text:
Sometimes I feel really bad for writing romance.
This is why…
I feel like ruining the new female generation for boys.
Since books have gotten a lot more popular today than let's say 70 years ago, and social media is replacing quite a bit of real human interaction, it seems likely that avid readers get a screwed vision of reality.
If I got one dollar for each time one of my readers told me she wished she would find a guy like my fictional characters Ryan Hunter or James Hook for herself, I'd be a millionaire by now.
Girls who inhale one romance book after the other sort of get brain washed over time. They have an image of a perfect guy in their mind and of course wish to meet Mr. Perfect one day. The problem with this is: Mr. THIS Perfect doesn't exist. It's fiction. Something written by women who pack all their dreams, wishes and fantasies into words. That has nothing to do with the truth at all.
When I write a book, I think incredibly hard about each and every single line of dialogue. In the end it should be everything – hot, sexy, spicy, tricky, awesome and with lots and lots of romantic impact. I want to create goosebumps on your skin with it. But please understand that I spend hours, sometimes even days, to think on one such great line.
In reality, a boy has like 3 seconds to think before he speaks.
Whatever he says then can't be as great or romantic as the lines in a romance book. They say the first best, like any girl would do too. How many times did you walk away from a conversation and 20 minutes later came up with an awesome retort to something the other person said? It would have been pure, sparkly diamonds in liquid form. But what you actually said at that moment was as unspectacular as clear water. No champagne spilling off your tongue. THAT is reality.
It's all about expectations. Romance writers create expectations in their female readers that no real guy can meet. The sad thing is, those girls walk past thousands of good guys in search of Mr. Epic, and they don't even know what they are missing out on.
No romance is perfect. No relationship is free of troubles and hard work. There's a line between fiction and reality, but for those girls who spend their best years in their rooms to read romances instead of going out and finding it, these lines get blurred. They expect flawless boyfriends and cinematic relationships. No fights, no misunderstandings, no sorrow. But all that is part of a real relationship, too. As much as the butterflies in your stomach are when you get kissed for the first time.
At the end of the day, some of these girls want something that doesn't exist, and maybe they even know it. But by making the decision to stay home and read more romance books instead of meeting the world, they miss out on a lovely boyfriend that could make them happier with simple things than the best romance book ever will.
I know this isn't true for ALL romance readers, but for some. More than you would like to believe. I am actually expecting a lot more from my relationship than I should. So, if you're not one of those people, I'm happy for you.
To all the other girls who rather spend their days in bookish worlds, dreaming of perfection, this is my sincere apology for misleading you.
Having said that, of course romance books are awesome and you should read them! At least one every day. 😉


text:
400 Maryland Drive
Fort Washington, PA 19034
Phone: 215-646-6000
Fax: 215-646-0379
Follow Us:
Who We Are
In Memoriam
Our Team
Elena M. Baylarian
Kevin D. Birkhead
Thomas A. Boulden
Daniel A. Czaplicki
Karen Schecter Dayno
Nicole M. Dovishaw
Christine M. Gordon
Allan D. Goulding, Jr.
Daniel J. Grossman
Catherine M. (Kate) Harper
James N. Hendershot
Robert T. Horst
James M. Jacquette
Andrew W. Knox
William O. Krekstein
Matthew B. Malamud
John J. McAneney
Elizabeth A. McBride
Christopher M. McMonagle
Michael O'Hara Peale, Jr.
Daniel L. Petrilli
George M. Riter
Robert M. Runyon
Colleen M. Shanks
Julia M. Shmilovich
Bernard F. Siergiej
Eric B. Smith
Kathleen M. Vermilion
Keith T. Vernon
Charles J. Weiss
Scott H. Wolpert
What We Do
Business, Corporate and Tax Law
Commercial and Civil Litigation
Education Law
Employment Law
Family Law
Insurance Industry Law
Municipal Law
Personal Injury Law
Real Estate and Zoning Law
Wills, Trusts and Estates Law
Firm News & Events
Community Involvement
Firm News & Resources
March 16, 2020 Friends and Clients of Timoney Knox: Timoney Knox has implemented measures to ensure that we continuously provide exemplary legal services to our clients, while at all times...
Read more
Rob Runyon Joins TK Insurance Department
Read more
Catherine "Kate" Harper was recognized with the 2019 Planning Advocate Award
(Nov. 13, 2019) Catherine "Kate" Harper, a practicing attorney for more than 30 years, received recognition for her passionate ongoing efforts to protect the natural world and promote...
Read more
We're Opening an Office in Washington, DC!
TIMONEY KNOX, LLP is pleased to announce the opening of a Washington, D.C. office. We are also pleased to announce that KEITH T. VERNON, ESQUIRE has joined the...
Read more
TK Lawyers Included in the BEST LAWYERS IN AMERICA 2020 EDITION
August 15, 2019 Fort Washington, PA. Timoney Knox, LLP is pleased to announce that 6 of its...
Read more
Christine Gordon Appointed to Board of Directors
Timoney Knox, LLP is pleased to announce that Christine M....
Read more
TIMONEY KNOX, LLP is pleased to announce that seven of its attorneys were nominated by its colleagues and selected for inclusion as 2019 Pennsylvania Super Lawyers® or Rising Stars®. We are...
Read more
Students' Rights at the Zoo
Our S
Read more
Bill Krekstein Receives Prestigious Award
Bill Krekstein, a Partner of Fort Washington-based Timoney Knox, LLP, received an Outstanding Presentation Award at this year's Annual Conference for the Property Loss Research...
Read more
Dan Petrilli Receives The Golden Gavel
Read more
Older »
Who We Are
Our Team
What We Do
Firm News & Events
©2020 Timoney Knox, LLP. All rights reserved.
Site Map
Site by LISI

subset: commoncrawl


text:
Hearsay Events is a San Francisco based, full service event planning and production company. Our goal is to make your event experience one to remember, whether it's a cocktail party, fundraising event, fashion show or conference. Hearsay Events will add an artistic touch to every aspect of your event – from decor to entertainment to lighting and audio/visual, Hearsay Events can bring your vision to life.
Contact us today to discuss your event needs – we offer free consultations and quotes.
read more show less


text:
Training Schedule for 3MT
The research you do today or in the future, potentially has the power to change people's lives – but only if they know about it and understand how it applies to them.
In a recent article in the Canberra Times, University of Canberra scientist, Professor Janine Deakin ranked communication skills as the number one 'soft skill' needed by researchers and academics because it can ensure your work gets heard.
The UC Three Minute Thesis (3MT) and Pitch for Funds (P4F) program (below) is a research communication training ground, where you will learn how to get your research on the radar of potential customers, supporters and beneficiaries and grab the attention of investors and collaborators.
At the end of the training program there will be a chance to present your research to the public and win prize money.
Thursday 30 August: Three Minute Thesis final


text:
It's going to be Christmas - the most anticipated weekend across the globe! It's the time when consumers make merry with out-of-the-ordinary offers coming their way. But this season also rings in every online and in-store vendor's logistics nightmare. From tracking, packing, and loading consignments to managing returns and facing unprecedented delays due to natural calamities and man-made hindrances, every seller is on the edge of the seat until all the delivery promises are kept. So, what's the way out of this mess to make some reasonable profits?
Manufacturers today prefer a hybrid solution of in-house, 3PL, and on-demand services to reach consumers on time. Years of experience in dealing with logistical challenges come in handy in making a timely delivery. But in times of changing purchase patterns and with online shopping skyrocketing as the most preferred option, challenges are manifold. From warehouse planning and transportation scheduling to analyzing inventory levels and managing last mile and real-time disruptions, roadblocks are umpteen. The need of the hour is an end-to-end solution that can provide transparency of every process, utilize powerful optimization engines for robust planning and scheduling, support mobility solutions for anytime access of information, arrest revenue leakage, and manage the entire logistics journey from a single contract to a single bill.
Warehouse optimization plays a pivotal role in supply chain. With every inch of space costing a premium, processes like receiving, storing, put-away, and picking are key to efficient packing and shipping of orders. Robust warehouse management solutions with capabilities such as barcoding and RFID chips connected to the main database help in locating packages faster, saving enormously on time and money. Such innovative methodologies could possibly save more than 30% on warehouse management costs.
Drivers, vehicles, container space, route, and load form an integral part of fleet management—an important function that influences on-time order fulfillment during times of high-volume sales. Technological solutions like in-memory planning and optimization help companies plan their supply and transportation by taking into consideration every element that contribute to an on-time delivery using algorithm-based flexi frameworks. Seamless integration of applications and processes supports logistics companies in honoring orders.
Tracking containers or cargo vessels on the road, making course corrections, is inevitable especially with perishable goods. GPS and satellite tracking integrated with enterprise applications help in getting the right packages into the right destination at the right time. Taking efficiency a level higher, options such as sign on glass simplify the POD stage and facilitate an almost real-time payment process.
Staying connected until the products reach the consumer is no easy task. Last mile challenges are mitigated with various sharing systems like bicycle sharing. With uberization making an entry into logistics, on-demand deliveries are in great demand.
A strong technology-backed logistics strategy is thus the need of the hour. After all, a smiling customer on Christmas day is the perfect start to the New Year for the logistics player looking to break new boundaries.


