAIN-2017-51 | http://www.priscillawoolworth.com/chris-drury/ | 2017-12-14T18:50:56Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-51/segments/1512948550199.46/warc/CC-MAIN-20171214183234-20171214203234-00129.warc.gz | en | 0.954514 | 431 |
General Radiography/ Fluoroscopy
We are located on the first floor between the Emergency Department and Lab. Drive around past the ED entrance and turn Right into the Diagnostic Imaging parking lot. There is an Outpatient Diagnostic Imaging entrance that will bring you directly into the Registration area.
Hours of Operation:
General Radiographic procedures are performed 24 hours a day, 7 days a week. General Radiography procedures do not need to be scheduled.
Fluoroscopic procedures are performed Monday through Friday from 7:30am to 11:00am andMUST be scheduled during our these hours.
A physician's order is REQUIRED for both General Radiographic procedures and Fluoroscopic procedures.
When having General Radiography procedures, please do not wear clothing with metal over the area that is to be imaged.
The following are fluoroscopic procedures we perform at TCRH with the appropriate preps for each procedure:
IVP - Nothing to eat or drink after midnight.
Esophagram - Nothing to eat or drink after midnight.
Upper GI - Nothing to eat or drink after midnight.
Small Bowel Series - Nothing to eat or drink after midnight.
Barium Enema/Air Contrast Barium Enema -
Clear liquids beginning with lunch the day before the exam
Full glass of water at 1PM, 3PM, 7PM, and 10PM
1 bottle of Magnesium Citrate (cold) at 8PM
4 Ducolax tablets and a full glass of water at 9PM
Patient may continue to have water, coffee or tea, carbonated beverages, strained fruit juices, and clear soup or broth.
DO NOT eat cream soups, gravies, noodles, crackers, milk, cream, eggs, or any solid foods
Insert Ducolax suppository at 6AM the morning of the exam
Report to Diagnostic Imaging department approximately 20 minutes prior to scheduled time to fill out registration forms.
Voiding Cystourethrogram (VCUG) - No Prep
Hysterosalpingogram - No Prep
Myelogram - Please call for the prep. Procedure must also be scheduled with the Outpatient Surgery Department.
Arthrogram - No Prep
Lung Biopsy - Please call for the prep. Procedure must also be scheduled with the Outpatient Surgery Department.
Modified Barium Swallow - No Prep. Procedure must also be scheduled with Leigh Ann Phillips in the Speech Therapy Department.
For additional information, please feel free to contact Diagnostic Imaging by phone or email.
Diagnostic Imaging/Radiology Services at TCRH | <urn:uuid:60653f03-efa0-45bf-96ef-c8a48cd093e3> | CC-MAIN-2015-18 | http://www.tcrh.org/services/diagnostic_imagingradiology/general_radiography_fluoroscopy.aspx | 2015-04-27T07:04:29Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-18/segments/1429246657588.53/warc/CC-MAIN-20150417045737-00110-ip-10-235-10-82.ec2.internal.warc.gz | en | 0.900393 | 544 |
Bloat (Killing Floor 2 VS)
- For the AI counterpart, see Bloat (Killing Floor 2).
The player-controlled Bloat is one of the playable ZEDs in Killing Floor 2's Versus Mode. The Bloat is a high health, extremely resistant and slowly moving tank of the ZED team, it's main role is to charge through the Survivor's positions in order to damage them and obscure their vision with the bloat bile. Additionally, Bloat works well as an area denial unit thanks to its ability to lay down puke mines.
For kill reward calculations read Dosh Mechanics.
Due to Game Conductor mechanics, player-controlled Bloats have their health modified based on the average level of the Survivor team. Values vary within (x0.85 - x2) range.
Player-controlled Bloats have a wide variety of damage type resistances as well as some notable weaknesses. They are also less resistant to damage from certain tier 1 weapons.
Bloats are weak against microwave, neutral to fire and are significantly resistant to other damage types.
|Sub-machine Gun||Assault Rifle||Shotgun||Handgun||Rifle|
Bloats are extremely vulnerable against Firebug's Caulk n' Burn and heavy (blunt) attacks of Berserker's Crovel Survival Tool. They also have different multipliers against Eviscerator's projectile and melee attacks.
|CaulkBurn||HX25||Eviscerator (proj)||Eviscerator (saw)||Crovel (bludgeon)|
Bloats are significantly vulnerable against certain handguns.
Bloats have only one weak spot, which is the head. Although the damage multiplier is miserable. Their meat cleavers deflect attacks.
Attacks and Moves
- Primary: Puke attack that damages Survivors and distracts their vision.
- Secondary: Puke mine that explodes when Survivor's within its proximity.
- Bash: A single slash with the meat cleaver.
- Bash + Jump: Belly slam.
Note: Damage values below vary between (x0.7 - x1.31) based on average level of the human team.
Block. Damage multiplier (firearms) - x0.3, Damage multiplier (melee) - x0.3. Cooldown - 0.5s.
Melee. Damage - 20. Maximum hit range - 2.5m. Cooldown - 0.5s.
Mine. Damage - 15. Radius - 4.5m. No falloff. Health - 100. Explodes after 300s. Cooldown - 1.55s.
Vomit. Damage - 20. Maximum hit range - 3.5m. Cooldown - 1.25s.
Note: Maximum mines allowed - 30.
Melee attack (jumping) - x1.
Melee attack (running) - x0.6.
Melee attack (walking / stationary) - x1.
Vomit attack perform multiple hits: normal puke and lunge puke - 2 hits per attack, 360 puke (while moving backward) - 4 hits per attack.
Jump cooldown - 1.5s. Mine explosion triggers: radius - 60 units, height - 22 units.
Puke mine travel speed = 1000 units per second.
Player-controlled Bloats start spawning at the second wave of the normal versus game.
Bloats are capable of blocking damage which, on top of their high health and damage resistance, makes them even more tougher. | <urn:uuid:dcf21860-a37c-46c0-9a2e-ac957e76081e> | CC-MAIN-2019-09 | https://wiki.tripwireinteractive.com/index.php?title=Bloat_(Killing_Floor_2_VS) | 2019-02-21T10:06:56Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-09/segments/1550247503844.68/warc/CC-MAIN-20190221091728-20190221113728-00394.warc.gz | en | 0.803146 | 742 |
In celebration of the 99th anniversary of Polish independence from imperial rule in 1918, All-Polish Youth, a far-right organization named after the Academic Union “All-Polish Youth,” a violent anti-semitic group from the 1930s, hosted an “alternative” independence parade. The parade has been an annual gathering of far-right and neo-fascist groups since 2009, but this year’s attendance swelled over 60,000, far larger than the “official” celebration.
Posters saying “White Europe,” “Pray for an Islamic Holocaust” and “Clean Blood” could be seen in the crowd, chanting slogans such as, “Get the Jews out of power” and “Refugees get out!”
Poland’s swing to the right, ushered in by the election of the Law and Justice party in 2015, has been marked by a common narrative switch: painting the oppressors as the oppressed. The phenomenon that that allows the majority of White Americans to feel that White people face discrimination is the same one Polish leadership has tapped into by painting Muslim immigration as an “invasion” and reframing the Holocaust to fit their needs.
The Polish government’s narrative surrounding the Holocaust is a work of historical revisionism that centers Polish suffering and absolves Polish Nationals of their role as perpetrators of violence. Tour guides at the Auschwitz memorial, a former Nazi concentration camp in Poland, have an official script that emphasizes the heroism of individual Polish nationals and completely fails to mention the countless pogroms and massacres Polish citizens enacted against the country’s Jewish residents during the same time period. In their version of events, no Polish national cooperated with Nazis of their own free will – a documentable falsehood. The death count in Auschwitz alone includes 960,000 Jews, 74,000 Poles, 21,000 Rroma, 15,000 Soviet prisoners of war and 12,000 others. However, when polled, 47% of Poles believe Auschwitz was primarily a place of Polish suffering and only 51% acknowledge that the majority of the victims were Jewish. Over 90% of the Jews living in Poland before World War II were murdered, many by Poles and yet Polish Nationalists have co-opted Jewish suffering for their own use.
Peddling these falsehoods, whether in Europe or America, that diminish the trauma of the marginalized and emphasize the suffering of the dominant class dually serve the same goal of perpetuating and exaggerating existing power structures. This technique of borrowing the words and experiences of the oppressed can be seen in the language of the Alt-Right; while Genocide, the intentional action to destroy a people, has meant the mass slaughter of the Tutsi in Rwanda or decimation of Armenians in Turkey, “White Genocide” refers to things like interracial marriage, immigration, and the acceptance of LGBT people. White nationalism is fueled by this false sense of victimhood created by both exaggerating injustices committed against them and the denying horrors they did commit. | <urn:uuid:8aa2d941-51f4-4fe6-9583-c90797a61cfa> | CC-MAIN-2018-22 | http://affinitymagazine.us/2017/11/14/from-poland-to-america-how-half-truths-fan-the-flames-of-the-fascism/ | 2018-05-26T17:35:26Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-22/segments/1526794867841.63/warc/CC-MAIN-20180526170654-20180526190654-00243.warc.gz | en | 0.957711 | 633 |
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If you need any more information please feel free to contact us at firstname.lastname@example.org | <urn:uuid:768ac31e-e586-4208-9565-25998e255344> | CC-MAIN-2018-17 | https://toolsadviser.org/disclaimer/ | 2018-04-19T19:12:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-17/segments/1524125937016.16/warc/CC-MAIN-20180419184909-20180419204909-00634.warc.gz | en | 0.930009 | 272 |
This electric grill/griddle is easy to use, delivers superb cooking results and delicious taste, and is easy to clean. The versatile unit features a top grill plate that is reversible so the user can choose the griddle side or the grill side; both sides have a non-stick coating that delivers superb cook results and allows for easy clean ups. Use the grill side to evenly grill poultry, meats, fish and vegetables. Not in the mood to grill? Flip the cooking plate to the griddle side and set the electric thermostat to perfectly cook pancakes, omelettes, and grilled-cheese sandwiches. The generous 18" × 10œ" grill plate is large enough to prepare a family-size meal. The grill/griddle offers adjustable temperature control with indicator light for perfect results. The cooking plate is designed to drain grease from food for healthy cooking and is removable for easy cleaning. The safety interlock automatically shuts off grill if plate is removed from base. A scraper cleaner is included; it allows for thorough cleaning of the grilled surface.
Colour/Pattern: Brushed stainless steel housing with black accents
Materials: Stainless steel housing
Warranty: 3 years limited
NOTE: Cuisinart Griddler & Griddle, model CGG-2C
A roomy 2-in-1 tool, this Cuisinart grill-griddle combo lets you cook blueberry pancakes for breakfast and rosemary chicken breasts for dinner with a simple flip of its cooking surface. Coated with nonstick for less fat in cooking and easier cleanup, the cooking plate features one smooth side and one ribbed side. In either configuration, excess grease and fat runs off through slits in one end to the drip tray below. Measuring 18-1/2 by 11 inches, the grill surface accommodates enough food for the whole family or cooks several different dishes at once. Streamlined yet substantial, the base combines a stainless-steel frame with plastic legs, making it stable yet manageable in weight. The temperature control probe inserts simply in one end, and an indicator light signals when the surface has achieved the desired heat. Cleanup is made easier on this model by an immersible cooking plate and dishwasher-safe drip pan and scraping tool. Altogether, the grill measures 24-1/2 by 12 by 5 inches. Cuisinart includes a three-year warranty. --Emily Bedard | <urn:uuid:76ee5769-26bd-4578-8716-c7eaa70bcb6c> | CC-MAIN-2015-22 | http://www.amazon.ca/Cuisinart-CGG-2C-Grill-Griddle/dp/B002RWJN6Q | 2015-05-25T05:53:09Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-22/segments/1432207928414.45/warc/CC-MAIN-20150521113208-00149-ip-10-180-206-219.ec2.internal.warc.gz | en | 0.913328 | 490 |
DEXTER - Cindy Bohannon Brown, 46, died April 26, 2005, at her home near Dexter.
Born July 28, 1958, at Sikeston, daughter of Gene and Betty Ross Bohannon of Sikeston, she was a member of the First Baptist Church in Dexter, a former member of the Salcedo Baptist Church, a homemaker, and had previously worked part-time as a real estate agent and a substitute school teacher.
On Dec. 30, 1996, at Dexter, she married Larry Brown who survives of the home.
Other survivors include: two stepdaughters, Larrie Ann Lower of Topeka, Kan., and Tracie Seabaugh of Cape Girardeau; one brother, Dennis Bohannon of Sikeston; and two grandchildren, Audrie Seabaugh and Ty Seabaugh of Cape Girardeau.
Visitation is scheduled from 5-8 p.m. today at the Rainey-Mathis Funeral Home in Dexter where services will be held at 10 a.m. Saturday with Ron Wilcoxson officiating.
Burial will follow in the Memorial Park Cemetery in Sikeston. | <urn:uuid:3b0cdf63-81ff-41af-868a-916b136d6c44> | CC-MAIN-2013-48 | http://www.standard-democrat.com/story/1349030.html | 2013-12-09T11:10:40Z | s3://commoncrawl/crawl-data/CC-MAIN-2013-48/segments/1386163964642/warc/CC-MAIN-20131204133244-00004-ip-10-33-133-15.ec2.internal.warc.gz | en | 0.975954 | 235 |
I was tickled to be asked to paint a third piece for one of the loveliest and talented women I know.
I’ve mentioned her before as she was my mother’s good and generous friend. Although younger, she shared my mother’s enthusiasm for politics and the willingness to get in the trenches.
She asked me to use the picture below with the hand painted frame for inspiration. Other than wanting to keep the fun triangle shaped knobs, she gave me free reign.
I had a devil of a time deciding what to do. I tried copying the three boxes on the edges of the drawers and ruled it out as looking too country.
Next I painted stripes outlining the drawers to mimic the lines around the drawing. I wasn’t crazy about that either. The triangle hardware knobs didn’t look quite right with either design, so I finally decided to use the diamond shape to play off the triangles.
Using the diamonds, I copied the basic premise of the frame’s handpainted pattern. Finally I’m happy with this design and I hope she is too! | <urn:uuid:f73f6fb2-47df-4e37-8326-abbdc78b126c> | CC-MAIN-2018-22 | http://cynfullyfunfurniture.com/antique/from-squares-to-stripes-to-diamonds-a-dresser-makeover/ | 2018-05-28T01:11:07Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-22/segments/1526794870604.65/warc/CC-MAIN-20180528004814-20180528024814-00135.warc.gz | en | 0.963925 | 232 |
May 8, 2012 (#1082)
Alan Watt "Cutting Through The Matrix" LIVE on RBN:
Poem Copyright Alan Watt May 8, 2012:
Dinosaurs Farted Up a Storm which Made the Planet Warm:
Climatologists' Wild Tales, Surely
are a Blast,
Blaming Farting Dinosaurs for Warming up the Past:
"Global Warming Enthusiasts,
Laying it on Thick,
Scraping the Barrel Bottom for any Dirty Trick,
Now it's the Dinosaurs, That's Where it All Started,
All That Vegetation They Ate - They Burped & Farted,
CO2 and Methane Caused World to Warm,
They All Fried to Death in "The Perfect Farting Storm",
Later the Great Mammoth had Digestive Problems,
Lack of Bacteria in Gut, and Nature Couldn't Evolve 'em,
But Evolved Woolly Coats 'cos They Caused Global Cooling,
Are These Scientists Mad, Greedy, or Just Tom-Fooling?
Of Course it's Analogous to Us and the Food We Eat,
Ruminant Animals (Food) Burp, None too Discrete,
Elite Want Us to Consume their Glyphosate GMO Greens,
Soon Snacking on Meat will Turn on Green Sirens,
Imagination's on a Roll, Better Please our Masters,
To Keep Farting Dinosaurs Away, Save Us from Disasters"
© Alan Watt May 8, 2012
Poem & Dialogue Copyrighted Alan Watt - May 8, 2012 (Exempting Music, Literary Quotes, and Callers' Comments)
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Hi folks. I’m Alan Watt and this is Cutting Through the Matrix on the 8th of May 2012. For newcomers, you should help yourself to the audios for free download at cuttingthroughthematrix.com. There’s well over a thousand. You can start to understand the big system you’re born into and how it operates across the whole planet, what its goals are, where it originated from, the big foundations, big bankers. All the intelligentsia of the day, over a 100 years ago, got on board together in their big clubs to take over the world, all of its resources and throw all religions out the window and basically bring in a humanist agenda, basically, where the elite, the intelligentsia would run the world and they decided they were the intelligentsia since they pretty well owned a lot of it even back then.
So, you’re living through the big changes as they use lots of excuses to take away your rights and freedoms and make you get down on your knees and beg the high priests of science to save you from your own carbon dioxide and all that kind of nonsense. It’s a clever strategy; it’s very well done. They own all the media, so there’s no problem in convincing the public to go along with it, the general public at least. There are lots of people exposing it now, thank goodness, because it’s been an uphill battle, between lots of little reporters compared to the big massive media giants at the top. They’ve also trained the children through schooling, through lots of very carefully constructed videos with the hypnotic voice and the music behind it, showing them scary scenarios if they don’t get on board with the green agenda. So they’re all ready for the Communistic system of internationalism and down on the knee to the big high priests of science.
Remember too, when you go into the website, they all carry transcripts in English as well. If you want transcripts in other languages go into alanwattsentientsentinel.eu, and help yourself there. Remember too, you bring me to you; you can help me go along by buying the books and discs at cuttingthroughthematrix.com. From the US to Canada you can still use a personal check or an international postal money order, or you can send cash or use PayPal. Across the world Western Union, and PayPal and Money Gram. Straight donations are awfully, awfully welcome during these austere and hyperinflationary times, and you all know what I mean by that.
As I said at the beginning there, we’re living through an incredible time. An incredible time of planned change. That’s why these big boys with all their international agreements between different organizations that we don’t vote in. No country votes these organizations in. They’re NGOs, non-governmental organizations that sometimes get your tax money, by the way, from your governments because they’re all part of it too. But they get their main funding from the big foundations, which front for the international moneylenders, who came up with this idea a long time ago. So they lobby the governments that are only too happy, to go along with them and to take their reports and sign treaties, etc., which are drafted up by these private organizations. Remember these treaties affect all of us, because there’s nothing democratic, as I say, about them. This is a planned agenda. Again, I’ll put up the Green Agenda tonight, you’ll see all the quotes given by top players in the IPCC and the various organizations that come out with the fake reports, that came out before with WikiLeaks and others; when they made up lies to convince the public that they really know what they’re talking about, when they don’t at all. They even admit that their own computer models give them scary scenarios because they feed in scary scenarios.
It’s a wonderful thing. You can put in large numbers of things for data, large numbers, into these computers and guess what? They’ll give you even bigger numbers back, oooh scary, scary stuff. Specially made computers for that. Just astonishing, isn’t it? That’s the world as it really is and we’ll touch on that tonight, it has to do with their conditioning of the general public. I’ve mentioned before, this is the time when they come out with all the scary, scary stories to terrify you, building up to the Rio+20 meeting. They always do this before the big meetings so that we’ll all go along with the signing or the leaders will sign your rights and freedoms away for you. You’ll just sit back, “Well, I guess they had to do it to save us”. Back with more, after this.
Hi folks. I’m back, Cutting Through the Matrix. Talking about the big system of illusion. It’s really management of perception. That’s what they’re into, is giving you really what you’re supposed to believe and you do that because you’re trained in a certain way. In fact, it’s a natural way to think. You’re given certain bits and bites of words, and sentences and they will steer you by nudges into coming to what you think is your own conclusion, but in actual fact it was designed for you to come to that conclusion. Much like a programmer of a computer knows the language of the computer. He knows its logic system and he knows what it must come to when he gives it a problem to solve; same thing with people.
These are all neuroscientific techniques that they use on the general public all the time. So, right now is the time to blast us all with scary, scary scenarios, as I say, because of the upcoming big Rio meeting, where they had Rio part one, of course, 20 years ago and that brought in Agenda 21. It brought in a whole bunch of laws and treaties that were signed at the top that took away the rights of people to even work their own land they supposedly owned for themselves.
If you think that was bad, it’s nothing compared to what’s coming up. Believe you me, this is to be the final killer, to bring in the big hope for the far, far left, you see, of the controlled dominated society where scientists run us from cradle to grave. That’s what it’s all about. That’s the only reason for it, and to bring you into austerity because they claim, well you’ve had it too good for too long and they want to supposedly bring up the third world countries to at least a basic standard, as you plummet down. That’s what’s happening right now. So even when you’re plummeting down across the world, like Australia, Britain, Canada, the US and lots of other countries, they’re also taxing you into the ground, to take your taxes and redistribute the wealth.
According to Karl Marx that was one of the planks of the manifesto and they’re doing that too. The people don’t even know what’s happening or the logic behind it. Remember the international bankers love socialism, that’s why they created it, because they prefer a managed society. Managed by government and governmental agencies. They like that kind of centralized system because all the departments have to go to the bankers via the government. So, there’s only one bunch of folk to see in the government, for the moneylending and getting the cash back, for the bankers. It’s far easier than going state to state, village to village, town to town, that kind of thing.
Anyway, to start off tonight too, people have gone on about pros and cons for Minister Farrakhan. I’m putting up a link tonight to a video where you’ll see him being interviewed in a radio interview. During the commercial he lambastes all the mainstream media that’s there, trying to catch them out on something. He tells them exactly what they are, who they work for, how they’re all basically prostitutes and how they’re putting America into slavery and they’re well aware of it. He says it as it is. So I’ll put up that link tonight and there’s nothing I can disagree with that he says, at all. It’s right on the money. So I’ll put that up to start it.
Now, there’s so many articles getting thrown out by the big boys and lots of them are really comical, as well. But again, scary scenarios remember, that’s what you’re seeing, scary scenarios. One of them is: Can geo-engineering solve the global warming? Well, the premise is that there is global warming, when actually in fact, it’s not, but good lies stick, you see. It’s interesting too, the lie that comes out first generally stays in your mind, even when the truth exposes it as a lie. It’s quite a technique; they know all this, of course, in neuroscience. This one here is from the New Yorker and it goes on about the scary things, oh, a volcano in the Philippine island of Luzon began to rumble etc. back in 1991. Then they go on to all the terrible things that happened, the gas and ash penetrated the stratosphere, yada yada ya. Then it goes into:
The heavy industrial activity of the previous hundred years had caused the earth’s climate to warm by roughly three-quarters of a degree Celsius....
(Alan: Which it hasn’t, of course. The fact is it’s great how they give these scary things that happened in real life, like volcanoes going off, and they immediately tie it to heavy industrial activity. That’s why they’ve de-industrialized most of us but it’s not enough anymore, you see. You got to make sure you get a permit to heat yourself in the home. They’ll fine you if there’s a bit of heat escaping here and there in the crappy houses we all are forced to live in because of the cost of them. It’s to bring you down into their way of thinking, so you’re the problem, remember. For all these guys that are on board with the climate change stuff, you’re all the problem. So they go into all the different stuff here:)
For years, even to entertain the possibility of human intervention on such a scale—geoengineering
(A: That’s spraying the skies with all the stuff they’ve been doing since 1998, as though they’re just going to do it now, for those who don’t know.)
geo-engineering, as the practice is known—has been denounced as hubris. Predicting long-term climatic behavior by using computer models has proved difficult, and the notion of fiddling with the planet’s climate based on the results generated by those models worries even scientists who are fully engaged in the research.
(A: In other words they make their living off imagination.)
There will be no easy victories, but at some point we are going to have to take the facts seriously, “David Keith, a professor of engineering and public policy at Harvard and one of geoengineering’s most thoughtful supporters, told me. “Nonetheless,” he added, “it is hyperbolic to say this, but no less true: when you start to reflect light away from the planet, you can easily imagine a chain of events that would extinguish life on earth.”
(A: And it goes on and on with the usual. Now don’t get confused by mathematics. They use the same technique as a con man who works as an economist, you see. It’s the same techniques. You know the guys who do all the hedge funds and yada, yada, ya. They throw out all these different scenarios of possibilities and present it as fact until you’re totally confused at the end and you say, “My, they must know what they’re talking about. I can’t keep up with it”. That’s the con trick. The snake oil salesmen of a hundred years ago did the same thing when they were selling you literally snake oil and battery acid mixed together and a bit of alcohol in there too, of course, to make you feel better. That’s how it worked. But they’d always throw in a bit of science to try and con you into why this actually worked. This is quite interesting, this article, because:)
Tens of thousands of wildfires have already been attributed to warming, as have melting glaciers and rising seas.
(A: All debunked in the last year or two, all that stuff, but it doesn’t stop them lying, you see.)
“We don’t know how bad this is going to be, and we don’t know when it is going to get bad,” Ken Caldeira, a climate scientist with the Carnegie Institution, told me. In 2007, Caldeira was a principal contributor to an I.P.C.C. team that won a Nobel Peace Prize.
(A: For lying with a straight face. I added the last part on, because that’s true.)
“There are wide variations within the models,” he said. “But we had better get ready, because we are running rapidly toward a minefield. We just don’t know where the minefield starts, or how long it will be before we find ourselves in the middle of it.”
(A: Oh isn’t that scary? Doesn’t that scare you, that one? I’ve got the full thing from the New Yorker here and it’s quite interesting here because what they give you are scientists or guys like professors, who always dress up with bowties and have funny habits; which they practice, actually, because you’re supposed to be a bit eccentric, to fool everybody that you’re actually more intelligent. So they all have this little shtick you see, like the Nutty Professor. And so this guy goes on to say:)
At Cambridge, Hugh Hunt and his team are trying to determine the best way to get those particles into the stratosphere.
(A: This is for geo-engineering. They’re talking about sulfur dioxide, which produces sulfuric acid. They want that to rain down on you folks, you know. No kidding.)
A third group, at Oxford, has been focusing on the effect such an intervention would likely have on the earth’s climate.
(A: Never mind us, eh, because we’ve been coughing and hacking since 1998 with the heavy spraying that’s going on.)
Hunt and I spoke in Cambridge, at Trinity College, where he is a professor of engineering and the Keeper
(A: It’s his title.)
of the Trinity College Clock,
(A: He’s got a little clock, you see.)
a renowned timepiece that gains or loses less than a second a month.
(A: Well, what’s that got to do with it? Now listen to it. Here’s the eccentricity they always give you.)
In his office,
(A: This scientist, this professor:)
dozens of boomerangs dangle from the wall. When I asked about them, he grabbed one and hurled it at my head. “I teach three-dimensional dynamics,” he said, flicking his hand in the air to grab it as it returned.
(A: See, that’s his shtick, you see, to pretend he’s eccentric, meaning clever.)
Hunt has devoted his intellectual life to the study of mechanical vibration.
(A: Well, you see those things in the stores, along the street in the little dirty stores, I guess that’s what it is.)
His Web page is filled with instructive videos about gyroscopes, rings wobbling down rods, and boomerangs.
(A: So then he gets a pink balloon, of course, it’s got to be pink, it tells you something too, attached to a string. He’s talking about putting this pipe up in the air, so this is to demonstrate how the pipe will work.)
“The principle is pretty simple.” Holding the string, Hunt began to bobble the balloon as if it were being tossed by foul weather. “Everything is fine if it is sitting still,”
(A: He’s talking about putting these big pipes up into the air attached to dirigible balloons, huge ones. You’ll pay for it all, folks, as they play, you see.)
he continued, holding the balloon steady. Then he began to wave his arm erratically. “One of the problems is that nothing is going to be still up there. It is going to be moving around. And the question we’ve got is …this pipe”—the industrial hose that will convey the particles into the sky--“is going to be under huge stressors.” He snapped the string connected to the balloon. “How do you know it’s not going to break?”
(A: That’s why he’s a genius, eh? The balloons and all that stuff.)
We are really pushing things to the limit in terms of their strength, so it is essential that we get the dynamics of motion right.”
(A: Yeah, they want to put miles of this stuff into the sky to do this little test, which is nonsense, since these big planes have been covering us with this stuff, as I say, since 1998. Pretty well daily up this way.)
Most scientists, even those with no interest in personal publicity, are vigorous advocates for their own work. Not this group.
(A: In other words, they’re real, you see, with their little pink balloons.)
“I don’t know how many times I have said this, but the last thing I would ever want is for the project I have been working on to be implemented.” Hunt said. “If we have to use these tools, it means something on this planet has gone seriously wrong.”
(A: Yeah, we’re poisoned by putting sulfur into the air, that’s what it is. And it goes through S-P-I-C-E.)
Last fall, the SPICE team decided to conduct a brief and uncontroversial pilot study. At least they thought it would be uncontroversial. To demonstrate how they would disperse the sulfur dioxide,
(A: Do you know how bad that is when you breathe it in? Well you all know, I’m sure you’ve all had the hacking coughs that don’t go away, and the bronchitis and your children do too.)
they had planned to float a balloon over Norfolk.
(A: Where they’ve done lots of experiments in the past, the 60s and 70s, they sprayed cadmium over the public there. I’ll put that up tonight again too. Poor old Norfolk, they’re always poisoning them. Back with more after this break.)
Hi folks. I’m Alan Watt. We’re Cutting Through the Matrix. Talking about the Climate Fixers. They start off with a volcano and then end up with, basically, industrial societies, meaning they’re just the same, you see. It’s all your fault. You’re the problem; you’re just like a whole bunch of volcanoes just spewing sulfuric acid. Meanwhile they want to use this stuff to spray on us just to see what happens, if they can cool the atmosphere, etc. etc.
These guys have got jobs for life. Don’t forget too, these are all recent sort of positions in universities and you get all these students coming in for years now. They can use their imaginations and dream up more scary scenarios because they’ve got to justify what they’re doing. I wouldn’t even call it a science at this level, to be honest with you. But it definitely is a political agenda, to please the big boys, and get us all, you know, properly run, the whole world run from cradle-to-grave, every individual, and living in utter austerity, you see, to give the top guys more power. Power, remember, is a drug to these guys at the top. Every generation creates psychopaths who crave power. In the past, read your history books, they’ve taken power by so many different means possible, but the best way is to convince the public that you’re all going to die and they’re going to save you. That’s the oldest trick in the book. Same thing here; same thing.
So, I’ll put this one from the New Yorker up and as I say it’s quite funny with their boomerang professors and all this nonsense and his vibrators and things like that, and explaining how we’re all going to die. Anyway, it’s getting even worse because this is the time for daily scary scenarios, daily. Every day they’re going to come out, you see, and it just goes on and on. Here’s one here and it’s a fascinating one from the National Geographic that’s funded by all the big players, for greening, the big agenda to take care of us all, etc. and put us all in a kind of prison camp where we just eat veggies all the time. They don’t want us eating meat at all. This is how this one works too. It’s about dinosaurs, you see, and the whole premise is that dinosaurs farted themselves into extinction. Now, don’t get all blustered and flustered because of the word farting; it’s in the dictionary. Even when I was a wee boy I looked it up, you see, because wee boys do that kind of thing to find out what it means. It was expressed in the Oxford one at that time as a small explosion between the legs. So the Department of Homeland Security is quite right after all, we’re natural-born terrorists, I guess, eh. So it says:
Dinosaurs may have helped warm ancient Earth via their own natural gaseous emissions, a new study says.
Like modern-day ruminants,
(A: See how they immediately bring it into cows, cattle, what you’re eating? So they start with dinosaurs, same as the last story. It started with a volcano and ends up with your industry. This is the technique they use.)
Like modern-day ruminants, giant plant-eating dinosaurs likely
(A: Even though they’re not. These dinosaurs were reptilian; they were not mammals. “Likely,” I love how scientists are so precise, they “likely”, that’s with their imaginations:)
had microbes in their guts that gave off large amounts of methane--
(A: We haven’t got one to experiment on so they can’t tell us, but they likely had this, you see.)
a potent greenhouse gas even more effective at trapping heat than carbon dioxide.
(A: Whenever, by the way, you’re going through some of the mountains, like the Smoky Mountains and that and the Blue Mountains, why do they call them that? You’re seeing methane come off as vegetation dies. It dies, you see, and it rots, and gives off methane, naturally, but it’s all your fault because you burp and you fart. No kidding, no kidding, this is from science. So, they’re right onto your food supply:)
Today cows, goats, sheep, giraffes, and other ruminants contribute to global warming by releasing as much as 50 million to 100 million (A: They’re good with their statistics.)
50 million to 100 million (A: There’s no difference here.)
metric tons of methane per year—a significant chunk of the 500 million to 600 million metric tons emitted annually,
(A: They’re so precise with their imagination, isn’t it? Amazing.)
annually, mostly due to human activity, according to the World Meteorological Organization.
The cud-chewing animals have large forestomachs packed with microbes that break down coarse plant material. The main byproduct of the process is methane—and it’s got to go somewhere.
"Methane can come out of either end of an animal. For example, with cows it’s mainly the front," said study co-author Dave Wilkinson, an ecologist
(A: Oh, an ecologist, eh?)
at Liverpool John Moores University in England.
As for how these approximately 20-ton beasts—the largest of all known dinosaurs—expelled their methane, Wilkinson said, "we don’t have any strong view (A: Strong is the word, I guess, eh.) on what happened with sauropods."
(A: Doesn’t that make you feel little? You don’t know what sauropod means? It’s supposed to, you see.)
Sauropods as Huge Methane Sources
(A: Then they go into the same thing as the last article.)
To estimate how much methane sauropods emitted, the scientists guessed
(A: That’s all they get with their theories. They’re just guesses.)
that there were roughly ten sauropods per square kilometer
(A: That’s pretty good guessing, eh?)
The team’s analyses of modern ruminants suggest a sauropod might give off about 4.2 pounds (1.9 kilograms) of methane daily. A U.S. cow, by comparison, might give off a daily average of 0.4 to 0.7 pound (0.2 to 0.3 kilogram).
Assuming there were 29 million square miles (75 million square kilometers) of vegetated land when sauropods lived, their global methane production might have reached a whopping 520 million metric tons annually.
(A: No, that wouldn’t happen because some caveman would’ve come along with a kind of bright brain and he would’ve somehow trapped this methane and used it to heat, you see. It burns really great, it’s clean burning, it’s really good stuff. Lots of cops in the US use it in the countrysides. They get these methane traps they come across and they fill up their cars. I tell you, one program says that the cars on the go 24 hours a day, with different shifts, used to have their engines changed at least once a month. They burned them out with the gasoline and the carbon but the methane burns so cleanly, that for a whole year they hadn’t had to change an engine in those cars. So some enterprising caveman would have come along with a familiar name and owned the whole kit and caboodle through monopoly. I’m sure of it. Back with more after this break.)
Hi folks. I’m back Cutting Through the Matrix. Talking about the guys who have big guesses, the guys up in university, who are professors and all that and they’re specialists, you see, they’re going to guide our lives for us and make us, well, eat vegetables and things because they don’t want us eating meat from ruminants, and all that kind of thing, you see, because they said that a long time ago, they’re bringing in a vegetarian-only society, that’s what they say. They mean it too; it’ll all be GM stuff soaked in pesticides because they want rapid depopulation. Anyway, this article here goes on, and it’s from National Geographic too. (There’s also a BBC one, I’ll put up too, but it’s the same thing because they’re all in it together, aren’t they? The BBC is all on board with this thing.) It says here:
(A: This is another guy.)
who wasn't part of the study—noted, for example, that the team's calculations of methane emissions based on body weight were made from measurements of modern reptiles and mammals, not birds, which are the closest living relatives to dinosaurs.
(A: So they swapped mammals for these reptiles.)
The problem is that it's still unknown how much methane plant-eating birds release.
(A: It’s amazing we don’t know what plant-eating birds release but we can tell exactly what these different dinosaurs released millions of years ago. Isn’t that fantastic? They had to do a lot of channeling, you know, I think a special channeling computer and put their hands on it and somebody goes into a trance, probably the professor, and he comes out with all this wonderful stuff and calculations and so on. He says:)
"If we would find that herbivorous birds produce less methane than similar-size herbivorous mammals, then ... the whole calculation might have to be redone," said Clauss, of the University of Zurich.
(A: So they go on to:)
Regardless of the calculations, fossil finds make it clear that sauropods lived in a much warmer world than we do.
Well they had volcanoes all over the place; we’ve all seen the Hollywood movies. That’s where it all comes from, isn’t it?
Anyway, that’s one as we go into scary scenarios, and how you got to stop eating meat and you got to take lots of antacids and things to stop farting. Speaking of farting, by the way, it’s interesting to see they’ve got another underwear bomber with Mark II or III lingerie, you know. Have you noticed that nonsense? Utter rubbish, I won’t even mention it because I think it’s utter rubbish. So many folk have complained about TSA patting them down and grabbing their genitals and so on. And so they’ve got to now come up with these stories as to why they’ve got to do it; so they make up these ridiculous, ridiculous stories. Ridiculous stories, absolute nonsense. There was never any danger, yada yada ya, but it’s to get the public to say, “Well, I guess they have to do all this groping stuff”. This is the world we really live in. It’s all make-believe, folks.
Now getting away from the dinosaurs and here’s another one, another one, mainstream again, big one.
Mammoth belch deficit caused prehistoric cooling?
(A: The mammoths, you see, they had a belch deficit. They caused the prehistoric cooling period. So the ones caused the warming period because of bacteria in their gut, supposedly, and a mammoth belch deficit caused prehistoric cooling. It’s great being one of these scientists because I’m telling you the sky is the limit for your imagination, isn’t it? And they keep throwing grants at you to shout “crisis, crisis” and the grants flow in. And then you can get boomerangs and throw them around the rooms at students and things.)
When mammoths and other Ice Age "megafauna"
(A: Oh, they love these names, “megafaunas”, eh, big fauna.)
disappeared from the Americas about 12,800 years ago,
(A: On a Friday afternoon when the cavemen were having tea.)
the animals took with them their planet-warming burps—spurring the mysterious cooling period known as the Younger Dryas, a new study says.
(A: I wonder how many folk will put their thesis in for that one?)
And because humans are thought to have killed the creatures off, the deaths hint that we’ve been changing the climate since long before the first Model T chugged out of Mr. Ford’s factory.
According to ice core studies, the Younger Dryas event began about a thousand years after mass human migrations into the Americas 13,400 years ago, near the end of the last ice age.
The world had been starting to warm, but the Younger Dryas brought on a freeze that lasted roughly 1,300 years, with estimated temperature drops of 7.2 to 14.4°F (4 to 8°C) in eastern North America and northern Europe.
Also within a thousand years of the human migrations, more than 114 species of large plant-eaters—including woolly mammoths, giant camels, and ground sloths—had gone extinct.
(A: And they give you pictures of drawings, wonderful drawings. They’re awfully good at giving you illustrated drawings and stuff. I saw one once where they found a tooth in the jungle, and it became a very famous tooth because out of that tooth they reconstructed, through their illustrations, a kind of ape-man, kind of walking through the jungle. They had different photographs as he got up and up and straightened up as time went on and he evolved and stuff, all from that tooth. Now, you can’t do that, but they can do that because they’ve got better imaginations than you. Anyway, it says:)
The link between the extinctions and cooling, the study says, is methane, a greenhouse gas 20 times more powerful than carbon dioxide when it comes to global warming.
As they digest plant material, large herbivores give off the gas, which, contrary to popular belief, escapes via the head.
(A: In some of them, I guess.)
"People just automatically assume that it’s farts," lamented study leader Felisa Smith of the University of New Mexico. "Eighty to 90 percent of methane ... is in the form of a burp."
(A: And it is with the hippopotamus, it can do it, fart through its mouth, you see. Some people do that too, that work in university. That’s why no one goes near them, and you never sit in the front row, eh.)
Missing Methane Mystery Solved?
(A: So anyway, they found out, you see:)
The cause, Smith said, is all those missing methane burps. "We estimate that just under ten teragrams [about ten million tons] of methane would have gone missing when these animals went extinct," she said.
(A: Maybe they got antibiotics and the bacteria in their gut just died off and they stop burping, you see. That’s what must’ve happened, eh? You could do your thesis on that and you’ll come through too with honors, no problem about that.)
"Next Ice Age Delayed by Global Warming”, the study says.
It goes on and on and on with all their imaginations. It’s quite entertaining certainly but unfortunately this is all going to get presented as fact at the Rio Summit and your willing politicians who are all in on the act, by the way, are going to ram all of their laws through, you know, to make you all take antacids and stuff like that for sure; because you never know. Curry will probably get banned altogether, I’d imagine. My goodness. What a world. What a world.
I’m also putting up tonight an article from Germany, it was by one of the co-founders or writers of the big 1970s Club of Rome report that started off this whole kick when they came up with the idea we’ll create global warming, that’ll fit the bill, starvation and so on. They didn’t mention burps or anything. So he’s come up with his next one for the year 2050, this co-writer from the Club of Rome, with more scary, scary scenarios, you see, and they can’t backtrack now because they said it in the 1970s, that would fit the bill, and come hell or high water they’re not going to change their minds. This nonsense is going to put us all into utter slavery. Mind you, you’ll have all these professors with boomerangs and that looking after you and pink balloons. I wouldn’t trust them personally.
Anyway, I’m also putting up a link too, to do with melamine. It says:
There’s Mercury in High Fructose Corn Syrup (A: in a lot of the foods), and the FDA Has Known for Years
That’s true, they actually use a big bath of mercury which steams a lot of this stuff over and it ends up in the fructose corn syrup and that’s in everything that they give children for sweeteners, in everything, lots of things, even your general food that’s processed it’s in that too. I’ll put that up tonight.
Also, I’m putting up a site as well. It’s called the GMO Compass for genetically modified organisms or food. It’s to do with what’s supposedly safe, what isn’t, different countries, how they’re using the laws on labelings, or not using them at all. It’s quite an interesting website to put up. And an article too that’s about the Met Office. Everybody’s heard about the Met Office, that came under massive flack from the scandals with the e-mails from the East Anglia University. They were cooperating with the Met Office you see, drumming up scary scenarios again and lying to the public and trying to cover up their lies too, when they got caught. Well, the Met Office, by the way, which used to always be sort of government run. This is a fairly new thing, though. This is their own site. It says:
An overview of the Met Office (A: The meteorological office.) as an organization including who we are and where we’re based, the work we do around the world and how to get in touch.
The Met Office is the UK’s National Weather Service.
(A: But you see it’s a corporation now.)
We have a long history of weather forecasting and have been working in the area of climate change for more than two decades.
We are a Trading Fund within the Department for Business Innovation and Skills,
(A: So the guys giving you your weather reports are actually a Trading Fund in the Department for Business Innovation and Skills.)
operating on a commercial basis under set targets. Our targets are verified and publicized in this section.
(A: What they’re actually all about, you see, and they work with lots of other locations across the world. You see, they’ve put your food, the 5 Agri-business companies own all the world’s food supply now, since they put all the small farmers under, are predicting in the stock market how the weather is going to be. And what crops are going to fail in what country, etc. etc. Naturally too they must know which ones are going to get sprayed, obviously, and cause failure of crops, or floods, or whatever they give them because they can do drought or flooding with the types of spray that they use. That’s old hat, that’s old stuff, weather warfare. Look it up yourself.)
So anyway, here they are making money out of your food supplies as they bet on it going up or down or failing altogether, for the big corporations. But mind you it’s supposed to be a government institute, it’s probably still getting your tax money going to them, as well, as they run their private business here, predicting who’s going to rise and who’s going to fall, who’s going to fail, all of that kind of thing. Quite something, eh.
Also I’m putting up a good video and it’s Judge Napolitano who talks about spying through your electronics because as you know Samsung was the first one to come out and admit it; that they’ve got your facial recognition, your television puts out these little beams and it will basically encode them into circuitry of the shape of your face and face identification. Same with anybody who walks in and sits down and watches television with you, or walks past even the television set and it’s doing an awful lot more.
Are you being spied on through your electronics, it says. It’s quite an interesting thing as he goes through the laws and how they’re just being trampled completely and there’s another article about it too, a written one which I’ll put up as well, on Samsung which is only one of the many ones doing this kind of stuff. And they send all your data back to the CIA, NSA and every other organization that wants to see what you’re doing in your living rooms, all the time, you see. So, things are really rampaging ahead.
Charity, charity is one of the biggest rackets and always was, mind you, because remember even the old Masons groups basically started big charitable business, all ended up being cons. Even themselves, most of the money goes to their lodges, you know. There’s a lot of articles that have come out in the past about how it goes into their own lodges, about 80 to 90% of what they bring in, goes into building the lodge and making it better. It was the same thing even pre them, because even when the guilds were working they used to build special hospitals for guild members only and that kind of thing too. Charity’s always been a racket, so many rackets involved. So:
The IRS forms show that a charity’s money isn’t going to disable vets
Tax records for the Disabled Veterans National Foundation show $55.9 million in donations.
Almost none of that money has been provided to American veterans.
It has also provided useless donations, including over 11,000 bags of M&Ms to one charity.
(A: That’s just what you need when you’re sick, right?)
The DVNF did not respond to repeated questions from CNN.
A national charity that vows to help disabled veterans and their families has spent tens of millions on marketing services,
(A: That’s what they spent the money on.)
all the while doling out massive amounts of candy, hand sanitizer bottles and many other unnecessary items to veteran aid groups, according to a CNN investigation.
The Disabled Veterans National Foundation, based in Washington, D.C., and founded in 2007, received about $55.9 million in donations since it began operations in 2007, according to publicly available IRS 990 forms.
Yet according to the DVNF’s tax filings with the IRS, almost none of that money has wound up in the hands of American veterans.
Well, what’s new? All these charities are rackets and they actually say this in this article that these guys come in, who see it as a profitable business, charities, and of course, it certainly is. That’s all they see it as, a very profitable business. There’s lots of them I could go through like that, the rackets to do…but it’s disgusting, disgusting. What can you say?
Also, I’m going to go into this one here, space weather, if it’s not bad enough, they’re bringing everybody in on everything, people you’ve never heard of before.
Space weather expert has ominous forecast. Mike Hapgood, who studies solar events, says the world isn’t prepared for a truly damaging storm (A: A solar storm). And one could happen soon.
(A: Oh, this is better than sci-fi, isn’t it?)
A stream of highly charged particles from the sun is headed straight toward Earth, threatening to plunge cities around the world into darkness and bring the global economy screeching to a halt.
(A: Well, we’re already at a halt anyway, except for the stuff coming from China.)
This isn’t the premise of the latest doomsday thriller. Massive solar storms have happened before — and another one is likely to occur soon, according to Mike Hapgood, a space weather scientist at the Rutherford Appleton Laboratory near Oxford, England.
Much of the planet’s electronic equipment, as well as orbiting satellites, have been built to withstand these periodic geomagnetic storms. But the world is still not prepared for a truly damaging solar storm, Hapgood argues in a recent commentary published in the journal Nature.
Hapgood talked with The Times about the potential effects of such a storm and how the world should prepare for it.
Then they tell you what a solar storm is, which everybody would obviously know anyway and solar flares coming from the sun, and so on, and yada, yada, ya. It tells you how the particles reach the earth, which of course is interesting for guys who are into this and how it could affect the power grid; probably the Smart one. Or can the Smart one outsmart it? Could the smart grid outsmart the solar radiation coming down to earth? I wonder, big, big test here. So anyway, they mention the one that put Quebec out in 1989, when a big solar flare hit and it could happen anywhere again, and should we be terrified. Maybe they’re just looking for bigger grants as well because all the other guys are getting the grants, you know. The guys with scary scenarios, with dinosaurs and boomerangs and big pipes going up into the sky, to puff out sulfur on us all. Anyway, that’s how they’re going.
The Green Cross started up with Mikhail Gorbachev when he was still president of the Soviet Union. It was registered in California, with him as the head of it, while he was still the president of the Soviet Union. You say history isn’t planned, folks, and the future’s not planned?
Green Cross International’s roots can be traced back to President Mikhail Gorbachev’s time in office as Head of State of the Union of Soviet Socialist Republics, a period during which he spoke repeatedly about the interrelated threats humanity and our Earth face from nuclear arms, chemical weapons, unsustainable development, and the man-induced decimation of the planet’s ecology.
He spoke at the Club of Rome conference at Muziekgebouw, it says, at Amsterdam in the Netherlands. He also spoke at the last Rio Summit too. Did you know that? He’ll be at the next one as well. Back with more after this
Hi folks. I’m back Cutting Through the Matrix. We’re really into this new Sovietized system because it’s a world Soviet, you know. Even guys who were in the Soviet Union, the old Soviet Union, complained about the new EU Parliament, saying it’s more Soviet than the Soviets were. In the Soviet system you were pulled up, as I say, if you even wrote a poem, to see if you were politically correct, was there anything in there at all that went against the Marxian ideals and thought, that kind of stuff, and now we’re getting it all now in the West. There’s even a group now of transsexuals that want to put into law that we must all believe, believe and say that they’re really what they say they want to be, if they’re a red-head, a female or whatever. Even your logic says no they’re not; they want it done in law. And here’s one here:
Blacklist is blacklisted:
(A: The word “blacklist” is blacklisted. The Metropolitan Police in London:)
Met bans word over claims it is racist…and staff have to say ‘red listed’
(A: Instead, you see. It used to be “blackballed”; that was the term when the Masons and the Knights Templars voted on something; they had white balls and black balls. If it was a yea, it was white and a nay was black, so you got “blackballed” as they called it. Then they put it into a blacklist, all the different names that were blackballed. So you can’t say that anymore and you have to say “red-listed”. So you have to learn all these new terms now to be PC.)
Staff told to avoid ‘inappropriate’ whitelist or blacklist
Red list and green list are ‘less sensitive’, boss says
Force has been hit by string of racism allegations
They have also struck out its opposite – ‘whitelist –
(A: So you can’t have whitelist either. I guess you’ve got to use colored paper.)
which is used by IT workers for a list of acceptable email contacts.
Scotland Yard employees have been told to use ‘red’ and ‘green’ instead.
The move baffled officers, who said it would do little to help the force emerge from its latest racism crisis.
Thirteen reports of racism, involving 27 officers and staff, are being probed by the Met and the independent police watchdog.
One officer said: ‘Frankly we all sigh when things like this come around. Lots of good work is done to make sure policing reaches into all parts of society and helps the most vulnerable.
(A: That’s why they’re there. They’re social workers, you know.)
This is not it.’
The Met was branded institutionally racist by the Macpherson Inquiry, set up following the death of Stephen Lawrence.
(A: So I guess they killed another one. They’re always killing people.)
‘I am sure we can appreciate the sensitivity around the use of such terminology today so please ensure it is no longer used.’
The measure is part of a drive by police chiefs to stamp out racism within the force. But officers within the organisation are said to have described the latest orders as 'bizarre'.
One source said that banning them won’t solve any genuine problems the Met has with racism.
They added: ‘Do we really think these words are discriminatory? The truth is they’re nothing to do with race whatsoever and are very common IT terms.’
The police watchdog announced last month that it is carrying out a review into how racism allegations are dealt with by the Metropolitan Police.
That’s the bizarre world we’re into folks. From nutty professors, of course they have to pretend they’re nutty, to be eccentric because they’re no brighter than you or I; especially when they’re dealing with a lot of imaginative theories, which are just guesses and they throw boomerangs around and they make vibrators and things, and make things spin. Because they want to put pipes up into the air, of course, and get their name on a building somewhere, maybe even a university building. They want to get their name there and they want to get lots of grants given to them so they can buy better boomerangs, you know, that go further and all that kind of thing. And get rid of all those herbivores, all these things that are eating and belching and, well, farting too. Ah, goodness me. No more champagne for you folks, even the beer, I guess that will be banned as well. You can burp that one away.
From Hamish and myself, from Ontario, Canada, it’s good night and may your God or your Gods, and God help you, go with you.
Transcribed by Mary Lou.
Topics of show covered in following links:
The Green Agenda PDF
Farrakhan Says it Like it is---Admonishes Lackey Media
The Climate Fixers, Boomerangs and Nutty Professors
UK--Millions Exposed in Germ Warfare Tests
National Geographic---Dinosaurs Farted their Way to Extinction
Dinosaurs Farted Themselves into Extinction say "Experts in Imagination"
Mammoth Belch Deficit Caused Global Cooling
Club of Rome Pushes New Scary Scenario
High Fructose Corn Syrup and Mercury
U.K. Met. Office---is a Trading Corporation---Betting on the Weather
Judge Napolitano on Electronic Spying
Spying on You by Electronics in the Home
Your TV Watching You
Charity Organization to Help Vets is a Fraud
Don't Worry about Global Warming----Solar Flares Could Finish us Off--Ooooh---Scary Scenario
Green Cross and Gorbachev
UK---The word Blacklisted is Blacklisted
Alan's Materials Available for Purchase and Ordering Information:
Ancient Religions and History MP3 CDs:
Blurbs and 'Cutting Through the Matrix' Shows on MP3 CDs (Up to 50 Hours per Disc)
"Reality Check Part 1" & "Reality Check Part 2 - Wisdom, Esoterica and ...TIME" | <urn:uuid:e975e859-7c01-4931-88db-5bd384091ba7> | CC-MAIN-2015-18 | http://www.cuttingthroughthematrix.com/transcripts/Alan_Watt_CTTM_LIVEonRBN_1082_Dinosaurs_Farted_Up_a_Storm_which_Made_the_Planet_Warm_May082012.html | 2015-04-18T16:37:54Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-18/segments/1429246635639.11/warc/CC-MAIN-20150417045715-00033-ip-10-235-10-82.ec2.internal.warc.gz | en | 0.956157 | 11,924 |
No, we’re not suggesting your nonprofit goes to a medium to get a glimpse of your successful future, we’re encouraging you to check out the ever-growing social blogging platform, Medium, founded by Ev Williams, who is also the co-founder of Twitter.
Here’s Why Medium Could Work Well For Your Nonprofit:
Storytelling is golden. Medium offers a simple, compelling way to share your stories. Because telling your story up close and personal is key. Julie Neidlinger of CoSchedule notes that instead of a focus on traffic, Medium is focusing on readers.
Medium is basing discovery of your content on whether or not people have read it. Not hits, not sexy headlines. Readability, not gimmicks or tricks. | <urn:uuid:49322f71-c7ca-41b8-ae43-dfb5824560cf> | CC-MAIN-2016-30 | http://www.care2services.com/care2blog/topic/blogging | 2016-07-30T05:16:41Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-30/segments/1469257832939.78/warc/CC-MAIN-20160723071032-00213-ip-10-185-27-174.ec2.internal.warc.gz | en | 0.883791 | 158 |
Quality of Care for Veterans with Stroke Did Not Diminish During Pandemic
This study compared the
quality of care and outcomes for Veterans with acute ischemic stroke (AIS)/ transient ischemic attack (TIA) before vs during the COVID-19 pandemic across the VA healthcare system. Findings showed that the overall
quality of care did not diminish among Veterans with stroke and TIA who received care in VA facilities during the COVID-19 pandemic. As measured by the without-fail rate,
quality of care improved from 50% in 2019 to 56% in 2020. The without-fail rate remained relatively stable for Veterans with TIA (44% in 2019 vs 44% in 2020) and increased for Veterans with stroke (54% in 2019 vs 62% in 2020). Fewer patients were eligible for the hypertension control measure in 2020 than in prior years due to lack of blood pressure (BP) measurements: 31% in 2020 vs 67% in prior years, likely explained by fewer patients having a primary care visit in the 90 days after discharge. When measured, BP was not as well controlled during the pandemic period (72%) as during the pre-pandemic period (78%). Healthcare providers should ensure that patients who have had an AIS/TIA receive priority as healthcare systems address deferred primary care, particularly hypertension management.
Date: April 5, 2022
- Specialized Primary Care Homes Effective in Treatment of Patients with Serious Mental Illness
This project studied the implementation and effectiveness of a primary care medical home specifically designed to improve the healthcare of Veterans with serious mental illness. SMI PACTs (Patient Aligned Care Teams) include a specialized, integrated team that can provide both primary and psychiatric care. Findings showed that a primary care medical home for Veterans with SMI can be safe and more effective than usual care, as well as feasible to implement. Compared with Veterans who received usual care, those who received the SMI PACT intervention had greater improvement in screenings, treatment
quality, chronic illness care (e.g., goal setting, counseling), care experience (e.g., doctor-patient interaction, care coordination, access), psychotic symptoms, and mental health-related
quality of life at 12 months. Investigators saw no signs of worsening of mental health status under the SMI PACT model of care. This care model can be effective and should be considered among the interventions for improving medical care in patient populations with serious mental illness.
Date: April 5, 2022
- Gap between Veterans Screening Positive for Depression and Receiving Timely Guideline-Concordant Treatment
This study examined adherence to guidelines for follow-up and treatment among Veterans in primary care who newly screened positive for depression. Findings showed that only a minority of Veterans in this study received timely follow-up after screening positive for and being clinically identified as having depression. While 77% met guidelines for completing at least minimal treatment in 1 year, only 32% received timely clinical follow-up within 3 months of screening. Younger age and comorbid mental illness were significant predictors of higher
quality depression care. For example, predicted probabilities for timely follow-up among VA patients with and without PTSD were 38% and 24%, respectively, and 85% and 72% for treatment.
Date: March 10, 2022
- Veterans Transported to VA Hospitals by Ambulance Have Substantially Lower Mortality Rates than Veterans Taken to Non-VA Hospitals
This study analyzed a national cohort of Veterans (age 65 and older) who were enrolled in both VA and Medicare and who were transported by ambulance to either a VA or non-VA hospital for emergency treatment between 2001 and 2018. Findings showed that Veterans transported to VA hospitals had substantially lower risk of death within one month than those transported to non-VA hospitals. The absolute difference of 2.35 deaths per 100 patients corresponds to a 20% lower mortality rate among Veterans taken to VA hospitals. The mortality advantage was particularly large for Hispanic patients (23% lower in VA), Black patients (26% lower), patients aged 65-74 (27% lower), and patients who arrived with a relatively low mortality risk (32% lower). Further, of the 50 subgroups of Veterans examined in this study, none experienced significantly lower mortality rates at non-VA hospitals. Findings suggest that enabling or encouraging Veterans to obtain care outside the VA system may lead to worse—not better—health outcomes, particularly for Veterans with established care relationships at VA facilities.
Date: February 16, 2022
- VA Surgeries across Eight Specialties Result in Lower Mortality among Veterans than Comparable Private Sector Surgeries
The objective of this study was to compare peri-operative outcomes among Veterans treated in VA hospitals to patients treated in private-sector hospitals using VASQIP (VA Surgical
Quality Improvement Program) and NSQIP (National Surgical
Quality Improvement Program) as comparable, high-
quality, and audited national registries. Findings showed that overall, unadjusted rates of 30-day mortality, complications, and failure to rescue were 0.8%, 10%, and 5% in NSQIP and 1%, 17%, and 7% in VASQIP, respectively. After adjusting for patient frailty and procedure-specific physiologic stress, VA surgical care was associated with lower perioperative mortality (approximately 40% lower), and this is likely due to a comparatively lower risk of failing to rescue patients from postoperative complications. Lower perioperative mortality in VA surgical care compared to the private sector remained robust in multiple sensitivity analyses, including among patients that were frail and non-frail, with or without complications, and those undergoing low and high physiologic stress procedures.
Date: December 29, 2021
- Low-Value Prostate Cancer Screenings Common in VA; Low-Value Breast, Cervical, Colorectal Screening Rare
This study sought to describe the prevalence and association of multilevel factors, including key patient-centered medical home (PCMH) domains, with four common low-value cancer screenings (breast, cervical, colorectal, and prostate) within the VA healthcare system. Findings showed that low-value prostate cancer screenings were common, although low-value breast, cervical, and colorectal testing was rare. Of the nearly 6 million Veterans in the cohort, less than 3% received a low-value test for breast, cervical, or colorectal cancer; however, 39% of men screened for prostate cancer received a low-value test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with the likelihood of receiving low-value tests among screened patients, but the direction of the association differed by cancer type. No single factor explained receipt of a low-value test across cancer screening cohorts. There was also no clear association between select domains of the PCMH model and low-value test receipt. While low-value cancer screenings may pose greater risk than benefit, testing outside established recommendations must be individualized, as algorithmic decisions may misclassify patients otherwise appropriate for screening. Individualized recommendations for cancer screening may help to advance care
quality, particularly for patients with advanced age or poor health status.
Date: October 22, 2021
- Receiving Hospice Services Improved Ratings of End-of-Life Care for Veterans in VA Home-Based Primary Care
This study sought to describe Veterans’ use of community-based hospice services while enrolled in home-based primary care (HBPC) and their associations with bereaved families’ perceptions of care. Findings showed that overall, 53% of family members reported that the care received by Veterans receiving HBPC in the last 30 days of life was excellent. Families of Veterans who received hospice services gave higher global ratings of end-of-life care
quality than those who did not (56% vs. 47%). The highest scoring secondary Bereaved Family Survey (BFS) outcomes were related to providers always being kind, caring and respectful (87%) and managing PTSD symptoms among Veterans experiencing stress (85%). The lowest scoring items were related to receiving enough information about survivor (38%) and burial and memorial (43%) benefits following the Veteran’s death. On 12 of the 14 secondary BFS outcomes, Veterans who received hospice services scored higher than those that did not. Findings suggest that increased referrals to community hospice partners for qualifying Veterans may result in more favorable perceptions of the overall end of life care experience.
Date: September 29, 2021
- Total Knee Arthroplasties have Significantly Lower Complication Rates when Performed in VA vs. Community Care Facilities
This study compared risk-adjusted post-operative complication rates for elective total knee arthroplasties (TKAs) that were delivered vs. purchased by VA. Findings showed that overall, adjusted complication rates were significantly lower for VA-delivered vs. VA-purchased TKAs. Those TKAs delivered in VA had significantly lower risk-adjusted odds of individual complications (AMI, mechanical, joint/wound, pneumonia, and sepsis/septic shock) compared to those performed in the community. The exceptions were pulmonary embolisms (not significantly different between settings) and bleeding complications (numbers too low to calculate). Hospital-level comparisons revealed five locations where VA-purchased care out-performed VA-delivered care. These five VA locations had significantly higher complications compared to relatively low community complication rates. As the amount of VA-purchased care continues to increase under the MISSION Act, these results support VA monitoring of overall and local comparative hospital performance, in order to improve the
quality of care VA delivers while ensuring optimal outcomes in VA-purchased care.
Date: August 1, 2021
- Healthcare Supplement Features HSR&D Articles on the Importance of Embedded Research
This supplemental issue of the journal Healthcare: The Journal of Delivery Science and Innovation considers the impact of embedded research on solving the disconnect between healthcare organizations and health services researchers. In November 2019, a national meeting was organized by a trio of Federal funders – VA, the Agency for Healthcare Research and
Quality (AHRQ), and the Patient-Centered Outcomes Research Institute (PCORI) – in collaboration with AcademyHealth and Kaiser Permanente to address the following themes: Organizational arrangements, including governance, staffing, and funding; Research support for management decisions; Data resources and use; Strengthening the embedded research community; and Accelerating implementation of embedded research output. Articles in this Supplement reflect the work that began during this national meeting.
Date: June 1, 2021
- Both “High-Needs” Patients and Facility Leaders Praise VA’s Intensive Primary Care Pilot Program
This qualitative evaluation explored the perspectives of patients and healthcare facility leaders to identify additional important outcomes that could augment utilization and cost studies of intensive primary care (IPC) programs for high-needs patients. Findings indicated that IPC programs may yield benefits beyond healthcare cost and use, including improved
quality of care, patient satisfaction,
quality of life, and patient health behaviors. Patients perceived improvements in their experience of VA care, including improved patient-provider relationships and access to their healthcare team. Patients frequently reported feeling a sense of connection with their IPC team because they could rely on them for support with health and non-health-related issues. Primary care leaders also observed greater proactive patient engagement with the IPC team, increased motivation for health behavior change and self-care, and improvements in patient health behaviors, physical and mental health, and social needs. Despite benefits, patients and providers noted how some patient health characteristics (e.g., chronic health conditions) and contextual factors (e.g., housing insecurity) may have limited the effectiveness of the program on healthcare costs and utilization.
Date: May 13, 2021
- Medication Therapy for Opioid Use Disorder Saves Lives and Can Save Money for Society
Investigators in this study developed a mathematical model to assess the cost-effectiveness of opioid use disorder treatments and the association of these treatments with outcomes in the US. Two analyses were done, the first considering only health sector costs, and the second also considering criminal justice costs. Findings showed that medication-assisted treatment (MAT), with or without overdose education and naloxone distribution, contingency management, and psychotherapy, is associated with significant health benefits and is cost-effective compared to usual benchmarks when considering only healthcare costs. When criminal justice costs were included in addition to healthcare costs, all forms of MAT (buprenorphine, methadone, and naltrexone) were cost-saving compared with no treatment, yielding savings of $25,000 to $105,000 in lifetime costs per individual. An analysis using demographics and cost data for VA yielded similar findings, but
quality of life gains from treatment were lower due to Veterans being older, on average, than the general population.
Date: March 31, 2021
- Veterans Receiving VA-Only Post-Kidney Transplant Care Had Lower Five-Year Mortality Compared to Non-VA Transplant Care
This study sought to characterize where Veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care – and to evaluate the association of post-transplant care source with longer-term mortality. Findings showed that in the first year following transplantation, 752 Veterans (12%) received post-transplant care in VA only, 2,092 (34%) through Medicare only, and 3,362 (54%) through both VA and Medicare. Veterans who received VA-only post-transplant care had the lowest 5-year mortality compared to those receiving such care via Medicare or both VA and Medicare. Over 5 years of follow-up, 1,053 Veterans (17%) died overall. Patients who received Medicare-only post-transplant care had a higher 5-year mortality rate compared with VA-only patients (20% v. 11%), as did dual care patients (16% v. 11%). There also was lower 30-day mortality among those transplanted within VA compared to outside VA (<1% v. 1.3%). The need for dialysis at one year was lower in Veterans who received VA-only post-transplant care than Medicare only (2% v. 3%) and dual care (2% v. 4%). These findings can inform patient decisions regarding the preferred venue of care following kidney transplantation and highlight the critical importance of monitoring patient outcomes as VA expands options for care in the community via the MISSION Act and other healthcare legislation.
Date: March 8, 2021
- Veterans Open to Discussing Firearms Storage Safety in Primary Care Setting
quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. Most Veterans in the study agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and non-judgmental approach. Veterans noted concerns about the legal consequences of disclosing firearm ownership and most did not support direct questioning about this, e.g., “Do you own a firearm?,” which may trigger fears of having firearms being taken away or limitations being placed on access to firearms. Veterans also noted the need to provide a clear reason for why a discussion on FSS was happening, such as promoting mental health or concern for household safety and wellbeing. Discussing FSS with Veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts but must be conducted in a Veteran-centric manner.
Date: January 26, 2021
- JAMA Features Reflections on “Crossing the
Quality Chasm” 20 Years Later
This issue of JAMA includes two articles that reflect on the recommendations of the Institute of Medicine’s 2001 Crossing the
Quality Chasm report that, 20 years ago, asked healthcare stakeholders to collaborate in order to provide care that is safe, effective, patient-centered, timely, efficient, and equitable. Both articles discuss how to make more progress toward these goals, while a third article from an HSR&D researcher is about the importance of patient safety in ambulatory care.
Date: December 22, 2020
- JGIM Supplement Features HSR&D/QUERI Research on the Importance of Implementation Science to
Sponsored by the Agency for Healthcare Research and
Quality (AHRQ), Kaiser Permanente, and VA, this supplemental issue of the Journal of General Internal Medicine (JGIM) on implementation science (IS) and
quality improvement (QI) marks the formal addition of IS/QI as an area of emphasis for JGIM. The supplement features innovative research that applied evidence across diverse delivery systems and settings, as well as a high-level overview of important contributions for implementation science with selected stories amplifying successes in the field. Editors discuss how the IS/QI research featured in this supplement can advance internal medicine care delivery and ensure that the foundational knowledge generated by internal medicine research finds its way into practice.
Date: November 10, 2020
- VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival
This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Findings showed that VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising access to care or survival. Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the
quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%). Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly.
Date: September 22, 2020
- Low-Value Diagnostic Testing for Back Pain, Sinusitis, Headache, and Syncope Is Common and Varies Across VA Medical Centers
This study sought to determine the frequency and degree of variation in low-value diagnostic testing for four common conditions across 127 VAMCs. Findings showed that low-value diagnostic testing for four conditions was common; it affected 5-21% of Veterans, varied 2-to-5 fold across VAMCs, and was significantly correlated at the VAMC level. Applying sensitive criteria, the overall and VAMC-level of low-value testing frequency varied substantially across conditions: 5% (range 3-10%) for sinusitis, 13% (9-23%) for headache, 18% (11-25%) for low-back pain, and 20% (16-28%) for syncope. Applying specific criteria lowered the overall frequency and range of low-value testing across VAMCs: 2% (range 1-5%) for sinusitis, 9% (6-15%) for headache, 6% (4-8%) for low-back pain, and 13% (11-17%) for syncope. Findings reinforce the need to address low-value diagnostic testing, even in integrated health systems like VA, with robust utilization management practices.
Date: September 22, 2020
- Project Identifies and Validates Recommendations to Stop or Scale Back Unnecessary Routine Services in Primary Care
Investigators in this study conducted a focused review of existing guidelines and recommendations – concentrating primarily on those published between 2011 and 2016 – to identify potential deintensification recommendations related to routine primary care. Investigators reconfigured about 50 high-priority recommendations by explicitly defining and specifying the deintensification action and appropriate target population. Starting from a set of 86 guidelines, Choosing Wisely recommendations, and National
Quality Forum measures, investigators identified 409 recommendations – corresponding to 178 unique indications – that represented opportunities to stop or scale back routine services in primary care. After prioritization, specification, and expert panel revisions, the panel rated 37 of 44 deintensification recommendations as valid – and 32 of 44 as both valid and an important improvement opportunity (i.e., likely to affect many patients or substantially impact a smaller number of patients). This study builds on previous guidelines and lists of recommendations by making explicit when and for whom ongoing medical services should be stopped or scaled back. The approach used in this study in the first to systematically identify, specify, and validate actionable and measurable recommendations for deintensification in routine primary care.
Date: September 14, 2020
Quality Improvement Intervention Improves Outcomes for Veterans with New Ischemic Stroke Symptoms
The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention was developed to improve the
quality of VA care for Veterans experiencing transient ischemic attack (TIA). This trial evaluated the PREVENT intervention at six diverse VA medical centers and assessed temporal trends in care
quality among 36 matched control sites (six control sites matched to each intervention site on TIA patient volume, facility complexity, and
quality of care). Findings showed that over the course of a one-year implementation period, the mean without-fail rate (Veterans with TIA at a specific facility who received all of the processes of care for which they were eligible) improved substantially at the six VA sites utilizing PREVENT (37% to 54%; +17%) and improved only modestly at the 36 matched control sites (39% to 42%; +3%). Investigators observed a net improvement of 14% at PREVENT intervention sites compared with matched controls. At PREVENT sites, the observed 90-day all-cause mortality rate decreased from 2.5% to 1.6%; at matched control sites this rate declined similarly from 2.3% to 1.7%. Decreases in the 90-day stroke rate, combined 90-day stroke or death rate, and the recurrent event rate were modestly higher for PREVENT sites than for the matched control sites, but differences were not statistically significant. Based on observed improvements in
quality of care, PREVENT was deployed nationwide across the VA healthcare system in 2019.
Date: September 8, 2020
- VA/HSR&D Research on Complementary and Integrative Health Therapies within VA
Funded by HSR&D, this special issue of Medical Care highlights how research on complementary and integrative health (CIH) therapies in the VA healthcare system has progressed along the QUERI (
Quality Enhancement Research Initiative) Implementation Roadmap – from pre-implementation to implementation to sustainment. CIH approaches are becoming more available throughout VA, due to: 1) increased implementation of the Whole Health System of Care, which integrates allopathic and CIH care; and 2) development of the infrastructure for CIH implementation, which includes new standards for hiring CIH providers, the involvement of volunteers who teach CIH, and development of policy and guidance for providing CIH at VAMCs, via telehealth, and/or in the community. Conducting pre-implementation, implementation, and sustainment phases of research on CIH approaches in VA is yet another way to boost the scale-up and spread of these therapies to reach as many Veterans as possible.
Date: September 1, 2020
- Effectiveness of Deprescribing Interventions for Community-Dwelling Older Adults
This systematic review and meta-analysis evaluated the effectiveness, comparative effectiveness, and harms of deprescribing interventions in community-dwelling persons aged 65 or older. Findings showed that medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. Comprehensive medication review may have reduced all-cause mortality but probably had little to no effect on falls, health-related
quality of life, or hospitalizations. Nine of thirteen trials reported fewer inappropriate medications in the intervention group. Among various educational initiatives, findings showed that they may reduce the use of inappropriate medications, but had uncertain effects on
quality of life and rates of hospitalizations and falls. Among computer decision support interventions, two studies reported a significant reduction in inappropriate medications and two studies reported no effect. No studies assessed the comparative effectiveness of the different deprescribing approaches.
Date: August 20, 2020
- Contextualized Care Planning Results in Improved Veteran Outcomes and Significant Cost Savings
Contextualizing care is the process of adapting research evidence to patient context. For example, recognizing that a patient is not managing their diabetes because they cannot afford the medication and switching them to a less costly alternative is a contextualized care plan. This study evaluated the effectiveness of a
quality improvement program in which providers receive ongoing feedback on their attention to patient contextual factors based on audio recordings of their clinical encounters. Findings showed that contextualized care planning was associated with a significantly greater likelihood of improved outcomes – and resulted in significant cost savings from avoided hospitalizations. At baseline, providers addressed 413 of out 618 contextual factors in their care plans (67%). Following either standard or enhanced feedback, they addressed 1,707 out of 2,367 contextual factors (72%), a significant improvement. In a budget impact analysis, estimated savings from avoided hospitalizations were $25.2 million at a cost of $337,000 for the intervention. Giving clinicians ongoing feedback on their attention to the life challenges that their patients face may be an effective strategy for heightening their awareness and attention to social determinants of health, which may significantly improve healthcare outcomes and reduce costs. QI programs may be well advised to consider routine incorporation of training in contextualizing care through audit and feedback.
Date: July 31, 2020
- VA Patients Have Fewer Potentially Avoidable Hospitalizations Post-Chemotherapy than Medicare Patients
The Centers for Medicare and Medicaid Services (CMS) released a new
quality measure to reduce potentially avoidable hospital admissions among patients receiving outpatient chemotherapy. In this study, investigators used this CMS measure to compare the
quality of care received by chemotherapy patients treated through traditional Fee-for-Service Medicare versus VA, using a cohort of dually-enrolled Veterans. Findings showed that Veterans with cancer receiving chemotherapy through VA have higher-
quality care with respect to avoidable hospitalizations than Veterans receiving chemotherapy through Medicare. Roughly 7% of Veterans treated through Medicare had potentially avoidable hospitalizations in the 30 days following chemotherapy compared with approximately 5% of Veterans treated by VA. In the entire cohort, the top reasons for an avoidable hospitalization were pneumonia (41%), sepsis (24%), anemia (21%), and pain (11%), though the order of frequency changed when evaluating Medicare versus VA treatment. This study was driven by recent legislation (Choice Act of 2014, MISSION Act of 2018) allowing Veterans to seek care in the private sector if VA care is difficult to access. As these policy changes are implemented, it is critical to understand whether this shift in system of care will impact care
quality, especially for conditions as serious as cancer.
Date: July 15, 2020
- Palliative Care During VA Hospitalization for Heart Failure Reduces Readmissions and Mechanical Ventilation
This study examined the association of palliative care during heart failure hospitalizations with transitions (i.e., multiple readmissions or intensive care admissions) and procedures (i.e., mechanical ventilation, pacemaker implantation, or defibrillator implantation) in the six months following hospital admission. Findings showed that palliative care during hospital admissions for heart failure was associated with fewer multiple readmissions (31% versus 40%), less mechanical ventilation (3% versus 5%), and less defibrillator implantation (2% versus 4%). Hospice use in the six months after discharge was significantly higher among Veterans in the palliative cohort vs those in the non-palliative cohort (35% vs 18%). These findings add to an increasing number of analyses that found associations between palliative care and positive outcomes for patients experiencing heart failure. As health systems develop population health approaches to care, palliative care for heart failure patients should be considered as an adjunct to improve patient
quality of life, symptom management, and goal setting – and to potentially reduce rehospitalizations and mechanical ventilation.
Date: June 2, 2020
- Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans
Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and
quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar
quality of care in the management of chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
Date: April 1, 2020
- Computer-Based Cognitive Behavioral Therapy with Peer Support Provides Greater Improvement of Depression Symptoms
This trial sought to determine whether computer-based cognitive behavioral therapy (cCBT) combined with peer support improved outcomes relative to enhanced usual care (EUC) for 330 primary care patients with depression who were treated at three Midwestern VA medical centers and two of their associated outpatient clinics. Findings showed that peer-supported cCBT as an add-on to usual primary care treatment for depression was associated with greater improvements in depression symptoms,
quality of life, and mental health recovery at three months compared to enhanced usual care alone. Improvements in mental health recovery, although not the other outcomes, were sustained up to six months. Remission rates were 14% for Veterans in the peer-supported cCBT group and 6% for Veterans in the EUC group at three months, and 22% and 11%, respectively, at six months. The more modest benefits found with peer-supported cCBT should be considered in the context that more than 50% of Veterans also received antidepressant medication with high levels of adherence and over 30% received some in-person psychotherapy. Computerized CBT with peer support should be considered for implementation and evaluation in primary care, and adaptations to the computer CBT and peer support components should be considered to further improve effectiveness.
Date: March 1, 2020
- Anti-MRSA Therapy Associated with Greater 30-day Mortality Compared with Standard Therapy for Veterans with Pneumonia
This study sought to determine the association of empirical anti-MRSA therapy with 30-day mortality for Veterans hospitalized with pneumonia. Findings showed that empirical anti-MRSA therapy was significantly associated with greater 30-day mortality compared with standard therapy alone. There was a significant increase in 30-day mortality associated with empirical anti-MRSA therapy plus standard therapy, compared with standard therapy alone, among patients admitted to the intensive care unit (ICU) and those with a high clinical risk for MRSA. Thus, investigators could establish no benefit of empirical anti-MRSA therapy, even when risk factors for MRSA were present or clinical severity warranted admission to the ICU. The use of anti-MRSA therapy also was associated with increased risk of kidney injury and secondary infections.
Date: February 17, 2020
- Payment Changes and Choosing Wisely Recommendations Affect Low-Value Lab Testing
This study examined the use of low-value lab testing, specifically, vitamin D screening and triiodothyronine (T3) level testing across three healthcare jurisdictions: Ontario, Canada; the VA healthcare system; and the U.S. employer-sponsored insurance market. In the three jurisdictions examined, Choosing Wisely recommendations were associated with only limited reductions in the use of low-value vitamin D screenings and were not associated with reduced use of low-value T3 testing. However, a December 2010 policy that eliminated reimbursement for low-value vitamin D screening in Ontario was associated with a 93% relative reduction in such screening. Corresponding Choosing Wisely recommendations were associated with smaller reductions: 5% in Ontario, 14% in VA, and 14% for U.S. employee-sponsored insurance. Thus, recommendations alone may not be enough to reduce the use of low-value services at a national or regional level – pairing recommendations with policy changes may be more effective.
Date: February 10, 2020
- Eight Organizational Target Areas for Improving Access to Primary Care
This study sought to identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. Findings showed that optimal access to primary care for enrolled patient populations requires active ongoing management of at least eight diverse target areas (two organizational structure targets, four process improvements, and two outcomes): 1) Clearly identified group practice management structure; 2) Interdisciplinary primary care site leadership; 3) Patient telephone access to ensure patient safety, scheduling, and coordination; 4) Contingency staffing (planned minimal excess staffing to cover routine absences); 5) Nurse management of demand through care coordination; 6) Proactive demand management by optimizing provider visit schedules; 7)
Quality of patients’ experiences of access; and 8) Provider and staff morale in relationship to supply-demand mismatch (e.g., provider vacancies, panels exceeding recommended size).
Date: February 1, 2020
- All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-
quality integrated healthcare, for both Veteran and non-Veteran white men.
Date: January 31, 2020
- Few Disparities in Medical Treatment for Opioid Use Disorder after Non-Fatal Overdose
This study assessed the association between race and ethnicity and patterns of opioid prescribing before and after a non-fatal opioid overdose – and also assessed the receipt of medications for opioid use disorder (MOUD: buprenorphine, methadone, and naltrexone) following such events among VA patients. Findings showed that receipt of an opioid prescription decreased by 16-21 percentage points in the 30 days after overdose, but remained high, with no significant differences across racial and ethnic groups. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively. Overall, MOUD prescribing in VA was very low in all racial groups in the 30 days after overdose, though statistically significantly higher in black and Hispanic patients. After overdose, 3% of patients received MOUDs (3% white, 5% black, and 6% Hispanic). Blacks and Hispanics had significantly larger odds of receiving MOUDs than whites. Findings demonstrate an opportunity to improve the
quality of care for all patients with opioid use disorder, particularly in the vulnerable period around a non-fatal overdose event.
Date: January 21, 2020
- Special Medical Care Supplement Features VA/HSR&D Research on Evidence Synthesis in a Learning Healthcare System
Titled “Evidence Synthesis in a Learning Health Care System,” this Medical Care supplement includes 14 original articles that present new insights and perspectives from HSR&D’s Evidence Synthesis Program (ESP). Articles discuss optimal evidence synthesis methods and applications in a learning healthcare system; some articles target the effect in one area (i.e., mental health, primary care), while others discuss a broader, system-wide effect. As the editors note, “The articles in this series demonstrate what can be accomplished when research synthesis is integrated with qualitative information from health system personnel and patients and quantitative data from health systems in the context of an overarching framework for health system learning."
Date: October 1, 2019
- Cardiovascular Benefits of Intensive Glucose Control in Veterans with Type 2 Diabetes Did Not Persist in Long-term Post-Trial Follow-Up
Long-term follow-up of glucose lowering in patients with type 2 diabetes may help clarify the duration of any potential cardiovascular disease (CVD) benefit. Investigators here report on the full 15-year follow-up of Veterans with type 2 diabetes who were randomly assigned to receive either intensive or standard glucose control as part of the Veterans Affairs Diabetes Trial. Findings showed that Veterans with type 2 diabetes at high CVD risk, with 5.6 years of intensive glucose lowering to a HbA1c of 6.9%, DID NOT experience reduced major cardiovascular events over 13.6 years of follow-up or reduced total mortality or improved
quality of life over 15 years of total follow-up. Although there was a 17% reduction in major CVD events during the approximate 10-year period when HbA1c levels were separated between the intensive and standard therapy groups, there was no evidence of a beneficial legacy effect in the subsequent 5-year period once levels equalized among the groups. Results suggest there are modest long-term cardiovascular benefits of intensive glucose lowering therapy in patients with more advanced diabetes, but that long-term maintenance of lower levels may be required to maintain these improvements.
Date: June 6, 2019
- How Do VA’s Frontline Cardiovascular Clinicians Engage with Concepts of Healthcare Outcomes and Value in their Clinical Work?
This study assessed VA clinicians’ familiarity with and attitudes toward VA’s efforts to measure and improve
quality-of-care processes, clinical outcomes, and healthcare value at their medical centers. Findings showed that, regardless of their medical center's healthcare value performance, most VA cardiovascular providers used feedback from process-of-care data (for example, appropriate use of aspirin or beta-blockers) to inform their practice. However, clinical outcomes data (for example, adverse events or 30-day readmissions) were used more rarely, and value-of-care data were almost never used.
While two-thirds of participants reported that process data were regularly shared with providers, only about one-third of participants were aware of who was responsible for reviewing, analyzing, and disseminating their facility’s outcomes and cost data. In addition, half of the participants stated that they did not receive any feedback on costs of care, and they were not aware whether their facility measured the cost of care in relation to processes and outcomes. Fewer respondents reported clinical outcome measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high-cost care. Providers expressed general enthusiasm for VA’s
quality measurement/improvement efforts, with few criticisms about workload or opportunity costs inherent in clinical performance data collection. This study identifies an opportunity for outcomes and value information to be more frequently measured and more commonly used in routine clinical care settings.
Date: May 7, 2019
- Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness
Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health
quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future suicide-related distress and/or attempts among a high-risk Veteran population.
Date: February 8, 2019
- Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the
quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Women’s Health VA Stakeholders Discuss “Ideal” Care
As part of a multisite implementation trial of evidence-based
quality improvement for tailoring PACT to women Veterans’ healthcare needs, investigators conducted semi-structured interviews with 86 local leaders. At the conclusion of interviews about women’s primary care, participants were asked to describe their conceptualizations of “ideal care” for women Veterans. Respondents commonly discussed whether women Veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women Veterans; physical appearance of facilities; fostering active interest in women’s health across providers and staff; and the relative priority of women’s health at VA. Paths toward ideal care could include projecting and anticipating growth in women’s health programs; building on VA’s pilot program to provide childcare for patients’ children during visits; designing a hiring process to more consistently recruit providers with a strong interest in caring for women; and conducting listening sessions and creating other opportunities that allow senior VA leadership to hear women Veterans’ perspectives and preferences directly.
Date: January 1, 2019
- New VA Center for Innovation for Care and Payment to Test Novel Payment and Service Delivery Models
VA’s new Center for Innovation for Care and Payment will be staffed by VA employees and contractors with expertise in demonstrations and evaluations. Through this Center, VA will have the ability to test novel payment and service delivery models. The new Center also empowers VA to collaborate with other payers to drive improvements in
quality, costs, or efficiency.
Date: December 25, 2018
- Mobile Acute Care for Elders (MACE) Consultation Lowers Readmission and Mortality Rates
Underlying geriatric syndromes in hospitalized patients can lead to complications such as delirium, falls, and functional decline, which in turn may lead to increased morbidity, mortality, readmission, longer hospital stays, decreased
quality of life, and increased costs. Mobile Acute Care for Elders (MACE) has emerged as a way to provide dedicated geriatric care designed to prevent these complications, without the need for a physical inpatient unit. This study examined records of Veterans admitted to the Indianapolis VA Medical Center who were age 65 and older and were screened within 48 hours of admission for geriatric syndromes. For positive screens, admitting staff was offered MACE consultation and ongoing collaboration with a geriatrician and gerontological nurse practitioner. Although no results were statistically significant, Veterans receiving MACE had lower odds of 30-day readmission than those not receiving MACE (12% vs.15%) and lower odds of 30-day mortality (6% vs.9%). The group of Veterans receiving MACE had lower median costs for 30-day readmission than the group not receiving MACE ($16,000 vs. $18,000). The MACE consultation model for older Veterans with geriatric syndromes leverages the limited supply of clinicians with geriatrics expertise. It has the potential to improve care of older Veterans while achieving cost savings to the health system.
Date: December 21, 2018
- No Difference in Intermediate Outcomes for Veterans with Diabetes by Type of Primary Care Provider
This study examined whether intermediate diabetes outcomes differed among Veterans treated at one of 568 VA primary care facilities by a physician, nurse practitioner (NP), or physician assistant (PA) primary care provider. Findings showed that there were no clinically significant differences in intermediate diabetes outcomes – or the control of those outcomes – among patients with NP, PA, or physician primary care providers. There also was no clinically significant difference in the proportions of NP, PA, and physician-treated patients with diabetes who used endocrinology or specialty diabetes services during the year outcomes were calculated. This study provides further evidence that using NPs and PAs as primary care providers may represent a mechanism for expanding access to primary care while maintaining
Date: December 18, 2018
- Intervention Utilizing Community Health Workers Improves
Quality of Patient Care and Reduces Hospitalizations
Individualized Management for Patient-Centered Targets (IMPaCT) is a standardized intervention in which community health workers (CHWs) provide tailored social support, navigation, and advocacy to help low-income patients achieve health goals. This randomized trial assessed the scalability and effectiveness of IMPaCT in three primary care settings that provide treatment to low-income patients: one VA medical center, a federally-qualified health center, and an academic family practice clinic. Findings showed that compared to those in the control group, those in the intervention (CHW) group, including Veterans, had nearly twice the odds of reporting high-
quality primary care, were less likely to be re-hospitalized within 30 days of discharge (12% vs. 28%), and spent fewer total days in the hospital at 6 months. Patients in the CHW intervention group also had lower odds of repeat hospitalizations, including 30-day readmissions.
Date: December 1, 2018
- Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines
This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Findings showed that receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller. Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the
quality and safety of prescribing.
Date: October 9, 2018
- Men Using VA More Likely to Receive Appropriate Prostate Cancer Imaging Tests Compared to Those Using Medicare
This study sought to assess the association between the
quality of healthcare within VA vs. Medicare, by comparing rates of guideline-concordant and guideline-discordant staging imaging among patients with newly diagnosed prostate cancer utilizing VA services only, Medicare only, or a combination of the two. Findings showed that among men with low-risk prostate cancer, the VA-only and VA-Medicare groups were most likely to receive guideline-concordant care (61% and 56%, respectively) compared with the Medicare-only group (53%). Among men with low-risk prostate cancer, more in the Medicare-only group received at least one inappropriate, guideline-discordant imaging test for staging (53%) compared with the VA-Medicare group (51%) and the VA-only group (46%). For men diagnosed with high-risk prostate cancer, guideline-concordance was similar across the 3 groups, with 71% of the VA-Medicare group, 69% of the VA-only group, and 67% of the Medicare-only group receiving guideline-concordant imaging. Findings suggest that Veterans using the Choice Act to seek care outside VA may experience more utilization of care with no guarantee of improved
quality of care.
Date: August 17, 2018
- Substantial Variation in Cardiovascular Mortality Rates across the VA Healthcare System
This study sought to determine whether there are substantial differences in cardiovascular outcomes across 138 VA medical centers. Findings showed that there is substantial variation in risk-standardized cardiovascular mortality rates across the VA healthcare system, suggesting differences in the
quality of cardiovascular healthcare. Ischemic heart disease (IHD) annual death rates at the VAMC with the highest mortality were 3.9 percentage points larger than at the VAMC with the lowest mortality, translating into 1 excess death per year on average among every 26 IHD patients at the highest-mortality VAMC. Similarly, chronic heart failure (CHF) annual death rates were 7.8 percentage points larger, translating into1 excess death per year among every 13 CHF patients at the highest-mortality VAMC compared with CHF patients at the lowest mortality VAMC. Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Cardiovascular mortality in VA medical centers’ chronic cardiovascular disease populations was only modestly correlated with post-hospitalization 30-day outcomes – or with VA’s 5-star
quality ratings system.