text:
By continuing to use the site, you agree to the use of cookies. You can find out more by following this link.
handmade shoes made with high quality leather and also with leather sole and leather inside.
Price: € 230.00
Available colours: Black
Choose your size: - - -39404141.54242.54343.5444546
Add to Cart
Giotto Firenze: Shoes - Hand-made Leather Shoes, Jackets, Bags and Accessories from Florence


text:
Cash on delivery 30-day money-back guarantee
Cash on delivery 30-day money-back guarantee
Max Muscle Smart Shaker, 550ml, Black.
Add your favorite whey protein, Shake it and Enjoy!
Smart Shaker is designed to be your favorite Shaker in the gym, you can store your essentials supplements in one smart tool.
Smart Shaker is 3 IN 1; bottle, Tablets Organizer and powder container.
It can be used for any drink, water, and a protein shake.
Made of high-quality plastic, BPA free, 5PP and leak proof.
Non-toxic Plastic.
Round Base.
550 Ml.
Easy To Clean.
Affordable Price.
100% Quality Guarantee.
|: Egypt
|: 550 Ml
|: Black - Clear
|: Plastic


text:
Free your music with the Meters Bluetooth Magnetics In-Ear leather ear-buds. Connect and go running, shopping, or enjoy on your commute. Superior HD audio without any physical connection to your device will give you a unique listening experience with all the ease of Bluetooth® connectivity.
Black, Tan, Red and Rose Gold options make sure any taste is covered and the magnetic design will make sure the headphones stay in place when youre not using them.
- Reviews
5 Year Warranty
We're so confident in our amplifiers, we offer a 5 year warranty on all new products.
Built for the road
Perfect for gigging musicians, our products are built to last.


text:
Gamay Beaujolais or Petit Syrah? California Viognier or Alsace Riesling? Don't panic.
You could fall back on that tired rule--white wine goes with fish and fowl-a Chardonnay perhaps. Beef and game gets something red; Cabernet or Merlot are safe bets. But why not be a little adventurous, tread in the waters of unfamiliar varietals?
Following are a few ideas to help expand your wine horizons.
Syrah (SIR-AH) is the most widely planted red grape in Australia, where it's called Shiraz. Known for its spicy, peppery flavors with hints of blackberry and plum, it goes very well with hearty foods, particularly Indian and Mexican.
Sangiovese (SAN-GEE-OH-VAYZE) is the primary grape of Tuscan Chianti, and gaining popularity in California. A robust wine with intense earthy flavors, it has hints of plum and cherry. Try it with meats, veal or mushroom dishes.
Rioja (REE-OH-HA) is a region in Spain, as well as a style of wine that comes in red, white and rosé. Seven types of grapes are used to make Rioja including Tempranillo, which accounts for the bold, fresh flavor of the red. Pair it with a juicy steak.
Riesling (REEZ-LING) is a sweet, fruity yet complex white wine. German Rieslings are often tart and "grapefruity,' while California Rieslings tend to be drier with a "melony' taste. Try it with seafood, Asian and Indian cuisine, and dessert.
Viognier (VEE-OH-NYAY) grapes produce medium-bodied wines that don't need much aging and are noted for apple, apricot, citrus and peach flavors. More complex than Chardonnay, it's an excellent complement to shellfish, seafood and poultry.
Gewurztraminer (GA-VERTZ-TRA-MEENER) is spicy and piquant with a fragrant, flowery nose that is reflected in its flavor. The Gewurtz grape grows in cooler climates, and the wine pairs well with Chinese and Thai dishes, as well as dessert.
You chose a wine, the sommelier brings it to the table, pours a bit in your glass and waits for your approval. First rule: No matter what you may have been told--don't touch the cork unless it looks like the wine has bled on it. Pick up the glass and take a good sniff--can you distinguish any aromas? Fruit, vanilla, tobacco? Now taste.
A wise man taught me a great technique for tasting: Sip a very small amount of wine--just a few drops. Hold it beneath your tongue for an eight count. Then slowly draw it back along the sides of your tongue and swallow. It's amazing how many subtleties you can pick up this way.
Success! You paired a crisp Sauvignon Blanc with a goat cheese and raddichio salad, and hearty '92 Zinfandel with perfectly rare filet mignon. And you have a second date. You decide to continue your wine explorations next weekend at one of the city's bars devoted to this passion. The following are a few places to get you started-- each offer "flights" that allow you to sample small tastes of different wines selected by the house for one price. Salud!
London Wine Bar
415 Sansome St.
Tucked in a corner of the Financial District, the country's oldest wine bar has a Barbary Coast feel, with big wooden booths and a knowledgeable, down-to-earth staff. Fifty or more wines, (predominately Californian with many boutique labels), are available by the glass and flights change weekly. The wine list achieves a good balance of price, variety and style. Light lunch selections and dinner appetizers available.
Hayes & Vine
377 Hayes St.
Hip and modern, with blonde wood accents and Warhol prints on the walls, this Hayes Valley locale offers vintages from all over the world. Red and white flights change weekly. Nibbles paired with wine include caviar, cheese, olives, smoked fish and antipasto.
First Crush
101 Cyril Magnin
This sultry, elegant Union Square lounge serves exclusively California wines - 350 vintages worth. Seven flights are offered daily including one devoted solely to Zinfandel and another to Chardonnay. Other flights mix it up a bit, one showcasing "big reds."
Café Niebaum Coppola
916 Kearny St.
Located beneath his film production offices, in the landmark verdigris flatiron on Columbus, Francis Ford Coppola's intimate café/wine bar/specialty gift shop offers relaxed wine tasting and prime people watching under Parisian awnings. A reasonably priced flight includes a souvenir logo glass. The Coppola-centric wine list features some other California vintages.
The Bubble Lounge
714 Montgomery St.
Swathed in velvet, with plush couches and exposed brick, this sexy, dimly-lit room offers champagne and sparkling wines served by the glass or bottle. Enjoy live music and sensuous appetizers like oysters, sushi and caviar with a flute of well-chilled bubbly.
It helps to get some of the lingo down to help describe what you're tasting, and educate your palate. Some common wine tasting terms:
Acid/Acidity: A sharp or tart taste.
Aroma: Refers to the smell of the wine, also called "nose" or "bouquet."
Balance: Denotes harmony of wine elements, (acid balances sweetness;
fruit balances against oak and tannin content).
Buttery: A feature often associated with Chardonnay. Richness, creaminess.
Chewy: High tannic content, big body, dense flavor.
Corked: Unpleasant taste or smell due to chemical changes in wine.
Dry: Little or no sweetness, very little residual sugar.
Finish: Aftertaste left in the mouth after swallowing. (Harsh, soft, lingering, smooth, etc.).
Full-bodied: Fills the mouth, weighty on the tongue.
Grassy: Herbaceous, slight vegetal undertone, associated with Sauvignon Blanc.
Hard: Refers to high acidity or tannin levels.
Jammy: Intense berrylike flavors found in reds, especially Zinfandel.
Oaky: Flavor and aroma of oak barrels in which wine was aged.
Tannic: Astringency that causes the mouth to pucker.


text:
With GTK, Glib and a few libraries/toolkits sending warnings at widget level, we recently saw people being unable to log in, or getting their system crawl. In Fedora a user reported his .xsession-errors had gotten larger than 500GB. Most of the information in that file was spammed by a single process and the output was irrelevant to the user himself.
In the upcoming MDM 1.8, the session output is limited to 200KB (between 2000 and 4000 lines of logs). This limit is enabled by default and the user can disable it in the MDM preferences. When .xsession-errors reaches 200KB, a footer is appended by MDM explaining that the limit was reached and how to disable it.
Another option coming in the MDM preferences allows the user to filter the session output. This option, which is disabled by default, prevents warnings and errors from GTK, Glib, Gio, Gobject, Glade etc… from getting into .xsession-errors.