Date: July 1, 2018
- Systematic Review: Pay-for-Performance and VA Healthcare
Investigators sought to identify studies that examined the effects of pay-for-performance (P4P) on the
quality of care and health of Veterans, including potential unintended consequences, as well as program design features and implementation factors important to P4P both within VA and in the community. Findings showed that overall, evidence is insufficient to determine whether P4P results in durable improvements in the
quality of healthcare in VA settings. Only 1 controlled trial and 2 observational studies examined the effectiveness of P4P on intermediate clinical outcomes (e.g., blood pressure) in Veterans. Interviews with key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in VA. Key informants’ views on P4P in community settings included the need to: develop relationships with providers and strong-performing health systems; improve coordination by targeting documentation and data sharing processes, and troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. Qualitative studies on P4P in VA found that participants felt performance measures may lead to unintended negative consequences, i.e., reduced focus on patient needs, un-incentivized areas of care, and/or healthier patient populations, and that they may negatively affect team dynamics. Key informants recognized the potential for unintended consequences of P4P, such as overtreatment in VA settings, and suggest that implementation of P4P in the community focus on relationship building – and target areas such as documentation and coordination of care.
Date: July 1, 2018
- No Decrease in Drinking among Veterans despite Alcohol-Related Nurse Care Management Intervention in Primary Care
The Choosing Healthier Drinking Options in Primary Care (CHOICE) intervention was designed to improve drinking outcomes by engaging Veterans at high risk for alcohol use disorders (AUDs) in patient-centered, alcohol-related care. Investigators in this study examined whether 12 months of alcohol care management via the CHOICE intervention – compared with usual primary care – improved drinking outcomes (abstinence was not a required goal). Findings showed that the CHOICE intervention did not decrease heavy drinking or alcohol-related problems at 12 months even though more Veterans engaged in alcohol-related care, including a four-fold increase in initiation of medications for alcohol use disorders. Primary outcomes improved at 12 months but did not differ between groups. The mean percentage of heavy drinking days decreased from 61% at baseline to 39% and 35% in the intervention and usual care groups, respectively. The percentage of Veterans with good drinking outcomes was 15% and 20% in the intervention and usual care groups, respectively. Current
quality measures for AUDs are based on the assumption that engagement in alcohol-related care emphasizing brief intervention and reduced drinking is sufficient to improve outcomes. This trial’s results, in addition to existing literature, suggest that more intensive measures, such as recommending abstinence (vs. reduction in drinking), engaging most patients in use of naltrexone, and/or offering effective behavioral treatment might be needed for alcohol care programs in primary care to be more effective.
Date: May 1, 2018
- Most Women Veterans Report Timely Access to Mental Healthcare, Leading to High Satisfaction with VA Care
This study evaluated access to mental healthcare by assessing women Veterans’ perceptions of the timeliness and
quality of care. Findings showed that of the 419 women Veterans in this study cohort, 59% reported "always" getting an appointment for mental healthcare as soon as needed, and another 22% reported “usually” getting an appointment as soon as needed. Two problems were negatively associated with timely access to mental healthcare: 1) medical appointments that interfere with other activities, and 2) difficulty getting questions answered between visits. Average ratings of the
quality of VA healthcare were high: 8.5 out of 10 regarding VA mental healthcare, 8.7 for VA primary care, and 8.2 for VA healthcare overall. Moreover, 93% of women Veterans reported that they would recommend VA healthcare to other women Veterans. This study highlights opportunities for addressing barriers to timely mental healthcare through practices such as non-traditional clinic hours, open access scheduling, telemedicine, and secure messaging.
Date: April 5, 2018
- Research Involvement Associated with Increased Satisfaction and Decreased Intent to Leave among VA Physicians
This study examined the influence of time spent on academic activities and perceived
quality of care in relation to job attitudes among inpatient medicine physicians from 36 VA medical centers. Findings showed that physicians’ ratings of perceived
quality of care and adequacy of physician staffing were the strongest predictors of overall job satisfaction and intent to leave. Adequacy of physician staffing was the strongest predictor of burnout. Among the job tasks that physicians spent their time on, research (involvement reported by 46% of respondents) was significantly associated with increased job satisfaction and decreased intent to leave. Research time showed a non-significant negative relation with burnout. Teaching involvement was reported by 72% of the respondents, and time spent in this activity showed a similar pattern with job attitudes as described above, but was not significant. Physicians’ perception of having sufficient registered nurse staffing also did not affect physicians’ attitudes about their job. Expanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance.
Date: April 5, 2018
- Then and Now: Medications for Opioid Use Disorder in VA
As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and
quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt.
Date: March 29, 2018
- Intervention to Lessen Low-Value Electronic Health Record Notifications Reduces Workload for Primary Care Physicians
This study evaluated the impact of a national multi-component
quality improvement program to reduce low-value electronic health record notifications. Findings showed that the program potentially saved 1.5 hours per week per primary care physician to enable higher-value work (based on prior estimates of 85 seconds to process each notification). The mean number of daily notifications per PCP decreased significantly from 128 to 116, however, the number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Program impact appeared to be achieved by reducing certain types versus just the sheer number of mandatory notifications, underscoring the complexity of addressing notification burden.
Date: March 5, 2018
- Study Compares VA Care to Community Care for Veterans Receiving Elective Coronary Revascularization
This observational study compared access,
quality, and cost of elective coronary revascularization procedures between VA and community care (CC) hospitals. Findings showed that compared to CC hospitals, Veterans who underwent PCI in VA hospitals had lower mortality (1.5% vs. 0.65%), lower costs ($22,025 vs. $15,683), and similar readmission rates. Compared to CC hospitals, Veterans who underwent CABG in VA hospitals had similar mortality, similar readmission rates, but higher cost ($55,526 vs. $63,144). Compared to VA-only care, Community Care reduced net travel distance for PCI by 54 miles, and CABG by 73 miles, on average. CC care also was associated with significantly lower travel costs – an average of $156 less for PCI and $690 less for CABG. One in five coronary revascularizations for VA patients was performed at CC sites. Findings demonstrate that, on average, Veterans seeking high-
quality care with low mortality and readmission rates are well-served by VA. As VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimizing outcomes and costs.
Date: January 3, 2018
- Veterans with Cancer Received Higher
Quality, Lower Intensity End-of Life Care in VA Compared to Medicare
This study evaluated the
quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted
quality-of-care metrics. Findings showed that Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital. Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in hospital.
Date: January 1, 2018
- More Patient-Aligned Care Team Components Translates to Improved
Quality of Care for Veterans with Chronic Disease
This study examined whether the extent to which clinics had implemented PACT components was associated with improvements in the
quality of care for Veterans with chronic conditions over a four year period. Findings showed that over four years concurrent with PACT implementation, primary care clinics with the most PACT components in place had greater improvements in 5 of 7 chronic disease intermediate clinical outcome and 2 of 8 chronic disease process measures when compared to clinics with the least PACT components in place.
Quality measures that improved more among the clinics with highest PACT implementation included LDL< 100 in CAD and DM patients, and BP < 160/100 in DM and HTN patients. Improvements in percentage of clinic patient population meeting clinical outcome
quality measures over four years in the high PACT implementation clinics ranged from 1.3% to 5.2%. VA primary care clinics may be able to achieve improved
quality of care for patients with common chronic conditions through patient-centered medical home-aligned changes in care delivery across all patients, if those changes are extensively implemented.
Date: November 20, 2017
- Use of Evidence-Based Care Processes Decreases Mortality among Veterans with Staphylococcus aureus Bacteremia
This study sought to determine how increasing use of evidence-based care processes may have contributed to improving survival for Veterans with Staphylococcus aureus bacteremia (SAB). Findings showed that mortality associated with SAB declined significantly in VA hospitals, and a substantial portion of the declining mortality (57%) was attributable to increased use of evidence-based care processes. Further, mortality declined progressively as the number of care processes a patient received increased. Although the use of evidence-based processes substantially improved over the study period, approximately half (48%) of VA patients did not receive all three recommended evidence-based care processes in 2014.
Date: October 1, 2017
- Evidence-based Psychotherapy Template Use Associated with Treatment
Quality for Veterans with PTSD
This study measured the prevalence of evidence-based psychotherapy (EBP) templated notes in VA, testing the hypothesis that template use would be associated with
quality of care for Veterans with PTSD. Findings showed that facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater rates of psychotherapy adequacy (8 psychotherapy visits in 14 weeks). Overall, an average of 4% of Veterans with a PTSD diagnosis received at least one EBP template. Among Veterans receiving psychotherapy for PTSD, an average of 9% received an EBP template. VA facilities with a greater percentage of patients who were service-connected at 50% or higher administered EBP templates to a smaller proportion of Veterans diagnosed with PTSD. The overall reach of EBP template usage was low, indicating that greater efforts are needed to improve usage.
Date: September 30, 2017
- Medical Care Supplement Features Articles by VA Researchers on Improving the
Quality and Equity of Health and Healthcare
In 2016, HSR&D’s Center for Health Equity Research and Promotion (CHERP) and the Health Equity and Rural Outreach Innovation Center (HEROIC) hosted a state-of-the-science conference. This field-based meeting to “Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System” brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance the implementation of evidence-based interventions to improve the
quality and equity of health and healthcare. The conference focused on three specific vulnerable Veteran populations: racial and ethnic minorities, homeless Veterans, and Veterans from the LGBT community. This supplement features several articles that emanated from this meeting.
Date: September 1, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the
quality of the evidence for effectiveness was very low. In 3 good-
quality trials of behavioral interventions and 11 fair-
quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-
quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and
quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
Date: July 18, 2017
- Using Yelp, VA Hospitals Rated Higher than Affiliated Non-VA Hospitals
Online patient ratings of hospitals (e.g., Yelp) have been shown to correlate strongly with more conventional measures of patient satisfaction, as well as patient outcomes. Therefore, this study compared online hospital ratings from Yelp between VA hospitals and their local affiliated hospitals. Findings showed that VA hospitals had significantly higher Yelp ratings than non-VA-affiliated hospitals, suggesting better patient satisfaction. This was not explained by bed size or teaching status of the hospital. Although Yelp reviews describe patient experience, they also may be a marker of patient outcome. This study was not powered to detect differences in outcome; however, a different study found that high Yelp ratings were significantly associated with lower 30-day all-cause mortality following an admission for myocardial infarction or pneumonia – and lower 30-day all-cause readmissions following a discharge for myocardial infarction, heart failure, or pneumonia.
Date: June 28, 2017
- Delivery of Brief Cognitive Behavioral Therapy in Primary Care Improves Mental Health Symptoms in Chronically Ill Veterans
This trial sought to determine whether an integrated brief cognitive behavioral therapy (bCBT) intervention would improve depression, anxiety, and
quality of life for medically ill Veterans. Findings showed that integrated bCBT resulted in significant immediate and 12-month improvements related to depression and anxiety. Brief CBT also resulted in significant short-term improvements related to physical health
quality of life for Veterans with chronic lung conditions. Delivery of bCBT in VA primary care clinics resulted in Veterans receiving an average of 3.9 sessions with high levels of Veteran engagement (84% receiving care) and treatment completion (63% with 4 or more sessions). Veterans and VA providers reported very high satisfaction with bCBT.
Date: June 20, 2017
- Systematic Review on the Benefits and Harms of Spinal Manipulative Therapy for Acute Low Back Pain
This systematic review was conducted to provide updated estimates of the effectiveness and harms associated with spinal manipulative therapy (SMT) compared with other non-manipulative therapies for adults with acute low back pain. Findings showed that spinal manipulative therapy was associated with statistically significant benefits in both pain (15 randomized controlled trials [RCTs] with moderate
quality evidence) and function (12 RCTs with moderate
quality evidence) – of an average modest magnitude at up to six weeks. Minor transient adverse events (i.e., increased pain, muscle stiffness, and headache) were reported in more than half of the patients (67%) in the large case series.
Date: April 11, 2017
- Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
This study evaluated the effectiveness and sustainability of the Enhancing
Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
Date: April 7, 2017
- Findings from an Evaluation of Partnerships within VA HSR&D’s
Quality Enhancement Research Initiative (QUERI)
This study sought to identify tensions that can undermine research/operations partnerships, as well as the positive behaviors that can enhance them. Two main themes were identified: 1) tensions in research/operations partnerships, and 2) key partnership building blocks that facilitate successful research/operations partnerships. Tensions in research/operations partnerships focused on two areas: differing incentives, and scientific rigor and integrity versus quick timelines. Partnership building blocks included: jointly designing the partnership up front; reducing the research bureaucracy burdens; prioritizing in-person communication and long-term relationships; understanding the importance of perspective-taking (mentioned by operations only); and overcoming the need for individual recognition (mentioned by researchers only).
Date: April 3, 2017
- Self-Management Intervention for Chronic Pain
Interactive voice response (IVR) – automated telephonic technology that allows patients to report symptoms, functioning, and pain coping skill use and to receive pre-recorded information and feedback – may improve access to cognitive behavioral therapy (CBT) for chronic pain. This randomized trial assessed the efficacy of interactive voice response-based CBT (IVR-CBT) as compared to in-person CBT among 125 Veterans who received treatment for chronic back pain in the VA Connecticut Healthcare System from June 2012 through July 2015. Findings showed that Veterans in both the IVR-CBT and in-person CBT groups experienced statistically significant reductions in average pain intensity at 3 and 6 months post-baseline, but not at 9 months. Veterans in both groups also experienced statistically significant improvements in physical functioning, sleep, and physical
quality of life at 3 months relative to baseline, with no advantage for either group. The treatment dropout rate was lower among Veterans in the IVR-CBT group, with patients completing an average 2.3 more sessions. IVR-CBT is a low-burden alternative that can increase access to CBT for patients with chronic pain; it also shows promise as a non-pharmacologic treatment option for chronic pain.
Date: April 3, 2017
- The Role of VA Research in a Learning Healthcare System
This overview discusses the ways in which VA research has contributed to improvements in care and health outcomes, reflects on ongoing challenges in getting new evidence taken up quickly in a diverse healthcare system, and offers suggestions about different roles for research in a learning healthcare system.
Date: March 20, 2017
- Systematic Review: Effects of Pay-for-Performance on Healthcare
This review updates and expands on a prior systematic review in order to summarize current understanding of the effects of pay-for-performance (P4P) programs on process of care and patient outcomes in ambulatory and outpatient settings in and outside the United States. Findings showed that overall, in the ambulatory setting there was low-strength evidence that P4P programs might improve process of care outcomes over the short term (2 to 3 years), but there were limited data on longer-term effects. Many of the studies reporting positive findings were conducted in the United Kingdom (where incentives are much larger than P4P programs in the U.S.), and the largest improvements were seen in areas where baseline performance was poor. There was low-strength evidence that P4P had little to no impact on intermediate health outcomes (e.g., changes in lab measures), though there were inconsistencies among study results. In addition, the evidence examining patient health outcomes was insufficient because few methodologically rigorous studies reported these outcomes. In the hospital setting, there was low strength evidence that P4P had a neutral effect on patient health outcomes and a positive effect on reducing hospital readmissions. Findings complement and add to prior reviews that have also generally found that P4P programs have not been consistently effective in improving patient outcomes. In addition, there is low-strength, contradictory evidence that these programs could improve processes of care. Thus, in the absence of strong evidence of benefit, the authors suggest that it may be particularly important to consider the potential harms and costs associated with P4P.
Date: March 7, 2017
- VA Pharmacy Use in the First Year of Choice Act
This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively.
Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost,
quality, and safety concerns.
Date: February 17, 2017
Quality Improvement Tool Shows Organizational Factors Related to Access and
Quality Measures in VA Mental Healthcare
This study analyzed performance on measures included in the Mental Health Management System (MHMS) – a performance data and
quality improvement tool used by VA to increase the value of mental healthcare for Veterans. The MHMS
quality improvement tool showed that organizational factors were associated with performance on key access and
quality measures related to VA mental healthcare. Better access was associated with higher staff-to-patient ratios for psychiatrists and other outpatient mental health providers, and with lower mental health provider staffing vacancies. Higher mental health staff-to-patient ratios were associated with higher performance on nearly all patient and provider satisfaction measures. Higher continuity of care was associated with lower no-show rates to appointments, better wait times, higher staff-to-patient ratios, lower mental health provider vacancies, and more space available for clinical work. Over the past decade, VA’s mental health population has grown rapidly compared to its overall patient population (71% vs. 21%, respectively), so these findings are important in showing that MHMS is a robust informatics and
quality improvement tool that can serve as a model for health systems planning to adopt a value perspective.
Date: February 1, 2017
- Lessons Learned from VA’s History of Transformation and Potential Future Scenarios
An article by O’Hanlon, et al presents an updated view of the evidence on VA’s
quality of care and a strong scientific case to support the conclusion that after its dramatic transformation in the 1990s, VA had
quality and safety measures that were as good, or better, than the private sector – and even top-rated healthcare organizations. However, does the controversy over wait times demonstrate that VA has reverted to its old ways? If so, how can the VA healthcare system find its way back? A return to VA’s earlier lessons of the value of decentralized decision-making, tight accountability for
quality and efficiency, and respect for two-way communication between the field and central management might result in a systematic review of VA 5 to 10 years from now that reaches the same conclusions as O’Hanlon, et al, but includes success in both
quality and access.
Date: January 1, 2017
- Intensive Outpatient Care for High-Need Patients Does Not Reduce Acute Care Use or Costs Compared to Standard VA Care
This study evaluated the effectiveness of augmenting VA’s Patient-Aligned Care Teams (PACTs) with an Intensive Management program (ImPACT). In February 2013, the Palo Alto VAMC launched an ImPACT multidisciplinary team that addressed healthcare needs and
quality of life through comprehensive patient assessments, intensive outpatient case management, care coordination, and social and recreational services. Findings showed that intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on healthcare experiences among Veterans who participated in ImPACT. During the first 16 months of the intervention period, the average number of primary care visits was 22 for ImPACT patients vs. 7 for PACT patients. However, after accounting for the cost of ImPACT encounters, the average baseline and follow-up person-level monthly costs declined at similar rates among ImPACT patients (21.0%) and PACT patients (20.7%). Implementing intensive outpatient programs in VA may offer high-need Veterans more comprehensive services. However, in settings with high-functioning PACTs, these programs may not prevent hospitalizations or achieve substantial cost savings.
Date: December 27, 2016
- Importance of VA’s
Quality Enhancement Research Initiative in the Choice Act Era
The Veterans Access, Choice and Accountability Act of 2014 (Choice Act) allows Veterans enrolled in VA healthcare who have waited longer than 30 days to see a provider – or who live more than 40 miles from a VA clinic – the option of seeking care from non-VA providers. The Choice Act also mandated an independent assessment of VA business and healthcare practices. This article describes how VA’s
Quality Enhancement Research Initiative (QUERI) is responding to the Choice Act, particularly through the implementation strategies that facilitate more rapid uptake of effective practices across different settings, and the rigorous evaluation of new VA programs and policies.
Date: December 16, 2016
- VA Diabetes and Cardiovascular Care
Quality Comparable between Physicians and Advanced Practice Providers
This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that the
quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.
Date: November 1, 2016
- Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions
This evidence review examined the effectiveness, safety, and cost of treating acute medical conditions in settings outside of a hospital inpatient unit. Findings showed that for low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed.
Date: November 1, 2016
- Racial Disparities in HIV
Quality of Care that May Extend to Common Comorbid Conditions
To more fully understand patterns of racial disparities in the
quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in
quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on
quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
Date: September 22, 2016
- VA Makes Significant Improvements in Surgical Care for Veterans
This study used VA Surgical
Quality Improvement Program data to examine post-operative outcomes for 704,901 Veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from FY2000 through FY2014 at 143 VA hospitals. Findings showed that over the last 15 years, there have been decreases of 25%, 54%, and 41% in morbidity, mortality, and failure to rescue (respectively), with an ~40%-50% decrease in the odds of post-operative adverse events over that time among Veterans undergoing surgery in VA facilities. Notably, these improvements have occurred VA-wide and not only at the best-performing VA hospitals.
Date: September 21, 2016
- Similar Effectiveness and Costs of Elective Open vs. Endovascular Aortic Abdominal Aneurysm Repair in VA
This study compared the total and abdominal aortic aneurysm (AAA)-related use of healthcare resources, costs, and cost-effectiveness of the randomized groups to the end of the Open vs. Endovascular Repair trial, with 9 years of follow-up. Findings showed that survival,
quality of life, costs, and cost-effectiveness were not significantly different between elective open and endovascular AAA repair after a mean of 5.2 years of follow-up. Mortality was significantly lower with endovascular repair at 30 days after surgery – and 2 and 3 years after randomization, but not thereafter. Total mean healthcare costs did not differ significantly between the two groups: $142,745 for endovascular compared to $153,533 for open. Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies. Thus, for patients with AAA who are candidates for both procedures, selection of either one remains reasonable and can be guided by patient and physician preference.
Date: September 14, 2016
- Barriers to Implementing Choosing Wisely® Recommendations
This study sought to determine whether particular Choosing Wisely® (CW) recommendations are perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. Findings showed that while PCPs found many Choosing Wisely® recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. For 4 recommendations about not screening or testing in asymptomatic patients, e.g., avoiding colorectal screening for 10 years in patients with negative colonoscopy, less than 20% of PCPs found the CW recommendations difficult to accept (7%-17%) or difficult for patients to follow (12%-19%). For 5 recommendations about testing or treatment for symptomatic conditions, e.g., limiting the use of antibiotics for sinusitis, avoiding imaging tests for low back pain within the first six weeks, however, there was both variation in reported difficulty to follow (10%-32%) and a high level of reported difficulty for patients to accept (36%-87%). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision-making, and the number of tests recommended by specialists.
Date: September 6, 2016
- Neuroimaging Overuse More Common among Medicare Patients Compared to VA Patients
This retrospective study sought to determine whether rates of inappropriate neuroimaging for headache and neuropathy differ between Veterans receiving VA care and a Medicare population enrolled in the Health and Retirement Study (HRS). Findings showed that while neuroimaging overuse was high in both populations, it was much less common for patients treated in VA compared to those who received care through Medicare coverage: 49% of all headache patients received neuroimaging in HRS-Medicare compared with 22% of VA patients, and 24% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9% in VA.
Date: July 8, 2016
- New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV
In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on
quality of care.
Date: July 1, 2016
- Pay-for-Performance Intervention Improves Blood Pressure Control among Black Veterans with Hypertension without Unintended Consequences
This study sought to evaluate the effect of a pay-for-performance intervention on the
quality of hypertension care provided to black Veterans. Findings showed that VA physicians who received performance incentives for meeting guideline-recommended hypertension
quality measures demonstrated better performance than control group physicians on a combined measure of BP control or appropriate clinical response to uncontrolled BP in black Veterans. The proportion of black patients who achieved BP control or received appropriate response to uncontrolled BP was 6% greater for physicians who received an incentive. There was no evidence found for risk selection, i.e., there was no difference between intervention and control groups in the proportion of Veterans who switched providers, and there were no differences in visit frequency or panel turnover, creating reassurance that the incentives did not have negative unintended effects on the care of black patients.
Date: June 22, 2016
- VA Captures More Complete
Quality Performance Data Compared to Medicare Advantage
Investigators in this study examined the agreement between VA and Medicare Advantage (MA)
quality assessments for a group of dually-enrolled Veterans, testing the hypothesis that private health plans under-report
quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Findings showed that despite assessing the same Veterans using identical performance measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. For example, VA’s performance advantage ranged from 10 percentage points (46% for VA vs. 36% for MA) for HbA1c <7.0% in diabetes to 55 percentage points (80% for VA vs. 25% for MA) for blood pressure <140/90mmHg in diabetes. In analyses limited to Veterans having at least 10 MA outpatient encounters, VA reported better performance than MA for 11 of 12 measures – ranging from 10 percentage points to 36 percentage points. Findings suggest that neither Medicare Advantage plans nor VA fully capture
quality of care information for dually-enrolled Veterans. However, VA captures significantly more information than MA.
Date: March 31, 2016
- Impact of Evidence-based
Quality Improvement Strategy on VA Patient-Aligned Care Team Implementation
This study assessed changes in VA healthcare utilization and costs for Veterans from six practices in three different medical centers using an evidence-based
quality improvement (EBQI) approach to implement PACT and 28 comparison practices over a five-year period (FY2009 to FY2013). Findings showed that after PACT implementation, the overall use of primary care, specialty care, and mental health/substance abuse care decreased, while the use of telephone care increased. Decreased outpatient care use occurred more rapidly for VA practices that employed an EBQI approach to PACT implementation, including outpatient visits for primary care, specialty care, and mental health and substance abuse care that appeared to augment the effects of PACT. EBQI practice was significantly associated with a 15% reduction in primary care encounters over the study period. For specialty care, there was a 17% decrease in encounters associated with EBQI overall, but the rate of decrease slowed each year after the implementation of PACT. There was no significant effect of EBQI status on emergency department visits, all-cause hospitalizations, or prescription drugs. Total VA healthcare costs per patient decreased by 5% each year across all practices, but there was no effect of EBQI practice on costs.
Date: February 1, 2016
- Mental Health Conditions Common among Patients Seeking and Undergoing Bariatric Surgery
This systematic review had three aims: 1) to estimate the prevalence of mental health conditions among bariatric surgery candidates and recipients; 2) to evaluate the association between preoperative mental health conditions and weight loss after surgery; and 3) to evaluate the association between surgery and the clinical course of mental health conditions. Findings showed that mental health conditions are common among patients seeking and undergoing bariatric surgery, particularly depression and binge-eating disorder (BED). Prevalence estimates for mood disorders (22%), depression (19%), and BED (17%) were higher than published rates for the general U.S. population, (10%, 8%, and 1-5%, respectively) suggesting that special attention should be paid to these conditions among bariatric patients. There was moderate-
quality evidence to support an association between bariatric surgery and lower rates of depression post-operatively. Depression improved following surgery in 11 of the 12 studies, including two randomized controlled trials evaluating preoperative behavioral health interventions.
Date: January 12, 2016
- Career Development Programs Successfully Prepare Future Health Services Researchers, Particularly VA HSR&D
This evaluation compared the accomplishments of HSR&D, NIH, and AHRQ Career Development Awardees. Findings showed that all three programs are successfully selecting and mentoring awardees, ensuring additional health services research capacity to improve the
quality and delivery of high-value healthcare. VA HSR&D awardees had been PI on significantly more grants of $100,000+ than NIH awardees, and also had more major journal articles than NIH awardees. No significant differences emerged among HSR&D, NIH, and AHRQ awardees in tenure-track academic rank, number of grants as primary investigator, major journal articles and articles as first or sole author, or mentoring post-graduate researchers.
Date: November 9, 2015
- VA Hospital Observation Stays Increasing
When acutely ill patients present to the emergency department (ED) and neither inpatient admission nor ED treatment followed by discharge is clearly indicated, physicians are likely to place the patients in the hospital under “observation” status. This study sought to identify trends and variations in observation rates across 21 VISNs and 128 VA hospitals nationwide. Findings showed that of the 4,423,010 hospital admissions in this study, 392,939 (9%) were initiated in medical observation status. From 2005 through 2013, observation rates across VA hospitals more than doubled, with substantial variation across both hospitals and VISNs. There were 451,229 acute admissions in the first year (2005), of which 29,119 (6.5%) initiated in observation status compared to 517,248 acute admissions in the last year (2013), of which 71,124 (13.8%) initiated in observation status. While most hospitals in this study increased their observation rate, some reduced their rate. Overall, changes in the use of observation ranged from a 27 percentage-point decrease to a 43 percentage-point increase, with the average change being an increase of 7.1 percentage points. Findings suggest that trends in the use of observation stays are similar in VA and Medicare patients despite differing payment structures and financial incentives in the two systems. VA policymakers, like their Medicare counterparts, will need to examine the impact of the growing number of observation stays on patient outcomes and costs.
Date: October 1, 2015
- ICU Treatment for Medicare Patients with Pneumonia Associated with Better Outcomes without Increased Costs
This study sought to determine the association between ICU admission and outcomes, 30-day mortality, and costs among Medicare beneficiaries hospitalized for pneumonia. To account for unmeasured confounding between groups (ICU vs. general ward admission), an instrumental variable (IV) was used – the differential distance to a high-ICU use hospital. Findings showed that ICU admission of those patients for whom the decision appeared to be discretionary (those meeting the IV criteria above, approximately 13% of the total sample) was associated with improved survival and no significant difference in costs. Patients living closer (<3 miles) to a high-ICU hospital were significantly more likely to be admitted to the ICU than patients living farther away (36% vs. 23%) – this was the basis of the IV analysis. In the IV analysis, ICU admission was associated with significantly lower 30-day mortality compared to general ward admission (15% vs. 21%), with a reduction in 30-day mortality of 6%. In the IV analysis, ICU admission was not associated with significant differences in total payment to Medicare or total hospital costs.
Date: September 22, 2015
- Effectiveness of Mindfulness-Based Stress Reduction Therapy for Veterans with PTSD
This randomized clinical trial compared mindfulness-based stress reduction with present-centered group therapy, a treatment that addresses current life problems. Findings showed that mindfulness-based stress reduction therapy resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect. Veterans in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity at two-month follow-up, but they were no more likely to have loss of PTSD diagnosis. Improvements in
quality of life made during treatment were maintained at 2-month follow-up for Veterans in the mindfulness-based stress reduction group, but reports of
quality of life returned to baseline levels for those in present-centered group therapy.
Date: August 4, 2015
- Wide Variation Documented Among VA Providers in Potential Overuse of Antibiotics for Acute Respiratory Infections
This study examined trends in antibiotic prescribing for acute respiratory infections (ARIs) within the VA healthcare system over an 8-year period – and identified patient, provider, and setting sources of variation. Findings showed that there was a persistently high prevalence of outpatient antibiotic prescriptions for ARIs among Veterans. Of more than one million ARI visits, the proportion resulting in antibiotic prescription increased from 67.5% in 2005 to 69.2% in 2012. Also, the proportion of antibiotic prescriptions that were macrolides increased from 37% to 47%. There was substantial variation in prescribing at the provider level. The 10% of VA providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, while the 10% who prescribed the least did so during <40% of their ARI visits. Mid-level providers prescribed antibiotics slightly more frequently than physicians (70% vs. 68%). Subgroups associated with higher prevalence of antibiotic prescribing included: diagnosis of sinusitis (86%) or bronchitis (85%), presence of a high fever (78%), occurrence in an urgent care setting (75%), and Southern and Central regions of the U.S. (both 71%). Variation in ARI management seems to be strongly influenced by the prescribing patterns of individual providers. This is a ripe target for further research,
quality improvement, and antibiotic stewardship interventions.
Date: July 21, 2015
- Mortality among Veterans with Severe Sepsis Declines, but Significant Variation across VA Hospitals Persists
This study sought to determine the extent to which variation in short-term mortality following severe sepsis is explained by the VA hospital and regional VA healthcare network where a Veteran receives care. Findings showed that unadjusted 30-day mortality among hospitalized Veterans with severe sepsis declined from 18% in 2008 to 15% in 2012, despite very similar severity of illness between years. After severity-of-illness and case-mix adjustment, variation persisted in 30-day mortality across hospitals – and to a lesser extent, across regions. For example, the median hospital in the worst quintile of performers had a risk-adjusted 30-day mortality rate of 17% in 2012 compared with the best quintile with a rate of 13%, suggesting a 20% greater risk of death (4% absolute mortality difference) when treated at a hospital in the bottom versus the top quintile.
Date: July 1, 2015
- Effects of Primary Care Provider Turnover
This study measured the effect of PCP turnover on patient experiences of care and ambulatory care
quality. Findings showed that nearly 9% of Veterans in this study experienced a PCP turnover. Primary care turnover was associated with worse patient experiences of care. For example, 75% who experienced no PCP turnover had a positive rating of their personal doctor compared with 68% of Veterans who had experienced PCP turnover. Also, 38% of Veterans with no PCP turnover had a positive rating of getting care quickly compared with 36% of patients who had experienced PCP turnover. In contrast, PCP turnover was not associated with lower ambulatory care
quality. In 9 measures of ambulatory care
quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1%.
Date: July 1, 2015
- Having a Diet Option Assigned vs. Choosing a Diet Leads to Greater Weight Loss among Obese Veterans
This randomized trial evaluated whether Veterans allowed the opportunity to choose between two diets would have greater weight loss than Veterans randomly assigned a diet. Findings showed that, contrary to popular opinion, the option of choosing a diet to follow, as opposed to being assigned a diet, did not improve weight loss among obese Veterans. At 48 weeks, the estimated mean weight loss was 5.7 kg for Veterans in the Choice group and 6.7 kg for Veterans in the Comparator group. Secondary outcomes of dietary adherence, physical activity, and weight-related
quality of life were similar between groups. Given that diverse diets have proven effective for weight loss, future research might examine matching patients to their optimal diet based on other characteristics (e.g., metabolic profile, genetics) instead of their preferences.
Date: June 16, 2015
- Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting
Given that adoption of electronic health records (EHRs) is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. Findings showed that Computerized clinical decision support that is integrated into the physician order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-
quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount. Interventions that include a “hard stop” to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness. Potential harms of computerized clinical decision-support interventions have been rarely studied.
Date: April 21, 2015
- Study Shows No Evidence that Dual Use of VA and Medicare Advantage Results in Worse Patient Outcomes
This study assessed characteristics of Veterans who were dually enrolled in both VA and Medicare Advantage (MA) – managed care plans administered by private health insurance companies that contract with the Centers for Medicare and Medicaid Services. This study also compared
quality of care using intermediate
quality outcomes among Veterans exclusively receiving outpatient care in VA with Veterans receiving outpatient care in both systems. No evidence was found that Veterans with dual use of VA and Medicare Advantage experienced either improved or worsened intermediate outcomes compared with Veterans who exclusively used VA healthcare. Outcomes were marginally better for VA-only users on the measures related to hypertension control and CHD control. Conversely, dual VA-MA users experienced slightly better outcomes on measures relating to diabetes control. Dually-enrolled Veterans with fewer VA outpatient visits had comparable outcomes to Veterans with many VA outpatient visits, suggesting the absence of a threshold number of VA visits for achieving better intermediate outcomes in diabetes, hypertension, and heart disease.
Date: April 6, 2015
- Patient Outcomes for Multi-faceted Intervention for Veterans with Heart Failure Comparable to Usual Care
Investigators in this study developed the Patient-Centered Disease Management (PCDM) intervention for patients with heart failure (HF) that combines multidisciplinary collaborative care by a nurse coordinator, cardiologist, psychiatrist and primary care provider, home tele-monitoring, and depression management. The primary aim of the study was to determine whether or not Veterans enrolled in the intervention experienced better health status (i.e., symptom burden, functional status, and
quality of life) compared with Veterans enrolled in usual care. Findings showed that the PCDM intervention did not improve HF health status for Veterans compared with usual care. While there was significant improvement in overall summary scores in both groups after one year (mean increase of 13.5 points in each group), there was no significant difference between Veterans in the intervention group compared to Veterans in the usual care group. Among secondary outcomes, there were significantly fewer deaths at one year among Veterans in the intervention group (8 of 187, or 4%) than in the usual care group (19 of 197, or 10%). Among Veterans who screened positive for depression, there also was greater improvement in depression scores after one year for Veterans in the intervention group compared to Veterans in the usual care group. There was no significant difference in 1-year hospitalization rates between groups (29% vs. 30%).
Date: March 30, 2015
- VA Maintains Access to Care as Need for Substance Use Treatment Grows
VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and
quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
Date: March 12, 2015
- Veterans Receiving Brief Alcohol Misuse Intervention Rate VA Providers and Care Higher than Veterans without Intervention
This study assessed the relationship between receipt of brief alcohol intervention and patient-reported indicators of care
quality. Findings showed that among Veterans who screened positive for unhealthy alcohol use, a higher proportion who reported receipt of a brief alcohol intervention, compared to those who did not, rated their provider (87% vs. 82%) and VA healthcare (83% vs. 76%) as high
quality. Sixty-one percent of Veterans in this study screened positive for mild unhealthy alcohol use, and 21%, 11%, and 8% screened positive for moderate, severe, and very severe unhealthy alcohol use, respectively. Of drinkers reporting unhealthy alcohol use, 44% of Veterans reported receipt of a brief intervention for unhealthy alcohol use in the previous year. Overall, 84% and 79% of Veterans rated their provider and VA healthcare as high
quality, respectively. Thus, although the literature suggests providers may be concerned that discussions of unhealthy alcohol use may negatively impact relationships with their patients, study findings do not support concerns that delivering alcohol-related advice adversely affects patients’ perceptions of care.
Date: February 18, 2015
- Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD
This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for
quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy.
Date: January 1, 2015
- Improved Performance on
Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
This study examined the
quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient
Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care
quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on
quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17
quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
Date: December 11, 2014
- Poor Communication between VA and Non-VA Primary Care Providers co-Managing Rural Veterans
This study examined the perspectives of community-based, non-VA primary care providers (PCPs) regarding their experiences co-managing Veterans with VA providers. Findings showed that communication with VA was viewed as poor by 66% of non-VA primary care providers, and many non-VA PCPs (42%) believed this led to poor patient outcomes. They also felt that they interacted with VA as a system rather than with individual VA providers. While the majority of non-VA providers were dissatisfied with their communication with VA providers, this did not translate into a negative opinion of VA healthcare; most felt the overall
quality of VA care was high. Veterans were identified as the main medium for information transfer between VA and non-VA providers, which was viewed as undesirable. When non-VA PCPs were asked about their ideal method of communication, they most commonly identified electronic health records and fax that would occur automatically. They also identified the need for a VA point of contact to triage direct calls from non-VA providers.
Date: November 1, 2014
- Enrollment in VA Healthcare Most Likely in First Year after Return from Deployment for Army Reserve/National Guard Members
This study examined rates and predictors of Reserve Component (RC) members’ enrollment and use of VA healthcare services in the first year following demobilization from an index deployment. Findings showed that, of the Veterans in this study, 57% of Army National Guard (ARNG) members and 46% of Army Reserve (AR) members used VA care within 12 months of demobilization, suggesting that Reserve Component members are most likely to enroll in VA healthcare in the year following return from deployment. Female members were more likely to enroll in VA healthcare than male members, an important finding given that women are the fastest growing segment of the Veteran population. The percent of ARNG and AR members in each VA facility’s catchment area who received VA healthcare as an enrollee varied substantially – from as low as 25% to more than 85%, even after adjusting for driving time, demographics, and service-related factors. Investigators suggest that future research and QI efforts with VA and DoD should strive to better understand this variation and the extent to which it is explained by factors such as the availability of non-VA healthcare options, actual or perceived
quality of VA care, and/or availability of education and outreach interventions.
Date: October 1, 2014
- Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans
Investigators in this study implemented a
quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. This systematic frailty-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort, study models suggest that for every four patients screened, one death was prevented or delayed at 180 days. After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons, and they were more likely to take place before the index operation. Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality.
Date: September 10, 2014
- Measures of Patient Care Experiences Reflect Fair Hospital Assessments
There are concerns about the fairness of using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures to compare healthcare facilities if some have more ”complex” patients that are harder to treat, and it has been argued that clinical variables should be included to adjust for such differences. Therefore, this study compared scores for different types of hospitals after making adjustments using only survey-reported patient characteristics – and then also using more complete clinical and hospital information. Findings showed that comparisons of composite patient-centered care (PCC) scores across types of hospitals that were adjusted only for patient-reported health status and sociodemographics were similar to those that also adjusted for patient clinical characteristics. Thus, study findings do not support concerns that measures of patient care experiences are unfair because commonly used models do not adjust adequately for potentially confounding patient clinical characteristics. The same was true when the various adjusted scores for specific dimensions of patient experience were compared across hospital types.
Date: July 1, 2014
- Most Patients with Type 2 Diabetes Obtain Little or No Benefit from Current Treatment for Tighter Glycemic Control
This study examined how considering treatment burden would affect the benefits of intensive versus moderate glycemic control in patients with type 2 diabetes. Findings showed that for most patients over the age of 50 with an A1c below 9% who were on metformin, further glycemic treatment usually offered, at most, modest benefits. Across all ages, patients who viewed treatment as modestly burdensome experienced a net loss in
quality of life years from treatments to lower A1c. The current approach of broadly advocating intensive glycemic control for millions of patients with diabetes should be reconsidered; instead, treating A1cs of less than 9% should be individualized based on estimates of benefit weighted against the patient’s view of treatment burden.
Date: June 30, 2014
- Outcomes Associated with VA Implementation of PACT
Investigators in this study created the PACT Implementation Progress Index (Pi2) to measure the extent and variation of PACT implementation, and then conducted an observational study to examine the association between the index and key outcomes (e.g., patient satisfaction, rates of hospitalization and emergency department use,
quality of care, and staff burnout. Findings showed that the extent of PACT implementation was highly associated with important outcomes for both patients and providers. Significant trends were observed in
quality of care in relation to the Pi2 score: 77 sites that achieved the most effective implementation exhibited higher clinical
quality outcome measures than less successful sites. The rate of emergency department visits was significantly lower in sites with more effective PACT implementation than in those with less effective implementation, and there were larger projected decreases in rates of ambulatory care sensitive condition admissions after the start of PACT. Patient satisfaction was significantly higher among sites that had effectively implemented PACT than among those that had not, and a similarly favorable pattern was observed for staff burnout.
Date: June 23, 2014
- Majority of Unplanned VA Hospital Readmissions Unrelated to Index Hospitalization
This study examined unplanned VA hospital readmissions – and compared the leading reasons for unplanned readmission between medical and surgical discharges. Findings showed that after excluding planned readmissions, 12% of all discharges were followed by an unplanned readmission within 30 days. Although nearly 42% of unplanned readmissions were identified as clinically related, the majority of unplanned VA hospital readmissions were unrelated to the index hospitalization for both surgical and medical discharges. The top five reasons for hospital readmission among medical discharges included: non-hypertensive heart failure (HF; 8%), pneumonia (5%), chronic obstructive pulmonary disease (5%), urinary tract infections (UTI, 3%), and fluid and electrolyte disorders (3%). Among surgical discharges, complications of surgical procedures or medical care (22%) or devices (7%) accounted for nearly 75% of the top five reasons for readmissions; the remaining three included HF, UTI, and pneumonia. These findings suggest that most hospital readmissions might reflect clinical and social factors, including the severity of the patient’s condition, inadequate social support, or post-discharge factors (e.g., lack of coordination between inpatient and outpatient settings). Thus,
quality improvement interventions should target those processes of care that may decrease related risks.
Date: March 1, 2014
- Underuse of Colorectal Cancer Screening among Healthy Veterans and Overuse among Unhealthy Veterans
This study examined whether the upper age cutoff of the colorectal cancer (CRC) screening
quality measure is associated with overuse of screening among 70- to 75-year-olds who are in poor health (limited life expectancy, but within the target age range of the measure) – and underuse in those older than age 75 who are in good health (longer life expectancy, but outside the target age range of the measure). Findings showed that screening rates were relatively stable for Veterans between ages 50-75, but dropped precipitously after age 75. On average, 39% of 75 year-old Veterans were screened, while only 21% of 76 year-old Veterans were screened. However, a Veteran who was 75 years of age and unhealthy – in whom life expectancy may be limited and screening is likely to result in net burden or harm – was significantly more likely to undergo screening than a Veteran who was 76 years of age and healthy (35% vs. 21%, respectively). Future patient-centered
quality measures should focus on clinical benefit rather than chronological age to ensure that patients who are likely to benefit from screening receive it (regardless of age), and that those who are are likely to incur harm are spared uncessary and costly care.
Date: February 26, 2014
- Health Information Technology
This review sought to examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of healthcare, such as
quality, safety, and efficiency. Findings showed that most published IT evaluation studies report positive effects on
quality, safety, and efficiency. Strong evidence supports the use of clinical decision support (CDS) and computerized provider order entry (CPOE). Fifty-seven percent of the studies in this review evaluated CDS and CPOE, and most reported positive results. Insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. Therefore, the most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Authors note that with the increasing adoption of electronic health records and other forms of health IT, it is no longer sufficient to ask whether health IT creates value, but rather the most useful studies will help us understand how to realize value from health IT.
Date: January 7, 2014
- Gaps in
Quality of Supportive VA Cancer Care for Veterans
This study evaluated non-hospice supportive VA cancer care in a nationally representative sample of Veterans with stage IV metastatic lung, colorectal, and prostate cancers who were diagnosed in 2008.
Quality of care was measured using the Cancer
Quality-Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST)
quality indicators. Findings showed that, overall, Veterans received only about half (49%) of recommended care as measured by ASSIST
quality indicators. Gaps in
quality of cancer care included: inpatient pain screening was common (96%) but lacking for outpatients (58%); few Veterans had timely dyspnea evaluation (16%) or treatment (11%); only 4% of Veterans had a new diagnosis of depression identified; of patients at high risk for diarrhea from chemotherapy, 24% were offered antidiarrheals; only 18% of Veterans had their goals of care addressed in the month after a diagnosis of advanced cancer; and 64% of patients had timely discussion of goals ICU admission. Most Veterans who died (86%) were referred to palliative care or hospice before death and 72% had an advanced directive or surrogate decision maker documented in the medical record.
Date: December 9, 2013
- VA’s Online
Quality Improvement Toolkits
In 2009, VA/HSR&D’s
Quality Enhancement Research Initiative (QUERI) was tasked by VHA leadership to develop online toolkits that would facilitate the spread of locally developed innovations to improve
quality of care for Veterans. The QI Toolkit Series was designed as a two-year pilot project that would offer VHA staff access to innovations to help improve performance on specific performance measures across a variety of high-priority care conditions. The Toolkit Series is now an enhanced Intranet website, accessible by all staff using the VHA network. This article describes the general approach to creating such toolkits, aspects of implementation, and a brief evaluation.
Date: December 1, 2013
- “Tailored” Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
Most current blood pressure (BP) guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual’s net absolute benefit from treatment – taking into account the patient’s estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Findings showed that BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more
quality-adjusted life years (QALYs), despite using 6% fewer medications, compared to TTT. While 55% of the 176 million “simulated” patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
Date: November 19, 2013
- Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health
This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and
quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007.
Date: October 1, 2013
- Receiving VA Care is Stronger Predictor of Appropriate Care for Veterans with Diabetes than Continuity of Care
This study examined whether
quality of diabetes care was associated with care continuity or Veterans’ usual source of primary care. Findings showed that reliance on VA primary care vs. Medicare fee-for-service (FFS) primary care was a stronger predictor of guideline-concordant diabetes care than continuity of care. When both over-provision (getting more tests than needed) and under-provision (getting fewer tests than needed) were examined for three diabetes
quality measures, reliance on VA care was a stronger predictor of appropriate care than continuity of care. For example, Veterans who relied only on Medicare FFS for primary care were more likely to be under-provided HbA1c testing than Veterans who relied only on VA primary care. However, dual users of VA and Medicare FFS primary care were significantly more likely to be over-provided HbA1c and microalbumin testing than Veterans who used only VA primary care. In both VA and Medicare FFS, under-provision of diabetes care was more common than over-provision during this period (from 2001 to 2004).
Date: October 1, 2013
- Individual Financial Incentives for VA Providers Result in Better Hypertension Treatment than Audit and Feedback Alone
This trial tested the effect of financial incentives to individual physicians and practice teams for the delivery of guideline-recommended care for hypertension. Findings showed that VA physicians randomized to the individual incentive group were more likely than controls to improve their treatment of hypertension. A physician in the individual incentive group caring for 1,000 patients with hypertension would have about 84 additional patients achieving blood pressure control or appropriate response after 1 year. The effect of the incentive was not sustained after the washout period. Although performance did not decline to pre-intervention levels, the decline was significant. None of the incentives resulted in increased incidence of hypotension compared with controls. While the use of guideline-recommended medications increased significantly over the course of the study in the intervention groups, there was no significant change compared to the control group.
Date: September 11, 2013
- Improvement in VA Patient Outcomes Related to Pay-for-Performance Remains after Removal of Incentives
This study sought to investigate the sustainability of performance levels following removal of performance-based incentives. Findings showed that performance improvements that occurred across 128 VA hospitals for three common conditions among Veterans – acute coronary syndrome, heart failure, and pneumonia – were sustained for up to three years after performance-based incentives were removed. For six of the seven performance measures, mean performance was over 90% prior to removal of the incentives. The only measure that did not demonstrate significant improvement over the study period was the heart failure measure for ACE-inhibitor/ARB therapy prior to admission.
Date: August 9, 2013
- Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better
Quality of Care
This study sought to determine the degree to which access barriers impact the
quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better
quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days).
Date: July 30, 2013
- Changes in VA Care since PACT Implementation
This study evaluated interim changes in PACT-related care processes. Findings showed that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12); shared medical appointments increased slightly; appointment access and continuity improved slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11). Facilities’ average overall score on the ACP Biopsy survey (assessing the presence of 127 PACT components via “yes” or “no” items in 7 categories) increased from 69% “yes” in 10/09 to 80% “yes” in 7/11.
Date: July 10, 2013
- Incentives to Impact Patient Engagement and Health Behavior
This essay discusses a range of efforts in implementing wellness programs and incentives intended to promote healthy behaviors by insurers, employers, and providers, and how they might be made more effective.
Date: July 1, 2013
- Issues for Sexual and Gender Minority Veterans Receiving VA Healthcare
This article summarizes emergent research findings regarding sexual and gender minority (SGM) Veterans, and the first initiatives that have been implemented by VA to promote
quality care. Being a member of both the Veteran and SGM communities may contribute to a higher level of risk for poor health than membership in just one of these populations. A recent VA study indicated that only 33% of SGM Veterans reported open communication about their sexual orientation with VA healthcare providers, while 25% reported avoiding certain VA services because of concerns about stigma. In another study of 202 VA providers and 58 SGM Veterans, less than one-third of all participants viewed VA as welcoming to SGM Veterans. To address these issues, VA has created new programs, such as the Office of Health Equity LGBT Workgroup, which works to address inequities in the healthcare environment for SGM Veterans. VA also created two new part-time LGBT Program Coordinator positions, through the Office of Patient Care Services, who advise leadership on policy and practice issues related to SGM Veterans. In June 2011, VA released the first national policy to describe the services that are available to transgender Veterans. Other recent VA policy changes include “sexual orientation” and “gender identity and expression” now being included in VA non-discrimination and caregiver policies. Educational resources and trainings have been developed for VA staff about culturally appropriate care for SGM Veterans. Further research is needed to better understand the SGM population, their healthcare needs, and how these needs vary in relation to gender, race/ethnicity, and other factors, as well as in evaluation of provider training and policies.
Date: July 1, 2013
- Cancer Genetics Toolkit Improves
Quality and Frequency of Family History Documentation among VA Primary Care Patients
Investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for hereditary breast-ovarian cancer (HBOC) and Lynch syndrome. They then evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women’s primary care clinics. Findings showed that the toolkit increased the frequency and improved the
quality of cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans; and increased the numbers of appropriate referrals for genetic consultation. A clinical reminder in the electronic health record was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. In addition, veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation.
Date: June 13, 2013
Quality of VA Care for Veterans with Newly Diagnosed Lung Cancer is Markedly Higher than Previous Studies Suggest
This study sought to determine the proportion of Veterans who did not receive evidence-based care who had a documented refusal or contraindication to recommended lung cancer therapy. Findings showed that when accounting for refusals and contraindications, the
quality of care for newly diagnosed lung cancer was markedly higher than previous studies suggested. Adherence to
quality indicators ranged from 81% for adjuvant chemotherapy in resected stage II/III non-small cell lung cancer (NSCLC) to 98% for curative resection of stage I/II NSCLC. However, many Veterans met
quality indicator criteria without having received recommended therapy by having a refusal (0%-14%) or contraindication (1%-30%). Authors note that study results underscore the need for performance measurement systems that capture both patient refusals and medical contraindications. Using data that may not accurately capture
quality of care may result in allocation of resources to improve
quality where it is not indicated.
Date: June 10, 2013
- Readmission Rates are Limited in Measuring Hospital
This study assessed readmission rates as a hospital
quality measure. Findings showed that the change in readmission rates between 2009 and 2011 was inversely related to readmission rates in 2009: hospitals with higher readmission rates in 2009 tended to improve by 2011, while hospitals with lower readmission rates in 2009 tended to worsen by 2011. On average, readmission rates for the “worst” performing hospitals in 2009 decreased over time by between 2% and 4%, depending on the condition, while readmission rates for the “best” performing hospitals in 2009 increased by between 3% and 7%. Readmission rates were higher in teaching hospitals and were weakly correlated with the other indicators of hospital
Date: June 1, 2013
- Multimodal Intervention Increases HIV Testing in VA Primary Care
Investigators with VA/HSR&D’s HIV/Hepatitis
Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Findings showed that the use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency with which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold. Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.
Date: April 19, 2013
- Prediction Model Using VA Data May Help Identify Primary Care Patients at Increased Risk for Hospitalization or Death
In an attempt to identify high-risk patients, investigators in this study developed statistical models using health information from VA’s clinical and administrative databases to predict the risk of hospitalization or death among all Veterans who were assigned to a primary care provider as of 10/1/10. Findings showed that prediction models using electronic clinical data accurately identified Veterans receiving VA primary care who were at increased risk of hospitalization or death. Of the top 5% of Veterans in terms of predicted risk, 51% were hospitalized or died within the following year. Predictors of death were quite different from predictors of hospitalization. In general, clinical and demographic characteristics (i.e., increasing age, metastatic cancer) were most predictive of death, while recent use of health services was most predictive of hospitalization. The authors suggest that in clinical settings, these values can be used to identify high-risk patients who might benefit from care coordination and special management programs, such as intensive case management, telehealth, home care, specialized clinics, and palliative care.
Date: April 1, 2013
- Racial Differences in Veterans’ Perception of the
Quality of PTSD Compensation Examinations
This study examined factors potentially associated with Veterans’ perceptions of the
quality of their PTSD compensation examination, including racial differences. Findings showed that the overall
quality of PTSD compensation examinations was predominantly rated as "excellent" or "very good" by both African American and Caucasian Veterans. However, compared to Caucasian Veterans, African American Veterans rated their examinations as having been of lower
quality. They also rated their examiners lower on interpersonal qualities but not on competence. Of Veterans participating in this study, 47% of Caucasian Veterans vs. 34% of African American Veterans rated the
quality of their examination as “excellent.” Ratings were not significantly related to the Veterans' age, gender, marital status, eventual diagnosis with PTSD, functioning score, the examiners’ perception of the prevalence of malingering, or the presence of a third party in the examination. The authors note that the Veterans’ perspective is only one component of the
quality of the PTSD compensation examination.
Date: April 1, 2013
- No Significant Association between Timing of Surgical Antibiotic Prophylaxis and Risk of Surgical Site Infection
This study sought to determine whether prophylactic antibiotic timing is associated with decreased surgical site infection (SSI). Findings showed that of the surgical procedures performed at VA hospitals included in this study, prophylactic antibiotics were administered at a median of 28 minutes prior to surgical incision; 92% of patients received antibiotics within the recommended time window. Of all patients, 5% of Veterans developed an SSI within 30 days of surgery. In adjusted models, no significant association between prophylactic antibiotic timing and SSI was observed. However, there was a significant association between choice of antibiotic and SSI for orthopedic and colorectal procedures: vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures, while cefazolin or quinolone in combination with an anaerobic agent were associated with fewer SSI events for colorectal procedures. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.
Date: March 20, 2013
- Journal Issue Highlights the State of Health Information Technology in VA Healthcare
This Medical Care Supplement focuses on the use and impact of health information technology (HIT) in
quality improvement research conducted within VHA. Articles in this Supplement highlight a range of specific HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems, as well as applications of automated systems for intervention, evaluation, and tracking patient care.
Date: March 1, 2013
- Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
This study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Findings showed that benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive. While prescribing variation at the regional, network, and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%. Rural veterans with PTSD received equivalent, if not higher,
quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers. The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
Date: January 1, 2013
- Previous Hospital Readmission Rates for Three Common Conditions are Poor Predictors for Future Readmission
This study sought to assess whether historic hospital readmission rates predict risk-adjusted patient readmission – and to measure the costs of readmission. Findings showed that previous hospital readmission rates are poor predictors of readmission for future individual patients, so policies using these meaures to guide subsequent reimbursement might prove problematic.
Patients who are readmitted do have substantially higher episode costs, even after conventional risk adjustment. Being readmitted increased total episode cost by 53% for Veterans with acute myocardial infarction, 83% for Veterans with community-acquired pneumonia, and 80% for Veterans with congestive heart failure.
Date: January 1, 2013
- Decreases in VA Hospital Length-of-Stay and Readmission Rates over 14 Years
This study sought to determine trends in hospital length of stay (LOS) and 30-day readmission rates in the VA healthcare system. Findings showed that VA hospitals demonstrated simultaneous improvements in hospital LOS and readmission rates from 1997 to 2010. This demonstrates that LOS reductions have not, thus far, adversely affected the likelihood of hospital readmission. For all medical diagnoses combined, the risk-adjusted mean hospital LOS decreased by 2% annually. Reductions in LOS also were observed for five specific common diagnoses, with the greatest reductions for acute myocardial infarction (2.9 days) and pneumonia (2.2 days). Risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 17% to 14%. Reductions also were observed for the five common diagnoses, with greatest reductions for AMI (23% to 20%) and COPD (18% to 15%). All-cause mortality 90 days after admission was reduced by 3% annually.
Date: December 18, 2012
- Protected Sleep Periods for Medical Interns Increase Overnight Sleep and Improve Morning Alertness
This study evaluated the feasibility and consequences of protected sleep periods among medical interns during extended duty. Findings showed that the implementation of a protected sleep period resulted in approximately a 50% increase in overnight sleep duration, a 200% reduction in nights without any sleep, a reduction of about 50% in disturbed sleep, and improved alertness the next morning. Interns with protected sleep, compared to those without protected sleep, were significantly less likely to have on-call nights with no sleep: 6% vs. 19% at the VAMC, and 6% vs. 14% at the University hospital. Interns with protected sleep also felt less sleepy after on-call nights. The proportion of interns who reported having disturbed sleep at the VAMC was 50% among interns with protected sleep periods compared to 85% among those without protected sleep periods.
Date: December 5, 2012
Quality of VA’s PTSD Disability Assessment Would Improve by Using Evidence-Based Assessment
This trial compared usual disability examiner practices with a standardized assessment that incorporates evidence-based assessments. Findings showed that administering a standardized disability assessment resulted in more complete diagnostic information on functional impairment and PTSD symptoms. Standardized assessments were 85% complete for diagnosis compared to 30% for non-standardized assessments; and for functional impairment, the rates were 76% compared to 3%. Standardized assessment elicited an increase in relevant information and nearly eliminated variation between examiners and medical centers. While the standardized examination was more sensitive than routine examination, it did not result in a significant change in the overall prevalence of diagnosed PTSD.
Date: December 1, 2012
- Determinants of Implementing Depression Care Improvement Models in VA Primary Care Practices
This study examined three VA-endorsed depression care models and tested the relationships between measures of organizational readiness and implementation of the models in VA primary care clinics. The three models include: 1) collocation of mental health specialists in primary care settings, 2) the Translating Initiatives in Depression (TIDES) model, and 3) the Behavioral Health Laboratory (BHL) model. Findings show that pre-existing demographic and readiness characteristics of primary care practices are associated with whether the practice chooses to implement a depression care improvement model – and with what type of model the practice chooses. Of the three approaches, primary care practices appear most ready to implement collocation, which had been present the longest (average 6 years) in practices adopting it. Moreover, the majority of practices that had not adopted it planned to do so. By 2007, 48% of clinics had implemented collocation, 17% had implemented TIDES, and 8% had implemented BHL. Having established
quality improvement processes or a depression clinician champion was associated with collocation. Being located in a VA regional network that endorsed TIDES was associated with TIDES implementation. The presence of psychologists or psychiatrists on primary care staff, greater financial sufficiency, or greater space sufficiency was associated with BHL implementation.
Date: October 5, 2012
- Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes
The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a
quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment.
Date: September 10, 2012
- Increasing Duration of Resuscitation Might Improve Survival among Patients Suffering Cardiac Arrest
Despite several advances in resuscitation care, overall survival after in-hospital cardiac arrest remains poor. Of the 64,339 patients in this study, 49% achieved return of spontaneous circulation, and 15% survived to discharge. Patients who had cardiac arrests at hospitals with longer median resuscitation durations had higher overall survival than did those who arrested in hospitals with shorter median durations. For example, compared with patients at hospitals with the shortest median resuscitation attempts in non-survivors (16 minutes), patients at hospitals with the longest attempts (25 minutes) had a higher likelihood of return to spontaneous circulation and survival to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 minutes compared with 20 minutes for non-survivors. The likelihood of patients surviving to discharge with a favorable neurological status did not differ significantly between hospitals with shorter or longer resuscitation durations.
Date: September 5, 2012
- Veterans with Greater Clinical Complexity Receive Higher
Quality of Care for Diabetes
This study examined the impact of clinical complexity on three
quality indicators for diabetes care: glycemic, blood pressure (BP), and lipid control. Findings showed that of the Veterans in this study,18% were controlled for all three
quality indicators at index, and 19% were controlled at 90-day follow-up. Veterans with the greatest levels of clinical complexity received higher
quality of care for diabetes based on BP, glycemic, and lipid
quality indicators compared to less complex patients, regardless of the definition of complexity.
Date: September 1, 2012
- Despite Individual Hospital Performance, Pay-for-Performance Program May Result in Small Changes in Medicare Payments
Despite differences across hospitals in terms of performance, expected changes in payments from Medicare under the new hospital pay-for-performance program were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of 1%, and only eight hospitals would have a change of greater than 0.75%. Hospital performance varied substantially across states, which translated into regional differences in Medicare payments. For example, in New Hampshire, one of the states with the highest scores, average Medicare payments would increase by $66,948 (0.24%), while in Hawaii, one of the states with the lowest scores, average Medicare payments would decrease by $25,596 (0.20%). Changes in expected hospital payment also varied by most hospital characteristics. For example, the percentage of hospitals that would have an increase in Medicare payment by 0.25% or more varied by teaching status: 10% of hospitals with a major teaching affiliation were in this category compared to 20% of non-teaching hospitals. These results raise questions about whether the new pay-for-performance program will substantially alter the
quality of hospital care, and findings highlight the challenges of designing effective
quality improvement incentives.
Date: September 1, 2012
- New Anticoagulants are Viable Option for Patients Receiving Long-Term Anticoagulation
New oral anticoagulants are a viable option for patients receiving long-term anticoagulation. Direct thrombin inhibitors (DTIs) and factor Xa (FXa) inhibitors have the advantage of a more predictable anticoagulant effect, and fewer drug-drug interactions as well as equivalent or better mortality and vascular outcomes compared with warfarin. However, treatment benefits compared with warfarin are small and vary depending on the control achieved by warfarin treatment. Six good
quality randomized controlled trials comparing new oral anticoagulants (NOACs) with warfarin showed that in patients with atrial fibrillation (AF), NOACs decreased all-cause mortality. In patients with venous thromboembolism, NOACs did not differ for mortality or outcomes. Across indications, the risk of major and fatal bleeding was decreased with NOACs compared with warfarin. However, the bleeding risk with NOACs may be increased in individuals over the age of 75, and in those with renal impairment. Sub-group analyses suggest a higher risk for myocardial infarction or acute coronary events with dabigatran (DTI) compared with FXa inhibitors. Recent thromboprophylaxis guidelines conclude that patients with AF who are on good warfarin treatment control have little to gain by switching to dabigatran.
Date: August 28, 2012
- No Advantage in Collaborative Care vs. Usual Care for Veterans with PTSD
Over a 6-month period, primary care patients with PTSD in both the Three Component Model (3CM, collaborative care) and usual care groups showed small but clinically insignificant improvement in PTSD, depression, and functioning. No additional benefit was found for Veterans assigned to the 3CM treatment compared to those receiving usual care, despite the fact that 3CM patients were more likely to receive an antidepressant and had more mental health visits. Among Veterans who provided a numeric rating for PTSD care, half rated it as excellent or very good; however, 3CM was associated with lower perceived
quality of PTSD care. Almost two-thirds of Veterans rated their overall care as excellent or very good, and the groups did not differ. Costs were similar for both groups, except that Veterans assigned to 3CM had higher outpatient pharmacy costs.
Date: August 3, 2012
- QI Intervention for VA Programs Serving Homeless Veterans
Through the Getting To Outcomes (GTO) intervention, staff members at three homeless programs were able to make noticeable improvements in their programming. Although none of the improvements incorporated the wholesale adoption of a specific evidence-based program, most improvements involved programs becoming more evidence-based; e.g., using evidence-based guidelines to manage high-risk patients (i.e., Veterans at risk of suicide) and supporting additional substance abuse treatment for Veterans who had relapsed, while keeping them in their current VA housing. Many staff members experienced some challenges adding GTO activities to their already busy workload, and some felt the process could be more transparent and inclusive. Staff members stated that high levels of communication, commitment to the program, and technical assistance were critical to the success of the intervention.
Date: August 1, 2012
- Collaborative Care Models Improve Physical and Mental Health Outcomes for Individuals with Mental Disorders
Collaborative chronic care models (CCM)s can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings and provide a robust clinical and policy framework for care integration. Meta-analysis of unadjusted outcomes demonstrated significant small-to-medium effects of CCMs across multiple disorders in clinical symptoms, mental and physical
quality of life, and social role function, with no net increase in total healthcare costs. Systematic review of a broader range of studies largely confirmed meta-analytic findings. The authors suggest that CCMs provide a framework of broad applicability for management for a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.
Date: August 1, 2012
- Wide Variability among VA Hospitals Regarding ICU Admission Patterns
About half of all Veterans in this study (53%) who were admitted directly to the ICU had a 30-day predicted mortality of 2% or less. In more than half of cases, Veterans with a predicted mortality greater than 30% were not admitted to the ICU. At all levels of patient risk, hospitals varied widely in the proportion of Veterans admitted to the ICU. For example, the rate of admission for Veterans in the low-risk group (predicted mortality <2%) varied from 1% to 39%, while the rate of admission for Veterans in the high-risk group (predicted mortality >30%) varied from 11% to 50%. Investigators also found that for a one standard deviation increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals, ranging from a 15% decrease to a 122% increase.
Date: July 23, 2012
- Majority of OEF/OIF Veterans with PTSD Use VA Healthcare for PTSD-Related Treatment, and Users are Increasing
Approximately 58% of OEF/OIF Veterans with PTSD used VA healthcare services and received some PTSD-related treatment from 2002 through 2010. Moreover, OEF/OIF Veterans with PTSD have been increasingly likely to use VA services over time. There is insufficient information about the
quality of PTSD-related services. Developing a broader understanding of the concept of
quality as it relates to PTSD treatment may lead to a better understanding of the services that OEF/OIF Veterans with PTSD receive when they access VA care.
Date: July 1, 2012
- VA Hospitals Caring for Lower Volumes of Mechanically Ventilated Patients Do Not Have Worse Mortality
VA hospitals caring for lower volumes of mechanically ventilated patients do not have worse mortality compared to hospitals with higher volumes. The relationship between hospital volume of mechanical ventilation (MV) and 30-day mortality was not statistically significant: each 50-patient increase in volume was associated with a non-signicant 2% decrease in the odds of death within 30 days, By comparison, the published civilian hospital literature suggests a 10% decrease in odds per 50 patient increase over the same range of volume observed in the present study. There were no substantive differences in the primary results after excluding either repeat admissions or patients who were transferred into the VA from a non-VA facility.
Date: June 22, 2012
- VA Care May Be Sub-Optimal for Veterans with Cirrhosis-Related Ascites
quality of healthcare, measured according to whether Veterans received recommended services, was sub-optimal for cirrhosis-related ascites. For five of eight QIs of ascites care, Veterans in this study received the recommended care less than two-thirds of the time, even after accounting for possible justified exceptions.
Quality scores varied across individual QIs, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis to 90% for testing paracentesis fluid for cell count and differential. In general, care targeted at treatment was more likely to meet standards than preventive care. Veterans with no comorbidity, who saw a gastroenterologist, or who were seen in a VAMC with an academic affiliation received higher
quality of care.
Date: March 27, 2012
- Factors Associated with Increased VA Preventable Acute Care Use
Prior mental health diagnoses and medication use were independent risk factors for ambulatory care sensitive condition- (ACSC) related acute care. These risk factors will require focused attention if the full benefits of new primary care models, such as PACT, are to be achieved. The highest rate of ACSC admissions was among Veterans with drug use disorders (46 admissions per 1,000 patients), followed by those with depression (35 admissions per 1,000 patients), compared to 21 admissions per 1,000 patients for those with no mental health diagnoses. The rate of ED visits for ACSCs was also higher among those with mental health diagnoses (70 visits per 1,000 vs. 44 visits per 1,000 for those without mental health diagnoses). Patients without mental health conditions experienced significantly lower rates of both all-cause and ACSC admissions than patients with mental health conditions. The mean cost and length of stay of ACSC admissions, however, was similar and not statistically different between the two groups.
Date: March 20, 2012
- Meditation-Based Mantram Intervention Shows Potential as Adjunctive Therapy for Veterans with PTSD
The Mantram Repetition Program (MRP) shows potential when used as an adjunct to treatment as usual (TAU) for mitigating chronic PTSD symptoms in Veterans. In this study, twice as many Veterans in the MRP + TAU group had clinically meaningful reductions in PTSD symptoms compared to Veterans in the TAU alone group: 24% vs. 12%, respectively, and PTSD symptoms continued to improve in the MRP + TAU group at six-week follow-up. Compared to Veterans in the TAU alone group, Veterans in the MRP + TAU group also experienced significant reductions in depression and greater improvements in mental health-related
quality of life and spiritual well-being. Reductions in anxiety were equivalent between groups. Of Veterans in the MRP + TAU group, 97% reported moderate or high satisfaction with MRP, and dropout rates were equivalent and low (7%) in both groups.
Date: March 12, 2012
- Top Performing VA Anticoagulation Clinics Share Characteristics
The top performing VA anticoagluation clinics shared six characteristics:
1. Adequate pharmacist staffing and effective use of non-pharmacist personnel;
2. Innovation to standardize clinical practice around evidence-based guidelines;
3. Presence of a
quality champion for the anticoagulation clinic (ACC);
4. Higher staff qualifications (e.g., all pharmacists had completed pharmacy residencies);
5. Climate of ongoing group learning; and
6. Internal efforts to measure performance.
No low-outlier ACC had more than two of these characteristics. Therefore, the authors suggest that efforts to improve performance should focus on the six common domains. At least five domains were not associated with ACC performance, including use of the electronic medical record, and configuration of the clinic (e.g., face-to-face patient contact vs. telephone care).
Date: February 1, 2012
- Publicly Reported
Quality Ratings have Small but Positive Effect on Patient Choice of Nursing Home for Post-Acute Care
Patients were more likely to choose facilities with higher reported post-acute care
quality related to resident pain control after public reporting was initiated; however, the magnitude of the effect was small. No changes in nursing home choice related to report card scores were seen in facilities not exposed to public reporting. A better pain score (less pain experienced by the patient) was associated with an increase in consumer demand after public reporting was initiated; for delirium, there was no significant effect, and for improved walking, the effect was unexpectedly negative. There was a differential response across patients by education level, which raises the possibility that the format and distribution of this information matters. Authors suggest that this information may be more influential if it is delivered to consumers in a more user-friendly format, or if it is delivered to patient advocates or surrogate decision-makers.
Date: January 10, 2012
- Chronic Disease Management Initiative Reduces Hospitalizations for Ambulatory Care Sensitive Conditions among Veterans
A chronic disease management (CDM) initiative in VISN 23 was associated with a significant reduction in hospitalizations for ambulatory care sensitive conditions (ACSCs) compared with other VA healthcare systems. The estimated annual effect of the CDM initiative is 2.9 fewer hospital admissions per 1,000 Veterans who have an ACSC. This is nearly 10% of the average of 30.8 ACSC admissions per 1,000 Veterans in the other networks in 2010. ACSC hospitalization ratios were nearly identical in 2006 (before CDM implementation) between VISN 23 and the other VISNs.
Date: January 1, 2012
- Relationship between Resources and
Quality of VA Primary Care
This study examined the relationship between resource use and care
quality in VA primary care clinics using the concept of organizational slack, which is defined as extra organizational resources (i.e., staff, budget, equipment) available to meet a given level of demand. Findings showed that Veterans seen in VA primary care clinics where staffing was below the recommended level were more likely to experience lower
quality of care. Although some level of organizational slack resource for staffing was associated with better
quality of care, additional staffing – beyond guideline recommendations – exhibited diminished returns. Thus, the addition of staffing resources in primary care clinics contributed to higher levels of
quality, but only to a point, at which more staff appeared to make only minimal contributions to
quality. Findings are relevant to understanding the cost and benefits of adding staff to new models of primary care, such as panel management and the Patient-Aligned Care Team (PACT). Also, staff cost and
quality trade-off issues may be an increasingly important issue in future policy discussions.
Date: December 20, 2011
- JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization,
quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
- Access to Healthcare and Framework for Reducing Hospital Readmissions
This Commentary discusses how a patient’s level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions – a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies.
Date: October 26, 2011
- Systematic Review Shows Most Current Readmission Risk Prediction Models have Poor Predictive Ability
This systematic review was performed to synthesize the available literature on validated readmission risk prediction models, describe their performance, and assess their suitability for clinical or administrative use. Findings showed that most current readmission risk prediction models that were designed for either comparing hospital performance or clinical purposes have poor predictive ability. Although in certain settings such models may prove useful, better approaches are needed to assess hospital performance in discharging patients, as well as to identify patients at greater risk of preventable readmission. Most models incorporated variables for medical comorbidity and use of prior medical services, but few examined variables associated with overall health and function, illness severity, or social determinants of health. The variable performance of predictive models in different populations suggests that the best choice of a model may depend on the setting and population in which it is being used. Even though the overall predictive ability of the clinical models was poor, investigators found that high- and low-risk scores were associated with a clinically meaningful gradient of readmission rates. Thus, even limited ability to identify a proportion of patients at highest risk for readmission could increase the cost-effectiveness of hospital interventions aimed at improving the discharge process and post-hospital follow-up.
Date: October 19, 2011
Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
This article highlights two ways that current
quality indicators may lead to unintended harms for older patients with complex medical problems and proposes ways to improve
quality indicators by minimizing or preventing those harms. For example, current
quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care, such as mammography screening for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit. The authors suggest that
quality indicators be refined and improved to drive real
quality improvement for the entire patient population.
Date: October 5, 2011
- Effect of Active versus Passive Monitoring of VA
Quality Performance Measures
This study compared the nature and rate of change in hospital outpatient clinical performance as a function of VA performance measures’ status (active vs. passive), and examined the mean time to stability of performance after changing status. Findings showed that performance measure monitoring status (active vs. passive) did not significantly impact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no impact on this finding. There was variability in whether or not measures stabilized after a status change, suggesting the possibility that some measures may take more than two years to stabilize. However, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times. All measures that stabilized did so immediately after the status change (e.g., time to stability was one quarter). Of the 6 measures that did not stabilize, 5 suggested continued improvement after the change.
Date: October 1, 2011
- Cognitive Processing Therapy Improves PTSD Symptoms More than Usual Care among Veterans in Residential Rehabilitation Program
This study examined one VA PTSD Residential Rehabilitation Program and compared clinical outcomes for two cohorts of male Veterans with PTSD that were treated with either cognitive processing therapy (CPT) or trauma-focused group treatment as usual (TAU). Findings showed that Veterans treated with CPT experienced more improvement of PTSD and depression symptoms, psychological
quality of life, coping, and psychological distress than Veterans who received TAU. In the CPT cohort, more Veterans reported PTSD symptoms that were classified as recovered or improved, compared to the TAU cohort.
Date: October 1, 2011
- Adherence to National Prevention Measures for Surgical Site Infection Does Not Impact VA Surgical Outcomes
This study evaluated whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates at the VA patient or hospital level. Findings showed that none of the 5 SCIP infection prevention measures were significantly associated with lower odds of SSI among Veterans after adjusting for variables known to predict SSI and procedure type. Individual hospital SCIP performance also was not associated with hospital SSI rates. While adherence to SCIP measures improved, risk-adjusted SSI rates remained stable. For Veterans with all measures assessed, the composite rate of adherence was 81%. Although SCIP measures are best practices and should continue, they may not discriminate hospital
quality. Mandatory SCIP reporting without improvement in care may lead to health professional skepticism and fatigue with
quality improvement measures.
Date: September 1, 2011
Quality of VA Mental Health Care Following Psychiatric Hospitalization for Veterans with Depression
This study sought to assess the
quality of depression care (e.g., antidepressant treatment, psychotherapy) during the high-risk period following a psychiatric hospitalization. Findings show that less than half of Veterans hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39%), which is similar to rates found in the general U.S. population among Medicare (38%) and Medicaid (43%) beneficiaries in 2008. Mental health follow-up within 30 days for Veterans in this study was substantially more common (76%). Many Veterans also received adequate psychopharmacologic treatment following a hospitalization for depression (59%), but relatively few received adequate psychotherapy post-discharge (13%).
Date: September 1, 2011
- Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated
quality assessment to assist in the performance of comparative effectiveness research.
Date: August 24, 2011
- Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness
This study sought to determine the association between the co-location of primary care services and
quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better
quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed
quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI.
Date: August 1, 2011
- Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
Integrated care for co-occurring substance use and general medical disorders is considered essential for improving
quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low
quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
Date: July 7, 2011
- Updated Literature Review Examines Research and Findings on Women Veterans’ Health
Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning OEF/OIF Veterans. Local organizational culture and
quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and
quality of care interventions/outcomes for physical and mental conditions affecting women Veterans.
Date: July 6, 2011
- Growing VA Research Agenda for Women Veterans
This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve
quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
Date: July 6, 2011
- Women’s Health Issues Journal Focuses on Women Veterans
This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related
quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
Date: July 6, 2011
- Most Veterans with Military Sexual Trauma Report High Satisfaction with VA Outpatient Care
This study examined the association of military sexual trauma (MST) to patient satisfaction with VA outpatient care. Findings showed that Veterans’ ratings of overall satisfaction with VA outpatient care (regardless of MST status) were high. The proportion of patients reporting very good or excellent overall satisfaction was 79% for male Veterans and 72% for female Veterans. After adjusting for patient characteristics, male and female Veterans’ MST status was not associated with satisfaction ratings of overall VA healthcare. However, female Veterans with a history of MST rated the patient satisfaction dimensions of overall coordination, as well as education and information, less favorably than female Veterans without a history of MST.
Date: July 6, 2011
Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs
Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a
quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Findings showed that even after considering the cost of implementing the program, a
quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs. In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the
quality improvement program). Improving TTR by 10% prevented 2,087 events and saved $29.7 million (again, minus the cost of the
quality improvement program).
Date: July 1, 2011
- Averaging Multiple Blood Pressure Measurements May Provide Optimal Assessment for Veterans with Hypertension
This study compared home, clinic, and research systolic blood pressure (SBP) measurements in Veterans with hypertension – and estimated the certainty with which an individual’s true BP can be determined. Findings showed that clinicians who want to be certain that they are correctly classifying patients’ blood pressure control should average multiple measurements. Hypertension
quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients. The relationship between mean clinic and home SBP varied substantially, e.g., 52% had a mean clinic SBP that was at least 10 mm Hg greater than their mean home SBP. The within-individual variance declined markedly with increasing number of measurements and the relationship was similar across all three modes of measurement, with little added value of additional readings beyond 4-6 observed SBP measurements for all three modes. The proportion of patients with their SBP in control within the first 30 days (<140 mm Hg for clinic or research measurement; <135 mm Hg for home measurement) differed between mode of measurement: 28% were in control based on clinic measurement; 47% based on home measurement; and 68% based on research measurement.
Date: June 21, 2011
- Effect of Housing Vouchers on Homeless Veterans with Mental Illness
This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest
quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
Date: May 1, 2011
- Despite Improved
Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
This article reports on trends in the
quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation,
quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
Date: April 1, 2011
- Positive Effect of Pay-for-Performance May Not be Long Term
The Affordable Care Act of 2010 establishes a pay-for-performance program for hospitals. This program, which will take effect in 2013, includes all U.S. acute care hospitals and will be similar to an ongoing hospital pay-for-performance demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS). This study examined the results of the CMS demonstration project in non-VA hospitals in order to inform efforts to implement pay-for-performance across all U.S. hospitals through the Affordable Care Act. Findings showed that although hospital performance improved under the pay-for-performance demonstration project, the effect was short-lived. By the end of the five-year study period, performance in control hospitals matched that in pay-for-performance hospitals. Over the first three years of the pay-for-performance demonstration project, participating hospitals had better average overall performance than hospitals that did not participate for all three conditions (acute myocardial infarction, heart failure, pneumonia). However, non-pay-for-performance hospitals caught up by the fourth and fifth years of this study. Performance scores were highest among hospitals that were eligible for larger bonuses, were well-financed, or operated in less competitive markets.
Date: April 1, 2011
- VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients
This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA.
Date: March 18, 2011
- Article Challenges Process for Disseminating Diabetes Performance Measures
Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in
quality, may provide some answers as to how diabetes performance measures got ahead of the evidence.
Date: February 16, 2011
- Intervention Targeting Trauma-Specific Sleep Disturbances Reduces PTSD Symptoms and Insomnia Severity among Veterans
This pilot study sought to determine whether or not the combined effects of cognitive behavioral therapy (CBT) for insomnia and imagery rehearsal therapy (IRT) for nightmares would produce significantly greater improvements in sleep disturbance than usual care alone. Findings show that the sleep intervention produced large short-term effects, including substantial reductions in PTSD symptoms, such as the frequency of nightmares and insomnia severity. In contrast, none of the participants in the usual care group responded or remitted from insomnia or PTSD, and did not improve from baseline on sleep
Date: February 15, 2011
- Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the
quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
Date: February 14, 2011
- Concepts for Evaluating High-Value, Cost-Conscious Healthcare
This article discusses three key concepts for understanding how to assess the value of healthcare interventions: 1) assessing the benefits, harms, and costs; 2) identifying the cost of the intervention as well as any potential downstream costs that will occur as a result of performing the intervention; and 3) estimating the incremental cost-effectiveness ratio. The authors suggest that the first step toward providing high-value healthcare is to reduce or eliminate the use of interventions that provide no benefit. A second step is to ensure that we provide interventions that are both effective and reduce costs. Finally, for interventions that provide additional benefit at additional cost, cost-effectiveness analysis is recommended, but should not be the sole determinant of use.
Date: February 1, 2011
- Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke
Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the
quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The
quality-adjusted life expectancy was 10.28
quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of
quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran.
Date: January 4, 2011
- Risk-Adjusted Time in Therapeutic Range Can Be Used as
Quality Indicator for Outpatient Oral Anticoagulation
This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential
quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the
quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for
quality measurement and
quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (
quality of care) that is stable over time.
Date: January 1, 2011
- Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of
quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
Date: November 1, 2010
- VA Performs Better than Non-VA Healthcare on
Quality Measures for Processes of Care
Since VA’s organizational transformation in the 1990’s, there have been both favorable and unfavorable reports of the
quality of VA care published in the peer-reviewed literature and lay media. In order to better understand the totality of the evidence, this systematic review compared the
quality of medical and other non-surgical care in VA and diverse non-VA healthcare settings. Findings show that VA outperforms non-VA healthcare on
quality measures assessing adherence to recommended processes of care. For example, studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA settings. In addition, more VA patients than Medicare patients received beta-blockers, angiotensin-converting-enzyme inhibitors, or aspirin at discharge. Studies of diabetes care processes also demonstrated a performance advantage for VA; one study reported that VA outperformed commercial managed care plans on all seven measures of care processes examined. Most studies found no significant differences in mortality rates between VA and non-VA care.
Date: October 18, 2010
- VA Residency Training Program Rankings May Predict Cost of Care but not Hospital Readmission or Mortality Rates
Investigators in this natural experiment analyzed data from nearly 30,000 Veterans from one large, urban VA hospital who had been randomly assigned by standard hospital procedure to teams comprised of physicians affiliated with one of two medical/surgical residency training programs. One program was affiliated with one of the higher-ranked medical schools in the U.S., while the other program ranked lower. Findings show that Veterans treated by a team of VA physicians affiliated with a higher-ranked medical/surgical residency training program had 10% lower healthcare costs compared to Veterans at the same hospital who were treated by a team of VA physicians affiliated with a lower-ranked training program – and up to 25% lower costs for more complicated conditions (e.g., heart failure, COPD). Differences in cost largely were the result of diagnostic-testing rates: the physician team affiliated with the lower-ranked program took longer to order tests, and ordered more of them. Hospital readmission rates and mortality were unrelated to the physicians’ training program.
Date: October 1, 2010
- Threshold for Glycemic Control among Veterans with Diabetes
In 2009, the National Committee for
Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the
quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “
quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
Date: October 1, 2010
- VA’s Brief Alcohol Intervention Strategy Successful
This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
Date: September 28, 2010
- Validated Alcohol Screening Questionnaire Not Enough to Ensure
Quality of Screening
This study evaluated the
quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
Date: September 22, 2010
- Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality
In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on
quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on
quality of life or costs associated with screening.
Date: September 1, 2010
- Rapid-Induction Group Clinic May Be Effective Method of Increasing Rates of Hypertension Control
This report describes the process of care and outcomes of a QI initiative that used group clinics to rapidly induce hypertension control among Veterans in a VA primary care setting at one VAMC. Findings show that among Veterans with chronically treated but persistently uncontrolled hypertension, more than half (54%) were able to rapidly lower their blood pressures to controlled levels within six weeks using a group clinic
quality improvement initiative. Moreover, Veterans maintained BP control over the follow-up period (10 months after QI protocol completion). Adherence to the QI protocol predicted hypertension control at follow-up, even after controlling for multiple baseline variables (e.g., diabetes, body mass index, medication compliance). Two-thirds of Veterans without diabetes achieved hypertension control, including more than 80% of those who adhered to the group-clinic protocol.
Date: September 1, 2010
- Measuring the
Quality of Mental Healthcare: Barriers and Strategies
This article discusses the barriers to mental health
quality measurement – and identifies strategies to enhance the development and use of
quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined
quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of
quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how
quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
Date: September 1, 2010
- Patients with Hepatitis C Benefit from Collaborative Care
This study evaluated the
quality of healthcare that patients (non-Veterans) with Hepatitis C (HCV) receive and factors associated with receipt of
quality care, using research data from one of the largest commercial health insurance carriers in the U.S. Findings show that collaboration between specialists and primary care physicians translates into better care for patients with HCV. Patients were less likely to receive any recommended care if they were being treated by specialists or generalists only, compared with being seen by both. Only about 19% of patients with HCV received all recommended care, and the proportion of patients who met
quality indicators varied substantially. For example, most patients (79%) received a genotype test before treatment, whereas relatively few (25%) received recommended vaccinations.
Date: August 17, 2010
- Heart Failure Mortality Decreases While Rehospitalization Increases among Veterans
Heart failure is the number one reason for admission among Veterans enrolled in the VA healthcare system. In order to improve care for this chronic disease, VA has incorporated the use of guideline-recommended treatments; however, it is unclear if the increased performance on process of care measures for hospitalized Veterans has led to improvements in outcomes. This study sought to determine if recent mortality and readmission rates have improved within VA. Findings show that mortality and rehospitalization rates for Veterans with a first hospitalization for heart failure in the VA healthcare system or in a non-VA hospital that was paid for by VA trended in opposite directions between 2002 and 2006. Mortality rates at 30 days decreased (7.1% to 5.0%), while rehospitalization rates for heart failure at 30 days increased (5.6% to 6.1%). Over the same time period, use of guideline recommended therapy increased. During the six months prior to hospital admission and during the three months following admission, there were large increases in the use of beta-blockers. The use of angiotensin-receptor blockers also increased. Examination of patient characteristics showed that most comorbid diagnoses increased significantly from 2002 to 2006, suggesting that Veterans hospitalized in 2006 were more ill. The authors suggest that the use of rehospitalization for heart failure as a marker of poor care may be flawed. Further studies to determine the reasons for the decline in mortality and the portion of hospitalizations that are preventable are recommended.
Date: July 27, 2010
- Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and
quality of life, with PTSD having the strongest negative relationship with social functioning and
quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
Date: June 9, 2010
- Self-Management Program for Veterans with Hepatitis C Improves Health, Independent of Antiviral Therapy
This randomized controlled trial sought to examine the effects of a Hepatitis C (HCV) self-management intervention on the
quality of life of Veterans with HCV who were not currently on or scheduled to start antiviral treatment. Findings show that the HCV Self-Management Program was well attended and produced significant improvements along a number of dimensions of
quality of life and other outcomes six weeks later. When compared to the information-only group, Veterans who attended the self-management workshop improved more on HCV knowledge, self-efficacy, and had more energy and vitality.
Date: May 31, 2010
- Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and
Date: May 11, 2010
- Processes of Care to Improve Stroke Outcomes
After adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) deep vein thrombosis (DVT) prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke
quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care
quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients.
Date: May 10, 2010
- Communication Regarding Health-Related
Quality of Life between Cancer Patients and Providers
quality of life (HRQOL) discussions between oncologists and patients were common, but the emphasis was often on treatment (e.g., side effects) and symptoms (e.g., pain), even in patients with advanced disease. All provider/patient encounters included some talk of HRQOL, ranging from 3% to 75% of the total conversation, with the average HRQOL discussion taking up 25% of the conversation. An analysis of topics showed that 56% concerned treatment, 14% concerned disease, and 3% concerned testing. Talk of emotions, mental health, and psychological HRQOL was introduced into the conversations more frequently by patients than providers and occurred in only 9% of the audio segments studied. Spiritual HRQOL also was introduced into the conversations more frequently by patients than providers, and was discussed in only 1% of all audio segments. The authors suggest that given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.
Date: May 1, 2010
- Obese and Overweight Patients Receive Equal or Better Care than Patients of Normal Weight
Among Medicare and VA patients, there was no evidence across eight
quality performance measures that obese and overweight patients received worse care than normal weight patients. In fact, obese and overweight patients received marginally better care on certain measures.