text:
In an interview with Democracy Now!, Julian Assange said that part of the 30,000 emails he released back in March from then-Secretary of State Hillary Clinton's private server include emails pertaining to Benghazi. Specifically, many of those emails pertain to heavy weaponry being sent to ISIS terrorists and Hillary knowing about it. In fact, not just Hillary knowing about it, but "pushing" it. Here's what he said:
"So, those Hillary Clinton emails, they connect together with the cables that we have published of Hillary Clinton, creating a rich picture of how Hillary Clinton performs in office, but, more broadly, how the U.S. Department of State operates. So, for example, the disastrous, absolutely disastrous intervention in Libya, the destruction of the Gaddafi government, which led to the occupation of ISIS of large segments of that country, weapons flows going over to Syria, being pushed by Hillary Clinton, into jihadists within Syria, including ISIS, that's there in those emails. There's more than 1,700 emails in Hillary Clinton's collection, that we have released, just about Libya alone."
Then-Secretary of State Hillary Clinton laughed at Senator Rand Paul during her January 2013 testimony when he asked if Benghazi was being used to funnel weapons to terrorist organizations:
She acted as if she had no idea what Senator Paul was talking about. But she was lying through her teeth.
The CIA annex in Benghazi was being used as a hub for weapons that were collected following Gaddafi's fall. These weapons were being shipped to the Turkey-Syria border and being given to members of the Free Syrian Army – which later joined ISIS.
These militant groups were being trained by our own CIA how to use these weapons – which included surface-to-air missiles and rocket-propelled grenades. The Obama administration were arming these terrorist groups so that they would be able to overthrow the Assad regime in Syria, giving the U.S. more control over their political and military affairs.
The entire debacle in Benghazi had simply been a CIA operation gone bad. The facility in Benghazi was not even the actual Consulate. That was just its "diplomatic cover." The embassy in Tripoli handled all the consular functions.
Chris Stevens was the man in charge of acting as liaison to the Libyan terrorist groups who took over Libya following Gaddafi's fall. He worked with these groups in collecting weapons from Gaddafi's leftover regime and shipping them over to the southern border of Turkey where CIA operatives were funneling these weapons to the Free Syrian Army.
The FSA was comprised largely of Libyan Al-Qaida members whom the Obama administration has been using to topple the Assad regime in Syria. They're the same militants that we used to topple Gaddafi's regime – after which, the Al-Qaida flag flew on top of the Benghazi Courthouse. Forces were told to stand down in Benghazi, because such actions would have compromised Stevens' operation and blown his cover.
The Free Syrian Army eventually joined forces with ISIS.


text: This is a selection of our favorite soft toys from our shop. Cyril is a long haired supersoft Jellycat sloth. We love Wolfie and we love her spoon collection. Wolfie is a Donna Wilson creature. Polly is one of our favorite Luckyboysunday dolls. We love her colors and her red lipstick!


text:
I think most will agree that when you list your house for sale, you should depersonalize it, meaning take down personal pictures, etc. The thinking is you want the buyers to focus on your house and its features not your personal life!
I'm not one to make a big deal about taking down personal photos, unless there are an excessive amount of them, it doesn't bother me that much with my listings as long as the home is in show condition. I know some agents are sticklers about this and will make recommend their sellers take down even 1 personal picture.
Recently I was showing a house to some buyer clients of mine. It was a nice listing, not a foreclosure or short sale, I know shocker, huh? Anyways, the house was in really nice shape, showed well and had some nice updates including a new kitchen with granite. I have been working with these particular buyers for a while now and I thought this one had most of the things Mr. & Mrs. Buyer were looking for. We went back for a second showing but I knew it was not the one. They weren't excited about it, you could just tell. So I asked what they liked about it and what they didn't. One of the dislikes was a certain aspect of the floor plan which I had already kind of figured, but more than that, Mrs. Buyer said there was just something about it, she said it didn't look lived in, there was no personal touches anywhere. Now this home was painted neutral colors, had neutral carpet and hardwood and was clearly occupied, but as I looked around I had to agree. There was nothing on any of the walls or counters or shelves. I think they over did it, depersonalizing the home. I'm sure a professional home stager would have had solutions for this house.
So fellow REALTORS(r) what is your opinion?
And current and future home sellers remember, don't make your house look like it's not a home. Also, consider hiring or consulting with a professional home stager.
Looking for a Great agent in Macomb County? Let me GOOGLE one for you.
Mike Mitchell -REALTOR®
Real Living Kee Realty
Call / Text: (586) 291-2652
Search Macomb County MI Homes for Sale


text:
A Review of Essays in School
The Aspects of Essays in University It will not require to be hard to get caught up in anything that's occurring anytime you're planning where to apply, and forget about to make certain you're engaging in what is going to make you happy. Sensing a spot you easily fit in is just as essential as finding a fantastic place to discover. You may think attempting build up your job application total, but tend not to come to feel as with you aspire to significantly reconsider anything. You've have got to provide them an thought of how old you are and how you're like a individual in the past. Building university or college low cost by cutting out the pricey campus real estate market hands race doesn't address the simple fact that cheap isn't an absolute end up costing. Nearly all the educational facilities operate the consistent use essay prompts. You need to understand what your university or college essay is roughly. When you're away from all kinds of things you prefer to say using the essay and write essay service also that you just suggest to prove, you are able to beginning structuring the essay. Essays should really be poignant. It's just like its in conclusion. But Have You Considered Essays in University or college? In reality, you have to be with a destination to be happy at each and every classes with your listing. Advanced schooling instructors use essay simply writing as an approach to examine the functioning of their own students. On the net writing products aren't supplied at no cost.
Though you're offering advice, it will be required to get a your own type, so that it fails to turn up replicated and plagiarized. There are a lot of internet expertise providing college applying essay trial samples at cheap prices. Even though you may already know just quite a lot with regard to the theme, research can tell you way more, that you simply never imagined about. You might also try posting your own personal essay with some other many people and acquiring their options. Discover a truly extensive question so you have the different words on this planet to experience. Among my practical knowledge, nearly every issue could be astounding. Retain the message of this notice positive and be sure that you deal with the many info about the one that you actually are discover in two or three lines. As a consequence, if you're given the obligation of simply writing a slowed monthly payment letter, talking to the pursuing letter examples will supply you with a competitive understanding of drafting the two note as well as explanation letters. If you have executed crafting your cancellation notice, then you will need to produce replicates of precisely the same.
Selecting regular message closings which has been chosen https://uk.grademiners.com/assignment ever since age range isn't completely wrong, nonetheless its right use is extremely important. The following is an general set up that could be utilized to create your notice. Lots of students have a tendency to write letters completely for those attention of it. On the list of traits of the software applications system through which being unfaithful is presently essentially the most prevalent was in standard assessment. Besides the marks and examination scores, the essay created along with the school application form is definitely the primary conditions to explore if or not a candidate will likely be admitted from the faculty or otherwise not. There are many different monthly payment settings that you simply canemploy in accordance with the composing services that you are currently utilizing. University admissions really is a problematic procedure which often is dependant on a blend of fortune and the unique flavor of admissions officers. If you'd prefer to engage in a training course in almost any spot and in case you want a point, then you'll be requested to carry out a composition on the assessment. Around my college, probably the greatest in america, it wasn't strange for your specific to bring 5 or even more via the internet programs to elevate one's GPA on the typical 4.. Essays in University - the plot Voice unearths the main difference amongst the things you jot down mainly because you simply must produce something and also you certainly need to present. The next few two generations decided to go by through the identical vein. School was never a large top-secret. My guide identifies colleges and universities in every place belonging to the united states that the reality is take students. At which your individual essay goes out to every one of the training centers you are applying to, vitamin supplements are focused and simply go to see a person faculty. Hints modify the Entire world, particularly when they're put together.
The True Secret to Successful Essays in College or university You must keep the following several factors into consideration when https://owl.excelsior.edu/ writing into a college or university. The choice with your attempts are also exceedingly fundamental. No matter, regardless if you want to prepare not, it's an very important that you just will need to accomplish so as to be professional to get yourself a college degree. Once you leave coming from the reader together with the verdict it will be relatively very important to complete your little simply writing very well. Whereas posting interest letter, you shouldn't only think about fantastic posting talents but even on the backdrop in the challenge along with pertinent specifics. As a final point, university essay editing and enhancing really should find yourself which represents precisely what the prospect wishes to convey. There are many of one-of-a-kind types of faculties, so give some thought to all of the alternate options and consider what suits you most. At minimum, you may have to decide on a university having a feeling procedure which satisfies your individual. Along with other places of knowledge, you will definitely be wanted to talk about the amount of education and learning that every one of your mother and father has contacted.
Secret Shortcuts to Book Report Format That Only the Pros Know
The New Angle On Book Report Format Just Released
Students add an alternative sheet over the box. The very first one is to learn to purchase personalized newspapers out of several on-line businesses. Any way, upgrading and editing is critical should you wish to be certain that your report is error-free.
Here's What I Know About Book Report Format
Whenever you're finished writing the publication document, update the previous replica by proofreading to make certain everything is writing paper spelled out correctly with the usage of appropriate punctuation and grammar. A proposal informative article is very simple to understand.
Writing kids' books may possibly be lonely because any other sort of writing, however there exists a sizable societal take into account the manner by which the books are taken to the visitors. By means of the cooperation obtaining a article author, you will possibly fully understand how research study parts of newspaper constructing will probably do the job. Nowadays you've got the components of one's book record arranged, you should consider how you are most likely to create it.
A more typical publication format mainly comprises of five sections that may even be known as sentences. Nonetheless, essaycastle there exists no necessity to point out the format needs to just serve as helpful information and does not in any manner imply it's an ideal one since you'll find unique types of book formats. The way that you make your record specific is the fact that it comprises stories about yourself.
When your particular writer you request is busy using different missions whenever you place your purchase, we'll often have the capacity to match the sequence for a different writer who also has excellent credentials. The key purpose of the publication report is to learn whether the exhibited publication is intriguing and noteworthy plenty of. Figure out what to include in the publication report and also the best way to present the advice in the interesting, cunning way with the aid of informative article samples it is possible to see in free access online.
Ensure you cover all the more important components of the plot. Plot SummaryThis part is utilized to show everything novel is about. Then you are going to provide a concise plot summary.
A wide collection of academic paper formats exists, so be certain you understand http://transportation.tsu.edu/master-degree/ which touse based in the analyzed area. In-market segment using a tall indicator is far more inclined to coincide with the getting aim of these folks on a checklist. The examples of novel report formats can be employed by different individuals depending on the sorts of those examples.
The biggest and among the very practical tactics to possess motivated just before composing your document would be to explore your matter with your teacher. In the same time, it's simpler to understand exactly the important concept of Tolstoy compared to Hemingway. It is possible to conserve time and headaches in case you have an extremely great idea exactly what you will be writing about before you make an effort to complete the item.
Together with all our group of gurus, you need to own essays as a piece of your scenario no matter simple fact which travelling. Exhibiting that you simply consideration about exactly what's essential to all of them out your time and effort setting is crucial to create a union that's definitely distinguishable by way of a standard operating relationship. Surprisingly, as it happens that professors are a few of the absolute most felonious men and women round, as stated by this test.
Look for the book that you would want to critique. The publication was proved to be first of the 20-novel Aubrey-Maturin series, set. It's quite a bit more than just a novel outline that has a superior introduction.
To locate a formal Solutions essay, you also ought to make a robust guide. Becoming assigned a publication title to complete can look like an intimidating endeavor, specially if in the event you have never composed a high-value report. In writing a book file, Deciding up of subject is your very first step.
A personal expression in the publication is a critical component of any book file, but it's important to include both abstract and objective judgments. If you are assigned with your own first publication accounts and also have no clue just how to begin it, do not fret. Since there really are a lot of novels, also mainly since we've minimal period in our lives, we write novel reviews.
Subsequent to the back ground, it is really a great notion to send a succinct paragraph inspection of this publication. The exact first paragraph of the newspaper needs to incorporate the basic reality in regards to your book. Only exactly the oddest phrases you may possibly look at.
Creating a novel review is merely one of the fundamental expertise that each and each historian must know. Producing an informative article ways to express your academic comment on a certain matter. The best way to Write an Outline creating a publication is really just a huge undertaking for any writer plus it's sometimes a challenging and hard advancement.
What the In-Crowd Won't Tell You About Book Report Format
If lots of authors don't use a summary it is sometimes a valuable software. In the event you discover the writer didn't provide precisely what you predicted, request a revision, and we're going to make the corrections. In the event that you find it possible to, then you could also suit that debate in the broader historiography about the discipline.
Details of Book Report Format
You have your rest and find yourself a brilliant paper in due moment. Subsequently, every single body paragraph could have an alternative going dependent about the purpose of the publication report. The aforementioned pyramid, the model clarified from the book, describes how one dysfunction leads to the following and at the lengthy term, causes an undesirable sin of the category.
You might have to begin off with an overall explanation of the manner where an debate was designed. Developing a excellent thesis statement is the most essential part of the full writing process. Or else, give a good example and make clear just what portion of the argument isn't supported with evidence.
The Ultimate Book Report Format Trick
The aforementioned templates are incredibly useful and will surely be of excellent assistance for your requirements personally. Book stories are a huge region of the program. Students should follow the home straightforward approaches to develop their e-guidebook evaluation efficient and receive grasp of excellent top quality degrees.
The Ideal Approach to Book Report Format
Professionals must look carefully at the academic portion of the examination. The very first one will be always to understand to order customized papers out of several online businesses. Book reports don't will need to become uninteresting.
The Most Popular Book Report Format
It really is of the utmost value to make the appropriate diagnosis to your kid's sake. Novel reports are sometimes a fantastic means to receive your kid enthusiastic about reading. If you would like to write for kiddies and get your testimonies published you've come to the suitable location.
A multi-page report is earned from the university college student and could take a lot more than 1 evening to complete. In the beginning, pupils are very likely to become desperate to supply their examination in the rescue. Therefore, they often look for publication report help to be able to understand how exactly to compose one.
The History of Book Report Format Refuted
Evidently, you ought to see the book. Before you're ready to understand to compose a novel document, you have got to comprehend exactly everything it can be original. It needs to include things like certain demands of the assignment.
Writing children's books might possibly be lonely as any different sort of writing, however there's a large social element in the way the books are accepted to the audience. Via the collaboration obtaining a essay writer, you are going to most likely fully understand how research study parts of paper building will probably do your job. Nowadays you have the components of your book report structured, you must look into just how you're very likely to style it.
You always have to encourage your personal idea using a particular example of why you are feeling that the way you simply just do away from the narrative read. It's mandatory that you convey your mindset to this book also. Before beginning, you must pick the book you're going to compose a new record on.