Date: April 7, 2010
- Relationship between Cost of Care and
Quality of Care for Two Conditions in Non-VA Hospitals
The relationship between (non-VA) hospitals’ cost of care and
quality of care for a particular condition was small and differed by condition. However, evidence did not support the hypothesis that low-cost hospitals discharge patients with congestive heart failure (CHF) or pneumonia earlier, only to increase readmission rates and incur greater inpatient cost of care over time. Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals. Hospitals in the highest-cost quartile for CHF care had higher
quality-of-care scores and lower mortality. For pneumonia, the opposite was true: high-cost hospitals had lower
quality-of-care scores and higher mortality. Risk-adjusted costs of care for CHF and pneumonia varied widely between hospitals, although hospital cost-of-care patterns seemed stable over time.
Date: February 22, 2010
- Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the
quality of information exchange (e.g., needs assessment, joint care planning).
Date: February 16, 2010
- Implementation of a VA
Quality Improvement Initiative Improves Knowledge and Perceptions Regarding MRSA Prevention
Implementation of the initiative at 17 VAMCs was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention. Between baseline and follow-up, there were increases in the number of respondents who: correctly identified that alcohol-based hand rub is more effective at inactivating MRSA than soap and water, reported cleaning their hands when entering and exiting a patient room in the past 30 days, reported using alcohol-based hand rub over soap and water when cleaning their hands, and felt comfortable reminding others about proper hand hygiene.
Date: February 3, 2010
- Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more
quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
Date: January 19, 2010
- Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional
quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
Date: January 7, 2010
- Assessing New HEDIS Blood Pressure
Quality Measure for Diabetes
To encourage aggressive treatment of hypertension, the National Committee on
Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor
quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
Date: January 1, 2010
Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
Mental disorders (MD) were associated with a decreased likelihood of obtaining
quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in
quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
Date: January 1, 2010
- Validity of Mental Health Diagnosis Using VA Administrative Data
This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and
quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
Date: January 1, 2010
Quality Measures for VA Alcohol Use Disorder Treatment
The goal of this study was to identify patterns of VA care that are associated with both facility- and patient-level outcomes in order to develop a new process-of-care measure for VA outpatient alcohol use disorder (AUD) treatment
quality. Findings show that nine candidate process measures of outpatient AUD treatment
quality can predict facility-level and patient-level improvement. The candidate measures with the strongest association with improvement in outcomes focused on Veterans who received 3 to 6 outpatient visits in the first month of care. Results also showed that while the literature indicates that longer duration of care should produce better patient outcomes, the investigators found no such link with overall outcomes.
Date: December 1, 2009
- Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and
quality of care.
Date: November 1, 2009
- Use of Medicare and VA Healthcare among Veterans with Dementia
This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high
quality care, particularly among those with multiple comorbidities.
Date: October 1, 2009
- Special Issue of Pain Medicine Highlights VA Research on Pain among OEF/OIF Veterans
This publication is in follow-up to a Pain Research Summit held in September 2007 by VA’s Rehabilitation R&D Service and VA/HSR&D’s Polytrauma and Blast-Related Injury
Quality Enhancement Research Initiative (PT/BRI-QUERI). This Special Issue begins with four articles that build on the growing epidemiological literature on the prevalence and correlates of pain among OEF/OIF Veterans, and considers the evidence for the assessment and management of pain in this population. The Issue also includes several original articles that provide a sample of the relatively large and growing body of research on pain, including research that focuses on the most prevalent and challenging of pain conditions observed among OEF/OIF Veterans, such as neuropathic pain, chronic widespread pain, musculoskeletal/joint pain, and pain secondary to spinal cord injury.
Date: October 1, 2009
- Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with Pneumonia
Time to first antibiotic dose (TFAD) is an important
quality indicator for pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted
quality improvement approaches and a top-down hospital leadership style to improve performance on this pneumonia
Date: October 1, 2009
- “Rights” of Safe Electronic Health Record Use
This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
Date: September 9, 2009
- Federal Investment in Electronic Medical Records
The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct
quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
Date: September 9, 2009
- Chronic Care Model Improves VA Care, with Opportunities for More Progress within and Outside VA
The Chronic Care Model (CCM) has been embraced by many healthcare systems including VA, whose reorganization in 1995 encouraged the type of organizational commitment that the CCM views as vital to providing high
quality care for patients with chronic illness. The return on VA’s investment in the CCM is reflected in significant improvements in
quality of care. Comparisons of the
quality of chronic illness and preventive care between VA and the private sector generally show that VA provides superior
quality of care. Looking ahead, the American Recovery and Reinvestment Act (ARRA) contains several provisions with the potential to support the widespread adoption of CCM processes throughout the US healthcare system.
Date: September 1, 2009
- Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve
quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
Date: September 1, 2009
- Guideline Concordant Care Improves Outcomes for Veterans with Venous Ulcers
Using VA data, investigators identified 155 Veterans with 400 venous ulcers who were treated in the VA Puget Sound Healthcare system between 10/03 and 9/07. Using the 2006 Wound Healing Society guidelines for venous ulcers, guideline-concordant care was defined as adherence during at least 80% of patient visits with the use of: dressings creating a moist wound-healing environment, use of a multi-layer compression device (excluding monolayer devices like ace wraps and compression stockings), and ulcer debridement. Findings show that guideline concordant venous ulcer care was significantly associated with venous ulcer healing, when provided at 80% or more of patient visits. The likelihood of ulcer healing increased when compression therapy or a moist wound-healing environment were provided during at least 80% of the visits; debridement alone was not significantly associated with ulcer healing. Veterans who received all three treatments during at least 80% of their visits were more likely to heal than those who received less than 80%. For this cohort of Veterans, a majority of ulcers (n=362) healed, with an average time to healing of 18.1 weeks, which is much better than the reported average of 36 weeks.
Date: September 1, 2009
- Focus Groups Recommend Strategies to Decrease Missed Test Results
This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial
quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
Date: September 1, 2009
- Study Questions Validity of HEDIS
Quality Measures for Substance Use Disorder Specialty Care
Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of
quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular
quality measures be considered measures of facility performance rather than measures of the
quality of SUD specialty care.
Date: August 1, 2009
- Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up
quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
Date: August 1, 2009
- Drugs-to-Avoid Criteria for the Elderly have Limited Value
Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for
Quality Assurance uses the criteria of Zhan et al. to compare the
quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as
quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the
quality of prescribing.
Date: July 27, 2009
- Significant Proportion of New Abdominal Aortic Aneurysms are not Recorded in VA’s Electronic Medical Record
This study examined the frequency with which newly identified abdominal aortic aneurysms were accompanied by evidence of clinician recognition of the abnormality in VA’s electronic medical record. Of the 91 Veterans with abdominal aortic aneurysms newly identified by CT, 60% lacked documentation in their VA electronic medical record within three months of CT detection, and 18% were never documented during an average follow-up of more than three years. Radiologists infrequently notified the clinical teams of aortic abnormalities, and notification did not appear more common for larger as opposed to smaller abnormalities. More than 40% of Veterans with new aortic aneurysms identified on CT scan had no follow-up contact with the provider who ordered the test, suggesting a potential mechanism for missed results. There was no evidence that any of the aneurysms ruptured or that deaths resulted from the delayed follow-up.
Date: July 7, 2009
- Standard-Based Method is Preferred Measure of Treatment Intensity for BP Control
One possible measure of the
quality of hypertension care is the intensity of clinical management when blood pressure (BP) is uncontrolled, thus there is increasing interest in measuring treatment intensification (TI). This study compared different TI measures in predicting BP control among 819 outpatients with hypertension. The three TI scores/measures evaluated were: 1) any/none score, which divides patients into those who had any therapy increase during the study vs. none; 2) Norm-Based Method (NBM), which scores each patient based on whether they received more or fewer medication increases than predicted at each visit; and 3) Standard-Based Method (SBM), which is similar to NBM but expects a medication increase whenever the BP is uncontrolled. Findings show that the SBM score was an excellent predictor of the final systolic blood pressure, thus the authors suggest that SBM serve as the basis for research and
quality improvement efforts for better hypertension care. The any/none measure produced paradoxical results (therapy increases were associated with a higher final BP), while the NBM was not predictive of BP control.
Date: July 1, 2009
- Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals
This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful.
Date: July 1, 2009
- Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
This study sought to determine the impact of different types of co-existing chronic diseases on
quality of care for hypertension, as well as patient perceptions of
quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good
quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of
quality of care, nor did Veterans’ assessment of
quality of care vary by the presence of co-existing conditions.
Date: June 16, 2009
- HSR&D Investigators Propose New Measure to Assess Diabetes Care
This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes
quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring
quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using
quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs.
Date: June 1, 2009
- Comparative Effectiveness Research Initiatives Fall Short without Commitment to Implementation
President Obama recently signed into law an initiative providing $1.1 billion to support research on the comparative effectiveness of drugs, medical devices, surgical procedures, and other treatments for various conditions. Although comparative effectiveness research (CER) funding has increased, the translation of this investment into practice is very slow, and little attention has been paid to a critical question: Will CER results significantly improve the
quality and safety of the healthcare received by the average patient? This Editorial focuses on the issue of translating evidence into practice, as well as existing programs that can serve as models for achieving important implementation research objectives. Authors note that Federal (CER) initiatives will fall short unless they include a commitment to implementation research to help translate findings into high-
quality health care. An implementation research and development program could fulfill three important objectives: 1) accelerate the translation of evidence into everyday care; 2) enhance opportunities for healthcare providers and patients to define value (balancing expected benefits with costs); and 3) provide the means for providers and patients to communicate with researchers and policymakers about clinically important issues earlier in the research process. Three programs already exist as models for achieving the aforementioned objectives: 1) VA’s
Quality Enhancement Research Initiative (QUERI), 2) VA’s Center for Implementation Practice and Research Support, and 3) the Agency for Healthcare Research and
Quality’s (AHRQ) John M. Eisenberg Clinical Decisions and Communications Science Center.
Date: May 7, 2009
- Establishing Appropriate Peer Group Method for Comparing Healthcare
Measuring and reporting healthcare facility performance via clinical measures of
quality has become a major strategic initiative in improving the
quality of healthcare. Establishing appropriate peer groups can help make equitable comparisons across hospital or healthcare systems. This study sought to develop a new methodology for constructing customized peer groups for VA medical centers by identifying the “nearest neighbor” medical centers, according to distance from each other and selected characteristics for comparison. Findings show that one of the advantages of the nearest-neighbor method is that the peer groups are more refined, reflecting the multi-dimensional diversity of healthcare providers. Moreover, the nearest-neighbor method incorporates the practical consideration that healthcare facilities or systems may have structural and patient-based differences that cannot be changed, but do affect financial or
quality outcomes. Authors suggest that nearest-neighbor peer groups may be more appealing to some researchers and administrators than standard cluster analysis, and thus may strengthen organizational buy-in for financial and
Date: April 1, 2009
- New Process for
Quality Improvement Suggests Local Focus on Improving, in Addition to Measuring
Authors suggest reforming
quality improvement (QI) so that instead of a focus on measures with national benchmarks, there is a focus on rewarding local actions that improve
quality of care using local norms to guide progress.
Quality improvement efforts should be tied to local actions and local results rather than national norms, acknowledging that QI efforts are not generalizable – one size does not fit all. Measures would be tailored to each institution to reflect local core causes. Measurement could remain a key part of local QI initiatives, however, the measurement of core causes and incentives to improve would be conducted at the local sites.
Date: April 1, 2009
Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted
quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
Date: April 1, 2009
- Taking Stock:
Quality Enhancement Research Initiative and Implementation Science
Quality Enhancement Research Initiative (QUERI) program and implementation research emerged at the same time – about 10 years ago. This Editorial takes stock of how much both QUERI and implementation science have grown in the intervening decade, and reflects on the opportunities and challenges ahead.
Date: March 6, 2009
Quality Enhancement Research Initiative Advances Implementation Science
This Editorial offers a perspective from implementation researchers outside the U.S. about VA/HSR&D’s
Quality Enhancement Research Initiative (QUERI) and its impact on and contributions to implementation science.
Date: March 6, 2009
- Costs and Benefits of Health Information Technology
The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness,
quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation.
Date: March 1, 2009
- Improving Audit and Feedback Strategies
Audit and feedback (A&F) furnishes providers with summaries of clinical performance over a specified period of time, offering providers current information and motivation to improve. This study found that A&F has a modest but significant positive effect on
quality outcomes. A&F reports containing specific suggestions for performance improvements – delivered in writing, rather than verbally or graphically, and delivered frequently – can noticeably improve the effectiveness of audit and feedback. Also, providing combined group- and individual-level feedback appeared to positively impact feedback effectiveness; however, definitive conclusions could not be made.
Date: March 1, 2009
- Research Agenda for Oral Anticoagulation
Efforts to measure the
quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with little effort in measuring the
quality of oral anticoagulation once therapy has begun. To address this knowledge gap, investigators propose a research agenda to advance our understanding of how to measure the
quality of care in oral anticoagulation. Authors propose that valid
quality indicators will provide a framework for
quality improvement that will maximize the effectiveness of therapy and minimize patient harm.
Date: March 1, 2009
- Evaluating Profiling Program and New
Quality Indicators for Diabetes Care
This study evaluated the addition of new
quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites.
Date: March 1, 2009
- Costs Associated with Providing Depression Care in the Primary Care Setting
This study reports on organizational costs associated with depression care
quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care.
Date: February 1, 2009
Quality Improvement Approach May Be Best
There is a growing consensus that a hybrid of two common approaches to
quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving
quality care across a variety of conditions. This study examined preferences of frontline staff and managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project regarding how to engage in QI dialogue and provide practical suggestions for implementation. Many study participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the
quality of care.
Date: February 1, 2009
- Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care
quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
Date: February 1, 2009
- Spaced Education May Improve Teaching by Surgical Residents
This randomized trial investigated whether feedback given by surgery residents to students could improve using a spaced-education program delivering succinct weekly e-mails. Findings show that succinct e-mails using spaced education methods are an effective tool to significantly improve both the frequency and
quality of feedback given by surgical residents to medical students. Authors suggest that spaced-education techniques may help educate busy residents, for whom service and education responsibilities are often at odds with effective teaching strategies.
Date: February 1, 2009
- Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
Although non-white Veterans have documented disparities in the
quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
Date: January 1, 2009
- Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings
Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of
Date: January 1, 2009
- Assessing Accuracy and Completeness of Research Data
VA benefits from one of the most highly developed health information systems in the world, which includes the Immunology Case Registry (ICR) that was designed to monitor costs and
quality of HIV care, and the Decision Support System (DSS) that was developed to monitor utilization and costs of Veterans in care. This study compared ICR and DSS datasets, which share overlapping laboratory data from the same VA electronic record system. Findings show that six of the laboratory tests for HIV patients that were studied demonstrated remarkably similar amounts of overlap (68% to 72%) between the two datasets, showing that ICR and DSS are both good sources of data for these tests. However, several other tests demonstrated much lower proportions of overlap (between 20% and 31%). These findings indicate that validation of laboratory data should be conducted prior to its use in
quality and efficiency projects.
Date: January 1, 2009
- Factors Associated with VA Employee Participation in
Quality Improvement Program to Reduce Patient Wait Times
Perceived group norms and attitudes were related to greater individual participation in the Advanced Clinic Access program, but perceived behavioral control was not found to be significant to participation. Overall, survey respondents typically engaged in just under half of the change behaviors. Employees with greater responsibility (e.g., nurse practitioners, RNs, and physicians) participated in more activities compared to other clinic employees. Team size, academic affiliation, and job satisfaction were not significant predictors of participation.
Date: November 1, 2008
- Clinically Complex Veterans have Higher Rates of Performance Measurement and Higher Satisfaction with Care
Veterans with higher clinical complexity had higher measured performance on common process measures used to assess the
quality of outpatient care. In addition, satisfaction with care was higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures does not crowd out unmeasured care.
Date: November 1, 2008
Quality Improvement Collaborative Improves ICU Care for Veterans
This study focused on two “bundles” (ventilator bundle and central line insertion bundle) – tools designed to facilitate the application of best practices and evidence-based care at the bedside. Using these bundles, the goals were to increase adherence with specific evidence-based ICU practices, and to determine whether this would promote additional and sustained
quality improvement across VISN 23. Adherence with all five elements of the ventilator bundle improved to 82% in the final three months of the intervention. The use of a central line insertion checklist to monitor adherence with the central line bundle increased to 74% in the final three months of the intervention. In addition, the implementation of the ventilator and central line bundles was associated with a reduction in rates of ventilator-associated pneumonias and catheter-related blood stream infections, respectively.
Date: November 1, 2008
- Healthcare Providers Should Adopt Principles of Both Patient Centeredness and Cultural Competence to Meet the Needs of All Patients
Authors suggest that healthcare organizations and providers should adopt principles of both patient centeredness and cultural competence so that services are aligned to meet the needs of all patients. Moreover, health services researchers should develop measures of cultural competence and patient centeredness and explore the impact of their unique and overlapping components on patient outcomes.
Date: November 1, 2008
Quality Indicators to Help Treat Veterans with HIV and Depression
Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that
quality indicators identified in this study provide a useful tool for measuring and informing the
quality of HIV depression care.
Date: October 1, 2008
- Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the
quality of care varied at the two sites.
Date: September 1, 2008
- Demographic and Clinical Factors Affect Ostomy Complications
Demographic factors (age) and clinical factors (marking the stoma pre-operatively and provider explanation of the ostomy prior to surgery) are potential risk factors for the development of ostomy complications. In addition, the four
quality of life domains measured in this study (physical, psychological, social, and spiritual) were strongly related to all three ostomy complications evaluated.
Date: September 1, 2008
- Veterans with Spinal Cord Injury Report Frequent Physical and Mental Health Concerns
Overall, veterans with spinal cord injury (SCI) were much more likely to experience frequent physically and mentally unhealthy days, and frequent days with depression than what has been reported for the general population. In addition, both chronic illnesses and smoking had a substantial effect on health-related
quality of life for persons with SCI.
Date: July 1, 2008 | <urn:uuid:fb6e2a04-da5f-47bc-bdd0-75a6d55774ce> | CC-MAIN-2022-21 | https://hsrd.research.va.gov/research/citations/PubBriefs/default.cfm?activeSearch=2&searchKeywords=Quality | 2022-05-28T01:42:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-21/segments/1652663011588.83/warc/CC-MAIN-20220528000300-20220528030300-00759.warc.gz | en | 0.95127 | 52,429 |
|Program Director: Dr. E. Del Chrol
The Graduate Certificate in Latin consists of 15 hours. The Certificate provides a series of Latin literature courses that covers Roman poets, historians, rhetoricians, and Roman civilization.Program Highlights:
- Students can advance their study of elementary Latin.
- The certificate serves as preparation for graduate degrees in Latin and education.
- Credits can be used toward teacher certification, the MAT, and the master’s degree in Latin.
- Prospective certificate-only students should apply for admission to Marshall University as a Certificate/Professional Development student and select the Latin Certificate on the application form.
- Applicants should follow the admissions process described in the Graduate Catalog, or at the Graduate Admissions website.
Applicants must have appropriate prerequisites for upper-level Latin courses, which generally consist of the completion of elementary Latin courses, or comparable practice and proficiency in Latin ascertained by a department exam.
Deadline for Application: December 1 (Spring semester); August 1 (Fall Semester) | <urn:uuid:e8252eab-6613-4b19-8468-a0e7fbd11e5f> | CC-MAIN-2016-30 | http://www.marshall.edu/graduate/programs/latin-2/ | 2016-07-28T16:27:57Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-30/segments/1469257828286.80/warc/CC-MAIN-20160723071028-00251-ip-10-185-27-174.ec2.internal.warc.gz | en | 0.892597 | 212 |
Well Behaved Women Long Sleeve Tee
Quiet compliance is not a womanly virtue. Let's forget all of that nonsense and go be noisy, rabble rousers, and trouble-makers. You, O Fabulous One, are most definitely not here to make up the numbers.
Click "Add to Cart" to order and then go get busy being the most fabulous version of You!
Remember, we're here to make a beautiful impact in women's lives which is why we donate 10% of everything to Global Fund for Women to contribute to their work for girls and women across the world combatting gender inequality in all its forms. And now, you, are a part of that too! Thank-you.
Impact made easy with PEBBLE + ROSE!
- 65% polyester/35% viscose
- 2x1 sleeves
- Drop shoulder
- Curved bottom hem
- Prints to order - Typically ships in 5 days
|Body Length Front (inches)||26||26 ½||27||27 ½|
|Body Width (inches)||22 ½||23 ¼||24 ¼||25 ¼| | <urn:uuid:5df185f9-43dc-4aeb-95c1-4fdbca7937e5> | CC-MAIN-2019-35 | https://pebbleandrose.com/products/well-behaved-women-long-sleeve-tee | 2019-08-24T13:42:02Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027321140.82/warc/CC-MAIN-20190824130424-20190824152424-00245.warc.gz | en | 0.912108 | 242 |
In this episode, Daisy Luther drops back by. We discuss starting and stocking your prepper pantry, cutting the grocery bills, and being a foodie in the apocalypse.
Let’s face it, building out and stocking a good pantry isn’t sexy for most of us. It’s meticulous work requiring a lot of thought and care — especially for new preppers. Stocking food and water doesn’t go bang, isn’t shiny, won’t word off zombies, and isn’t something we can brag to our friends about. (Well you could, but it’s not advisable.)
And it can require a lot of planning ahead. You must know what your family will and won’t’ eat. There’s no point in stocking and squirreling away food items if it’s going to go uneaten. You may be thinking, “they can just eat it or go hungry” or you may be thinking, “if they’re hungry enough they will eat it”. But this creates unnecessary stress for everyone. Why bother?
But with a bit of thought, planning, observation, and smart buying you can put together a great pantry. Then it’s just a matter of maintenance; that’s the easy part.
There are many considerations, obviously. Fortunately, Daisy did most of the thinking for you and shares her great tips and strategies with you in this episode…
Building out a Propper Prepper Pantry Topics Discussed:
- Where to begin
- Why it’s important
- Leveraging a pantry for saving money and budgeting
- What are good food items to store
- How to store food with bugs and vermin in mind
- Keeping everything organized
- Staying on top of what you have so you don’t waste or turn meal time preparation into a scavenger hunt
- The place for freeze dried food | <urn:uuid:d9096f23-88c2-494c-a1f9-d15e2876f5ce> | CC-MAIN-2019-35 | https://www.intherabbithole.com/e227/ | 2019-08-19T12:57:25Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027314732.59/warc/CC-MAIN-20190819114330-20190819140330-00496.warc.gz | en | 0.894084 | 416 |
Volunteer Opportunities at St. John's Hospitals
St. John’s volunteers donate their time and energy to provide valuable and important resources to hospital departments. St. John's volunteers raise funds for hospital equipment and programs through gift shop sales and other events. Their dedication, perseverance, creativity, enthusiasm and devotion help make St. John’s an outstanding healthcare provider.
Volunteer Services at both hospitals provide volunteer opportunities for adults age 18 and over. In addition, high school and college students age 16 and older can volunteer at both hospitals through the Student Volunteer Program.
Volunteer Opportunities for Adults
Volunteer opportunities through Volunteer Services at St. John's Hospitals are open to all adults over age 18 who are willing to make a responsible commitment to uphold the purpose, objectives and policies of both Volunteer Services and the hospitals.
Volunteers may be assigned to the following services:
- Community Education
- Emergency Department
- Expectant Parents Tour
- Patient Care Programs
- Gift Shop
- Health Services Library
- Intensive Care Unit/Coronary Care Unit
- Intensive Care Unit/Coronary Care Unit Waiting Room
- Information Desk
- Mail Service
- Short-Stay Unit
- Surgery Waiting Area
- Baby Cuddler Program
- Mother-Infant Unit/NICU
- Labor and Delivery
- Auxiliary Office
- Certified Therapy Dog Program
- Crafts/Flower Arranging
- Flu and Immunization Clinics
- Magazine Cart
- Bulk Mailings (on call)
- Hospitality Cart
- Reception Desk
- General Office Duties
- Special Events
- Employee Health
- Nursing Education
Interested in becoming a volunteer? Please complete the application (PDF). You must also submit at least one letter of recommendation, or you can use the recommendation form (PDF). Once complete, please do not mail or drop off the application or recommendation form. Please call the director of Volunteer Services at 805.988.2627 (Oxnard) or 805.389.5651 (Camarillo) to schedule an interview.
Membership dues to join Volunteer Services are $15 annually. You must also purchase the uniform. At St. John’s Regional Medical Center, the volunteer smock is $25. At St. John’s Pleasant Valley Hospital, the volunteer smock/jacket is $28 and the polo shirt is $25.
You will be required to take a tuberculosis test before you can begin volunteering (compliments of St. John’s Hospitals), which will be scheduled at the time of your interview. | <urn:uuid:61b84783-25f2-4e08-8e60-a38613d96fb6> | CC-MAIN-2014-23 | http://www.stjohnshealth.org/Who_We_Are/201636 | 2014-07-28T08:16:36Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-23/segments/1406510257966.18/warc/CC-MAIN-20140728011737-00417-ip-10-146-231-18.ec2.internal.warc.gz | en | 0.898606 | 549 |
The multi-function physical simulation testing system of deep coal and rock engineering developed by Popwil for the College of Resources and Environment of Chongqing University is mainly used for the laboratory simulation testing research of deep coal and rock engineering under the action of ground stress and gas pressure, such as roadway excavation, support, gas outburst control, etc.
The system consists of a set of cylindrical loading frame composed of multiple circular loading rings together with front and rear end covers. Each loading ring and front and rear covers of the loading frame are fixed together to form a loading chamber by 20 pull rods with prestressed loading device. Inside the loading chamber, 432 20 ton surface loading actuators, which are divided into 11 loading channels, are installed on the rear end cover and cavity, together with the front end cover, to form a 1200 * 1200 * 2000 mm testing space. The surface loading actuators can apply up to 10MPa stress on the specimen in the testing space. As the surface load actuators are grouped by rows and columns, this made it possible to realize the automatic synchronous or asynchronous group step loading. Another important feature of this loading frame is that there are sealing rings between each loading ring and between the loading ring and the front and rear end covers. During the test, gas (usually use cabon dioxide instead of methane for safe reason) can be fullfilled into the closed loading chamber under controllable pressure. The maximum inflation pressure can reach 5MPa. The front cover is provided with drilling holes, through which the drilling machine can drill the specimen. The problems of water and gas outburst or dig chamber support in different depth are simulated and researched by drilling under different surface load and inflation pressure.
The design drawing, site photo and main technical specifications of the system are as follows.
Design drawing of Multi-function Physical Simulation Testing System
Onsite Photo at Chongqing University
Main technical parameters:
1. Loading frame: cylindrical loading frame with seal and prestressed locking between rings. The prestressed pull rod ensures the reliability of sealing;
2. Surface load actuators: 432 surface load electro-hydraulic servo actuators are divided into 11 groups, which can realize closed-loop steped and layered loading;
3. Test chamber size: 1200 * 1200 * 2000mm;
4. Load simulation capability:
1) maximum surface stress 10MPa;
2) maximum gas pressure 5MPa;
5. Controller and software:
The windows application software popware-m controls the pop-m multi-channel controller with 11 closed-loop control capabilities, which can realize the simulation of the earth stress of 432 surface load actuators with a maximum of 10MPa and the inflation pressure of 5MPa, and complete the simulation research of mine support, gas and Water Outburst under the deep and complex geological conditions.
6. Auxiliary device:
1) The system is equipped with a model drill, which can be fixed on the front cover and drill the sample in the cavity through the reserved holes.
2) The system is equipped with a test making device, which can compress the sample in advance when making the sample, so as to prevent excessive sample deformation after being sent to the closed chamber. | <urn:uuid:c62a04aa-5fbe-444c-9428-d8aa707b7e28> | CC-MAIN-2020-24 | http://popwilglobal.com/case-studies/case-studies_geo_eng_test_system/cases2-9/ | 2020-06-05T21:08:56Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-24/segments/1590348504341.78/warc/CC-MAIN-20200605205507-20200605235507-00571.warc.gz | en | 0.906069 | 665 |
Spectacular Use of DYWIDAG Systems: The Glacier Skywalk in Canada’s Jasper National Park
Since May 2014, Jasper National Park in Alberta, Canada, features a spectacular highlight for visitors: The Glacier Skywalk. The skywalk is a visitor platform with a glass floor on a steel frame structure that extends from a cliff at a height of 280m. The cantilevered platform was erected at an existing road and extends over 30m from the rock. It provides tourists with an impressive view of the Sunwapta Valley with its glacier fields and steep rock walls.
The viewing platform contains a draped cable in its inside radius. A large compression chord acts together with steel framing members to provide torsional resistance under partial load.
Tuned mass dampers in the walkway minimize vibrations caused by walking, and wind deflectors attached to the outer handrails reduce swinging caused by crosswinds.
The 30m long glass skywalk is supported by 600t of cantilevered, trapezoidal box girders secured onto tied back foundation blocks. The foundations were anchored in depths of 10 to 20m in the load-bearing rock using rock anchors. DSI Canada supplied 48 Ø 63mm DYWIDAG Rock Anchors for tying back the foundation blocks.
64 Ø 46mm GEWI® Micropiles and Ø 46mm double corrosion protected (DCP) DYWIDAG Rock Anchors were installed in the concrete foundations for the box girders. The concrete foundations were further post-tensioned with 77 Ø 46mm THREADBAR Tendons. The steel frame structure was secured to the concrete foundations using 80 post-tensioned Ø 36mm DYWIDAG Anchor Bolts. 2 Type 9-0.6" DYWIDAG Strand Tendons in steel ducts were used to support the cantilevered glass platform. DSI Canada provided technical assistance for all of the products that were supplied and also provided the equipment needed for tensioning the anchors. An experienced DSI technician supervised the construction work on site.
DSI worked closely with the design engineers and the general contractor from the beginning conceptual stage through to completion of the project. Due to the remote sub-alpine terrain, construction work was very difficult. The constrained site access prevented using cranes for the stressing. Scaffold sections had to be set up and manual chain falls had to be used to hoist equipment. This meant all materials and equipment had to be prepared ahead of moving the suspended structure into place, as the large lifting crane blocked any subsequent access to the jobsite.
Site conditions required quick design changes. In some cases, DSI had to produce and supply additional products just in time in order to make use of the short time frame in which the construction work could be carried out due to the extreme local weather conditions. Even before construction of the skywalk started in 2011, the project won the Future Projects Category at the World Architecture Festival in Barcelona. | <urn:uuid:e03ec44e-a93f-44c0-8177-6b482eb2588e> | CC-MAIN-2020-24 | https://www.dsicanada.ca/projects/2013-info-21/spectacular-use-of-dywidag-systems-the-glacier-skywalk-in-canadas-jasper-national-park/ | 2020-05-27T08:49:44Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-24/segments/1590347392142.20/warc/CC-MAIN-20200527075559-20200527105559-00215.warc.gz | en | 0.941237 | 619 |
Band, Gates, & Dramis, P.L.
, we proudly offer exceptional legal services to residents of Sarasota
County, Manatee County, and their surrounding areas. We have
extensive legal experience and are passionate about obtaining justice on behalf of our clients. The
moment you secure our representation, we will do everything within our
power to help you obtain the sense of ease that you deserve amidst this
difficult and trying time. In order to do so, we will address each of
your concerns, answer each of your questions, and guide you down the path
that best suits your needs. Our mission is to achieve your goals in the
most timely and effective manner possible. Do not hesitate to
contact our skilled and qualified Sarasota attorneys today! | <urn:uuid:5f0c3b81-6884-475a-b71c-89b4ff178813> | CC-MAIN-2016-07 | http://www.bandgatesdramis.com/ | 2016-02-07T08:10:24Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-07/segments/1454701148758.73/warc/CC-MAIN-20160205193908-00271-ip-10-236-182-209.ec2.internal.warc.gz | en | 0.92945 | 161 |
Coco/R is a compiler generator, which takes an attributed grammar of a source language and generates a scanner and a parser for this language. The scanner works as a deterministic finite automaton. The parser uses recursive descent. LL(1) conflicts can be resolved by a multi-symbol lookahead or by semantic checks. Thus the class of accepted grammars is LL(k) for an arbitrary k.
There are versions of Coco/R for different languages.
- Category: Parser Generators
- License: GNU General Public License (GPL)
- HomePage: http://www.ssw.uni-linz.ac.at/Projects/Coco/Coco.html/ | <urn:uuid:a81a7210-8977-4b1e-9b11-280839bfddfa> | CC-MAIN-2014-41 | http://java-opensource.com/open-source/parser-generators/601-cocor.html | 2014-09-22T02:09:40Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-41/segments/1410657136523.61/warc/CC-MAIN-20140914011216-00170-ip-10-234-18-248.ec2.internal.warc.gz | en | 0.814742 | 149 |
Reading books for a decade now has switched medium and people are no longer into paper bound titles that you would have to lug around. Check out what the digital mediums for reading books like Audible and Kindle have to offer to the users. Read the https://www.change.org/p/amazon-kindle-unlimited-vs-audible-which-is-better-for-audiobooks-in-2019 policies before you get started.
Audible has the policy to allow the subscriber the privilege of one credit within the subscription amount you have paid. The titles of purchase can be of different categories which the listener can choose from. If the user doesn’t want to choose any audiobook on credit that particular month, he/she gets a chance to roll over the credit to the next subscribing month. If you want to have more books then you would have to opt for audible credits which are more in number, you could do this by buying them. Member has the option of getting to purchase two of the originals from the selection he/she does for the month, this happens on the first Friday of the month of the subscription. These can be kept forever even after you have ended the subscription and they won’t cost you a penny.
The cost of kindle is a bit on the higher side, and it may be over whelming to some to match up your reading to this monthly subscription amount. You could subscribe for a period of a month, or for six months or for a whole year or even two years. Just because you have subscribed for longer periods, you won’t get any rebate in the amount or discount either. This is kind of a non-starter for many who want to join the service and take up reading using kindle. Well, the free trial period will help you decide whether you could go on for paying the sum each month and read up to the potential. There are unlimited memberships plans that are part of the deal when you subscribe this service. | <urn:uuid:92315d74-58ad-4c34-81cf-7685c9e14ada> | CC-MAIN-2020-29 | http://templodelgato.com/2019/09/09/choosing-between-audible-and-kindle/ | 2020-07-07T01:55:04Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-29/segments/1593655891640.22/warc/CC-MAIN-20200707013816-20200707043816-00016.warc.gz | en | 0.949758 | 411 |
LIKE IN GOOD OLD TIMES
The new model “Retro Classic” from Poljot-International
When you talk about retro, you think of the “good old days”, in contrast to today’s time, which is passing us by faster and faster.
Poljot-International’s new “Retro Classic” model stops time short and revives the feeling of the bygone era by referencing the past with various design elements.
The main feature of the watch are the numbers. They are authentically designed in the old retro style, while the shadow in the background in nostalgic style, clearly emphasizes the numbers. In addition, the numbers glow in the dark to be easily visible. The red number 12 sets with its color a characteristic feature of the 20s/30s and underlines the affiliation to the “good old” time.
The colors of the dials are in classic finish – champagne, green and silver. The sunburst finish is a common production method of the time and was also used on these dials. The hour and minute hands are made in the onion shape with luminous material. This shape was also popular in the days of “swing and jazz”. In any case, they make reading the watch very easy and convenient.
The case is made of stainless steel, the size – 38.5 mm in diameter – corresponds to the revolutionary times. Without the front glass, the case measures only 9.15 mm and houses a hand-wound mechanical movement by Vostok, caliber 2409, which also has its beginnings in the last century. The movement is visible through the glass back of the case. It was left completely unfinished to preserve its nostalgic character and not be affected by additional finishing.
The model is worn on the wrist with a calfskin strap. It is very soft and supple. As an eye-catcher, it has contrasting stitching on the side.
All in all, the new “Retro Classic” is an expressive, classic retro watch with charisma that will make any enthusiast’s heart beat faster.
About Poljot International
The roots of the watch brand “Poljot-International” date back to the 1930s, when the “First State Watch Factory” was founded in Moscow. In 1961, after the flight of the first citizen of the earth, Yuri Gagarin, into space, the watches produced by the factory were given the designation “Poljot” (the flight).
All watches of the brand “Poljot-International” are manufactured in Germany today. Nevertheless, the charm and delicacy in the design, the skilful hands of the master watchmakers, the warmth of the Russian soul and, of course, the love for Russia can be seen and felt.
Reference number: 2409.1220333
Movement: Manual winding cal. 2409 Vostok, 17 jewels, 38 hours power reserve
Functions: Hours, minutes, center second
Case: Stainless steel case, Ø 38,5 mm, h = 11,5 mm, 5 atm, glass bottom
Crystal: Sapphire crystal on the front
Dial: Green with sunburst, large Arabic numerals with luminous material
Hands: Silver colored with luminous material, second hand in red
Strap: Light brown calfskin strap with side stitching
Warranty: 2 years | <urn:uuid:b25eb092-fd33-4475-8aea-e4a19c64b8ba> | CC-MAIN-2023-06 | https://redarmywatches.com.my/products/copy-of-poljot-international-retro-classic-green | 2023-01-28T23:31:59Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764499695.59/warc/CC-MAIN-20230128220716-20230129010716-00257.warc.gz | en | 0.929759 | 720 |
Mid century modern open plan kitchen, dining and BBQ area in newly built home. Lightng white concrete and wood and replica Scandinavian with 3m high ceiling featuring acoustic panels and high windows overlooking two pack kitchen in white with grey/green glass tile splash back and stainless steel appliances. Dulux Whisper White on trims and cabinetry. Oyster Linen on walls. Orange floral arrangement on Caesarstone Bianco Drift bench top. Blackbutt wide board wood floor and travertine French lay stone otdoors. Features indoor-outdoor living with built-in BBQ. Marble dining table, white oak legs and navy blue dining chairs with oak legs. Turquoise bowl on dining table. | <urn:uuid:27aed218-8b95-4733-8cd3-fe1e9b4b4df8> | CC-MAIN-2019-43 | https://showhomes.design/projects/2109821/colour-psychology-house-new-build-interior-design | 2019-10-23T00:15:46Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-43/segments/1570987826436.88/warc/CC-MAIN-20191022232751-20191023020251-00468.warc.gz | en | 0.87798 | 138 |
The reason these two rooms of the home
are often considered inappropriate locations for hardwood floors comes down to the nature of wood. If you use solid wood, you're utilizing a natural resource known to expand and contract in
response to the surrounding environment. The bathroom and kitchen are two rooms known to fluctuate in humidity and attract moisture, so they were traditionally considered off limits for wood
It's difficult not to fall in love when
you see pictures of large kitchens lined with shiny dark hardwood floors, so you're probably hoping there's a solution. Luckily, you can now choose laminate flooring to achieve the look of wooden floors in any room that may fluctuate in humidity or
involve the use of water. This is a manufactured flooring made from fiber board and other synthetic materials, but the top layer is imprinted to create the look of wood grain.
If you want to add wood to your kitchen
and bathroom, it's important to work with a hardwood flooring professional to ensure that you select the best material and that the materials are properly installed. | <urn:uuid:c2449615-9c36-4236-957d-e91be2adcdd2> | CC-MAIN-2021-25 | https://www.globalallianceon.com/flooring/hardwood/faq/ | 2021-06-16T20:32:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-25/segments/1623487626008.14/warc/CC-MAIN-20210616190205-20210616220205-00243.warc.gz | en | 0.959226 | 219 |
OntoDoc describes a (prospective) ontological
Although based in Elixir, it attempts to be language neutral.
The organization of the Elixir documentation reflects the structure of the code base.
So, for example, all of the functions in the
module are lumped together.
There are two problems with this:
- Related functions from other modules (e.g.,
Stream) are not shown.
- Cross-module categories of functions (e.g., Filter, Inspect) are not indexed.
It should be possible to create some ontological
using a combination of crowd-sourcing and appropriate tooling.
This could let users (for example) skim a list of categories,
looking for potentially relevant functions.
The Elixir environment provides a wealth of data sources for automated documentation.
These include generated files from Elixir, Erlang, and Phoenix,
as well as hand-edited files (e.g.,
See Data Sources
I hope to have more examples over time (:-).
As a quick hack, I wrote a script to generate the wiki markup for the lists above.
This wiki page is maintained by Rich Morin
an independent consultant specializing in software design, development, and documentation.
Please feel free to email
comments, inquiries, suggestions, etc! | <urn:uuid:870fbec7-92a6-4ff3-9443-52811c9e7c78> | CC-MAIN-2019-47 | http://wiki.cfcl.com/Projects/Elixir/OD/WebHome | 2019-11-18T07:34:46Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-47/segments/1573496669454.33/warc/CC-MAIN-20191118053441-20191118081441-00247.warc.gz | en | 0.798923 | 268 |
This Saturday’s workshop is aimed at those of us who want to grow our own food at home but don’t know how or where to start. We’ll cover lots of tried and tested techniques for making edible gardening reasonable and achievable without breaking our backs or our bank balances. A delicious meal from our garden in ten minutes a day? Possibly. You don’t need to attend both parts, but if you did come to part 1, there’ll be plenty more to learn.
Ask questions, see examples of real solutions to common problems and get enthusiastic about a realistic and sustainable approach to edible gardening.
Please register early to reserve your space as spaces are strictly limited due to venue space constraints.
Other participants said:
Practical. Well worthwhile.
Reactive to attendees requirements.
If you’re not a gardener it would be very useful as a way to plan.
Came away with a definite plan.
It’s worth it!
In part 2 of the workshop we’ll cover:
Planning what and how much you want to grow
- Seasonal growing and eating
- Sowing seeds and sourcing seedlings
- Growing our own soil and recycling our waste
- Planning some practical next steps
We highly recommend beginner and intermediate gardeners attend both sessions and take away tips for growing a great edible garden, ideas for what to do in the next few weeks and a renewed enjoyment of the gardening experience. | <urn:uuid:5f2b3db4-9b03-4525-bddf-6909184f2849> | CC-MAIN-2021-17 | https://thekitchengarden.co.nz/home-food-production-workshop-part-2-this-saturday-10-12-noon/ | 2021-04-22T11:06:57Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-17/segments/1618039603582.93/warc/CC-MAIN-20210422100106-20210422130106-00033.warc.gz | en | 0.926022 | 304 |
Since Twitter has gone public, we’ve frequently heard about their growth problems; in particular, their trouble converting new users into active users. These problems aren’t difficult to believe. As a new user, what do you tweet about? With zero followers, why begin tweeting? And, who do you follow? Your timeline is useless until you follow enough of the right people.
I’ve been mulling over this problem for fun, and thought I’d play armchair quarterback for a blog post.
Back to basics: what is Twitter?
First, it is important to understand the core product that is Twitter. What is it? Some might call it a social network. Others might call it a micro-blogging platform. These might have been somewhat accurate in the early years, but at scale, I believe Twitter to be something else.
Twitter is the world’s democratized newswire.
Anyone can add to the newswire by tweeting. And anyone read the newswire by following users who tweet.
From newswire to newspaper.
There’s just one problem with being the world’s newswire: most people have little to no use for a newswire.
Most people don’t create news to add to a newswire. And, most people don’t keep up with real-time news. This presents a big problem for Twitter. The only way to grow is provide value to a mass audience, and in the history of news, the newswire has never been widely used by the masses.
The good news for Twitter is that the masses do want the news: they just want an easily accessible form of the news. They want a great newspaper. Or a great news report on the TV.
If Twitter understand this, the next steps are clear: Twitter needs to become the world’s best personal newspaper.
Twitter power-users might say that Twitter is already their personal newspaper. I would be inclined to agree. I check it everyday and use it as my personal newspaper. But if that was the goal of the current product, Twitter would be doing a poor job of it.
The New York Times, Twitter style.
As a fun thought exercise, lets imagine a Twitter-like New York Times experience:
- A friend raves about their version of the NYT. You go online to check it out, and can’t read it.
- You subscribe to an empty paper, and are prompted to follow your favorite reporters and columnists.
- You are given a reverse-chronological feed of stories, and need to figure out what is important for yourself.
Sound like a terrible newspaper experience?
A Twitter that could be.
Fortunately, these points lead directly to product suggestions:
- Let us see other newspapers. If I have a friend that loves Twitter, I want to know why. The easiest way to do that is to let me see what my friend sees.
- Let us subscribe to someone else’s newspaper. If I think my friend’s Twitter feed is interesting, I’d like to start with it. If I’m into startups, and find that @pmarca has an interesting newspaper, I’d like to merge it into my newspaper.
- Tell us what matters. If there are a few important stories, tweets, or tweet-storms from the past 24 hours, I want them to be easily accessible.
And this is just the beginning; the newspaper analogy can be taken further. As an example, The New York Times has various sections including International, Technology, Weather, Sports, etc. Perhaps my personal newspaper should have sections for my interests. These might be generalized Twitter lists, or something else.
Obviously, these are high level suggestions. Designing specific mechanisms for enabling these interactions isn’t trivial. For example, suggestion 2 might change how following works on Twitter, potentially breaking Twitter’s follow limits and increasing follow spam. Suggestion 3 would change Twitter’s relationship with some apps built on top of Twitter (which has always been a shaky relationship anyways).
Twitter for non-tweeters.
In a recent interview, Dick Costolo, the CEO of Twitter, acknowledges this, saying that it is OK for users not to tweet (excerpted below).
Farhad Manjoo: Do you ever meet people who don’t use it or don’t know why they would use it? What is your pitch to them?