If you are watching out for scrappy narrators in blustery books, then you may at the same time do Dickens. A dream publication has things that aren't actual. Beaver personalities are astoundingly resourceful.
Write a different ending for the publication, one which you prefer, however make certain that the plot outlines jive on this particular. At length, you need finalize your book report from the last paragraphs. Although you must feature a breakdown of the key plot events that you don't will need to experience every single chapter and also offer details about each item which happened.
Book Report Format Ideas
With an expert vacation rental organization, you could be confident that the quality you visit would be the caliber you'll get. Our huge assortment of templates can assist and guide a young child in a thorough manner about the perfect manner of creating a novel summary with out feeling too anxious or worried. The examples of book report formats may be employed by distinct individuals dependent around the sorts of the cases.
The Secrets of Writing Essay The english language That No One Is Discussing
Posting Essay The english language and Composing Essay English language - The Right Arrangement You're truly being reviewed over the grade from your British, to not ever the level of your respective options. When highlighting you have to think about personally and exactly how the individual experience evolved you. You receive to read more regarding life-style at high school, in conjunction with where exactly they're at and strategies which you'll have the capacity to make them. The Compass evaluate is provided by way of laptop or computer and lacks anytime limitations. The essay laws go across all instructional places and they're prepared to be applied to all of all the formatting designs and styles, far too. Moreover, you'll locate a short trial that you can know what sort of result you need to get. The 5-Moment Principle for Posting Essay Language Have mass media of all types during the fingers, if you can to. The set up of innovative formulating essays is they will obtain a reasonable plan with a quick flow of insights. It is important to clarify why the way it is is relevant.
It's also recommended that you arrange and summarize how to exhibit the thing is relating to your thesis affirmation. With out esteem to the article's significant stage, the writer need to be capable of help make the a trio of promoting issues and appropriate evidence required by your system. The conclusion from the essay openly asks a bottom line that does considered one of a few facts. The write my essay for me Crafting Essay English language Testimonies The essay is viewed as most important part your university application technique or endure exam. Faculties utilize the evaluations to distinguish some locations each student might benefit from remedial assist. Learners have got a hard time in composing once they don't get a draft or summarize to adhere to combined. Each easy browsing will have the language and conditions a university-educated student. Authoring an excellent essay requests activity of material that should not be completed in the 20-a half hour you've received through the entire assessment. There's no requirement to do new examining to get a awesome class on these ( very, you may discover a unhealthy level by ignoring to discuss the course numbers adequately ). Making Essay Language - What Is It?
Homework Know precisely what you want to produce available. Also, perhaps you may check out trial expository essay ideas so you will certainly be informed about things to search and what you would handle. You may not really know how you're sense about a theme or what you'd always like to say concerning the topic that you choose to enable the examine plus your possess believing to decide on to the end result. Thoughts alter the Planet, specifically when they're written and published. The more often you explain to us about your needs, the more effective essay help out we'll be capable of inventory. Posting for TOEFL employment is certainly not basic! The paying attention right until its possible to merge the discussion can be regarded engaging in examine. If you are able to accumulate from the history of crafting every day, it is going to help obvious the mind to get your opinions running to your remainder through the day. Settle back, it is really dependent on your disposition. Your crafting needs to be brief and succinct. You're not re-suggesting to the tale. Should you get a complex opportunity to jot down, it is possible to please take a look at quick autobiography test. Next, be sure your producing is apparent and focused. An autobiography essay relies upon the writer's lifespan http://www2.umf.maine.edu/fieldservices/wp-content/uploads/sites/99/2015/08/UMF-ST-Handbook-Fall-2016-FINAL.pdf belonging to the standpoint with the contributor. Freelance writers have a very problematic time in posting if they don't take a summary of exactly what it is because they will produce.
For additional information i highly recommend you don't be afraid to go into contact with our Customer Satisfaction. Only beneficial creating products will be able to help you receive honors. As our band of writers is quite large, we have always cost-free authors wishing to give you a achievable and nicely-paid out shop for. One Of The Keys to Effective Crafting Essay British In a very extended essay, the thesis should maintain the preliminary or minute section. You don't need to comprehend anything you give consideration to your topic when you begin making your very important planning article. There are various kinds of essays, it is not challenging to remove your eyes on all of the writing jobs. Regardless whether you've obtained to have a old fashioned paper of specific flawlessness, only purchase an essay here and our editors may give support. There are a lot features linked with resourceful publishing essays. Basically, precisely what purpose do you wish to exhibit in the essay. If you're an individual, or somebody different who's visiting do a whole lot of creating, then it is best to allow yourself with the best technological advances, notably now, when it's basically costless to get that. There's no larger methodology to accomplish this than to prepare. In reality, it ought not be exceptionally confusing, given that you may perhaps exhaust your time planning on to cover all your thinkings in the event the most crucial thesis is very elaborate. One other necessary denote work with when considering tongue is figuring out text you may be employing improperly. Each one physical structure paragraph really should be like a sub-thesis planning to prove to be a little bit part of this thesis. You shouldn't aim to demonstrate greater than 1 considered in every paragraph.
How should I compose a legislation essay?
The Basic Principles of Essay Writing Help Free That You Will be Able to Learn From Beginning Today
The Ultimate Essay Writing Help Free Trick
If you get a topic or you choose to settle a topic, you need to only write strictly with regard to this topic. Therefore, it should be easy in such a way that you will find it convenient to write around. You should start with selecting an excellent topic.
In a History article you're asked do my essays to do and answer certain jobs. Essay Assist is your here to provide you with understanding about the phases to earn a fantastic essay. On-line essays are expensiveIf you want to acquire good essays online, you need to be prepared to part with good money.
Academic papers need you to ascertain a specific angle to pursue in writing, which is going to be the basis of the newspaper. The usage of this outline would be to supply you with a blueprint' of the paper and simple reference when writing. You need to be able to shield you paper nicely.
In a fashion of speaking, you are going to be contributing to the subject of psychology through presenting your discussions. Even essays written utilizing the flow of consciousness technique have a particular goal at the conclusion of the essay. In the event it suits their comprehension, essay4less.com they will appear further.
Using Essay Writing Help Free
You may almost take into consideration the body of your document in conditions of the link between a attorney and a quote. Your readers want to discover your paper interesting from begin to finish. You don't want to have an amateur to deal with your paper, which may determine your future.
The use of the outline is to supply you with a blueprint' of the newspaper and simple reference when composing. Examples don't have to be too wordy.
Issues the students combat with At the start, the assignment writing seems easy but the truth is it's a really hard job. Again, you do not need to understand what you would like your change to be, just how you need to feel! If you're not content with the paper, don't hesitate to ask revision because your satisfaction is our final goal.
The major idea of your entire article is going to be your thesis statement. To put it differently, just what purpose do you want to express in your essay. Before beginning to prepare your essay, only observe a few examples of similar sort of essay which you are very likely to compose.
The Rise of Essay Writing Help Free
Action research papers are extremely interesting to do but you may not get the marks you're aiming to do. The article is considered http://www.vit.edu/images/PDF/VIT_Brochure_17_18.pdf most significant part your college application procedure or last exam. What's written in the draft is one and the specific same thing which will be seen in the last paper.
Essay Writing Help Free: the Ultimate Convenience!
To purchase essay writing support from our company student have to experience some measures that assist with establishing a path and receiving essay writing aid with no effort. Therefore, hiring specialist aid in essay writing is useful in lots of ways. A school essay can be extremely difficult so there isn't any reason to feel awkward if seeking help.
Describe the principal idea you need to demonstrate in your essay and begin to compose an opening sentence or two. In the first couple of lines you ought to be in a position to introduce and recapitulate your whole papers research, subject in addition to your explanation or debate. If it's essential to present the topic is front of an audience then you ought to be ready to understand the oppositions perspective point in addition to the justifications for your own stand.
To start an article, all you want to do is simply to concentrate and decide on a right name for your composition. It's tough to write a distinctive and well designed composition but does not indicate that nobody can do it.
Entrepreneurship Secrets That No A person In addition Is aware of About
The Secret to Entrepreneurship
Entrepreneurship isn't very just researched at Macalester, it's was living. Entrepreneurship is a procedure of designing, starting, and managing a new business that is definitely frequently initially a small firm. Biblical entrepreneurship is merely a single of the pursuing goes of Bra.
Business owners often experience encounter and techniques associated with several sectors that they use to produce products and solutions. That they identify possibilities, large or perhaps small, that no one particular else includes recognized. Enterprisers are seeing out for cutting edge small enterprise options and enjoying the guts it should start up a company. Though there isn't any single method to develop into a flourishing entrepreneur, there are many means to at the same time determine if students have what it requires for making it like an unaffiliated worker and as well make them indulge in activities which check the aforesaid expertise.
Any time you would like to come to be an businessperson, you've got to set up a business structure, '' your woman states. Business people are normally on a arm or leg when this regards their initiatives. For the reason that a result, they can be constantly pressing away with their convenience zone and innovating distinctive business versions every moment. Whilst they call up it the right career focus but workers deem this as a catastrophic option. In fact that they have started launching sites and apps that happen to be made meant for mobile interface only since a huge amount of folks are employing internet about the mobile now and desktops happen to be almost out of employ. Basically, the most wealthy entrepreneurs are comparatively risk-averse.
Today really recognized while an efficient means to work. As a provider increases and gives staff, authority turns into a great important percentage of a business user's skill collection. Powerful businesses have lucrative rise and market leading marketplace share over a sustained period.
When it's actually merely you, or perhaps in case you have other people in your organization that may help you compose procedures, begin with the very same absolutely consistent format and you'll come to be well soon on your way building your company's Treatments Manual. Study in the application and you'll anticipate to get the corporation away the basic quickly, as the program is specially manufactured to assist you to produce the own small business. Write down what you should prefer to achieve from the institution, and what your previous desired goals are, where do you want to lead that and how are you going to get generally there.
You may make a decision to do business with partners. The instant you get the business away the ground, it might shell out to employ a marketing manager that will certainly help you promote your internet site better. Beginning a company calls for at least that. If you entered business or your cause of starting a business is to generate a living (survive), that is a good idea to re-evaluate the options and go back to the illustrating plank once again. You are going to do well just so you know about for what reason you want to start a company inside the very first place and the way your organization will most likely be of benefit to your market. You get to construct a business around some thing you prefer and are also warm about. You ought require a blind step whenever you're most likely to established an company. Visit our website:www.shwehteestore.com
Plus d'articles...
Page 4 sur 28
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 89
Warning: Illegal string offset 'active' in /home2/fubojtzm/public_html/templates/target/html/pagination.php on line 93


text:
New Research In
Physical Sciences
Social Sciences
Featured Portals
Articles by Topic
Biological Sciences
Featured Portals
Articles by Topic
- Agricultural Sciences
- Anthropology
- Applied Biological Sciences
- Biochemistry
- Biophysics and Computational Biology
- Cell Biology
- Developmental Biology
- Ecology
- Environmental Sciences
- Evolution
- Genetics
- Immunology and Inflammation
- Medical Sciences
- Microbiology
- Neuroscience
- Pharmacology
- Physiology
- Plant Biology
- Population Biology
- Psychological and Cognitive Sciences
- Sustainability Science
- Systems Biology
Empirical confidence interval calibration for population-level effect estimation studies in observational healthcare data
Edited by Victoria Stodden, University of Illinois at Urbana–Champaign, Champaign, IL, and accepted by Editorial Board Member Susan T. Fiske October 26, 2017 (received for review June 15, 2017)
Observational healthcare data, such as electronic health records and administrative claims, offer potential to estimate effects of medical products at scale. Observational studies have often been found to be nonreproducible, however, generating conflicting results even when using the same database to answer the same question. One source of discrepancies is error, both random caused by sampling variability and systematic (for example, because of confounding, selection bias, and measurement error). Only random error is typically quantified but converges to zero as databases become larger, whereas systematic error persists independent from sample size and therefore, increases in relative importance. Negative controls are exposure–outcome pairs, where one believes no causal effect exists; they can be used to detect multiple sources of systematic error, but interpreting their results is not always straightforward. Previously, we have shown that an empirical null distribution can be derived from a sample of negative controls and used to calibrate P values, accounting for both random and systematic error. Here, we extend this work to calibration of confidence intervals (CIs). CIs require positive controls, which we synthesize by modifying negative controls. We show that our CI calibration restores nominal characteristics, such as 95% coverage of the true effect size by the 95% CI. We furthermore show that CI calibration reduces disagreement in replications of two pairs of conflicting observational studies: one related to dabigatran, warfarin, and gastrointestinal bleeding and one related to selective serotonin reuptake inhibitors and upper gastrointestinal bleeding. We recommend CI calibration to improve reproducibility of observational studies.
Observational healthcare data, such as electronic health records and administrative claims, offer the potential to estimate the effects of various medical product exposures on many health-related outcomes of interest. Population-level effect estimation has many applications throughout healthcare, including safety surveillance by product manufacturers and regulatory agencies and evaluation of comparative effectiveness for payers and providers.
A critical challenge limiting the acceptance of observational data as part of any causality assessment is the inherent uncertainty around how much we can trust the results from nonrandomized experiments. There have been many observational studies that proved to be nonreproducible (1). Failure to reproduce results likely stems from error in the original study, in the replication, or in both. Error, the difference between true and estimated effect sizes, can be decomposed in two components: random error and systematic error. Random error arises from sampling variability and is commonly reflected in most study statistics through an estimate of variance and some calculation of a confidence interval (CI) around the point estimate of the average treatment effect. Systematic error can manifest from multiple sources, including confounding, selection bias, and measurement error. While there is widespread awareness of the potential for systematic error in observational studies and a large body of research that examines how to diagnose and statistically adjust for specific sources of bias, there has been comparatively little work in devising approaches to empirically estimate the magnitude of systematic error or clinical applications that show how to integrate this error into effect estimation methods.
The acuity of this problem is only exacerbated as the size of observational databases grow: random error (the only component that is typically quantified) converges to zero as sample size increases, but systematic error persists independent from sample size. Some sources of systematic error may potentially increase if expanding the size of a data source comes with compromise in the depth or quality of the data captured. Therefore, the hype of "big data" has brought with it an increased number of studies with vanishingly narrow CIs, while our collective uncertainty about the accuracy of any given observational estimate has steadily increased. While we expect an accurate 95% CI to have a 95% coverage probability—the proportion of time that an interval contains the true value of interest—we have little empirical evidence to support that observational estimates exhibit this basic, nominal operating characteristic.
A promising development toward better explication of systematic error has been recent proposals and examples to apply negative controls as a diagnostic tool or "falsification hypothesis" (2⇓–4). Negative controls are exposure–outcome pairs where one believes no causal effect exists. Executing a study on negative controls and determining whether the results indeed show no effect can help detect bias inherent to the study design or data used. This can include bias from multiple sources, such as confounding (5), selection bias, and measurement error (6). For example, in one study (7) investigating the relationship between childhood diseases and later multiple sclerosis, the authors include three negative controls that are not believed to cause multiple sclerosis: a broken arm, concussion, and tonsillectomy. Two of these three controls produce statistically significant associations with multiple sclerosis, suggesting that the study may be biased. However, an open question is how to interpret findings from these negative controls. In this example, should we consider all study results to be invalid? Or, as the authors in this case do, should only effect sizes greater than those observed for the controls be considered to be true effects? Alternatively, is it possible that rejection of the null hypothesis for the two negative controls is caused by random chance alone and that the study is, in fact, unbiased?
One path forward is to incorporate the error observed for negative controls into the estimates of observational studies, in effect calibrating the estimates in a way similar to how one would calibrate a scale using objects of known weight. Other researchers have proposed such calibration methods using a single negative control (8, 9), but these approaches require the negative control to have identical systematic error as the effect under study, which is unlikely to be true for any negative control and will always be unknowable. In our prior work, we have shown that estimates from a sample of negative controls can be used to derive an empirical null distribution that can be applied to unknown effect estimates to calibrate P values in a manner that accounts for both random and systematic error (10, 11). In effect, our empirical calibration aims to restore nominal operating characteristics (for example, having only 5% of negative controls return a calibrated P value < 0.05).
In this paper, we extend our notion of empirical calibration to improve the validity of CIs in observational studies. We describe a statistical procedure for CI calibration that uses negative controls as well as positive controls. Positive controls are exposure–outcome pairs, where a causal effect of known magnitude is believed to exist. For reasons explained in Materials and Methods, we use synthetic positive controls constructed by modifying real negative controls. We show the procedure using three large observational databases to evaluate internal validity and show how the procedure restores the nominal operating characteristics, such that a 95% CI achieves a 95% coverage probability. We further illustrate the impact of the procedure by replicating two pairs of conflicting observational studies and examining the extent to which calibration identifies bias within each design and resolves the apparent inconsistency reported in the literature. The two pairs of studies are as follows.
i) Dabigatran vs. warfarin drug exposure for the risk of gastrointestinal (GI) bleeding outcomes as performed by Southworth et al. (12) compared with the study by Graham et al. (13). Both studies used a new user cohort design, but only Graham et al. (13) used propensity scores to adjust for potential confounding between exposure and outcome. The incidence rate ratio implied by Southworth et al. (12) was 1.6/3.5 = 0.46. The hazard ratio (95% CI) reported by Graham et al. (13) was 1.28 (1.14–1.44).
ii) Selective serotonin reuptake inhibitor (SSRI) drug exposure for the risk of upper GI bleeding outcomes in two studies performed by Tata et al. (14). The first study used a case–control (CC) design, and the second used a self-controlled case series (SCCS) design. The CC analysis produced an odds ratio (95% CI) of 2.38 (2.08–2.72). The SCCS produced an incidence rate ratio (95% CI) of 1.71 (1.48–1.98).
Negative Controls.
For each study, we select 50 negative control outcomes using a semiautomated process as detailed in Materials and Methods. One of the negative controls for the dabigatran studies is "ingrowing nail," because we firmly believe that neither dabigatran nor warfarin exposure cause ingrowing nails, and we, therefore, believe that the true hazard ratio when comparing these two drugs for this outcome should equal one. We can now apply our observational study designs to confirm whether they produce estimates close to the truth. Note that both drugs could still be noncausally associated with ingrowing nails, which is acceptable, since such an association could be a source of systematic error in our effect estimates and therefore, an opportunity to measure a study's ability to account for such error. We explore this example further below.
Synthetic Positive Controls.
We exploit the negative controls to construct synthetic positive controls by injecting simulated outcomes during exposure. For example, assume that, during exposure to dabigatran, n occurrences of ingrowing nail were observed. If we now add an additional n simulated occurrences during exposure, we have doubled the risk. Since this was a negative control, the relative risk compared with warfarin was one, but after injection, it becomes two. Using this process, we have generated positive controls based on each negative control with relative risks of 1.5, 2, and 4. To preserve measured confounding, we sample the simulated outcomes based on the predicted probabilities of the outcome for each subject that we generated by a model fitted for each negative control outcome. We provide these models in Dataset S1. For example, the largest predictors in the model fitted for ingrowing nail are prior diagnosis of "onychomycosis due to dermatophyte," "gender = FEMALE," and prior use of piperazine derivatives. The accuracy of this model as measured using the area under the receiver–operator characteristics curve for predicting occurrence of ingrowing nail in the first year after index is 0.71.
Negative and Positive Control Estimates.
In our replication of the study by Southworth et al. (12), the estimated incidence rate ratios for ingrowing nail and derived positive controls are 0.89 (0.77–1.03), 1.33 (1.18–1.50), 1.75 (1.57–1.95), and 3.30 (3.01–3.62) for real and synthetic incidence rate ratios 1, 1.5, 2, and 4, respectively. Fig. 1 reports effect size estimates for all negative and positive controls across the four studies as well as the percentage of CIs containing the true effect size. (All effect size estimates reported in this study can be found in SI Appendix.) Note that, for most studies, the 95% CIs do not show nominal characteristics; they do not contain the true effect size 95% of the time. Our replication of the study by Southworth et al. shows large bias in both positive and negative directions, probably because of the fact that the study design does not adjust for any confounding. In contrast, the Graham et al. (13) study replication shows little to no bias. Both the CC and SCCS designs in our Tata et al. (14) replications identify bias that tends to be positive.
A slightly different perspective on these results is provided in Fig. 2, where we have plotted the fractions of controls where the true effect size is above, within, or below the CI for various widths of the CI.
CI Calibration.
Table 1 shows the maximum likelihood estimates for the systematic error model parameters described in Materials and Methods. In brief, a and b are the intercept and slope, respectively, of a model for estimating the mean, and c and d are the intercept and slope, respectively, of a model for estimating the logarithm of the SD. Note that an unbiased observational study would have , , , and .
Fig. 3 reveals effect size estimates for all negative and positive controls after calibration, showing that the coverage of the 95% CIs is much closer to the nominal 95%.
Internal Validity.
To validate our CI calibration procedure, we apply a leave-one-out cross-validation approach. For each negative control and the positive controls derived from that negative control, we fit systematic error models using all other controls and compute calibrated CIs for the left-out controls across a wide range of widths. We subsequently check how often the true hazard ratio was within, above, or below the CI as shown in Fig. 4. These results show the calibrated CIs showing near-optimal coverage.
External Validity.
Figs. 5 and 6 report effect size estimates for the outcomes of interest in the original studies as well as our replications both before and after calibration. Fig. 5 shows that, for our replication of the study by Southworth et al. (12), CI calibration leads to vastly wider CIs to account for the residual bias in this unadjusted design. In contrast, for the study by Graham et al. (13), our calibration generates little effect. To account for the strong positive bias observed in the Tata et al. (14) CC replication, Fig. 6 shows that the calibrated CI not only is made wider but also, moves toward lower effect sizes.
Evidence from observational studies can only be trusted to the extent to which we have confidence in the validity of the statistics generated as part of the studies. In this paper, we discuss an empirical approach to calibrating CIs as a means of improving the value of the evidence produced from observational analyses. We showed CI calibration in the replication of two observational healthcare study pairs and evaluated internal and external validity of calibration. The procedure can be applicable to observational estimates generated from any study design as illustrated here with examples of cohort, CC, and SCCS studies from the literature. In all cases, the internal validation establishes that CI calibration restores nominal characteristics for various widths of the CI. Most importantly, the 95% calibrated CI contains the truth ∼95% of the time. The external validation indicates that accounting for potential residual bias inherent in a study design reduces the disagreement between conflicting observational studies. Not all disagreement was removed, but we would also not expect so. There are other differences between the studies for which calibration would not adjust. For example, the studies by Southworth et al. (12) and Graham et al. (13) use different populations of different ages, which could explain some of the remaining differences in estimated effect sizes.
In some analyses, like our Southworth et al. (12) study replication, the calibrated CI is much larger than the uncalibrated one. Some may object to this apparent loss of precision in the estimate, but the unadjusted study design is highly susceptible to residual bias in both positive and negative directions, and our calibrated CI merely reflects the uncertainty caused by this systematic error. In contrast, for other analyses, such as our Graham et al. (13) replication, the calibrated CI is virtually identical to the uncalibrated one. Although some might argue that, in this case, our calibration does not contribute anything, that would be incorrect. In the face of systematic error, the nominal characteristics of the uncalibrated CI remain unknown until our extensive empirical evaluation. After evaluation, we know that the calibrated CI contains the truth about 95% of the time.
This work is complementary to prior work in P value calibration, although we expect it to have a broader impact in our ability to interpret observational study results. Whereas the P value statistic has utility in the context of hypothesis testing and has commonly been used to gauge "statistical significance" at P < 0.05, the CI provides a richer collection of information: it not only estimates and bounds the magnitude of the effect, but it also expresses the extent of uncertainty attributable to both random and systematic error. While additional work should be conducted to further evaluate and validate the procedure, we believe that the evidence already provided suggests that CI calibration to quantify systematic error and produce more realistic statistics should be considered as part of standard practice in retrospective observational studies moving forward.