Dick Costolo: I meet people who way, “Oh, I don’t tweet.” I think there’s still a misconception that the reason they’d sign up is to tweet. When I meet then, I tell them, “No, you don’t have to.”
Twitter seems like they are beginning to understand the importance of the news consumption experience, although they haven’t been good getting this across, and they haven’t been good about designing for it.
There is one startup seems to get it. Their product isn’t glitzy, fast, or beautiful, but it solves a need. Nuzzel takes your Twitter account, and generates a daily newspaper of frequently shared links from the people that you follow. This is great for Twitter users who are busy and can’t keep up with the barrage of tweets in their timeline every day.
If you check out their home page (above), you’ll also see that Nuzzel lets you see the links frequently shared within other people’s newsfeeds (just like suggestion 1 earlier).
If I were Twitter, I would think about acquiring Nuzzel. | <urn:uuid:0f502106-397b-4474-affd-be1ecde54abd> | CC-MAIN-2017-13 | https://alexshye.com/tag/twitter/ | 2017-03-24T07:57:13Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-13/segments/1490218187744.59/warc/CC-MAIN-20170322212947-00268-ip-10-233-31-227.ec2.internal.warc.gz | en | 0.951568 | 1,183 |
Agrium Advanced Technologies is focused on giving you SMARTER WAYS TO GROW ® healthy turf, plants and crops.
Agrium Advanced Technologies is a strategic business unit of Agrium Inc., a major retail supplier of agricultural products and services in both North and South America and a leading global producer and marketer of agricultural nutrients and industrial products.
Agrium Advanced Technologies distributes products for the professional turfgrass, horticulture, and consumer lawn and garden markets.
We deliver innovative, premium quality products with unsurpassed customer service.
Direct Solutions Distribution
Focused on leading the industry in distributing environmentally sound and high performance fertilizer, seed and plant protection products for professional turf managers and ornamental growers.
To achieve sustainability, we remain committed to governance, ethics, transparency, innovation, stakeholder engagement and continual improvement. We constantly look for ways to increase positive impacts on our stakeholders and the environment, while decreasing the negative. | <urn:uuid:c6799823-7a02-4453-bd3f-e9d93e046348> | CC-MAIN-2014-41 | http://www.agriumat.com/about_us.jsp | 2014-09-16T21:27:06Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-41/segments/1410657119965.46/warc/CC-MAIN-20140914011159-00052-ip-10-196-40-205.us-west-1.compute.internal.warc.gz | en | 0.884211 | 189 |
Episode 11 Season 2 Duck Face and Cover Impractical Jokers Season 2 - Ep. 11 Joe is running for office to draw attention to the hidden danger of the duck face photo. Replay Share 5 Up Next Investing Explained Impractical Jokers Season 2 - Ep. 11 Full Episodes Impractical Jokers Up Next Impractical Jokers Investing Explained Impractical Jokers Seeing Things Impractical Jokers Bad Sensei Impractical Jokers Joker Journalism Impractical Jokers Bad Directions Impractical Jokers Fairytale Kingdom Impractical Jokers Season 2 Episode 11 Thursday 10/9C Duck Face and Cover Joe is running for office to draw attention to the hidden danger of the duck face photo. Facebook Share on Twitter Watch Full Episodes Up Next Investing Explained To make a lot of money, under no circumstances follow this investment advice. More From Impractical Jokers Impractical Jokers Jampaloon Goofdookie As a public service, Joe and Sal attempt to expand the vocabularies of some grocery shoppers. Impractical Jokers DELETED SCENE: Sweaty Palms Joe describes the side effects of this woman's purchase. Impractical Jokers DELETED SCENE: The Running of the Bullhorns Everything you never wanted to hear through a megaphone. Impractical Jokers Roommate From Hell Imagine the worst roommate ever, these guys are worse. Impractical Jokers Grill Master Sal wants you to prepare for something amazing. Impractical Jokers Kiss Your Abs? A spin on the Wheel of Doom leaves Sal with a seemingly impossible task. Impractical Jokers Shake On It Some people can really shake it, and shake it, and shake it. Impractical Jokers Beach Towel Invaders The Jersey Shore, a perfect getaway to relax and share your beach towel with the <i>Impractical Jokers</i> Impractical Jokers Don't I Know You? NYC has millions of people and the <i>Impractical Jokers</i> are sure to know at least one! Impractical Jokers DELETED SCENE: You Don't Want That Murr doesn't want these girls to go through with their purchase because he says so! Show Clips Impractical Jokers Tasteless Taste Test Sal conducts a food survey with a series of uncomfortable questions. Impractical Jokers Watch My Kid Murr must convince a group of strangers to watch his son while he "makes it rain on dem ho's." Impractical Jokers Sal in Hi-Def Glory The guys admire an unflattering blown-up photo of Sal brought by an audience member. Impractical Jokers Challenges You'll Never See on TV The guys give an inside look at the many questionable Jokers challenges that didn't make it to air. Impractical Jokers Live Punishment After-Show The guys discuss what was going through their heads during their death-defying act. Impractical Jokers Live Punishment Pre-Show Look back at the funniest, most cringe-worthy moments from the show and sit down with a few familiar faces. Impractical Jokers Greeting Card Dares Q chats about his ugly children and gets low with a stranger at a greeting card store. Impractical Jokers Unreal Estate Q and Joe teach an introductory real estate course to a group of hopeful realtors. Impractical Jokers Deeply Disturbing Carriage Ride Q gets morbid during an uncomfortable horse-and-buggy ride. Impractical Jokers Wheel of Voo-Doom The guys hit Bourbon Street for a series of dares determined by a spin of the wheel. | <urn:uuid:0bc22ccf-f6c1-4726-a1d5-9d8353271bca> | CC-MAIN-2015-40 | http://www.trutv.com/shows/impractical-jokers/videos/duck-face-and-cover.html | 2015-10-06T22:32:32Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-40/segments/1443736679281.15/warc/CC-MAIN-20151001215759-00224-ip-10-137-6-227.ec2.internal.warc.gz | en | 0.881763 | 728 |
We propose to develop a novel and innovative system for studying very early stages of colon cancer development. This in vitro culture system involves promoting embryonic stem cell (ESC) differentiation into intestinal organoids through a definitive endoderm intermediate, and then initiating cell transformation through oncogene expression or tumor suppressor gene knockdown. This experimental system, which we have been developing with mouse and human ESCs, is anticipated to be robust and highly flexible and enable cancer biologists to address fundamental questions relating to very early events in colon carcinogenesis. Advantages of this system include an in vitro format compatible with the rapid analysis of nutrients, small molecules, siRNAs or other biologics. Furthermore, intestinal organoids can be generated from human ESCs, allowing the detailed study of intestinal cells from individuals with distinct colon cancer risks. In the proposed studies we will assess the utiliy of intestinal organoids for studying the effects of Braf oncogene activation. Our interest in Braf mutated cells stems from the fact that BRAF-mutated cancers frequently develop in the human proximal colon where they can be difficult to detect and remove, making effective chemoprevention of these cancers an important goal. Intestinal organoids will be prepared from mouse ESCs in which Braf oncogene become activated during intestinal lineage commitment (using Villin- Cre/LSL-BrafV600E mice) and are regulated by their native promoters. We will then evaluate how oncogene expression influences the organoids in relationship to endogenous intestinal tissues in vivo. This work will focus on oncogene effects on cellular turnover dynamics, intestinal stem cell expansion and cellular differentiation. Since Braf activation is associated wih epigenetic alterations, we will also determine the effect of oncogene activation on the expression of epigenetic modifying factors and the silencing of growth regulatory genes. We will also determine the ability of cell growth modulating chemopreventive agents to correct molecular and proliferation defects in oncogene-expressing intestinal organoids. Finally, we will develop high throughput assay systems to screen natural compound and pharmacological agent libraries for novel chemopreventive agents that selectively inhibit the growth of Braf-expressing intestinal cells. We anticipate indentifying novel chemopreventive agents (or agent combinations) for further development in subsequent proposals. Finally, establishing the organoid system for cancer research could facilitate the study many factors and variables that impact cancer promotion and prevention.
The KRAS and BRAF oncogenes can be activated early in colon carcinogenesis and stimulate a complex combination of pro-growth and anti-growth signaling pathways that ultimately determine whether the cells can progress to colon cancer or not. In this proposal we will derive intestinal cells from embryonic stem cells to establish a simple system to study the complex events that follow KRAS and BRAF oncogene activation. Our focus will be to determine the role of epigenetics in promoting the growth effects of the oncogenes with an eye towards understanding how the pro-growth signaling might be suppressed for colon cancer prevention.
|Chopra, Avijeet; Bond, Michael J; Bleiler, Marina et al. (2016) Efficient Activation of Apoptotic Signaling during Mitotic Arrest with AK301. PLoS One 11:e0153818|
|Giardina, Charles; Nakanishi, Masako; Khan, Awaad et al. (2015) Regulation of VDR Expression in Apc-Mutant Mice, Human Colon Cancers and Adenomas. Cancer Prev Res (Phila) 8:387-99|
|Cao, Li; Kuratnik, Anton; Xu, Wanli et al. (2015) Development of intestinal organoids as tissue surrogates: cell composition and the epigenetic control of differentiation. Mol Carcinog 54:189-202|
|Kuratnik, Anton; Giardina, Charles (2013) Intestinal organoids as tissue surrogates for toxicological and pharmacological studies. Biochem Pharmacol 85:1721-6| | <urn:uuid:3d2c96cc-a979-4381-a55d-cefa9d0ab2b4> | CC-MAIN-2017-43 | http://grantome.com/grant/NIH/R21-CA158743-02 | 2017-10-19T00:25:33Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-43/segments/1508187823168.74/warc/CC-MAIN-20171018233539-20171019013539-00778.warc.gz | en | 0.881679 | 829 |
With our vast lease planning and asset management experience in dealing with lessors and airlines over the past decades, the company has strategically expand it’s aviation products and services portfolios into leasing and asset management. Fusion Aero also provides comprehensive financing solutions designed to fit our customers requirements in managing their aviation assets.
Aircraft leasing companies and financial institutions involved in providing aircraft leasing and financing either have in-house technical experts to manage their aircraft assets or these activities can be outsourced to 3rd party experts. Thorough and regular oversight of aircraft technical inspections including documentations to ensure the assets are maintained and operated at or above industry standards to SECURE RESIDUAL VALUES of the assets.
Fusion Aero provides end-to-end aircraft lifecycle management to address key requirements of preserving the aircraft residual values. Among the key scope are as follows:
- Oversight of assets technical conditions and periodically review the maintenance planning and maintenance reserves to adjust for variations in the technical or financial performance of the lessee.
- Performance of regular aircraft inspections, aircraft maintenance records audit, airworthiness directives review by Licensed Aircraft Maintenance Engineers.
- Identification of any shortcomings in the compliance management of the asset’s lease or financing contract and provide advise to address those discrepancies.
- Provide expertise in aircraft maintenance reserve analysis ensuring that any reserve paid by the lessee are appropriately distributed in order to preserve the full residual value of the assets.
- Provide aircraft repossession team on standby to take actions in cases of defaults leading to insolvency. | <urn:uuid:6e64a681-160a-4d3b-a5ee-b8d7c1ae0104> | CC-MAIN-2023-23 | https://www.fusion-aero.com/a-homepage-section/leasing-asset-management/ | 2023-05-28T15:11:52Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-23/segments/1685224644309.7/warc/CC-MAIN-20230528150639-20230528180639-00053.warc.gz | en | 0.927467 | 307 |
WHERE WILL THEY STOP
Up, up and away - It’s time to take notice. Diesel fuel prices continue to rise and have now been above the three dollar mark for the second week in a row. This week the national average retail pump price for diesel jumped 3.2 cents to $3.042 per gallon. This is 48.6 cents higher per gallon compared to the same time period in 2017. It really matters where in the US you are operating your trucks, move your goods and buy your fuel. As would be expected the west coast (driven by California) leads the country with the highest diesel fuel costs $3.714 per gallon up 4.5 cents last week. The New England region was the least expensive at $3.117 per gallon up just 2/10ths of a cent.
Currently, there are more trucks on the road than ever before with approximately 850,000 vehicles using diesel to move goods across the country. We have seen oil prices trending higher for the last year as demand for fuel grows and as OPEC, Russia and other major producers moved to limit their output and reduce the global overabundance of crude. This is being further fueled by policy measures that the US has taken with the restoration of punitive sanctions against Iran. In addition, Venezuela, the world’s third largest oil producer struggles with their own economic and political challenges, reducing their output.
There are other potential concerns that could drive fuel prices north of four dollars. National Oceanic and Atmospheric Administration (NOAA) is forecasting that 2018 could see a near or above normal hurricane season. NOAA said there's a 70 percent chance of 10 to 16 named storms developing this hurricane season. They expect that that this could result in five to nine of the named storms potentially becoming significant hurricanes. The Gulf of Mexico is a major transport hub for fuel. This area of the country has the nation's biggest concentration of refineries.
Last year a devastating hurricane season knocked out about a quarter of U.S. refining capacity along the Gulf Coast causing a sudden spike in fuel prices. The impact of increased fuel prices on express shipment costs should also be noted. The following chart of FedEx Express shipments shows an increase of 1.25% in their published fuel charges in the past seven weeks. | <urn:uuid:47d8b7df-1eb9-4866-963f-f7a27c8dfd3b> | CC-MAIN-2019-30 | https://www.data2logistics.com/newsletters/where-will-they-stop | 2019-07-23T17:27:24Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-30/segments/1563195529481.73/warc/CC-MAIN-20190723172209-20190723194209-00113.warc.gz | en | 0.967153 | 462 |
I AM NOMAD
What do the Drury’s Heartland Bowhunter, and Red Arrow all have in common? They are Nomad.
We don’t stop where the trail ends.
We don’t do rain checks.
We don’t do sick days.
We don’t clock out at five.
And we never say good enough.
We are Nomad. We are authentic hunting. | <urn:uuid:7dc096f9-4f9d-469b-9c3f-cbbb61be55a2> | CC-MAIN-2023-06 | https://nomadoutdoor.com/pages/i-am-nomad | 2023-01-29T09:22:59Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764499710.49/warc/CC-MAIN-20230129080341-20230129110341-00620.warc.gz | en | 0.767302 | 94 |
Remove Duplicate Photos on Mac: 6 Best Methods
You might be asking how to delete duplicate photos on Mac because you are a photographer who probably has tons of duplicate photos cluttering the storage. Or a selfie lover with a surplus of pics that need tidying up.
Whatever the case, having more storage or the cloud won’t solve the clutter or duplicates problem. Moreover, syncing devices only reel in more duplicates. Therefore, in this article, we’ll show you how to erase duplicate photos on Mac both manually and automatically to free up storage space and boost system performance. Let’ dive in!
Part 1: How to Delete Duplicate Photos on Mac
To delete duplicate photos on Mac automatically, use a duplicate finder for Mac photos. Or, if you have some time on your hands and don’t mind sorting through duplicate images, you can either use the Finder or Photos app, depending on where the pics are stored.
1. Use Best Duplicate Photo Finder for Mac
The easiest and quickest way, of course, is to remove duplicate photos Mac with the help of the best duplicate photo finder Mac, like 4DDiG Duplicate File Deleter. It uses an advanced MD5 Message-Digest Algorithm to locate and remove duplicates and organize your files. Here’s what this tool can do:
- Locate duplicate photos, videos, audio, and documents successfully and accurately.
- Provides real-time duplicate reminders.
- Compatible with the latest macOS Sonoma.
- Preview and remove duplicates from Google Drive, network drives, and various internal/external storage devices like hard drives, USBs, and SD cards.
- Customize search options by including/excluding files.
Here’s how to remove duplicate photos on Mac with this tool:
Step 1: Scan for Duplicates
Download and install the tool on your Mac and launch it. Then,click the “+” button to select folders or disks containing duplicate photos for scanning.
Step 2: Customize Scan Settings
The tool will scan for duplicate images based on your settings. To do so, simply click on the “gear” button in the lower left corner.
Step 3: Preview and Remove Duplicate Photos
Once the scan is complete, it will display a list of duplicate files categorized by file type. Click “Auto Select” and then click “Remove” to get rid of duplicate photos on your Mac easily and quickly.
With this best duplicate photo finder for Mac, you will no longer need to worry about how to delete duplicate photos on Mac.
2. Delete Duplicate Photos Mac by Finder
If you don’t want to use third-party software to get rid of duplicate photos on your Mac, you can use Finder to tackle those. This program allows you check out details like file names, types, and creation dates in your folders. Just compare the images and pick out the duplicates by eyeballing them. Here’s how to delete duplicate photos on Mac with Finder:
Step 1: Open “Finder,” choose “File,” and then “New Smart Folder.”
Step 2: Select “This Mac” and click the “+” button.
Step 3: From the drop-down list, pick “Kind” and “Image.” To sort your pictures by name, select the “Name” column. Note that duplicates often have similar names, but you can sort by date or size.
Step 4: Select duplicate photos you want to delete and hit “Save.” Right-click on the selected pictures, and choose “Move to Trash.”
3. Remove Duplicate Photos Mac in Photos App
Honestly, the method above can be time-consuming and less efficient compared to using a specialized duplicate finder for Mac photos. Another manual way to delete duplicate photos on Mac is from the Photos app.
While this app doesn’t have a feature to reveal duplicates, you can use Smart Albums, just like Smart Folders, to find related pics. These Albums also let you filter and view photos based on specific criteria like file name, camera model, date taken, and more.
This method works great if most of your duplicate photos are shot at the same time or at least on the same day. Here’s how to erase duplicate photos on Mac by using the Photos app:
Step 1: Create a new “Smart Album.” To do that, open “File” and choose “New Smart Album.”
Step 2: Now, you can set filter criteria to easily delete duplicate photos on Mac.
Step 3: Review the photos in the Smart Album to identify potential duplicates.
Step 4: To remove duplicate photos, Mac, select the pics, right-click on them, and hit “Delete.”
4. Delete Duplicates With the “Merge” Feature
- In macOS Ventura and Sonoma, the Photos app also includes a “Merge” feature that can combine duplicate sets into a single photo. You can also merge multiple duplicate sets or all duplicates in your Photo Library. Here’s how to merge duplicate photos on Mac with the Photos app:
- Step 1: Open the Photos app and click “Duplicates” to open the album. Inside the Duplicates album, hold the “Command” key and click to select the duplicates you want to merge.
- Step 2: Click “Merge x Items” at the window’s top-right, where x represents the number of selected images.
- Step 3: Choose “Merge x Exact Copies.” The duplicated photos will move to the “Recently Deleted” album, where you can click “Delete All” to delete them completely.
- Once all duplicates are merged or deleted, the “Duplicates” album will vanish. So, that’s how to merge duplicate photos on Mac.
Part 2: Why Should We Use Duplicate Finder for Mac Photos?
In today’s digital age, managing our growing photo collections is crucial. Using a duplicate finder for Mac photos is a smart move to tackle digital clutter, keeping your photo library accessible and well-organized.
It’s versatile, works with various image formats, and saves you the time and hassle of hunting down duplicate pictures. Here are the advantages of employing a duplicate finder for Mac photos:
- Clearing out duplicate photos frees up valuable disk space, enhancing your Mac’s performance.
- A duplicate finder keeps your photo collection neat and efficient, making image management a breeze.
- Automated duplicate detection and removal save you the hours you’d otherwise spend searching manually.
- A duplicate-free photo library speeds up and makes your backups more space-efficient.
Part 3: Alternatives to the Best Duplicate Photo
Finder for Mac
Aside from the 4DDiG Duplicate File Deleter, undoubtedly the best duplicate photo finder Mac, we’ve got two more fantastic alternatives worth checking out. Here they are:
Option 1: Duplicate Photos Fixer Pro
Duplicate Photos Fixer Pro is a user-friendly choice among those searching for a simple duplicate photo finder. It provides an uncomplicated yet effective way to spot and remove duplicate photos Mac.
It boasts advanced scanning algorithms, compatibility with multiple platforms like Windows, Mac, iOS, and Android, and the handy option to preview duplicates before deletion.
The preview feature ensures you can review duplicates before deciding what to remove.
While the two Standard and Similar Match scan modes offer varying degrees of scanning to find duplicates. Some users have also noted occasional glitches in Duplicate Photos Fixer Pro, and there’s limited support for file formats. But it still delivers great value for its price.
Option 2: Duplicate Photo Cleaner
Duplicate Photo Cleaner is another alternative tool to delete duplicate photos on Mac, especially if you have an extensive collection. It utilizes advanced algorithms to detect duplicates, even if they have slight variations, and you can use it on both Windows and Mac.
The tool offers various scan modes, including Standard, Similar Match, and Exact Match, and support for various file types. Its customizable search criteria allow you to tailor the scan to their preferences.
What sets Duplicate Photo Cleaner apart is its reputation for uncovering the most subtle duplicate images. While it comes at a slightly higher price point, its precision and feature-rich offering make it a valuable investment.
By knowing how to delete duplicate photos on Mac, you can regain valuable storage space and enjoy a more organized digital life. With various manual and automatic methods available, you can choose the best approach that suits your needs.
But the best option to effectively declutter your photo library is the 4DDiG Duplicate File Deleter. It offers an automatic and convenient way to locate, preview, and remove duplicate photos from Mac or other storage devices.
How to Delete Duplicate Photos on Mac FAQs
Q1: Does Mac Have a Duplicate Photo Finder?
Yes, Mac does have a duplicate Photo Finder feature in the Photos app if your device is running on macOS Ventura or Sonoma. This feature, called Merge, automatically finds and groups any duplicate photos in your library so you can review them.
Q2: What is the Best Duplicate Photo Finder for Mac?
The best duplicate photo finder Mac is the 4DDiG Duplicate File Deleter Mac, which uses an advanced algorithm to locate duplicate photos, videos, and documents. Moreover, the tool also helps organize files, delete duplicates, and provide real-time reminders for duplicate files.
Q3: How do I Delete Duplicate Photos in Mac Finder?
To delete duplicate photos in Mac Finder, follow the steps below:
- In “Finder,” click “File” and choose “New Smart Folder.”
- Then, hit the “+” button by the search bar.
- Now, pick “Kind” from the first menu and “Image” from the second.
- Finally, sort the files by name. Since duplicate photos often share the same name, they’ll appear next to each other. Select them to delete. | <urn:uuid:6e3d01cb-30d8-4bfe-9385-1632a832e0d8> | CC-MAIN-2024-10 | https://www.ilounge.com/articles/how-to-delete-duplicate-photos-on-mac | 2024-02-21T22:32:33Z | s3://commoncrawl/crawl-data/CC-MAIN-2024-10/segments/1707947473558.16/warc/CC-MAIN-20240221202132-20240221232132-00832.warc.gz | en | 0.862158 | 2,191 |
Review: 2011-07-15, important victory for the undefeated Nikola Sjekloca (20-0-0) that defeated Khoren Gevor (31-6-0) by unanimous decision, but the fight was not very exciting: two stars. In this fight against Gevor, Sjekloca was defending for the second time his WBC International super middleweight title. Watch the video!
Where: EWS Arena, Goeppingen, Baden-Württemberg, Germany
Division: super middleweight
Title: WBC International super middleweight title
Result: Nikola Sjekloca def. Khoren Gevor (unanimous decision, 115-113, 116-112, 115-114) | <urn:uuid:40502ce1-b9dc-4d3c-b74e-943b6be5ae4e> | CC-MAIN-2019-22 | https://www.allthebestfights.com/gevor-vs-sjekloca-video-full-fight-pelea-2011/ | 2019-05-20T06:37:12Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-22/segments/1558232255773.51/warc/CC-MAIN-20190520061847-20190520083847-00349.warc.gz | en | 0.887787 | 159 |
The online casino industry is gaining popularity and profits with the innovative gambling software. The white label poker software holds maximum game genres and has the capability of attracting huge audience. The Poker white label has numerous set of games and few of them are trending in the online casino world as Pineapple Poker, Seven Stud Poker, Texas Poker and Omaha Poker.
If you are enthusiastic to commence business with Poker software, then it is ideal to get white label poker software than to opt for multiple development phases with various stages of technical aspects. We advise you to show your interest in white label poker software where you can get a readymade application developed by the organizations and you can spend your money and valuable time for marketing strategies. You can also get maximum audience out of the gambling spectators with the help of poker software. AIS Technolabs has tailored made plans for game entrepreneurs. We offer a complete white label poker software.
Our poker software is highly attractive and interactive. There is no better poker software solution in the market at any price. Our poker software is carefully crafted and designed to perfect your poker skills.
Features of White Label Poker Software offered by AIS Technolabs
Play for fun
We build fun poker software, that will attract plenty of players when you launch the game. The increasing usage of software will build an immense fan following for your game.
Instant and smart liquidity
This feature is also important as it affects the user experience of your website. Right from the moment when you launch your software, we use our liquidity asset that is social media platforms. The players can display their score on the leadership board and can play with their friends on social platforms.
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Rewards are the motivating factor for your players. We implement a seamless reward solution that can house all your customized rewards.
Why you should choose AIS Technolabs?
We have a renowned team to deliver multiple set of gaming solutions to our strong client base spread across the world. We provide them with ideas that could be incorporated into competitive poker game. It is a fact that our poker software is used by a large number of gaming companies for over the years. We can give you a demo player to see with your own eyes how our software performs in real life.
Our software has a complete set of features to put your game in the top league amongst your competitors. You can get your Android or iOS based apps which will help you to grab the attention of mobile device users. Our back office provides you the ability to monitor over 20 different statistical values.
We also integrate different payment options so that your players can process payments through VISA, Ukash, PayPal, Neteller, Bitcoin and others. We can also help you to manage your Poker site. Our additional services include consulting, reporting, daily management, marketing and anti-fraud services.
Poker is a highly amusing game for many players and it is a good idea to start and develop your own business. Our poker software is fully customizable, innovative, and creative. It offers a lot of tools to convert your ideas into reality. All you need to do is to customize the frontend as per the likes and preferences of your players and the rest we will handle.. | <urn:uuid:e2da835d-f992-4480-8d5e-7ab90b57def6> | CC-MAIN-2019-09 | https://www.aistechnolabs.com/white-label-poker-software/ | 2019-02-16T18:07:48Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-09/segments/1550247480905.29/warc/CC-MAIN-20190216170210-20190216192210-00028.warc.gz | en | 0.95591 | 734 |
Monday, August 22, 2011
Oikos Philos, Oikos Aristos
Zeus invited all the animals to his wedding. The tortoise alone was absent, and Zeus did not know why, so he asked the tortoise her reason for not having come to the feast. The tortoise said, 'Be it ever so humble, there's no place like home.' Zeus got angry at the tortoise and ordered her to carry her house with her wherever she went.A case could be made for translating φίλος here as "one's own" (Liddell & Scott, s.v., sense I.2.c), i.e. "one's own home is [the] best home." Note the medieval Latin version (Hans Walther, Proverbia Sententiaeque Latinitatis Medii Aevi #6259)Domus propria, domus optima.
The fable shows that people often prefer to live simply at home than to live lavishly at someone else's house.
Note: The Greek maxim pronounced by the tortoise can be translated literally as 'home is dear, home is best,' oikos philos, oikos aristos.
Ζεὺς γαμῶν πάντα τὰ ζῷα εἱστία. Μόνης δὲ χελώνης ὑστερησάσης, διαπορῶν τὴν αἰτίαν, τῇ ὑστεραίᾳ ἐπυνθάνετο αὐτῆς διὰ τά μόνη ἐπὶ τὸ δεῖπνον οὐκ ἦλθε. Τῆς δὲ εἰπούσης· Οἶκος φίλος, οἶκος ἄριστος, ἀγανακτήσας κατ' αὐτῆς παρεσκεύασεν αὐτὴν τὸν οἶκον αὐτὸν βαστάζουσαν περιφέρειν. Οὕτω πολλοὶ τῶν ἀνθρώπων αἱροῦνται μᾶλλον λιτῶς οἰκεῖν ἢ παρ' ἄλλοις πολυτελῶς διαιτᾶσθαι.
Eric Thomson sent me a photocopy of Renzo Tosi, Dicionário de Sentenças Latinas e Gregas, tr. Ivone Castilho Benedetti (São Paulo: Martins Fontes, 1996), pp. 487-488 (#1047 = Οἶκος φίλος, οἶκος ἄριστος), in which the Portuguese translation of the proverb is "Casa nossa, casa ótima."
On the other hand, another Latin version is Domus amica, domus optima, which is the translation adopted by Erasmus. See The Adages of Erasmus, selected by William Barker (Toronto: University of Toronto Press, 2001), pp. 268-270 (III iii 38, on Οἶκος φίλος οἶκος ἄριστος, tr. R.A.B. Mynors, footnotes omitted):
A loved home is always the best home. Nowhere can a lucky man live in more convenience, more freedom, and more comfort than at home. Some people with humorous distortion apply this to the tortoise, of which the following tale is told. Jupiter once invited animals of all kinds to attend his wedding, and all the others came, but not the tortoise. He was much surprised, and when she turned up (which was not until the feast was over), he asked her what the reason was for the delay. And she replied 'A loved home is the best home.' Jupiter was angry, and gave orders that wherever she went in future, she should carry her home about with her. Hence the tortoise is described in the second book of his On Divination, with deliberate and humorous obscurity, as 'Earth's tardigrade, home-carrying. bloodless creature.' (For we must, I take it, read terrae, earth's, for terrigenam, earth-born).One of the earliest references to this proverb seems to be by the poet Philoxenus (died 380 B.C.), as preserved in Suda 291 (Εἰς λατομίας, cited by Tosi, tr. Tony Natoli):
Besides which, the privacy of home has the support of the civil law. This Gaius in the Pandects, book 4, title De in jus vocando: 'It has been commonly held that no man may be summoned to court from his own home, because each man's home is his safest refuge and place of resort, and he therefore who should summon him to court from his home was thought to commit a violent assault.' Similarly Paulus in Book I, title De regulis juris. Cicero alludes to the fable in one of his letters, writing to Dolabella: 'This place is pretty, or at any rate remote, and if you have something to write, free from interruption. But somehow, "a loved home," you know.' This corresponds with one I have placed elsewhere: 'He for whom all goes well should stay at home,' for to him alone a loved home is the best home. Otherwise, to the man whose home contains a quarrelsome wife and nothing to eat, home is a prison. On the other hand, Plutarch has a word for this idle sort of man who is happy indoors and in the shade, and loves to be always sitting motionless at home. he calls them oikouroi, home-keepers. And in his essay 'On Tranquillity of Mind' he disapproves of this stay-at-home lack of activity. Again in his 'Advice to Bride and Groom' he records that Phidias made a stuatue of Venus for the people of Elis with her foot on a tortoise, as a tacit suggestion that wives should stay at home and hold their peace. Plutarch also tells of a custom in Egypt that newly wedded wives should not wear sandals, to prevent them of course from ever leaving the house. All the same, this ideal would have little chance of acceptance by our own countrywomen, as they flit busily round all the markets and all the wine-shops and everywhere on earth by land or sea.
This seems the place to add a remark recorded by Plutarch in his life of Titus Flaminius. When seeking to persuade the Achains that they should not lay claim to the island of Zacynthos, 'They would' he said 'run risks like tortoises, if they struck their heads out beyond the Peloponnese.' Livy has simething very like this in book six of his Macedonian War, where Quinctius speaks as follows: 'If I thought that the possession of that island was of any value to the Achaeans, I would recommend the Roman government to let you have it. But I have my eye on the tortoise: gathered into its shell, it is safe from all attacks, but when it puts out any part of itself, whatever it exposes is at risk and defenceless. It is much the same with you Achaeans: you are enclosed on all sides by the bounds of the sea, and what lies within the Peloponnese, you can add to your own, and easily defend what you have added; but if you exceed those limits in your greed for further acquisitions, all your overseas possessions are naked and exposed to all attacks.'
To the quarries: Philoxenos the dithyrambic poet could not stand the poetry of the tyrant Dionysius because it was so bad. On one occasion Dionysius sent him to the quarries, but later decided to have him brought back up. However, upon enquiring the reason [sc. for the tyrant's change of heart] Philoxenus replied, 'How much better it is to stay there than to suffer his [i.e. Dionysius'] poetry'; and he added, 'Truly, home is dear, home is best', just as it is for the tortoise.
Εἰς λατομίας: Φιλόξενος ὁ διθυραμβοποιὸς οὐκ ἀνεχόμενος τῶν Διονυσίου τοῦ τυράννου ποιημάτων ὡς φαύλων, ποτὲ πέμψαντος αὐτὸν εἰς λατομίας τοῦ Διονυσίου, τὸ δὲ ὕστερον αὐτὸς ἑκὼν ἐξανέστη, τοῦ δὲ ἐπερωτωμένου τὴν αἰτίαν, τοῦτο εἰπεῖν, ὡς κρεῖττον εἶναι ἐκεῖ διατρίβειν ἢ τῶν αὐτοῦ ποιημάτων ἀνέχεσθαι, τοῦτο ἐπειπόντα: ἦ οἶκος φίλος, οἶκος ἄριστος: ἅπερ ἐστὶ τῆς χελώνης. | <urn:uuid:4d33bc0f-a5a3-4e50-86dd-ce111886d211> | CC-MAIN-2016-30 | http://laudatortemporisacti.blogspot.com/2011/08/oikos-philos-oikos-aristos.html | 2016-07-23T19:11:51Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-30/segments/1469257823387.9/warc/CC-MAIN-20160723071023-00076-ip-10-185-27-174.ec2.internal.warc.gz | en | 0.94347 | 2,473 |
You may remember me complaining (Who me? Complaining? Never!) about my sincere hatred of maternity clothes because I can’t find anything comfortable or nice to wear. Well, it gets worse. Of course it does. Not only do clothes look awful on me, but hey my undergarments are less than flattering and well, let’s be honest, they’re down right painful. For me, the worst part is that god awful restricting bra. I swear, if I didn’t have to wear one, I wouldn’t. Investing in a decent and comfortable is the only way to go. Take a peek, ladies, at Hotmilk’s massive collection of stylish and oh yes, uber comfortable maternity and nursing bras. Did I mention I have one to giveaway!
I’ve always been skeptical of maternity and nursing bras thinking they were simply the same thing but overpriced. I suffered my first pregnancy with an abundance of ill fitting and uncomfortable bras resulting in even worse back ache. Bras that used to fit, cut into me, digging into my sides, grated on my skin and pulled on my back making my rib cage feel crushed and compacted. Isn’t pregnancy so glamorous?
You may not realise it, at least I didn’t realise it until near enough the end of my first pregnancy, but your body changes in more ways than just getting bigger and rounder during pregnancy. For your torso it’s not simply a case of fulfilling your other halves’ dreams with larger bosoms (Wahey!) Your body consistently changes, grows and moves – yes, muscles and organs move – throughout the nine months causing discomfort and pain. Let’s take a peek at your bust:
- Your breasts will feel swollen, sore, tingly and sensitive.
- You may go up a cup size or two. This can cause itchy breasts as the skin stretches.
- With the added weight of your breasts and belly, your centre of gravity and posture changes. These adjustments can lead to weakened muscles in your back.
- With hyperextension of your upper back you can suffer rib pain and difficulty breathing.
For these reasons, a proper and supportive bra will help see you through the whole nine months. Oh how little did I know just how much these maternity and nursing bras help! I noticed these changes almost straight away this time round, back in early October, when I was just five weeks gone. I knew what to look out for but, to be fair, I didn’t need to keep my eyes open. My cheap, old, uncomfortable bra taunted me, made jibes at me as it poked me and prodded me. My back was forever sore as a thin back band offered zero support. Poor straps and an underwire that dug into all the wrong places meant the accursed bra was whipped off the second I could get away without wearing one.
As you can imagine, I bought new bras. Regular bras, which would be perfectly acceptable If I was not a hormonal beacon for inconsiderate and quick body changes. I was chuffed when Hotmilk Lingerie got in contact and asked if I’d like to review one of their maternity or nursing bras. Well hello, my back screamed at me, you better say yes! Of course, I said yes.
I will, first off, admit to spending way too long browsing through the Hotmilk web store trying to determine if a maternity or nursing bra was best suited to my sprawling back and temporarily updated cleavage! The maternity bras I have come across in stores haven’t been the most flattering. Functional but not appealing to my feminine charm! Hotmilk Lingerie (what an awesome name by the way), however, have an abundance of bras suitable for every woman during any stage of her pre pregnant, pregnant and post pregnant life. With various styles, colours, and designs that ooze character and appeal high in the fashion stakes. I was pretty much in my element browsing through row after row of beautiful lingerie to make any hormonal, exhausted and worn out pregnant woman feel sexy!
In the end I chose a Nursing Bra in Fuscia with Leopard Print Straps called Forever Yours Wild. This t-shirt style, foam contoured bra is practical, functional, comfortable and also cute and sexy.
Comfort is of the highest priority for nursing and maternity bras, in my opinion, and to say this bra is comfortable, I’m afraid, is putting it way too mild. I’d rather say it is more like having the gods themselves protecting your bosoms and your back with a soft plume of feathers and gravity defying air! The moment I wore this bra, I felt the difference. There was no pulling, no tugging, no tightening, no squeezing and no chaffing. Says it all really.
So what makes this bra so great?
- The large and deep back strap supports your back and muscles.
- With six rows of hook and eye extensions on the strap, you can easily adjust the bra to your comfort as you grow throughout your pregnancy.
- All seams in the bra are away from the nipples avoiding any chaffing and scratching from fabric to tender and sensitive nipples.
- With wide side seams and a foam molding, this bra is comfortable and supportive of your growing chest.
- The straps are cotton lined and are convertible to a cross over back strap.
- The lining is cotton and breathable.
- There are easy one handed drop down cups for breastfeeding.
The last thing I have to say about this bra is, I love it and I know I’ll get a lot of wear out of it throughout my pregnancy and afterwards when I’m in full nursing mode.
So, Who Wants One?
Hotmilk Lingerie are kindly giving away the Forever Yours Wild Nursing Bra to one of my readers!
Entries close midnight (GMT), 1st February. One lucky winner will be contacted directly by Hotmilk Lingerie to arrange delivery of your prize.
Giveaway Closed! The Winner is Laura S. Congratulations 🙂
*This is a collaborative post. All opinions are honest and whole heartedly mine* | <urn:uuid:0f8be496-09fb-4ad7-a902-affbd6fe3638> | CC-MAIN-2019-13 | http://www.overheavenshill.com/giveaway/hotmilk-bra-review/ | 2019-03-25T14:16:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-13/segments/1552912203991.44/warc/CC-MAIN-20190325133117-20190325155117-00213.warc.gz | en | 0.944059 | 1,298 |
CALRL2 involved in several pathways and played different roles in them. We selected most pathways CALRL2 participated on our site, such as Protein processing in endoplasmic reticulum, Phagosome, which may be useful for your reference. Also, other proteins which involved in the same pathway with CALRL2 were listed below. Creative Biomart supplied nearly all the proteins listed, you can search them on our site.
CALRL2 has several biochemical functions, for example, calcium ion binding, unfolded protein binding. Some of the functions are cooperated with other proteins, some of the functions could acted by CALRL2 itself. We selected most functions CALRL2 had, and list some proteins which have the same functions with CALRL2. You can find most of the proteins on our site.
Function calcium ion binding
Related Protein CAPSLA; CDH17; MAN1B1; EHD4; FAT4; PCDH2G12; S100A7A; MYL13; NELL2; SYTL3
Function unfolded protein binding
Related Protein ERLEC1; DNAJA3; GRXCR2; CCT4; HSP104; AIP; CCT6A; HSPA5; HSPA1B; DNAJA3B | <urn:uuid:3e37ef5c-148f-450e-bb79-d2d9d4040816> | CC-MAIN-2018-22 | https://www.creativebiomart.net/symbolsearch_CALRL2.htm | 2018-05-28T05:31:48Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-22/segments/1526794871918.99/warc/CC-MAIN-20180528044215-20180528064215-00356.warc.gz | en | 0.944655 | 269 |
Acta Natura et Scientia , vol.0, no.0, 2021 (Peer-Reviewed Journal)
Aquarium fishing is an important sector in aquaculture, which is carried out for economic and hobby purposes. Diseases are one of the most important economic losses in this sector. Parasitic infestations have an important place in aquarium fish. Planarians are flatworms that can live in both freshwater and marine waters, appearing in many shapes and forms.
In this study, fish mortality and treatment due to planaria infestation in Electric blue Jack Dempsey (Rocio octofasciatum) and parrot cichlid aquariums were investigated. In a freshwater aquarium with a 400 liter capacity, consisting of 13 fish with an average length of 12 cm and a weight of 50 g, the infestation of planaria was formed as a result of overfeeding and equipment contamination, with a mortality rate of 60%. For the treatment of morphologically identified planaria species, it was observed that the virulence was reduced and the development of the parasite stopped with the use of 3ml/100L FMC (Formalin-Methylene-Malachite) suspension.
As a result of the study, it was seen that the water temperature was increased to 31 oC after removing the infested fish from the aquarium in planaria infestation and disinfection of contaminated tools and equipment after FMC application could get rid of the infestation. | <urn:uuid:1ab7bf2b-b021-407b-b8b3-e35de12097c9> | CC-MAIN-2023-06 | https://avesis.yyu.edu.tr/yayin/ec674233-aede-4802-9563-fdf48b00296d/mortality-and-treatment-of-electric-blue-jack-dempsey-rocio-octofasciatum-and-blood-red-parrot-cichlid-fish-in-planarian-infestation | 2023-01-29T15:10:02Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764499744.74/warc/CC-MAIN-20230129144110-20230129174110-00588.warc.gz | en | 0.951358 | 300 |
Fuel Your Body. Fuel Your Goals.
It’s time for a better relationship with food. Get the personal attention and support you need to live your healthiest life, and discover the joy of eating well.
Behind every great initiative , is a true & authentic story. And we certainly have a tale to tell. Who are we? Why did we start our Events & Coaching for Healthy Nutrition & Lifestyle? What makes us one of the best at what we do, today?
Nutrition Coaching for a Healthy Body & Mind
Your body is unique—and your nutrition should be too. Let’s create an individualized and realistic program to help you reach your goals.
During your initial consultation, we’ll do a complete evaluation of your health. Our goal is to truly understand your needs so that we can create a plan together.
A little bit of preparation goes a long way. Our planning services can help take the stress out of shopping and cooking and make you healthier, one meal at a time. | <urn:uuid:fdd625fc-b1b9-408a-8f34-9e31360f0b4a> | CC-MAIN-2019-35 | https://www.vitaaleasy.nl/ | 2019-08-21T22:05:40Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027316549.78/warc/CC-MAIN-20190821220456-20190822002456-00503.warc.gz | en | 0.927002 | 212 |
One of the more appealing things about Enslaved
was the beautiful environment, unique characters brought to life by dedicated voice actors and the evolving storyline. I wasn’t a particular fan of the gameplay, given how expensive upgrades were and how ridiculously monotonous it became to only face off against mechs. Pigsy’s Perfect 10, the add-on content that was released on November 16th, is - for the most part - the opposite of the game it extends.
The storyline of Pigsy’s Perfect 10 is more like a parable than the lengthier storyline told by Enslaved. Pigsy is bored and intent on finding a friend, even if that means he has to create it. In order to build this mech-friend, players must guide Pigsy through the ruined cities to seek out the necessary pieces. Most of the rest of the game becomes an expedition to find these pieces.
This was unfortunate, because a downloadable content focused primarily on Pigsy would have been the perfect opportunity to divulge more about the character and potentially explore his back-story. Perhaps Pigsy was on his own adventures, battling the mechs and attempting to establish his “paradise” while Trip and Monkey were on a path that would eventually lead them to him. Instead, Pigsy’s Perfect 10 seems more like a comic relief to the entirety of Enslaved rather than an extension of that story.
While the storyline is thematically different from the game itself, the DLC’s gameplay is also a departure from that of Enslaved’s. Pigsy plays quite differently than Monkey. Monkey - an incredibly strong and limber character - is built for melee attacks. Pigsy, on the other hand, is slow and feeble. He depends on his gun, which can double as a sniper, for defense. Because of Pigsy’s inadequacies, he relies on grappling to maneuver around the ruins. Pigsy’s Trouble Vision allows him to see points of interest such as grappling points and hidden collectibles. As you can imagine, his primary strategy for tackling mechs is also affected by these factors. Not being able to survive a one-on-one with any of these enemies, Pigsy must find high ground to shoot from, or make use of one of four of his devices that are slowly unlocked in the chapters of the DLC.
The devices are all incredibly useful and suited to the levels. You begin with a familiar device: a decoy. A holographic Pigsy will dance for the enemies while you roll your plump protagonist to the next area of cover. Eventually Pigsy will gain access to an EMP blast, a remote-controlled bomb and a temporary enemy-to-ally converter. Different moments call for different strategies and devices. This bodes well for an interesting twist in the gameplay that players have gotten accustomed to in Enslaved.
The goal in the game is to attain several objects necessary to complete Pigsy’s creation. However, Pigsy’s Perfect 10 is the sort of game that stretches this goal thin and far beyond its capacity to entertain. Ninja Theory went the route of introducing the same goal consistently by always keeping it just outside of your reach. Each time you think you are about to achieve your goal, some new obstacle arises and a cut scene takes control and your goal off with it. It’s incredibly aggravating to feel like any progress you make is actually no progress at all. It also indicates a great lack of creativity to making a new circumstance to lengthen the game as opposed to recycling the same one. Although enemy formations still vary and are therefore challenging, the storyline proves to be no form of motivator to continue to fight them.