We require that our negative controls are truly negative, meaning that the true effect size is exactly zero. Our process for selecting negative controls requires there to be no evidence for drug–outcome pairs where both the drug and the outcome have sufficient evidence, but lack of evidence does not necessarily equate to evidence of a lack of an effect. However, an analysis of effect sizes of negative controls appearing in randomized trials suggests that the null is consistently and completely true for our negative controls (SI Appendix).
We furthermore require that our negative and positive controls are, to some extent, exchangeable with the outcomes of interest. Note that we do not require the controls to have exactly the same magnitude and structure of confounding as the outcome of interest as other proposed approaches do (8, 9) but rather, assume that they draw from the same distribution. Our leave-one-out cross-validation provides evidence that this assumption holds in general.
Negative controls represent both unmeasured and measured confounding, but our injection of outcomes to synthesize positive controls can only maintain measured confounding. As a consequence, positive controls may have less unmeasured confounding than what exists in reality, which could thereby lead to the calibration procedure underestimating the magnitude of systematic error. Nonetheless, we argue that calibration based on the systematic error that can be explicated, even if that comes with its own measurement error, is always preferable to ignoring systematic error entirely.
The uncalibrated estimates for some of our replications were not in agreement with the results of the original studies. For the study by Southworth et al. (12), this is most likely because we did not have access to the same database; for the SCCS study by Tata et al. (14), we suspect that this is because we adjusted for age using spline functions, and the original study may have used a step function instead. These discrepancies warrant caution if one wants to extrapolate our findings to the original studies, but we argue that our "replications" are still valid studies in their own right.
Here, we use 50 negative controls for each study. While an exploration of the required number (SI Appendix) suggests that perhaps that number could be lowered to 30 with little impact, selecting these controls may still require a significant amount of work. We do have a semiautomated process that can ease this burden as detailed in Methods and Materials and strive to make tools supporting this process available to the public soon.
Our process for computing calibrated CIs is computationally expensive. For each negative control, we must fit an outcome model, and we must perform the study itself not just for the outcome of interest but also, for each control. For example, for the Graham et al. (13) study replication, we need to estimate the hazard ratio for 50 negative control and 150 positive control outcomes in addition to the outcome of interest. However, as we show here, performing these computations is feasible and mostly requires computer time, which is cheap. In matters of public health significance, we would argue that computational complexity is acceptable when it leads to more reliable inference. To support the community in applying this practice, we have developed standardized tools to run these analyses efficiently and make them available as open source R packages.
As observational databases grow larger, the uncertainty caused by random error diminishes. As a consequence, the relative importance of quantifying nonrandom error mushrooms. Nowadays, observational studies report ever tighter CIs, but these do not truly capture the uncertainty in effect size estimates. We recommend producing calibrated CIs in all observational studies and presenting these calibrated intervals alongside the noncalibrated intervals to provide insight into the uncertainty inherent in evidence caused by systematic error.
Materials and Methods
Here, we provide an overview of the materials and methods used in this paper. More details can be found in SI Appendix, and the full code for executing the analyses described here is available as open source R package (https://github.com/OHDSI/StudyProtocols/tree/master/CiCalibration).
Negative Control Selection.
We use the standardized process described elsewhere (15) for selecting negative controls. In brief, information from literature, product labels, and spontaneous reporting is automatically extracted and synthesized using a logistic regression model that we fit and evaluate on existing reference sets of negative and positive controls. For each of our drug exposures, we use the fitted model to predict negative control status for all outcomes having some data not related to the exposure. We rank-order the probable negative controls by prevalence in the observational database and manually review these in order until the target number of controls is selected For the Southworth et al. (12) and Graham et al. (13) replication studies, we selected 50 negative control outcomes that are assumed not to be causally related to either dabigatran or warfarin. For the replication studies by Tata et al. (14), we selected 50 negative control outcomes that are assumed not to be causally related to any SSRI. The full lists of negative controls can be found in SI Appendix.
Synthesizing Positive Controls.
To understand the behavior of a method when the true relative risk is smaller or greater than one requires the use of positive controls, where the null is believed to not be true. Unfortunately, real positive controls for observational research tend to be problematic for three reasons. First, in most research contexts (for example, when comparing the effect of two treatments), there is a paucity of positive controls relevant for that specific context. Second, even if positive controls are available, the magnitude of the effect size may not be known with great accuracy and often depends on the population in which one measures it. Third, when treatments are widely known to cause a particular outcome, this shapes the behavior of physicians prescribing the treatment (for example, by taking actions to mitigate the risk of unwanted outcomes), thereby rendering the positive controls useless as a means for evaluation (16). We, therefore, use synthetic positive controls created by modifying a negative control through injection of additional simulated occurrences of the outcome during the time at risk for the exposure. One issue that stands important is the preservation of confounding. The negative controls may show strong confounding, but if we inject additional outcomes randomly, these outcomes will not be confounded, and we may, therefore, be optimistic in our evaluation of our capacity to deal with confounding for positive controls. To preserve confounding, we want the outcomes to show similar associations with baseline subject-specific covariates as the original outcomes. To achieve this, we fit large-scale predictive models for each negative control using regularized survival regression (17, 18). We insert outcomes by drawing from the per-subject predicted probabilities within the exposed population until we achieve the desired incidence rate ratio. The target incidence rate ratios are 1.5, 2, and 4.
When fitting the predictive models, we include covariates for demographics (age, gender, race, ethnicity, year of index date, month of index date), all diagnose codes, groups of diagnose codes (Medical Dictionary for Regulatory Activities as well as Systematized Nomenclature of Medicine groups), all drug exposure codes, groups of drugs [ATC (Anatomical Therapeutic Chemical Classification System) groups], all procedure codes, all observation codes, all measurement codes, and several risk scores [Charleston; Diabetes Complications Severity Index; CHADS2 (congestive heart failure, hypertension, age ≥75, diabetes mellitus, stroke or transient ischemic attack); CHADS2VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, stroke or transient ischemic attack or thromboembolism, vascular disease, age ≥65, sex category)]. The four replication studies return between 5,482 and 26,097 potential covariates for prediction. The full details are in the Observational Health Data Science and Informatics FeatureExtraction R package (https://github.com/OHDSI/FeatureExtraction).
CI Calibration.
For CI calibration, we build on our previous work in calibrating P values (10). Using the computed effect size estimates for the negative and positive controls, we observe to what extent random error alone explains the difference between the estimates and their true effect sizes. Systematic error explains any additional difference. We fit a systematic error model using the effect size estimates for the controls and subsequently use this model to compute calibrated CIs for the effect sizes of interest. The model assumes that systematic error follows a Gaussian probability distribution around the true effect size. We have found that a Gaussian distribution provides a good approximation, and more complex models, such as mixtures of Gaussians and nonparametric density estimation, do not improve results. Let denote the computed log effect estimate (e.g., hazard ratio) from the ith negative or positive control, and let denote its corresponding estimated SE for . Let denote the true log effect size, and let denote the asymptotic bias associated with pair i: specifically, the difference between the log of the true effect size and the log of the estimate that the study would have returned for control i had it been infinitely large. As in the standard CI computation, we assume that is normally distributed with mean and variance . Note that the traditional CI calculation always assumes but that we assume that for all i arises from a normal distribution with mean and SD that follow linear models, after appropriate transformation, with unknown intercepts a and c and slopes b and d, respectively. Specifically, we model[1]Where[2]Also, denotes a Gaussian distribution characterized by its mean and variance. We estimate a, b, c, and d by maximizing the marginalized likelihood in which we integrate out the unobserved :[3]where fixed , measured , and , yielding maximum likelihood estimates .
We compute a calibrated CI that uses the systematic error model. Let denote the log of the effect estimate for a new outcome of interest, and let denote the corresponding estimated SE. From the assumptions above and assuming that arises from the same systematic error model, we have[4]
We find the lower bound of the calibrated 95% CI by solving this equation for :[5]where denotes the cumulative distribution function of the standard normal distribution. We find the upper bound similarly for probability 0.975. We define the calibrated point estimate by using probability 0.5.
The R code for estimating calibrated CIs is included in SI Appendix and is also implemented in the EmpiricalCalibration R package (https://cran.r-project.org/web/packages/EmpiricalCalibration).
Study Replication.
In this section, we provide a short overview of how we replicate the four observational studies. Full details can be found in SI Appendix.
Southworth et al. (12) replication.
This Southworth et al. (12) study is a new user cohort design that compares new users of dabigatran with new users of warfarin for the outcome of GI hemorrhage. Subjects are required to have 183 d of continuous observation before initiating treatment, a prior diagnosis of atrial fibrillation, and no prior exposure to either dabigatran or warfarin. The study computes an incidence rate ratio without any adjustment for confounders. Time at risk is defined as the time on the drug. The original study used the "Mini-Sentinel Database," a network of private payer claims databases. For our replication, we use the OptumInsight's deidentified Clinformatics Datamart (Optum), a private payer claims database that is part of the Sentinel network. We analyze 5,982 dabigatran-exposed and 19,155 warfarin-exposed subjects.
Graham et al. (13) replication.
The Graham et al. (13) study is also a new user cohort design that compares new users of dabigatran with new users of warfarin for the outcome of GI hemorrhage. Subject are required to have 183 d of continuous observation before initiating treatment, be at least 65 y old at index date, and have no prior exposure to warfarin or dabigatran (or any other anticoagulant). Additionally, subjects are required have a prior diagnosis of atrial fibrillation or flutter and no prior diagnosis of other indications. Propensity scores are generated by fitting a model for predicting treatment assignment based on baseline patient characteristics and are used to perform one-on-one matching. Hazard ratios are estimated through a Cox regression on the matched population. Time at risk is defined as starting on the day after initiating treatment and stopping when treatment is stopped, the outcome occurs, or observation time ends, whichever comes first. The original study uses the Centers for Medicare & Medicaid Services Medicare database. For our replication, we use the Truven MarketScan Medicare Supplementary Beneficiaries database. We analyze 15,796 dabigatran-exposed and 15,796 warfarin-exposed subjects.
Tata et al. (14) CC replication.
The Tata et al. (14) CC study matches cases of upper GI bleeding to up to six controls on age, gender, and general practice. Only cases and controls ages 18 y old or older are included. Conditional logistic regression is used to estimate the odds ratio for the first upper GI bleed associated with exposure to any SSRI in the 30 d preceding the index date. The original study uses the The Health Improvement Network (THIN) database (19). For our replication, we use the Clinical Practice Research Datalink (CPRD) database (20), since both databases are United Kingdom general practice databases. We analyze 30,987 cases and 184,775 controls.
Tata et al. (14) SCCS replication.
The Tata et al. (14) SCCS study uses a conditional Poisson regression to estimate relative incidence of upper GI bleeding compared with within-person control periods. Time at risk is defined as the time when exposed to any SSRI. Also included in the model are subject age using a spline model and exposures to nonsteroidal antiinflammatory drugs and tricyclic antidepressants. Patient time is restricted to time when the patient is at least 18 y old. To account for possible contraindication of antidepressants shortly after a GI bleed, the 30 d before SSRI exposure are excluded from the analysis. The original study used the THIN database (19). For our replication, we use the CPRD database (20). We analyze 31,386 cases.
The use of Optum and Truven Marketscan databases was reviewed by the New England Institution Review Board (IRB) and was determined to be exempt from broad IRB approval, as this research project did not involve human subjects research. The use of the CPRD for this study has been approved by the CPRD Independent Scientific Advisory Committee (ISAC) as protocol number 17_017R.
This work was partially supported through National Science Foundation Grant IIS 1251151 and NIH Grant R01 LM006910. Infrastructure to carry out the project was funded, in part, by Janssen Research and Development.
- ↵1To whom correspondence should be addressed. Email: schuemie{at}ohdsi.org.
Author contributions: M.J.S., G.H., P.B.R., D.M., and M.A.S. designed research; M.J.S. performed research; M.J.S. and M.A.S. contributed new reagents/analytic tools; M.J.S. and M.A.S. analyzed data; and M.J.S., G.H., P.B.R., D.M., and M.A.S. wrote the paper.
Conflict of interest statement: M.J.S. and P.B.R. are full-time employees and shareholders of Janssen Research & Development.
This paper results from the Arthur M. Sackler Colloquium of the National Academy of Sciences, "Reproducibility of Research: Issues and Proposed Remedies," held March 8–10, 2017, at the National Academy of Sciences in Washington, DC. The complete program and video recordings of most presentations are available on the NAS website at www.nasonline.org/Reproducibility.
This article is a PNAS Direct Submission. V.S. is a guest editor invited by the Editorial Board.
Data deposition: The ISAC application forms have been deposited on GitHub and are available at https://github.com/OHDSI/StudyProtocols/blob/master/CiCalibration/extras/ISACapplication.zip.
This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10.1073/pnas.1708282114/-/DCSupplemental.
Published under the PNAS license.
- ↵
- Overhage JM,
- Ryan PB,
- Schuemie MJ,
- Stang PE
- ↵
- ↵
- ↵
- Arnold BF,
- Ercumen A
- ↵
- ↵
- Arnold BF,
- Ercumen A,
- Benjamin-Chung J,
- Colford JM
- ↵
- ↵
- ↵
- Flanders WD,
- Strickland MJ,
- Klein M
- ↵
- ↵
- Schuemie MJ,
- Hripcsak G,
- Ryan PB,
- Madigan D,
- Suchard MA
- ↵
- ↵
- Graham DJ, et al.
- ↵
- ↵
- Voss EA, et al.
- ↵
- ↵
- Tibshirani R
- ↵
- Suchard MA,
- Simpson SE,
- Zorych I,
- Ryan P,
- Madigan D
- ↵
- ↵
Citation Manager Formats
Article Classifications
- Physical Sciences
- Statistics
- Biological Sciences
- Medical Sciences