Yet another grievance I had with the downloadable content was the controls. Pigsy’s roll into cover is not always accurate, and he is slow to go in and out of crouching. Because the character feels so sluggish, fighting the quick mech enemies feels even more so frustrating and unbalanced. Camera angles are no help, either. Although I found a similar problem in Enslaved, the DLC continues to demonstrate unhelpful camera angles to an even worse degree. Some camera angle decisions are laughable. For instance, a boss battle will even force the player to direct Pigsy to safety from the first-person perspective of the boss. Oftentimes zooming in to shoot will result in staring into the depths of the object behind Pigsy. Beyond being annoying, it is also hindering when Pigsy needs to react quickly to dangerous situations.
Towards the end of the DLC, enemies become more aggressive and attempt to run after you instead of lurking around waiting to catch you in their sights. One hit is really all the enemy needs to kill Pigsy. Pigsy can defeat them with quick thinking and some strategizing, but it is certainly a challenge. This is finally where the gameplay picks up pace and becomes more than just a sneak game. It proves that sheer force isn’t just what is needed to defeat your enemies.
Pigsy’s Perfect 10 is definitely not a perfect ten as far as downloadable content goes. The storyline’s intention for motivation quickly becomes trite, and Pigsy is not the most favorable protagonist. The gameplay, however, is surprisingly unique compared to Enslaved’s. Pigsy depends on a sneak approach to his attacks, and this will demand that players make intelligent use of the four devices as his disposal.
Rating: 7.9 Above Average | <urn:uuid:04b68a1c-2d1b-4550-a88d-df95223bc872> | CC-MAIN-2015-11 | http://www.gamingnexus.com/Article/Enslaved---Pigsys-Perfect-10/Item2933.aspx | 2015-03-01T20:54:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-11/segments/1424936462555.21/warc/CC-MAIN-20150226074102-00239-ip-10-28-5-156.ec2.internal.warc.gz | en | 0.971581 | 1,137 |
Found this today. How to do a triangle setup from mount. Well worth a look.
For more information on how what a triangle is, see here:
A triangle choke, or sankaku-jime (三角絞) in judo, is a type of figure-four chokehold that encircles the opponent's neck and one arm with the legs in a configuration similar to the shape of a triangle. Applying pressure using both legs and the opponent's own shoulder, the technique is a type of lateral vascular restraint that constricts the blood flow from the carotid arteries to the brain, potentially resulting in loss of consciousness in seconds when applied correctly. Recent studies have shown that the triangle choke takes an average of 9.5 seconds to render an opponent unconscious from the moment it is properly applied. | <urn:uuid:c54f2c7c-c2cf-44de-96dd-c47affb74d04> | CC-MAIN-2023-06 | https://www.thismmalife.com/hannahwoking1/how-to-do-a-triangle-set-up-from-mount-2nkl | 2023-02-07T02:29:10Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764500368.7/warc/CC-MAIN-20230207004322-20230207034322-00568.warc.gz | en | 0.895117 | 174 |
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Meet The Writers
Taunting Us Over LeBron
Taunting Us Over LeBron
It seems like the ink is still wet on the contract extension LeBron James signed with the Cavaliers, one that keeps him in Cleveland until at least the summer of 2010. But that hasn't stopped the national media from counting the ways that LeBron could wriggle his way out of Cleveland, even before his contract with the team expires. In his latest, Erik Cassano looks at the latest of these stories, and also examines Danny Ferry's work as Cavaliers GM.
is one of the best NBA blogs out there, tested and approved by the Akron Beacon Journal's Brian
says it's a good source for NBA news, it's a good source for NBA news. That's how much I trust him with my basketball knowledge.
But, damned if
still isn't affiliated with ESPN, and thus, still among the national media legion
counting the ways
James could leave Cleveland.
Apparently, we in Cleveland shouldn't dread only the approach of the summer of 2010, when
can opt out of his deal and become an unrestricted free agent. We should also fear the summer of 2009, when
could express his displeasure with the state of the
roster by telling Danny Ferry that he's not signing a new deal here come hell or high water, thereby forcing Ferry to trade him.
No rest for the weary. As long as
stays in Cleveland, we will constantly be subjected to this relentless onslaught,
many escape hatches from the
paraded in front of us for the pleasure of East Coast basketball fans who know, in their heart of hearts, that it would be best for the league if
would ditch our little, nondescript Midwestern burg for the
, Nets or Celtics.
East Coast basketball fans and scribes just want what's best for the NBA, after all. I got choked up as I wrote that. On vomit, not tears.
It's easy to count the ways
could leave Cleveland when it's Sanitized For Your Protection.
just takes off the
uniform and puts on a
uniform. Simple, right?
, and Cleveland ... well, who cares?
But this is what irritates me:
can talk about
demanding a trade from the
like it's moving a chess piece on a giant table. But do you realize how cutthroat a move like that would be? Do you realize the set of brass ones it would take to go up to your boss and say "I think you've done a terrible job building a team around me, trade me now because I'm leaving."
Bridge nuked? Check. Now
gets to head to his new team with a Jeff
reputation as an "independent contractor" who will simply demand a trade when he doesn't like a situation.
fancies himself a slick businessman. He'd have to know that treating the organization that drafted him with such coldness would be a bad move. The East Coast media might think Cleveland is an insect to be squashed in the world of sports, a doormat that can be trampled with no fear of retribution. But
would have to be a better businessman than to callously demand a trade without seriously considering all options and discussing it with many different people.
These are the residual scenarios that are seldom considered when spinning the "Where Will
Most scribes who pen columns insinuating that
loyalty to the Cavaliers is hanging by a perpetual thread seem to come to the same conclusion: Danny Ferry is a dolt who has butchered the construction of the roster around
. It's a sentiment shared by many
fans who claim to know what's going on with the team.
(Keep in mind there are many
fans who think Ferry is the one who let Carlos Boozer out of his contract. Hopefully those fans will arrive in 2008 any day now.)
I tend to defend Ferry in these matters, and I take a lot of heat for it. Why do I defend a GM who is viewed as so uniformly indefensible? I could go the route of blaming all the draft picks wasted by his predecessor, Jim
trade that robbed the
of two first-round picks in three years and the Boozer fiasco
But the missed draft picks were a big reason why the
were bad enough to get
in the first place, so it kind of becomes a Catch-22.
My reasoning for defending Ferry on roster matters is this: what more do you want from the guy? In two years, he infused the team with enough talent to allow Mike Brown to implement a defense that allowed
to use his vast talents to beat a superior Pistons team and earn the franchise's first NBA Finals berth.
in 2003, they were among the worst organizations in pro sports. They had Boozer,
, and literally nothing else worth building around -- even though Ricky Davis had a pretty high opinion of himself at that point.
Two years later, the
were starting Ira
at the two-guard and completely fell apart down the stretch, narrowly missing the playoffs with Brendan Malone, an interim head coach, at the helm because Paul Silas decided that spiting Jeff
was more important than winning a game in which
scored 56 points, and was subsequently fired.
At the same time, Gordon
was selling his majority stake in the team to Dan Gilbert, signifying an organizational paradigm shift from old-school to new-school.
Enter Ferry and Mike Brown shortly thereafter. Starting together from essentially scratch, with
their only real asset, the tandem that everyone loves to hate has won 120 regular season games through Tuesday and four playoff series in about two and a half seasons.
Yet everyone expects Ferry to poof a roster rivaling that of the Spurs and Mavericks onto the floor, or his name is mud and we can't blame
for wanting to leave.
Ferry hasn't batted 1.000 with his moves. Far from it. But no GM does. Given the compost heap Ferry inherited, with no huge expiring deals save for
, one free agent class of note and one draft in three
, I don't know if the greatest
in the game could have done much better with the
Ferry hasn't had a lot to work with in his three years running the
roster. He's going to make mistakes, like any GM. But to go from no playoffs to the top of the conference while still enduring
veterans and fallout from the Jim
era, that's as close to a magical transformation as you'll find in the NBA.
No one here is looking to heap undue praise on Ferry, who still has a lot of work to do. But with tens of millions of dollars in expiring deals over the next two
, Ferry has a chance to do the work. It would be nice if he'd get credit for what he has already done.
For crying out loud,
probably has more confidence in Ferry than anyone in the stands or on press row. And he's the one who is supposed to be storming into Ferry's office and telling him to shove it, remember?
Jan 16, 2008 7:00 PM
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This week I am waiting on….Two Books!
Nothing could possibly get worse. Everything and everyone that could be in jeopardy already is, and Jared knows that he is The Society’s only hope. If he doesn’t find a way to escape he fails everyone including Vera, the bear shifter he can’t seem to get out of his head.
Casey and Toby are in love. Head over heels in love, but is their love strong enough to survive a magic so powerful that Casey’s mind is no longer in her control?
Vera will do anything to help her sister, and unfortunately that means she is well acquainted with Jared, the most frustrating man she has ever met. Now she has to find a way to fight her annoyance and growing attraction long enough to help save Levi and Allie.
Racing against the clock, all four must face their greatest fears to save The Society and all the people they love.
Why am I waiting on it?
Come on guys, is ARI!!! Of course, I am waiting on it. Enough said.
Falling never felt so good . . . Seven best-selling stories of love, heartbreak, and redemption.
Grab your copy of this limited-time anthology featuring a New York Times and USA Today bestseller, along with some of the hottest debuts of 2014 for ONLY 99 cents!
(These full-length novels are either stand-alones, or the first in a series.)
Spin My Love by Chantal Fernando, NYT & USA Today Bestselling Author
World renowned DJ Tane Miller returns to his hometown after leaving when he was eighteen and never looking back. When he runs into his beloved childhood friend Giselle, his life takes a turn he could never have anticipated.
Dearest Clementine by Lex Martin
Clementine Avery doesn’t date. Not after her ex cheated and a professor stalked her. But when she accidentally signs up for a romance writing class, she has a hard time resisting hot RA Gavin Murphy, who volunteers to help her find a little “inspiration.”
Deep Blue by Jules Barnard
Recent college grad Cali Morgan thinks she has her life all figured out, until she returns to Lake Tahoe and runs into an old crush she barely recognizes. A serious accident pushes Jaeger’s life in a new direction, but he’s hotter than ever, his presence rocking the foundation Cali staked her future on.
Dazzled by Jane Harvey-Berrick
Young London actor Miles Stephens gets a chance to star in a big-time Hollywood movie, but when the dream of a lifetime doesn’t match reality he turns to Clare, lifelong friend and girl next door. Clare knows two important facts: when you break chocolate, the calories fall out; and that she’s totally in love with clueless Miles.
He Found Me by Whitney Barbetti
Andra disappeared from an abusive environment when she was seventeen, choosing to build a new life, full of secrets. But when she met Julian, everything changed. And the moment she let her guard down, a threat from her past caught up to her.
The Right Kind of Wrong by Jade Eby
Kara Pierce and Vince Gage have a tumultuous past. As in – he almost ruined Kara’s life. When they’re forced to work together on a final college project, Kara must learn how to do the hardest thing she’s ever done: forgive.
The Year We Fell Down by Sarina Bowen
Corey Callahan thought she’d start college playing varsity ice hockey. But she’ll start it in a wheelchair instead. The only perk? Her too-delicious-to-be-real neighbor, Adam Hartley. They’re just friends, until one crazy night when things fall apart. Or fall together. All Corey knows is that she’s falling. Hard.
Why am I waiting on it?
Look at all those awesome new adult authors! And there are 7 full length novels in that thing! I got this book as part of a cover reveal and I normally don’t post those but this one totally got me excited so I decided to share it as my waiting on wednesday pick! I can’t wait for it. And because it was part of a planned cover reveal there is a giveaway for you guys to enter!
Fill out the rafflecopter to enter
Note: this giveaway is not sponsored by book briefs. All of the prizes, terms and conditions should be contained in the rafflecopter below. Void Where Prohibited
What are you waiting on?
Let me know in the comments below 🙂
Have you entered these awesome giveaways?
Click on the banners to enter | <urn:uuid:2e3eea41-e226-47a0-9ba2-3a5b390ecf6d> | CC-MAIN-2023-50 | https://bookbriefs.net/2014/09/24/wow-double-feature-stay-falling/ | 2023-12-01T02:48:23Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-50/segments/1700679100264.9/warc/CC-MAIN-20231201021234-20231201051234-00006.warc.gz | en | 0.943255 | 995 |
I am a new graduated interaction designer and have just started my professional career in a consultant company. I have a background in industrial design, so don't have any concrete knowledge about different programming languages. Just I know a little about html and css. Now I need your advice about what should I focus on? a new language like C or continuing with html and css? and what more I should add to this list!
I am a psych student preparing to apply to HCI masters programs. I currently have very little programming background and would like to take some courses before I apply. I was hoping you might have some advice as to which language will be the most beneficial for me to concentrate on. Programming, C#, C++, java, Visual Basic | <urn:uuid:3386f331-0ec3-4f11-bb08-d54b6d3e4865> | CC-MAIN-2014-41 | http://www.ixda.org/category/tags/programming | 2014-09-22T08:00:03Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-41/segments/1410657136896.39/warc/CC-MAIN-20140914011216-00327-ip-10-234-18-248.ec2.internal.warc.gz | en | 0.97196 | 153 |
Despite its not-so-impressive financial results, AMD apparently managed to snag some market share away from Intel last quarter. Mercury Research numbers quoted by PC World say AMD's slice of x86 processor shipments grew to 19.1% last quarter, up from 18.2% in the first quarter of 2012. Intel's share declined from 81% to 80.2% over the same time period.
More encouraging for the underdog, the data shows AMD's share of desktop x86 CPU shipments held steady at a cool 43%. PC World doesn't quote Mercury Research's mobile data, but it says customers "also opted for lower-priced laptops, many of which had AMD's chips."
The report makes another thing clear: AMD's market share growth was due more improved execution than to Intel slipping up. "Intel didn't have specific weak spots," PC World explains, while AMD "recovered from a myriad of issues."
Considering the iffy competitive positioning of its A-series APUs and FX-series CPUs—and the fact that Intel is still largely unmatched dollar-for-dollar above $200—I'm surprised AMD still holds such a huge chunk of the desktop market. I suppose most of the volume lies at lower price points, though, and the A-series product line does have a leg up over the competition on the graphics side of things. In any case, it's nice to see Intel isn't completely crushing its rival; healthy competition is a good thing.
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Peter Piper Picked a Peck of: Pickled Cherries
Posted By Susan On June 24, 2012 @ 4:49 pm In Appetizers, Dips and Small Bites,Fruits,Quick and Easy,Recipes | 7 Comments
For most kids, June signifies the end of the school year and the beginning of summer vacation. For me, it meant the end of school and the beginning of cherry season. I adored fresh cherries! I still do – especially the Bings. Their season is short – only about six weeks – beginning in early June. Every year at this time, I practically pant with anticipation as I wait for those sweet, succulent and sumptuous little jewels of nature to make their appearance in our local markets. Once they arrive, there’s no stopping me. I bake them into muffins, churn them into ice creams and stew them into compotes. That is, if I can keep myself from gobbling them all up right out of the bag!
There are those who may disagree, but some of the most prized cherries in the world come from the Pacific Northwest, particularly Washington and Oregon. I’ve been lucky enough to spend time in both places during cherry season and am here to tell you that it’s true. There really is nothing like Pacific Northwest cherries.
You may recall that last summer, I had the good fortune of being a guest of the Oregon Board of Tourism at Full On Oregon , a food and wine event celebrating the bounty of the region. It was a foodie’s paradise! One of the highlights of the trip was a tasting luncheon featuring the best and brightest of Portland’s up and coming chefs. It was there that I fell in love with Chef Christopher Israel’s Spicy Pickled Cherries from Grüner Restaurant . In fact, I loved them so much that I begged for the recipe. And because I love you so much, dear readers, I want to share it with you.
These pickled cherries are delightfully deceptive – and wickedly addictive. At first glance, they look like regular Bing cherries, which are pretty fabulous on their own. But, pop one in your mouth and you’ll experience a harmonious mingling of sweet, spicy and tart. Before you know it, you’ll be looking into an empty jar and wondering what happened!
The cherries make a tasty nosh with your favorite libation, especially a nice, dry champagne. They go great with roasted pork, lamb and chicken, work well in salads and and are right at home adorning a cheese plate. Versatile and delicious is a winning combination.
They’re super easy to make too. The pickling liquid is brought to a boil, poured over fresh cherries and left to “cure” in the fridge. Chef Israel served his pickled cherries unpitted. I like to pit mine. I don’t think it matters, so the choice is yours. However you choose to make them – just do make them. You’ll be oh so glad you did!
Grüner’s Pickled Cherries
Chef Christopher Israel, Grüner Restaurant , Portland
Note: These cherries are pickled and not canned using a traditional heat process. However, I do recommend sterilizing your jars and lids in boiling water for 2 minutes before using them. You can also run them through the dishwasher. The cherries must be stored in the refrigerator and will keep for about 2 weeks.
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URL to article: http://stickygooeycreamychewy.com/2012/06/24/peter-piper-picked-a-peck-of-pickled-cherries/
URLs in this post:
Full On Oregon: http://stickygooeycreamychewy.com/2011/09/19/full-on-oregon-food-wine-friends-and-fun/
Grüner Restaurant: http://www.grunerpdx.com/about.htm
Copyright © 2009 StickyGooeyCreamyChewy.com. | <urn:uuid:7a12f439-3201-44d6-a473-8714d76a5a7d> | CC-MAIN-2014-41 | http://stickygooeycreamychewy.com/2012/06/24/peter-piper-picked-a-peck-of-pickled-cherries/print/ | 2014-09-15T09:27:53Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-41/segments/1410657104131.95/warc/CC-MAIN-20140914011144-00306-ip-10-196-40-205.us-west-1.compute.internal.warc.gz | en | 0.936553 | 929 |
The unofficial house band of the Northwest Territories is set to release a country album six years in the making.
Singer Karen Novak told Cabin Radio the album, crafted during a period in which she suffered loss and heartache, is designed to give back to northern fans.
Welders Daughter recently celebrated 16 years in the North and 23 years playing together. “It’s pretty amazing nowadays to have a band that long-term,” Novak told Cabin Country’s Samantha Stuart. “And that’s our full-time job.”
Welders Daughter features Novak, guitarist Attila “Novi” Novak, bassist Tommy B, and G!Force on drums.
While working on their album, Novak’s father passed away. At that point, she said, sad songs began pouring out – but were shelved for another day to focus on the album as the band had imagined it, one of “hope and joy and dancing.”
“My job is really important: to get people dancing and forget about whatever troubles they’ve got,” Novak said. “We’ve got lots of issues in the North. People come to hear music to forget them. And that’s what I want to do.”
The fact that Welders Daughter even exists is in part due to her father, a big fan of country classics, who would tell her if she “would only play some country music, you’d be a star one day.”
“This album was released for my dad. I am a welder’s daughter,” said Novak. “So this band and this album was all about my dad and his love of country music.”
Novak, originally from Mission, BC, said she and the band found a home in Yellowknife after weeks-long stints in the North. She credits a bylaw officer with their permanent move north.
“Our vehicle was parked on the street for longer than 90 days and he says, ‘You have to change over your insurance to the Northwest Territories if you’re here longer than 90 days.’
“And so we thought, OK, I guess we’re staying,” she recalled.
Sixteen years later, the band is planning a “give back” tour of smaller NWT and Nunavut communities. The tour, which Novak hopes will begin in 2020, is intended to include concerts alongside youth workshops in communities.
Novak is also re-releasing an album from another artistic iteration of the band, the Karen Single Band. A theatrical rendition of that album, Wide Open, will appear at Yellowknife’s Northern Arts and Cultural Centre on May 23 next year.
Through her five years of involvement with Music NWT and presence on the board of the Western Canadian Music Alliance, Novak is also working to get the Breakout West music awards show to Yellowknife. Breakout West is being hosted in Whitehorse this year.
“We’re going to hopefully put in a bid and try to make that a successful endeavour,” said Novak, “to have all of the industry people, all the western Canadian artists to come up to Yellowknife.”
She believes bringing the awards and accompanying festival to Yellowknife can help to alleviate the difficulties northern artists have with the costs of travel, and allow them to perform where they are comfortable.
Welders Daughter is nominated for small business of the year, as well as customer service and community impact awards, in the recently revealed Yellowknife Chamber of Commerce shortlists. The winners are to be announced at an awards gala on October 25. | <urn:uuid:76edc3a5-d843-4192-a68c-f34c27306dd9> | CC-MAIN-2021-10 | https://cabinradio.ca/21817/news/arts/after-16-years-welders-daughter-to-release-a-country-album/ | 2021-03-02T23:32:53Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-10/segments/1614178364932.30/warc/CC-MAIN-20210302221633-20210303011633-00089.warc.gz | en | 0.973184 | 788 |
paper, 363 pp., $27.95
This is the second edition of a greatly enlarged guidebook to the Sonoran desert: a vast, arid region, most of it in southwestern Arizona and southeastern California as well as Baja California in Mexico. The author has devoted his life to guiding the desert enthusiast toward a more accurate and more enjoyable appreciation of the desert environment.
This book is user-friendly, with a tremendous introduction to cacti; classified, color-coded pages by floral color; and with information on such animals as the coyote and desert rat as well as some birds. The author has photographed most of the images in the work and the pride in his study is apparent. This is a terrific book as a guide to a hostile environment, allowing you to appreciate a unique landscape.
— Adele Kleine, Library volunteer and garden writer, Chicago Botanic Garden | <urn:uuid:85a01321-13da-47a1-99f4-a8c149942d9d> | CC-MAIN-2016-36 | http://www.chicagobotanic.org/book/sonoran_desert_life_understanding_insights_enjoyment | 2016-08-26T17:36:03Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-36/segments/1471982296020.34/warc/CC-MAIN-20160823195816-00073-ip-10-153-172-175.ec2.internal.warc.gz | en | 0.959011 | 180 |
Thank you to Geno Prussakov, founder of AM Navigator agency and Affiliate Management Days conference, for contributing this guest post. In part one of this two-part post, Geno shares what he deems to be the most important considerations for publishers looking to join an affiliate program. Every affiliate wants to make the right choice when choosing an affiliate program, to avoid getting burnt by programs that do not yield fruit. You will often hear that the choice is as simple as “promoting those who pay higher commissions.” I strongly disagree with this simplistic approach. It can cost you a lot of money and time spent on a bad fit before you realize it was wrong in the first place.
With this in mind, I would like to propose 20 criteria for every affiliate to examine prior to spending time, money and effort on any affiliate program.
Start by examining the advertiser’s website both as a consumer and as an affiliate. As a consumer, pay attention to its ease-of-use (both overall and the checkout process, in particular), professionalism, and how compelling its offer is. As an affiliate, make sure to check for any “leaks,” or ways for the end consumer to take a route that does not lead to commissions. Most commonly, leaks come in the form of untrackable phone numbers, online chat assistants who also take orders, links to other merchants, and even AdSense units and affiliate links of their own.
Not only is Google making it clear that it is starting to treat mobile-friendliness as a “ranking signal,” but end consumers also increasingly use mobile devices to purchase. We now know that as much as 36% of all affiliate-referred sales occur on smartphones and tablets. Use tools like Screenfly to test how an advertiser’s website looks and works on an array of mobile devices.
Once again, approach this both as a consumer and as an affiliate. As a consumer, turn to independent review sites; as an affiliate, visit affiliate forums and blogs. If there is something you need to be aware of, it should be easy enough to find.
Examine the attractiveness of the merchant’s customer-facing offer. Competitive product prices are directly correlated to conversion rates (one of the crucial key performance indicators to take into account). In the age of comparison shopping, online consumers are increasingly savvy and won’t buy from uncompetitive merchants.
5. Serviceable Areas
Do your due diligence to ensure that the advertiser services the geographic area where you plan to market them. MetLife Defender, for example (whose affiliate program I built and manage), services the Unites States only. They have a terrific product, but if your primary focus is on another geographic territory, this affiliate program won’t be good fit for you.
6. Market Saturation
Some niches are already too crowded, and unless you have something truly unique to add to the pre-purchase process, look for a less saturated niche. Take hosting, for example. It’s an interesting niche with plenty of good players. But it is, generally, way too saturated – especially for newer affiliates.
7. Advertiser-Affiliate Compatibility
Evaluate how compatible your promotional focus is with the advertiser’s goal(s) for their affiliate program. A classic example is that of an incompatibility of incentive-oriented promotional methods with pay-per-lead affiliate programs – especially those that compensate affiliates for free trials.
When you put together a comparative table with all of the criteria to consider (which I hope you will), commission rates will be one of the factors you’ll want to compare among immediate competitors – but don’t focus too much on this one alone. There are many other variables that go into the final formula (described below and in Part 2 of this article), and you’ll want to look at all the pieces to get a complete picture of what you may expect to see in program earnings.
9. Commission Recurrence
Some merchants pay commission on new and unique customers only, but I do not believe this is an optimal practice. In the survey conducted for my Online Shopping Through Consumers’ Eyes book, I asked consumers: “When shopping for products requiring ongoing replenishing (e.g., grocery, ink, bank checks, etc.) and receiving satisfactory service, would you still compare your retailer’s offer to other offers next time you need their product?” Close to 72% replied “yes.” Therefore, it is my belief that advertisers that run affiliate programs should compensate affiliates for every sale, but also offer an additional incentive for new customers. For example, eBay Partner Network pays a 200% commission bonus for each new or reactivated eBay buyer.
10. Payment Methods
Per Affiliate Summit's 2014 AffStat Report, the top three preferred methods of receiving commission payments are: bank transfer (41.8% for direct deposit and 11.9% for wire transfers), PayPal (34.3%), and check in the mail (11.9%). Check that the payment methods supported by the affiliate program you are about to promote will work for you.
It is pivotal to keep in mind that not any one of these criteria exists in isolation. They are closely interconnected, and performance with any advertiser will depend on a combination of these variables and key performance indicators.
The above 10 represent only half of the criteria Geno Prussakov urges affiliates to consider. Take a look at Part 2 where we share the remaining 10 of Geno’s essential factors to consider when selecting an affiliate program!
Geno Prussakov is a well-known affiliate marketing expert, best-selling author of four books, popular speaker, Founder and Chair of Affiliate Management Days conference, CEO and Founder of AM Navigator – an award-winning affiliate marketing management agency. You may follow him Twitter at @ePrussakov. | <urn:uuid:8e4d8291-64be-491c-8216-55edb7a577e0> | CC-MAIN-2019-26 | https://partnernetwork.ebay.com/epn-blog/2015/03/20-critical-criteria-for-choosing-an-affiliate-program-part-1 | 2019-06-18T23:35:07Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-26/segments/1560627998844.16/warc/CC-MAIN-20190618223541-20190619005541-00327.warc.gz | en | 0.943796 | 1,224 |
To complete our Geography topic on 'Rainforest', Year 5/6 have been creating their own 'Rainforest Inspired' block prints.
First of all, they looked at a selection of different logos and images of the rainforest and came up with their initial ideas. Then they created their block print using cardboard, string and any other materials they found in the classroom.
Once the prints had been glued together, it was time to get messy and experiment with different colours. They were able to see what their print looked like using different colours, when layering different colours and when printing onto different papers.
Have a look at the results below and see what you think! | <urn:uuid:9def27fa-fc2d-44f7-aefc-193898c96652> | CC-MAIN-2020-24 | https://www.mosps.hants.sch.uk/rainforest-block-printing/ | 2020-05-28T14:37:39Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-24/segments/1590347399820.9/warc/CC-MAIN-20200528135528-20200528165528-00110.warc.gz | en | 0.970754 | 136 |
I’ve been going back through some old images and this is one I’ve always liked. I find that I prefer self-portraits that do not include my eyes or nose. I like the anonymity.
i like the glossy lips…nice touch…oh and cute butt too ;-)
that was taken in the nest under the stairs, where i spent some very special nights with very special people. you know it there.
ah the nest.. the nest was new and precious then.. i was admiring but not entering…
I love this one too, although I also like photos with your eyes in them because you have Special Eyes. Actually now that I think of it, there is a pic of your eyes that you took in my van behind some feathers that I love. Can I post it on my blog with an ode to Breanna? xo luv you
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Floderus Y, Shoolingin- 1 Jordan P, Harper P. Acute intermittent porphyria in Sweden. Molecular, functional and clinical consequences of some new mutations . Porphyria, Acute Intermittent. Porfyri, akut intermittent. Engelsk definition. An autosomal dominant porphyria that is due to a deficiency of. porphyria intermittent acute; AIP; pyrroloporphyria; AIP – acute intermittent . ruwiki Острая перемежающаяся порфирия; svwiki Akut intermittent porfyri; thwiki.
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University of Washington, Seattle; September 27, ; Last Update: It is characterized clinically by life-threatening acute neurovisceral attacks of severe abdominal intfrmittant without peritoneal signs, often accompanied by nausea, vomiting, tachycardia, and hypertension. Attacks may be complicated by neurologic findings mental changes, convulsions, and peripheral neuropathy that may progress to respiratory paralysisand hyponatremia.
Acute attacks, which may be provoked by certain drugs, alcoholic beverages, endocrine factors, calorie restriction, stress, intermittan infections, usually resolve within two weeks.
Akut intermittent porfyri (AIP) – Medibas
Other long-term complications are chronic renal failure, hepatocellular carcinoma HCCand hypertension. Attacks, which are very rare before puberty, are more common in women than men. All individuals with a genetic change in the gene HMBS that predisposes to AIP are at risk of developing acute attacks; however, most never have symptoms and are said to have latent or presymptomatic AIP. With one exception 5-aminolevulinate dehydratase deficiency [ALAD]acute attacks of porphyria are associated with an increased urinary concentration of porphobilinogen PBG.
Demonstration that an increased PBG concentration is caused by AIP requires exclusion of other acute porphyrias by analysis of porphyrins in stool and plasma. Molecular genetic testing is used in a symptomatic individual to identify a pathogenic variant that can then be used to identify AIP in relatives of the proband. Assay of erythrocyte HMBS enzyme activity may be useful in families in which an HMBS pathogenic variant cannot be identified or when molecular testing is not available.
Manage together with a porphyria specialist; treatment options include ovulation suppression with gonadorelin analogues, regular hematin infusions, or as a last resort liver transplantation. Evaluation of relatives at risk: If the HMBS pathogenic variant is known in a family, at-risk relatives can benefit from molecular genetic testing to clarify their genetic status, so that those at increased risk of developing acute attacks of AIP can be identified early and counseled about preventive measures.
Prevention of primary manifestations: All individuals with latent porphyria, the parents of affected individuals, and patients in remission should be advised about measures that diminish the risk of acute attacks:. Prevention of secondary complications: Patients treated regularly with heme arginate require monitoring of iron status to detect iron overload. Individuals who have experienced acute attacks require monitoring of renal function; in some countries annual hepatic imaging to detect HCC is also offered to all individuals with an HMBS pathogenic variant after age 50 years whether or not they have experienced acute attacks.
AIP is inherited in an autosomal dominant manner. Prenatal testing is possible but is rarely requested because of the low clinical penetrance and favorable clinical outcome for the great majority of symptomatic adults. Evidence of an increased concentration of PBG in urine, using a specific quantitative assay, is essential to establish an unequivocal diagnosis of acute porphyria in a symptomatic individual.
ACUTE INTERMITTENT PORPHYRIA IN CATALONIA (SPAIN) | European Porphyria Network
View in own window. PBG concentrations decrease during remission but may remain increased for months or years. ALA is often measured with PBG by specialist laboratories but does not appear to provide any significant additional diagnostic information in uncomplicated AIP see Differential Diagnosis.
Increase mainly indicates in vitro condensation of PBG to uroporphyrins. Total urinary porphyrin, but not PBG, concentration may be increased in various disorders, including alcohol abuse and liver disease [ Badminton et al ].
The increase may be large if an analytic method that includes ether-insoluble porphyrins, e. Excludes hereditary coproporphyria see Differential Diagnosis. Plasma porphyrin concentration is usually increased during an acute attack. Plasma porphyrin fluorescence emission scanning excludes variegate porphyria if the peak is at less than nm see Differential Diagnosis.
Determination of PBG in urine. Testing is best performed on a random urine sample, protected from light prior to analysis. Thus, increased urinary PBG excretion does not necessarily confirm that symptoms are the result of porphyria.
Note that a minimum two-fold increase in urinary PBG concentration above the baseline for that individual is consistent with symptoms due to AIP [ Aarsand et al ]; however, in practice, baseline information is rarely available.
Genes and Databases for chromosome locus and protein. See Molecular Genetics for information on allelic variants. The ability of the test porfiti used to detect a pathogenic variant that is present in the indicated gene. Sequence analysis detects variants that are benign, intermitttant benign, of uncertain significancelikely pathogenic, or pathogenic.
For issues to consider in interpretation of sequence analysis results, click here. To confirm the diagnosis in a proband. The diagnosis of AIP in a symptomatic individual is based on increased PBG in a random urine sample protected from light prior to analysistogether with evidence of a normal total fecal porphyrin or normal coproporphyrin isomer ratio, and plasma porphyrin fluorescence emission scan that is either normal or shows a peak emission around nm.
Molecular genetic testing is not required to confirm the diagnosis in a symptomatic individual but may help to confirm or refute a previous diagnosis of overt AIP in an individual who is in full clinical and biochemical remission [ Whatley et al ].
Predictive testing for at-risk asymptomatic adult family members requires poorfiri identification of the pathogenic variant in the family. Prenatal diagnosis and preimplantation genetic diagnosis PGD for at-risk pregnancies require prior identification of the pathogenic variant in the family.
Symptoms intemrittant present in akuy a minority of those with a genetic change that predisposes to acute intermittent porphyria AIP. Symptoms are more common in women than men and very rare before puberty. Onset typically occurs in the third or fourth decade [ Anderson et alElder et al ]. The course of acute attacks is highly variable within and between individuals. Affected individuals may recover from acute AIP attacks within days, but recovery from severe attacks that are not promptly recognized and treated may take weeks or months.
Clinical intermitttant of AIP is typically caused by exposure to certain endogenous or exogenous factors in most individuals, but it is not uncommon for individuals to have acute attacks akuh which no precipitating factor can be identified.
Ontermittant abdominal pain, which may be generalized or localized and not accompanied by muscle guarding, is the most common symptom and is often the initial sign of an acute attack. Back, buttock, or limb pain may be a feature. Gastrointestinal features including nausea, vomiting, constipation or diarrhea, abdominal distention, and ileus are also common.
Tachycardia and hypertension are frequent, while fever, sweating, restlessness, and tremor are seen pofriri frequently. Urinary retention, incontinence, and dysuria may be present. Peripheral neuropathy is predominantly motor and is less common now than in the past. Muscle weakness often begins proximally in the legs but may involve the arms or legs distally and can progress to include respiratory muscles resulting in complete paralysis with respiratory failure.
Bilateral axonal motor neuropathy may also involve the distal radial nerves [ King et al ].
Motor neuropathy may also affect the cranial nerves or lead to bulbar paralysis. Patchy sensory neuropathy may also occur [ Wikberg et al ]. These symptoms resolve after the attack, though anxiety may persist. The cause of hyponatremia is not clear; both SIADH syndrome of inappropriate antidiuretic hormone release and renal salt wasting have been proposed as mechanisms.
Seizures may also occur as a manifestation of central nervous system involvement of the acute attack. Attacks of acute porphyria may be precipitated by endogenous or exogenous factors [ Anderson et al ]. Mortality directly related to acute attacks is now very rare in most countries as a result of improved treatment use of human hemin and identification and counseling of presymptomatic relatives.
Deaths may occur as a complication of HCC or liver transplantation. To date, five children with homozygous HMBS pathogenic variants have been described. Two major hypotheses for the pathogenesis of the neurologic lesions that give rise to the clinical features of acute porphyria have been proposed: However, the success of liver transplantation as a cure for recurrent acute attacks [ Soonawalla et al ] and the transplant of a liver from persons with AIP into unaffected persons who then experienced acute attacks [ Dowman et al ] clearly implicate release of a hepatic neurotoxin, probably ALA, as their cause.
The penetrance for clinical manifestations of an HMBS pathogenic variant is not accurately known. The minimum prevalence of disease-specific HMBS variants in France is per million inhabitants [ Nordmann et al ]. The penetrance of overt AIP in France was recently reported as 5. In most countries AIP is the most common of the acute hepatic porphyrias [ Anderson et alPuy et al ]. Clinically indistinguishable acute neurovisceral attacks occur in acute intermittent porphyria AIP and the three other acute porphyrias: Lead poisoning may also mimic the symptoms and disturb heme biosynthesis; however, anemia, a feature of lead poisoning, is not a feature of AIP.
Diagnostic abnormalities are shown. See Table 1 for biochemical characteristics of clinically manifest AIP. Uroporphyrin from in vitro polymerization of PBG and coproporphyrin; measurement is not required for diagnosis and may mislead.
Plasma porphyrin concentration may occasionally be normal; fluorescence emission spectroscopy does not distinguish between HCP and AIP. Protoporphyrin is the main stool porphyrin, but a small increase in coproporphyrin III is also observed. Plasma porphyrin concentration is always increased and fluorescence emission spectroscopy distinguishes VP from all other porphyrias.
Hematuria, ingestion of beetroot, some drugs and food additives, and porphyrin excretion in other porphyrias e. To establish the extent of disease and needs in an individual diagnosed with acute intermittent porphyria AIP the following evaluations are recommended:. Immediate treatment of an acute neurovisceral attack does not require confirmation of the specific type of acute porphyria.
Peripheral cannulas used to administer hematin should be replaced after each use. Recurrent acute attacks are best managed with support and advice from a porphyria specialist.
Acute intermittent porphyria
See information and contact details of specialist porphyria centers at porphyria. Medical therapy aims to reduce the frequency and or severity of acute attacks by the following measures:. Liver transplantation is curative and reported from several centers [ Soonawalla et alWahlin et alDowman et al ].
Indications include repeated life-threatening acute attacks, failure of medical therapy, and poor quality of life [ Seth et al ]. Combined liver and kidney transplantation, which has been successful, can be considered in those with AIP with repeated severe attacks and renal failure [ Wahlin et al ]. Cimetidine has been suggested as an alternative treatment [ Rogers ]; however, evidence for clinical efficacy remains elusive.
No recent formal study has been performed, but informal feedback from experienced clinicians at international porphyria meetings indicates that few patients have benefited from this treatment.
Patients should be advised to register with an organization that provides warning jewelry in case of an accident e. Patients should be advised about support available from national patient associations where available.
Good-quality information is now widely available from patient or professional organizations either in paper form or from the Internet; see Resources.
Advice on safe treatment of persons with porphyria in some specific clinical situations e. | <urn:uuid:35860824-6fb6-4ffb-9705-7d0ab368641f> | CC-MAIN-2021-25 | https://rihc.info/akut-intermittant-porfiri-26/ | 2021-06-17T16:55:31Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-25/segments/1623487630518.38/warc/CC-MAIN-20210617162149-20210617192149-00220.warc.gz | en | 0.904846 | 2,735 |
Webcam chat arab
You may configure the chat room to require a password to enter.
Whether you would like to meet new friends or you would like to possibly date someone who is an Arabian, you may want to know more about their culture first.
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Where you can broadcast your webcam live on public for everyone in the chat room to view your cam without any permission.You are not allowed to record other’s webcam live through our website. | <urn:uuid:ebbf8035-4015-4ae4-84bb-ad4753990823> | CC-MAIN-2021-17 | https://reefball.ru/webcam-chat-arab-5625.html | 2021-04-21T20:45:02Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-17/segments/1618039550330.88/warc/CC-MAIN-20210421191857-20210421221857-00382.warc.gz | en | 0.935594 | 141 |
Te Reo Māori is an important part of New Zealand culture and the earlier you can introduce it to your bubba, the better. What better way to start teaching your child than through Global Baby’s selection of books written in Te Reo?
With classics like The Very Hungry Catepillar (Te Anuhe Tino Hiakai) and Who’s Hiding? (Ko Wai E Huna Ana?) expertly translated into Te Reo, as well as educational books like Everyday Words in Māori, your Kiwi kid will embrace Māori language from day dot. | <urn:uuid:a69456d9-495c-4d43-aac2-50e7c04f68de> | CC-MAIN-2022-05 | https://globalbaby.co.nz/collections/te-reo-maori-books | 2022-01-17T05:19:06Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-05/segments/1642320300289.37/warc/CC-MAIN-20220117031001-20220117061001-00674.warc.gz | en | 0.923056 | 126 |
- Category: Other
Tiim to go electric, couldn't really find a charger that fitted the bill, also moving between houses really wanted one that could be moved. You can buy the parts, so went for that and built my own.
These parts came from Ecoharmony. I went for the one with the more expensive one, which hasmost safety features, including PEN earth detection and 6mA Residual Current Monitor. The EPC 2 basic alows control of the current from 6A to 32A, using a resistor or voltage. Utilising the in future I intend to make it work better with solar panels.
A few mor parts. Crimped connections for better contact and a 32A plug to be able to move it from one place to another. The on/off switch hadn't arrived at the time of buiding.
Mounting the rail and charging socket, plenty of wire on the socket to use in the rest of the wiring.
Inside the EPC a series of switches to be set to cover the various settings.
The wiring is simple, just like jioning the dots. Some of the parts need permanent fixing, waiting until electrical test have bee done to do the fixing.
The box ready to use. | <urn:uuid:bf84e528-5ea0-4acb-adda-638a9d111c78> | CC-MAIN-2022-05 | https://goodlife.org.uk/index.php/categories/13-other | 2022-01-23T06:36:38Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-05/segments/1642320304134.13/warc/CC-MAIN-20220123045449-20220123075449-00699.warc.gz | en | 0.958074 | 262 |
As she steps into her new roll as COO for LISC, Annie Donovan, former head of the CDFI Fund, shares some reflections on the current promise—and challenges—of doing community investment, the origins of her personal commitment to service and creating equitable opportunity, and the reasons she decided to come to LISC.
From the unprecedented $1.5 billion we invested last year in people and communities across the country, to our burgeoning collaborations with sectors ranging from tech and healthcare to sports and local government, the LISC 2018 Annual Report is chock full of good news, good numbers, and good ideas. These resources and strategies propel us on our journey to shape a brighter future for all our nation's residents. And that, in a nutshell, is the heart of LISC's mission. Read on!Read Our Report
Tuesday might have been President Obama’s last State of the Union address. But he made it clear that the work needed to lift families out of poverty is ongoing. LISC’s Matt Josephs considers the president’s remarks from a community development perspective, looking at programs that improve the quality of life in places where Americans struggle to make ends meet. | <urn:uuid:349cfc8b-a98f-4b52-a369-9205c3fd070f> | CC-MAIN-2020-29 | https://www.lisc.org/our-stories/category/lisc-stories?initiative=15 | 2020-07-08T12:12:25Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-29/segments/1593655896932.38/warc/CC-MAIN-20200708093606-20200708123606-00504.warc.gz | en | 0.937584 | 242 |
"The Sermon of the Bin" by Jeffrey Dunn
Jeffrey Dunn, writer, culture critic, teacher, and dyslexic, holds a Ph.D. in Culture Studies and English Literature. For forty years his teaching has integrated natural history, creative writing, DIY publication, film, and psychology—all summed up as place-based learning. His first novel, Dream Fishing the Little Spokane, has been described as “melancholic, irreverent, untamed” (Kirkus Reviews) and “a hoot that goes down easy” (natural historian Jack Nisbet). Recently, his interview, “A Conversation: Ginsberg on Burroughs,” was anthologized in David Stephen Calonne, ed, Conversations with Allen Ginsberg, 2019. More information and his author website can be found at jeffreydunnspokane.com. | <urn:uuid:b2ce68a6-7ea1-4f60-a0d4-93c7fa4553e3> | CC-MAIN-2022-49 | https://www.spokanepublicradio.org/programming/2020-05-15/the-sermon-of-the-bin-by-jeffrey-dunn | 2022-12-06T18:44:47Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-49/segments/1669446711111.35/warc/CC-MAIN-20221206161009-20221206191009-00087.warc.gz | en | 0.962004 | 185 |
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Re: Charged twice for an order
It sounds like the double charge is a pending authorization; which will ultimately fall off so you won't be charged twice. I will be happy to confirm this though. I've gone ahead and sent you a private message so that we can chat about this in more detail. Please respond when you can. Thanks! | <urn:uuid:ed5d72fb-bc55-45ed-a308-5356dbedf81a> | CC-MAIN-2015-27 | http://community.sephora.com/t5/Customer-Support/Charged-twice-for-an-order/m-p/492617/highlight/true | 2015-07-08T03:24:12Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-27/segments/1435375635604.22/warc/CC-MAIN-20150627032715-00138-ip-10-179-60-89.ec2.internal.warc.gz | en | 0.931326 | 71 |
A year in review and look ahead at the market Down Under. Editorial is provided by License! Global’s Australian content partner, The Bugg Report.
Women’s lifestyle brand Real Simple has teamed with online fashion brand Cuyana to create a line of apparel and accessories.
Twentieth Century Fox Consumer Products and 3DBA are helping to cool down a resort in Jakarta, Indonesia, with an Ice Age-themed attraction.
NBCUniversal has launched an original video programming initiative that will be featured across its digital platforms.
Rovio Entertainment has partnered with the bakery chain Mrs. Fields for an Angry Birds kids program that will take place through the rest of the year.
Copyright Promotions Licensing Group, a DHX Media company, has appointed Stephen Gould as its new U.K. managing director.
Macy’s is bringing back its American Icons campaign for a second year featuring fashion from big-name brands, events and a charity partnership.
Destination Maternity has partnered with family lifestyle expert and designer Wendy Bellissimo for her first foray into maternity wear.
Kohl’s Department Stores is offering exclusive merchandise from the new animated feature Rio 2 through the Kohl’s Cares merchandise program.
Signature Publishing is promoting GP Flairs’ modeling brand Plasticine in its children’s magazines over the next three months.
Studio 100 will raise the curtain on its new musical production of the turbulent background of World War One Sunday in Belgium.
Kick scooter brand Razor has introduced the first game to come from its licensing agreement with Scarab Entertainment, the “Razor Trickshare” app.
Former Lonestar band member and “Celebrity Apprentice” winner John Rich has launched the new lifestyle brand.
Platinum Films has appointed Big Balloon as its Australian toy partner for the animated adventure series, “Matt Hatter Chronicles.”
Egmont has unveiled details of its 2014 book program for the online game from Mojang, Minecraft.
Major League Baseball Properties and Church & Dwight have signed a multi-year, multi-category sponsorship agreement.
Toys ‘R’ Us will offer an expanded range of Daniel Tiger’s Neighborhood toys, as the brand heads to other top retailers.
John Lewis is now featuring the Wish You Were Here product range from artist Tina Crawford.
Pillow Pets has added a number of new brands to its line of convertible plush characters from Disney, Nickelodeon and Sanrio.
The Collegiate Licensing Company and the NCAA are coordinating to clear the marketplace of fake merchandise before the Men's Final Four.
Mercis has partnered with the animation studio Blue-Zoo to produce a brand-new 52 x 7-minute animated TV series for the Miffy brand.
©2014 ADVANSTAR COMMUNICATIONS INC. All rights reserved. | <urn:uuid:8b7f2f45-c92c-4792-898e-618d8c8db55f> | CC-MAIN-2014-15 | http://www.licensemag.com/license-global/category/78 | 2014-04-17T13:37:09Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-15/segments/1397609530131.27/warc/CC-MAIN-20140416005210-00540-ip-10-147-4-33.ec2.internal.warc.gz | en | 0.925002 | 595 |
SENSO UNICO OPENED A CREATIVE FACTORY IN EHRENFELD, BUT WHAT EXACTLY DOES THAT TERM MEAN?
Senso Unico already has two shops in Cologne and and their handmade Unisex Clothing many fans. Now the owners and brothers Mika and Lividi turned an old food manufacture into an impressive creative factory, with their team. In detailed handycraft the Senso Unico team created space for a fabric archive, studio, tailor, showroom, shoe manufactury, film production and »creative relaxation«.
Rough brick walls, meat hooks used as hangers, buckets full of old buttons, walls of yarn, a large wooden table in the open kitchen and a frequently used table tennis all call for a visit. Just like uniform or sailing fabric, exquisit pieces from Paris and Milan are turned into the wearable uniqum. Those who find the rough vintage look – a mash up of 40s streetstyle and detailed avantgarde – too daring may order tailormade pieces. There’s no limits to the creativity here. Of course the process isn’t cheap, but the concept is definetely also a protest agains cheap fabric and child labour in the mass production. Senso Unico’s theme is: »Things that will last forever (and all their pieces have a lifetime warranty) may as well cost a bit more.« Visiting this creative factory is – even if your mind isn’t set on shopping – absolutely worth a visit!
Kreativfabrik & Showroom
Senefelder Straße 3
Concept Store & Outlet:
WONDROUS by SENSO UNICO
SMART URBAN STAGE Website / | <urn:uuid:9c1cfc9d-860a-4f7e-9c83-3fbd75a0c7c1> | CC-MAIN-2016-50 | http://coutequecoute.blogspot.com/2011/11/smart-urban-stage-presents-senso-unico.html | 2016-12-06T16:05:10Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-50/segments/1480698541910.39/warc/CC-MAIN-20161202170901-00047-ip-10-31-129-80.ec2.internal.warc.gz | en | 0.865344 | 363 |
As a wealth management advisor, Justin offers a comprehensive array of financial planning resources and proven asset management services to high-net-worth individuals around the U.S. Justin delivers a wide range of retirement-planning expertise, with a focus on wealth preservation, to business owners and corporate executives within the technology industries, as they contemplate this next chapter in their lives. Justin is also an integral team member of Pacific Divorce Management, supporting their financial planning efforts as Southern California’s leader in high-net-worth divorce consulting.
Justin committed to a career in the investment advisory industry in 2006, while working as an intern with Pacific Wealth Management and later at university with Morgan Stanley. After earning his college degree, Justin began his professional career as a financial advisor with Wells Fargo Advisors. A native of San Diego, Justin is a graduate of the University of California Davis with a degree in Economics and Art History while also attending the University of California Study Center in Siena, Italy. He is a graduate of the College for Financial Planning.
Justin is a CERTIFIED FINANCIAL PLANNER® Practitioner and Certified Divorce Financial Analyst®. He has passed the FINRA Series 7 and 66 financial services examinations and holds a Life and Disability insurance license from the State of California.
Check the background of this investment professional on FINRA’s BrokerCheck. | <urn:uuid:35d6c602-99b0-4690-9647-0beea205b569> | CC-MAIN-2017-13 | http://www.pacwealth.com/justin-c-kuntz/ | 2017-03-23T00:12:59Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-13/segments/1490218186530.52/warc/CC-MAIN-20170322212946-00291-ip-10-233-31-227.ec2.internal.warc.gz | en | 0.953577 | 279 |
'Tarot' a method of divination that makes use of a pack of cards to achieve insights into and predictions concerning the long run has actually been all around considering the fact that at least the fifteenth Century, and maybe quite a bit longer. In its standard kind Tarot readings are created making use of a pack of (typically ornate) photo cards, by using a pack ordinarily becoming made up of seventy eight Tarot cards. The playing cards are then either dealt for or picked out via the individual who wants clarity, and the images that adorn the cards are then interpreted from the Tarot card reader. As well as in this regard the virtual Tarot card reader operates in exactly a similar fashion, along with the Tarot virtual working cards, then examining the hand as dealt, and providing up insights which could be valuable within the path to harmony, or unwelcome by those that don't have any want to vary.
гадаене на руни
A quick go searching the internet will transform up all method of virtual divination tools lately, from on-line Ouija boards to digitized magic 8 balls, electronic psychic exams, and of course the virtual Tarot playing cards.
Does Virtual Tarot On the internet Operate?
Although for most the Tarot virtual will never be much more than an amusing video game, and an satisfying method to pass several moments, it really is vital that you recall exactly where the powers of this kind of divination strategies as Tarot and the Ouija Board have their roots. For it's usually thought that Ouija boards, Tarot playing cards, Crystal balls, and many others. are minor a lot more than concentrating equipment, and therefore incorporate no mystical electrical power them selves. But as a substitute when perception, concentration and complete emphasis are used on these decided on mediums, it is the pure will in the usually untapped part on the human psyche that compels these kinds of applications to work.
So with this particular said there is no true cause (in idea) as to why (while using the similar degree of target) digital Tarot playing cards on-line couldn't be equally as helpful as their bodily counterparts, getting just the instrument that they are. And as a result there's no authentic explanation why free digital Tarot readings on the internet couldn't be equally as accurate.
Cost-free Tarot Card Studying On-line
To acquire a cost-free Tarot card looking at on the internet it's essential to 1st simply enter your identify and date of beginning, so as to deliver the digital Tarot reader that has a frame of reference with which to match to its comprehensive astrological database. Will the virtual Tarot warn of hazards to get side-stepped, classes to generally be learnt, grievances to generally be laid to relaxation, or really like chances on the horizon. | <urn:uuid:4428fae2-6b19-4dbb-b6f4-ee79942b733c> | CC-MAIN-2018-39 | http://ufoport.cd.st/accueil-c29034582 | 2018-09-20T03:47:42Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-39/segments/1537267156376.8/warc/CC-MAIN-20180920020606-20180920040606-00254.warc.gz | en | 0.956089 | 590 |
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Welcome Emerald City to HubPages
Looks like Emerald City doesn't have any Featured articles on HubPages to share yet. Now's your chance to inspire, encourage, and welcome Emerald City to the amazing HubPages community. Follow Emerald City to show your support and get updates on new content Emerald City publishes. | <urn:uuid:f4252773-cc1c-4375-9e2a-7ac7bef7e9b7> | CC-MAIN-2017-47 | https://hubpages.com/@emerald-city | 2017-11-19T05:49:54Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-47/segments/1510934805362.48/warc/CC-MAIN-20171119042717-20171119062717-00023.warc.gz | en | 0.85596 | 67 |
Pop quiz: Who brought an end to U.S. combat operations in Iraq? Those who say President Barack Obama get an "E" for effort, but the correct answer is President George W. Bush. And the Iraqi government.
Few Americans realize that U.S. military operations in Iraq have been authorized by the UN and the Iraqi government since shortly after the U.S. invasion in 2003. That's when the UN Security Council agreed to a status of forces agreement renewable at the consent of the Iraqi government every six months. The last one was to expire in 2008. President Bush could have allowed it to lapse and let his successor pick up the pieces, but he negotiated a new agreement that was signed in Baghdad on Nov. 17, 2008-after Obama was elected but before he took office. It set a timetable for U.S. withdrawal, stating, "U.S. combat forces must withdraw from cities, villages and localities by June 30, 2009" and "All U.S. forces must withdraw by Dec. 31, 2011."
Those remain the two significant deadlines, with this year's Aug. 31 deadline for withdrawal of all U.S. combat forces a tacked-on date set by Obama for political effect: It allowed him to pacify the anti-war wing of the Democratic Party and show that he was doing something tangible to end the war in an election year. The 2009 deadline proved the more important one on the ground, as the U.S. pullback from cities and towns effectively ended combat operations. As one recently returned Army officer told me, "All we've been doing the last year is supporting each other. We've not engaged Iraqis."
The looming question is whether President Obama intends to negotiate a follow-on to the current status of forces agreement, something even critics of the war effort in Iraq say is necessary.
"I worry more about total withdrawal and the expectation that the Sunnis and Shias will just get over their differences" in the absence of a U.S.-Iraq agreement, said Council on Foreign Relations fellow Stephen Biddle in a recent conference call with reporters.
Biddle went further: "I worry more about the end of 2011 than I worry about August 2010."
That's when not only are the last of the U.S. soldiers in Iraq scheduled to leave the country, but also the drawdown of forces from Afghanistan is set to begin.
Biddle, a former professor at the U.S. Army War College and author of Military Power: Explaining Victory and Defeat in Modern Battle, has long argued that turning over fighting to local forces in Iraq is risky in the face of the sort of communal fighting (Sunni vs. Shia with outside terrorists thrown in) that has characterized the Iraq war. Judging by the 2010 drop in U.S. casualties, one might assume that fighting is over. But consider: While three U.S. soldiers were killed in Iraq last month, 273 Iraqis died (90 soldiers, 183 civilians). Added to the country's political instability-it has yet to settle on a government following March elections-it looks clear that Obama's August deadline was tied to a domestic agenda, not the realities on the ground.
That's not to say that troops should remain indefinitely, but to say that our objectives should drive a timetable, not the other way around.
The president threatens to make the same mistakes in Afghanistan. And there we have a pitched battle with U.S. and Afghan forces against the Taliban, terrorists, and related insurgents. Our objective, plainly laid out by Biddle and a host of military experts, is to defeat the Taliban and al-Qaeda. If we do not, those forces are likely to take over a weak Pakistani government and its nuclear arsenal.
And the only way that's no longer our problem-in 2010 or 2011-is if the investment of thousands of lives and billions of American dollars doesn't matter. Or if the threat of nuclear terrorism is to be left in the hands of the next commander-in-chief.
Email Mindy Belz | <urn:uuid:439e3229-0a6e-4c48-926b-ebf13f90a724> | CC-MAIN-2015-14 | http://www.worldmag.com/2010/09/let_s_borrow_trouble | 2015-03-30T16:21:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-14/segments/1427131299496.98/warc/CC-MAIN-20150323172139-00288-ip-10-168-14-71.ec2.internal.warc.gz | en | 0.971358 | 831 |
A Most Unusual Collection Agency
When Saddam Hussein raised the possibility of attacking U.S. planes in Turkey last week, his threats illustrated what many in diplomatic circles regard as an international disgrace the emasculation of the UN by the U.S.
When UNSCOM, the UN's arms-inspection group for Iraq, was created in 1991, it drew on personnel who, despite their respective nationalities, would serve the UN. Whatever success UNSCOM achieved, however, was in spite of its multinational makeup. While a devoted group of UN staffers managed to set up an independent unit aimed at finding Saddam's weapons and ways of concealing them, other countries seeking to do business with sanctions-impaired Iraq notably France and Russia used inspectors as spies for their own ends.
But what ultimately killed UNSCOM were revelations that the U.S. government had manipulated it by assuming control of its intelligence apparatus last spring (or perhaps even earlier by using the group to slip spies into Iraq) not so much to aid UNSCOM's mission, but to get information for use in future aerial bombardments. When stories to this effect broke last month, however, there was almost no consistency in descriptions of the agencies involved or techniques used. The New York Times, for example, said only one CIA spy had been sent into Baghdad last March to set up an automated eavesdropping device. Time had multiple Defense Intelligence Agency (DIA) operatives planting bugs around Baghdad throughout 1998. The Wall Street Journal referred to the use of one "device" from the National Security Agency (NSA) last year and "a series of espionage operations used by the U.S. [since] 1996 to monitor the communications" of Saddam and his elite.
When probing the world of espionage, rarely does a clear picture emerge. But according to a handful of published sources, as well as assessments by independent experts and interviews with current and former intelligence officers, the U.S. government's prime mover in Iraqi electronic surveillance was most likely a super-secret organization run jointly by the the CIA and the NSA the spy agency charged with gathering signals intelligence (known as SIGINT) called the Special Collection Service. Further, there is evidence to suggest that the Baghdad operation was an example of the deployment of a highly classified, multinational SIGINT agreement one that may have used Australians to help the U.S. listen in months after the CIA failed to realize the U.S. objective of overthrowing Saddam Hussein through covert action.
According to former UNSCOM chief inspector Scott Ritter, when the U.S. took over the group's intelligence last year, a caveat was added regarding staffing: only international personnel with U.S. clearances could participate. "This requirement," says Ritter, "really shows the kind of perversion of mission that went on. The U.S. was in control, but the way it operated from day one was, U.S. runs it, but it had to be a foreigner [with a clearance] operating the equipment."
Under the still-classified 1948 UKUSA signals intelligence treaty, eavesdropping agencies of the U.S., United Kingdom, Canada, Australia, and New Zealand share the same clearances. According to Federation of American Scientists intelligence analyst John Pike, this gives the U.S. proxies for electronic espionage: "In the context of UKUSA, think of NSA as one office with five branches," he says. As UNSCOM demonstrates, though, sometimes the partnership gets prickly; the British, according to Ritter, withdrew their personnel following the U.S.'s refusal to explain "how the data was going to be used." (According to a longtime British intelligence officer, there was another reason: lingering bad feelings over the NSA's cracking a secret UN code used by British and French peacekeepers during a Bosnian UN mission.) At this point, says Ritter, he was instructed to ask the Australian government for a "collection" specialist. "We deployed him to Baghdad in July of 1998," recalls Ritter. "In early August, when I went to Baghdad, he pulled me aside and told me he had concerns about what was transpiring.
He said there was a very high volume of data, and that he was getting no feedback about whether it was good, bad, or useful. He said that it was his experience that this was a massive intelligence collection operation one that was not in accordance with what UNSCOM was supposed to be doing."
In other words, the Australian most likely an officer from the Defence Signals Directorate, Australia's NSA subsidiary, who was supposed to have been working for the UN may have been effectively spying for the U.S. Stephanie Jones, DSD's liaison to NSA, did not take kindly to a Voice inquiry about this subject; indeed, despite being reached at a phone number with an NSA headquarters prefix, she would not even confirm her position with DSD. However, a former high-ranking U.S. intelligence official said that such a scenario was probable. "The relationship between the UKUSA partners has always been of enormous value to U.S. intelligence, even when their governments have been on the opposite sides of policy issues," the official said. "I would not be surprised at all if the Aussies happened to be the ones who actually did this [at U.S. behest]."
With an intelligence community of over a dozen components, billion-dollar budgets, and cutting-edge technology, the U.S. can cast a wide net, be it with human sources or signals interception. Iraq, however, has presented a special challenge since Saddam's Ba'ath party took power in 1968. "In Iraq," says Israeli intelligence expert Amatzai Baram, "you are dealing with what is arguably the best insulated security and counterintelligence operation in the world. The ability of Western or even unfriendly Arab states to penetrate the system is very, very limited."
According to the former Cairo station chief of the Australian Secret Intelligence Service (ASIS), the West got this message loud and clear after Iraqi counterintelligence pulled British MI6 case officers off a Baghdad street in the mid '80s and took them to a warehouse on the outskirts of town. "They had arrayed before them the various agents they had been running," the exASIS officer told the Australian Broadcasting Corporation in 1994. "There were wires hanging from the rafters in the warehouse. All the men were strung up by wires around their testicles and they were killed in front of the faces of their foreign operators, and they were told, you had better get out and never come back."
When UNSCOM was inaugurated in 1991, it quickly became apparent that the organization's intelligence capability would depend largely on contributions from various UN member countries. According to several intelligence community sources, while the CIA did provide UNSCOM with information, and, later, serious hardware like a U-2 spy plane, the focus of the U.S. intelligence community at the time was on working with anti-Saddam groups in and around Iraq to foment a coup.
What resulted, as investigative authors Andrew and Patrick Cockburn demonstrate in their just published book Out of the Ashes: The Resurrection of Saddam Hussein, were two of the most colossally bungled CIA covert operations since the Bay of Pigs. While details of one of the failed operations were widely reported, the Cockburns fleshed out details of an arguably worse coup attempt gone awry in June 1996. Iraqi counterintelligence had not only managed to finger most of the suspects in advance, but months before had even captured an encrypted mobile satellite communications device that the CIA gave the plotters. Adding insult to injury, the Cockburns report, Iraqi counterintelligence used the CIA's own device to notify them of their failure: "We have arrested all your people," the CIA team in Amman, Jordan, reportedly was told via their uplink. "You might as well pack up and go home."
Some UNSCOM staffers first under Russian Nikita Smidovich, later under American Scott Ritter managed to create what amounted to a formidable micro-espionage unit devoted to fulfilling UNSCOM's mission. Between information passed on from various countries and use of unspecified but probably limited surveillance equipment, the inspectors were gathering a great deal. But in March 1998, according to Ritter, the U.S. told UNSCOM chair Richard Butler of Australia that it wanted to "coordinate" UNSCOM's intelligence gathering.
Ritter insists that no U.S. spies under UNSCOM cover could have been operating in Baghdad without his knowledge prior to his resignation in August 1998. However, as veteran spies point out, if they were, Ritter probably wouldn't have known. A number of sources interviewed by the Voice believe it possible that Special Collection Service personnel may have been operating undercover in Baghdad.
According to a former high-ranking intelligence official, SCS was formed in the late 1970s after competition between the NSA's embassy-based eavesdroppers and the CIA's globe-trotting bugging specialists from its Division D had become counterproductive. While sources differ on how SCS works some claim its agents never leave their secret embassy warrens where they perform close-quarters electronic eavesdropping, while others say agents operate embassy-based equipment in addition to performing riskier "black-bag" jobs, or break-ins, for purposes of bugging "there's a lot of pride taken in what SCS has accomplished," the former official says.
Intriguingly, the only on-the-record account of the Special Collection Service has been provided not by an American but by a Canadian. Mike Frost, formerly of the Communications Security Establishment Canada's NSA equivalent served as deputy director of CSE's SCS counterpart and was trained by the SCS. In a 1994 memoir, Frost describes the complexities of mounting "special collection" operations finding ways to transport sophisticated eavesdropping equipment in diplomatic pouches without arousing suspicion, surreptitiously assembling a device without arousing suspicion in his embassy, technically troubleshooting under less than ideal conditions and also devotes considerable space to describing visits to SCS's old College Park headquarters.
"It is not the usual sanitorium-clean atmosphere you would expect to find in a top-secret installation," writes Frost. "Wires everywhere, jerry-rigged gizmos everywhere, computers all over the place, some people buzzing around in three-piece suits, and others in jeans and t-shirts. [It was] the ultimate testing and engineering centre for any espionage equipment." Perhaps one of its most extraordinary areas was its "live room," a 30-foot-square area where NSA and CIA devices were put through dry runs, and where engineers simulated the electronic environment of cities where eavesdroppers are deployed. Several years ago, according to sources, SCS relocated to a new, 300-acre, three-building complex disguised as a corporate campus and shielded by a dense forest outside Beltsville, Maryland. Curious visitors to the site will find themselves stopped at a gate by a Department of Defense police officer who, if one lingers, will threaten arrest.
There are good reasons, explains an old NSA hand, for havingelectronic ears on terra firma in addition to satellites. "If you're listening to something from thousands of miles up, the footprint to sort through is so huge, and finding what you are looking for is not a simple chore. If you know more or less specifically what you want, it's easier to get it in close proximity. And if it happens to be a low-powered signal, it may not travel far enough."
According to two sources familiar with intelligence activity in Iraq, the U.S. may have been aided by information delivered either to UNSCOM or SCS from Ericsson, the Swedish telecommunications firm. It's not an unreasonable assumption; though Ericsson brushes off questions about it, in 1996 a Middle Eastern businessman filed suit against the company, claiming, among other things, that it had stiffed him on his commission for brokering a deal between the Iraqis and Ericsson for sensitive defense communications equipment, which, reportedly, included encrypted cell phones.
Speaking on condition of anonymity, a veteran intelligence official confirmed that the NSA has "arrangements" with other communications firms that allow NSA to access supposedly secure communications, but cooperation from Ericsson would be "a breakthrough despite our best efforts, they always kept their distance. But it's not beyond the realm of possibility." (This is not without precedent; though hardly covered in the American press, it has been reported that Switzerland's Crypto AG long the supplier of cipher equipment to many of the world's neutral and "rogue" states enjoyed such an "arrangement" with the NSA for decades. Crypto AG denies this.)
There is, however, another possible scenario regarding participation by Ericsson in an intelligence venture. According to FAS analyst Pike, it's much more likely that anyone doing intelligence work in Iraq would want a schematic of Baghdad's telephone system which Ericsson installed in the late '60s and has subsequently updated. "I would find it to be far more plausible that the U.S. intelligence community would be interested in acquiring, and Ericsson would be interested in supplying, the wiring diagram for Baghdad's telephone exchange than encryption algorithms for cell phones," he says.
Also, he explains, finding ways to tap into a whole phone system or pull short-range signals out of the air without being obvious is clearly SCS's portfolio. "This type of risky close surveillance is what SCS was formed to do," he says. "When you think of NSA, you think satellites. When you think CIA, you think James Bond and microfilm. But you don't really think of an agency whose sole purpose is to get up real close and use the best technology there is to listen and transmit. That's SCS."
Regarding any possible collaboration in Iraq with SCS or UNSCOM, Kathy Egan, Ericsson spokesperson, said she had no information on such an operation, but if there was one, "It would be classified and we would not be able to talk about it." It's also possible, according to Mike Frost, that cleverly disguised bugs might have been planted in Baghdad SCS, he recalls, managed to listen in on secured facilities by bugging pigeons. But, says a retired CIA veteran, with UNSCOM effectively dead, bugging is now out of the question. "I hope the take from this op," he says, "was worth losing the only access the outside world's disarmament experts had to Iraq."
The Radome Archipelago
During the Cold War there were hundreds of secret remote listening posts spread around the globe. From large stations in the moors of Scotland and mountains of Turkey that were complete with golf balllike structures called "radomes" to singly operated stations in the barren wilderness of Saint Lawrence Island between Alaska and Siberia that had only a few antennae, these stations constituted the ground-based portion of the United States Signals Intelligence (SIGINT) System or "USSS."
Operated by the supersecret National Security Agency (NSA), these stations were designed to intercept Morse Code, telephone, telex, radar, telemetry, and other signals emanating from behind the Iron Curtain. At one time, the NSA contemplated a worldwide, continuously operated array of 4120 intercept stations. While the agency never achieved that goal, it could still boast of several hundred intercept stations. These included its ground-based "outstations," which were supplemented by other intercept units located on ships, submarines, aircraft (from U-2s to helicopters), unmanned drones, mobile vans, aerostats (balloons and dirigibles), and even large and cumbersome backpacks.
With the collapse of the Communist "bloc" and the advent of microwaves, fiber optics, and cellular phones, NSA's need for numerous ground-based intercept stations waned. It began to rely on a constellation of sophisticated SIGINT satellites with code names like Vortex, Magnum, Jumpseat, and Trumpet to sweep up the world's satellite, microwave, cellular, and high-frequency communications and signals. Numerous outstations met with one of three fates: they were shut down completely, remoted to larger facilities called Regional SIGINT Operations Centers or "RSOCs," or were turned over to host nation SIGINT agencies to be operated jointly with NSA.
However, NSA's jump to relying primarily on satellites proved premature. In 1993, Somali clan leader Mohammed Farah Aideed taught the agency an important lesson. Aideed's reliance on older and lower-powered walkie-talkies and radio transmitters made his communications virtually silent to the orbiting SIGINT "birds" of the NSA. Therefore, NSA technicians came to realize there was still a need to get in close in some situations to pick up signals of interest. In NSA's jargon this is called improving "hearability."
As NSA outstations were closed or remoted, new and relatively smaller intercept facilities such as the "gateway" facility in Bahrain, reportedly used for retransmit signals intercepted in Baghdad last year to the U.S. sprang up around the world. In addition to providing NSA operators with fresh and exotic duty stations, the new stations reflected an enhanced mission for NSA economic intelligence gathering. Scrapping its old Cold War A and B Group SIGINT organization, NSA expanded the functions of its W Group to include SIGINT operations against a multitude of targets. Another unit, M Group, would handle intercepts from new technologies like the Internet.
Many people who follow the exploits of SIGINT and NSA are eager to peruse lists of secret listening posts operated by the agency and its partners around the world. While a master list probably exists somewhere in the impenetrable lair that is the NSA's Fort Meade, Maryland, headquarters, it is assuredly stamped with one of the highest security classifications in the U.S. intelligence community. W.M. & J.V.
The United States SIGINT System (USSS)
The following list is the best unclassified shot at describing the locations of the ground-based "ears" of the Puzzle Palace. It is culled from press accounts, informed experts, and books written about the NSA and its intelligence partners. It does not include the numerous listening units on naval vessels and aircraft nor those operating from U.S. and foreign embassies, consulates, and other diplomatic missions.
NSA Headquarters, Fort Meade, Maryland
Buckley Air National Guard Ground Base, Colorado
Fort Gordon, Georgia (RSOC)
Imperial Beach, California
Kunia, Hawaii (RSOC)
Sabana Seca, Puerto Rico
San Antonio, Texas (RSOC)
Shemya, Alaska -3
Sugar Grove, West Virginia
Winter Harbor, Maine
Two Boats -1
Bamaga -6 -7
Canberra (Defense Signals Directorate Headquarters) -5
Kojarena, Geraldton -1
Pine Gap, Alice Springs -1
Shoal Bay, Darwin -1
Al-Muharraq Airport -3
Bosnia and Herzegovina
Mapharangwane Air Base
British Indian Ocean Territory
Diego Garcia -1
Bandar Seri Begawan -7
Masset -6 -7
Ottawa [Communications Security Establishment (CSE) Headquarters] -5
Korla -1 -6
Qitai -1 -6
Brac Island, Croatia -6
Zagreb-Lucko Airport -7
Ayios Nikolaos -1
Almindingen, Bornholm -7
Dueodde, Bornholm -7
Dahlak Island -1 (NSA/Israel "8200" site)
Addis Ababa -1
Kourou -7 (German Federal Intelligence Service station)
Bad Aibling -2
Bad Münstereifel -7
Pullach (German Federal Intelligence Service Headquarters) -5
British Consulate, Victoria ("The Alamo") -7
Herzliyya (Unit 8200 Headquarters) -5
Mitzpah Ramon -7
Mount Hermon, Golan Heights -7
Mount Meiron, Golan Heights -7
San Vito -6
Higashi Chitose -7
Higashi Nemuro -7
Kanghwa-do Island -7
Pyong-dong Island -7
Taegu -1 -2 -6
Amsterdam (Technical Intelligence Analysis Center (TIVC) Headquarters)-5
Wellington (Government Communications Security Bureau Headquarters -5
Goat Island, Musandam Peninsula -3
Khasab, Musandam Peninsula -3
Masirah Island -3
Galeta Island -3
Papua New Guinea
Port Moresby -7
Terceira Island, Azores
São Tomé and Príncipe
Pico de las Nieves, Grand Canary Island -7
Playa de Pals -3
Lovön (Swedish FRA Headquarters) -7
Shu Lin Kuo -5 (German Federal Intelligence Service/NSA/Taiwan J-3 SIGINT service site)
Khon Kaen -1 -3
Galangala Island, Ssese Islands (Lake Victoria)
United Arab Emirates
Ras al-Khaimah -3
Sir Abu Nuayr Island -3
Belfast (Victoria Square) -7
Brora, Scotland -7
Cheltenham (Government Communications Headquarters) -5
Culm Head -7
Hawklaw, Scotland -7
Irton Moor -7
Menwith Hill, Harrogate -1 (RSOC)
Westminster, London -7
Socotra Island (planned)
-1 Joint facility operated with a SIGINT partner.
-2 Joint facility partially operated with a SIGINT partner.
-3 Contractor-operated facility.
-4 Remoted facility.
-5 NSA liaison is present.
-6 Joint NSA-CIA site.
-7 Foreign-operated "accommodation site" that provides occasional SIGINT product to the USSS.
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- Breaking: Crane Collapses in Lower Manhattan, One Reported Dead
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- Left-Wing Jewish Groups Claim Responsibility for Fake 'New York Times'
- Father of New York's Medical Marijuana Program Wants More Companies Licensed to Grow... | <urn:uuid:e65d0149-fe1c-4157-8b43-df239c9d700e> | CC-MAIN-2016-07 | http://www.villagevoice.com/news/a-most-unusual-collection-agency-6422300 | 2016-02-05T22:23:58Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-07/segments/1454701145519.33/warc/CC-MAIN-20160205193905-00185-ip-10-236-182-209.ec2.internal.warc.gz | en | 0.950408 | 4,748 |
Jana of Cherry Tea Cakes was our July Daring Bakers’ host and she challenges us to make Fresh Frasiers inspired by recipes written by Elisabeth M. Prueitt and Chad Robertson in the beautiful cookbook Tartine.
I had a great time with the challenge this month. The challenge came at a perfect time of year here in New England for the strawberries are still really tasty. I made the Frasier over a series of days. For one thing, many of the different elements ( and there were a lot of them ) needed a lot of cooling time. When it came time to put everything together though, it went very quickly.
I made a traditional variation with the strawberries. Then I looked at the beautiful lavender in my yard and decided a peach.lavender version would be my alternate. The taste of the peach and lavender version was extraordinary. The lavender perfumed the dessert without overwhelming it. The strawberry version was like a really light strawberry shortcake. It was so light that I had two slices! It is not light in calories however so I will be giving the rest of it away because I have no willpower.
|Fresh local strawberries dipped in chocolate|
Basic Chiffon Cake:Ingredients:
1 cup + 2 tablespoons (270 ml) (5½ oz/155 gm) all-purpose flour
1 teaspoon (5 ml) (4 gm) baking powder
3/4 cups (180 ml) (6 oz /170 gm) sugar
1/2 teaspoon (2½ ml) (1½ gm) salt, preferably kosher
1/4 cup (2 fl oz/60 ml) vegetable oil
3 large egg yolks
⅓ cup + 1 tablespoon (3.17 fl oz/95 ml) fresh orange juice
3/4 teaspoon (3¾ ml) (3 gm) orange zest, grated
5 large egg whites
¼ teaspoon (1¼ ml) (1 gm) cream of tartar
Preheat the oven to moderate 325°F (160°C/gas mark 3).
- Line the bottom of an 8-inch (20 cm) spring form pan with parchment paper. Do not grease the sides of the pan.
- In a large mixing bowl, stir together the flour and baking powder. Add in all but 3 tablespoons (45 ml.) of sugar, and all of the salt. Stir to combine.
- In a small bowl combine the oil, egg yolks, water, vanilla and lemon zest. Whisk thoroughly.
- Combine with the dry ingredients and mix thoroughly for about one minute, or until very smooth.
- Put the egg whites into a stand mixer, and beat on medium speed using a whisk attachment on a medium speed, until frothy. Add cream of tartar and beat on a medium speed until the whites hold soft peaks. Slowly add the remaining sugar and beat on a medium-high speed until the whites hold firm and form shiny peaks.
- Using a grease free rubber spatula, scoop about ⅓ of the whites into the yolk mixture and fold in gently. Gently fold in the remaining whites just until combined.
- Pour the batter into the prepared pan. Bake for 45 to 55 minutes or until toothpick inserted into the center comes out clean.
- Removed the cake from the oven and allow to cool in the pan on a wire rack.
- To unmold, run a knife around the sides to loosen the cake from the pan and remove the spring form sides. Invert the cake and peel off the parchment paper. Refrigerate for up to four days.
Pastry Cream Filling:Ingredients:
1 cup (8 fl oz/250 ml) whole milk
1/2 teaspoon (2½ ml) pure vanilla extract
1/8 teaspoon (1/2 ml) (¼ gm) salt, preferably kosher
2 tablespoons (30 ml) (10 gm)cornstarch
1/4 cup (60 ml) (2 oz/55 gm) sugar
1 large egg
2 tablespoons (30 ml) (1 oz/30 gm) unsalted butter
3/4 teaspoon (3¾ ml) (4 gm) gelatin
1/2 tablespoon (7½ ml) water
1 cup (8 fl oz/250 ml) heavy cream
- Pour the milk, vanilla, and salt into a heavy sauce pan. Place over medium-high heat and scald, bringing it to a near boiling point. Stir occasionally.
- Meanwhile, in a stand mixer add the cornstarch and sugar. Whisk to combine
- Add the eggs to the sugar and cornstarch and whisk until smooth.
- When the milk is ready, gently and slowly while the stand mixer is whisking, pour the heated milk down the side of the bowl into the egg mixture.
- Pour the mixture back into the warm pot and continue to cook over a medium heat until the custard is thick, just about to boil and coats the back of a spoon.
- Remove from heat and pass through a fine mesh sieve into a large mixing bowl. Allow to cool for ten minutes stirring occasionally.
- Cut the butter into four pieces and whisk into the pastry cream a piece at a time until smooth.
- Cover the cream with plastic wrap, pressing the plastic wrap onto the top of the cream to prevent a skin from forming. Chill in the refrigerator for up to five days.
- In a small dish, sprinkle the gelatin over the water and let stand for a few minutes to soften.
- Put two inches (55 mm) of water into a small sauce pan and bring to a simmer over a medium heat.
- Measure 1/4 cup (2 oz/60 ml) of the chilled pastry cream into a small stainless steel bowl that will sit across the sauce pan with the simmering water, without touching the water.
- Heat the cream until it is 120 F (48.8 C). Add the gelatin and whisk until smooth. Remove from the water bath, and whisk the remaining cold pastry cream in to incorporate in two batches.
- In a stand mixer, fitted with the whisk attachment, whip the cream until it holds medium-stiff peaks. Immediately fold the whipped cream into the pastry cream with a rubber spatula.
|Yummy pastry cream|
1/3 cup (2⅔ fl oz/80 ml) (2⅔ oz/75 gm) of sugar, flavored or white
1/3 cup (2⅔ fl oz/80 ml) of water
2 teaspoons Grand Marnier
- Combine the water and sugar in a medium saucepan.
- Bring the mixture to a boil and let the sugar dissolve. Stirring is not necessary, but will not harm the syrup.
- Remove the syrup from the heat and cool slightly.
- Transfer syrup to a lidded container or jar that can be stored in the refrigerator. Simple syrup can be stored for up to one month.
1 baked 8 inch (20 cm) chiffon cake
1 recipe pastry cream filling
⅓ cup (80 ml) simple syrup or flavored syrup
2 lbs (900 g) strawberries
confectioners’ sugar for dusting
½ cup (120 ml) (5 oz/140 gm) almond paste
- Line the sides of a 8-inch (20 cm) spring form pan with plastic wrap. Do not line the bottom of the pan.
- Cut the cake in half horizontally to form two layers.
- Fit the bottom layer into the prepared spring form pan. Moisten the layer evenly with the simple syrup. When the cake has absorbed enough syrup to resemble a squishy sponge, you have enough.
- Hull and slice in half enough strawberries to arrange around the sides of the cake pan. Place the cut side of the strawberry against the sides of the pan, point side up forming a ring.
- Pipe cream in-between strawberries and a thin layer across the top of the cake.
- Hull and quarter your remaining strawberries and place them in the middle of the cake. Cover the strawberries and entirely with the all but 1 tbsp. (15 ml) of the pastry cream.
- Place the second cake layer on top and moisten with the simple syrup.
- Lightly dust a work surface with confectioners' sugar and roll out the almond paste to a 8-inch (25 cm) round 1/16 inch (1.5 mm) thick. Spread the remaining 1 tablespoon (15 ml) of pastry cream on the top of the cake and cover with the round of almond paste.
- Cover with plastic wrap and refrigerate for at least 4 hours.
- To serve release the sides of the spring form pan and peel away the plastic wrap.
- Serve immediately or store in the refrigerator for up to 3 days. | <urn:uuid:23d56b73-7fc1-4512-84be-d19cf4ff37df> | CC-MAIN-2018-09 | http://evelynssugarlab.blogspot.com/2011/07/july-daring-bakers-challenge-frasier.html | 2018-02-26T01:49:07Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-09/segments/1518891817908.64/warc/CC-MAIN-20180226005603-20180226025603-00614.warc.gz | en | 0.885769 | 1,852 |
When your heating system breaks down, you want answers—but more importantly, a fast solution. For the latter, Adon Complete Property Solutions is here to help homeowners with heating repair in the McKinney, TX area with prompt service when you need it. To know what’s wrong with your heater, we’d have to take a close look at the system, but we can give you an idea of some common heating repairs to help you narrow down the source.
Repairing the ignition system in a gas heater used to mean one thing—lighting the pilot light. However, today’s furnaces do not have standing gas pilots, as this was inefficient—using fuel throughout the day and night—and often unsafe.
Instead, today’s furnaces use electronic ignition to start up. A hot surface can create a flame or an electronic spark, which means it only starts up once you need heat, saving a lot of fuel. However, this ignition switch may fail and require replacement eventually. Luckily, this usually isn’t too costly.
Safety Switch Repairs
Your furnace is loaded with safety switches to protect you from a gas leak, an overheated system, or a carbon monoxide leak. This is absolutely a good thing, but those switches may malfunction over time. For example, the fan limit switch, meant to stop the furnace plenum from overheating, may fail and shut down the system even when there is no danger present. It likely needs replacement at this point.
One safety switch repair is a relatively simple one, but we still recommend professional repairs just in case. The flame sensor, the component that detects when there is no flame present, may simply become dirty and fail to work properly. This means it needs to be cleaned!
Often, a furnace simply fails because of electrical issues with the system or within the home. If your furnace won’t start at all, we recommend resetting the circuit breaker to see if this helps. Your furnace doesn’t run on natural gas alone!
Otherwise, you may run into trouble with the fan motor, wire connections, or other electrical components powering your furnace. These all require someone with the right experience and training for repairs, as it may be unsafe otherwise.
Changing Out Dirty Air Filter
This one tends to surprise people. We show up for an AC repair—usually for a system that’s not putting out enough hot air or one that is short cycling or hard starting—and find that the only problem is a dirty filter and a bit of wear and tear. If you allow the air filter to get too dirty, it can be clogged enough to restrict airflow and prevent the system from working properly.
Many of the problems you’ll encounter with a furnace are due to poor installation or a dirty filter. Make sure qualified heating technicians help keep your system maintained, and replace the filter every 1-3 months, and you can prevent many of the issues that could come up.3 DIY Tips to Lower Your Heating Bills This Winter » « Save Today with an HVAC Maintenance Plan | <urn:uuid:74cd0716-1ede-4a8d-9905-34742bcb7503> | CC-MAIN-2023-06 | https://www.adoncps.com/4-common-heating-repairs/ | 2023-02-06T08:38:17Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764500334.35/warc/CC-MAIN-20230206082428-20230206112428-00142.warc.gz | en | 0.931909 | 641 |
8.1% Imperial IPA / Double IPA
Sanitas Brewing Company (United States)
A bright, refreshing Belgian style ale brewed with the new Azacca hop variety (think peach, grapefruit peel, pine) and wild alfalfa honey. The brainchild of our brewer, Marty.
5 years ago | <urn:uuid:916a2078-2c86-4a6e-937a-2033a297437b> | CC-MAIN-2023-06 | https://www.pintplease.com/en/beer/68950/ceres | 2023-02-05T01:01:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764500158.5/warc/CC-MAIN-20230205000727-20230205030727-00876.warc.gz | en | 0.76637 | 89 |
PETERBOROUGH -- The London Knights have tried both their goalies in the OHL final but neither has managed to beat David Shantz yet.
The Peterborough puckstopper, who lost a game each to both Adam Dennis and Steve Mason in the regular season, has rebounded to beat them both when it counts most -- and has his Petes two games from a Memorial Cup berth following yesterday's 4-3 overtime win over the Knights at the Peterborough Memorial Centre.
"There haven't been very many nights where we've had to worry about our goaltending," Peterborough head coach Dick Todd said. "We've been very happy with him (since an off-season trade that sent Shantz to the Petes from Mississauga). He's the only one (on the Petes) who has played in May."
Shantz might have gone to Peterborough last year but a rumoured deal fell through at the last minute. He finished the season with the IceDogs.
"I heard there was a trade in the works at the deadline but it didn't end up happening," Shantz said. "I was excited to come here and it's been a good season."
However, no one has tested his patience like the Knights.
"It's almost like a waiting game against them," said Shantz, who kicked aside 33 shots for his 14th post-season win. "You have to be patient because they'll hold the puck to the last possible second (before shooting)."
Before the OHL final started, the biggest question mark for Peterborough was whether or not the six-foot-one, 190-pound Shantz could match Dennis, the league's top netminder, in the series' closely-fought contests.
That wasn't an issue yesterday with Mason starting in net for London. However, Shantz remembers -- as an 18-year-old rookie with the IceDogs -- being swept in four games by Dennis and the Guelph Storm in the 2004 final.
That's why the Petes' 6-5 victory in double overtime on Friday night at the John Labatt Centre was a huge confidence boost to Shantz. Not only was it his 20th birthday, but he won the marathon contest over his nemesis.
"It meant a lot because I finally won a game in an OHL final," the Florida Panthers prospect said. "I had played in it before and lost four straight."
Both Dennis and Shantz let in questionable goals in regulation but both goalies shone in overtime before Patrick Kaleta won it for the Petes.
"Usually, a goalie loses a lot of water during those longer games but I felt pretty good the whole time," the Hamilton native said. "You don't worry about what's happening at the other end too much."
So yesterday's mere 3:17 of overtime wouldn't have caused him to break a sweat. He has the Knights thinking, though, that they might have to change tactics against him.
"Maybe we have to change up a bit and shoot from anywhere," London forward Kris Belan said. "That's what they do and they charge the net hard to see if they can get a rebound or bank one in off a shin pad." | <urn:uuid:c32fb920-e360-4e91-a4c5-14798392cb21> | CC-MAIN-2017-04 | http://slam.canoe.com/Slam/Hockey/Junior/2006/05/08/1569625-sun.html | 2017-01-16T17:44:50Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-04/segments/1484560279224.13/warc/CC-MAIN-20170116095119-00448-ip-10-171-10-70.ec2.internal.warc.gz | en | 0.985033 | 668 |
News with a twist
Misogynist race baiter Phyllis Schlafly tells us that Republicans shouldn't waste their time recruiting Latinos, because they have too many illegitimate children.
- Coalition of Conscience director and Gender Studies scholar Michael Brown asks of transgendered youth:
"What if the child was sure he or she was an alien? Or an animal? Or a black child in a white body? ... Do we then normalize these alternate realities as well?"
Nice compassion there, sport. (Charisma Magazine)
- Students for Life Of America's president Kristin Hawkins discovers that Gay Marriage is what logically follows legalized abortions, or something. (NRO, the most intellectually dishonest rest stop on the information super highway)
- Floating away on the Titanic or on the Hindenburg? - TruNews host Rick Wiles says that immigration reform is actually part of The Kenyan Usurper's wiley scheme to enslave us all:
"At some point Americans desiring to flee the growing tyranny in the USA will not be allowed to leave, and we’ll have to float on rafts to Cuba to get away from El Presidente Obama’s Communist revolution." | <urn:uuid:c08c88b3-a833-4492-9517-056f7cefe054> | CC-MAIN-2014-41 | http://www.dependablerenegade.com/dependable_renegade/2013/06/happy-7.html | 2014-09-30T11:48:55Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-41/segments/1412037662910.19/warc/CC-MAIN-20140930004102-00074-ip-10-234-18-248.ec2.internal.warc.gz | en | 0.906902 | 244 |
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