text:
Prez Mahama is naked if Stan Dogbe is managing him - Bagbin
Former Majority Leader Alban Sumana Bagbin appears to have taken off his gloves, taking the fight to Presidential Staffer Stan Dogbe, whom he accuses of insulting him.
Mr Bagbin said it was shocking that that President John Mahama, known for his benign and amiable qualities, would have "people like Stan Dogbe following him around."
'If such characters as Stan Dogbe, are those managing the president, then our president is naked, very naked!" he stated.
The former Majority Leader probably courted the anger of Mr Stan Dogbe when he told Joy FM that he had so far not seen any commitment of political leadership in the fight against corruption and that he had decided to advise the president because attempts to meet with him had failed.
Replying the experienced legislator, the Presidential Staffer wrote a treatise in which he accused the MP of lying.
"But why must he lie and expose the President of our beloved country and leader of our dear party to public ridicule when he knows very well that he was only spewing out falsehood against an innocent man,"? he asked.
Mr Dogbe also attacked the record of Mr. Bagbin as Health Minister under the late John Atta Mills' Presidency.
"What concrete actions did Hon. Bagbin take as Minister for Health when issues of concern arose in Korle Bu? If he had acted decisively and in the manner he is spewing out now, would we have been where we are"?, he asked, referring to reports of corruption at Ghana's premier teaching hospital.
The Kaleo-Nadowli Member of Parliament, responding to Mr. Dogbe's charge on Accra-based OK FM, said, "What he (Stan Dogbe) ignorantly doesn't know is that the minister doesn't take decisions."
All proposed actions, he said, are discussed with the president who ultimately takes the decisions.
He said the reforms he brought about at Korle Bu when he was Health Minister were there for all to see.
"They have been in office since June last year and they are still in first gear," Mr. Bagbin parried, alluding to the President's statement a couple of weeks ago that he was in his first gear and that things would get better by the time he is in his fourth gear.
The MP said he had been saddened by what the president, a likable person by all standards, had become. For him, it was a complete misnomer for a decorous person as President Mahama to have Mr. Dogbe as one of his confidantes.
"You all know Stan Dogbe, he is the one and he has stated that he is the first person the president sees every morning and so he is one of those managing the president; Stand Dogbe has been in the media before and he worked at Joy FM before; we all know him; you can even see the language he has used against me; in all my statements, I never insulted any single person; his statement in response is a complete insult to me and they say they have a code of conduct for the executive which was launched recently; but that is somebody very close to the president coming out and attacking his very senior member in governance; I who led the president for many years, and anchored him and supported him from his constituency to the national [level] to ensure that he is president this is the response from them against me!"
According to him, the presidency had lost touch with the aspirations of the people who voted for the governing National Democratic Congress in the last elections.
"My hopes are being dashed, that is why I am standing up to ensure that the right thing is done," he stated.
He dismissed suggestions that there was bad blood between him and the president over his [Babgin's] presidential ambitions.
"Those who are saying I have presidential ambition are saying it out of ignorance;" because it is not possible to have a succession of presidents from the north, he maintained.
The former Works and Housing Minister was genuinely concerned because "People are getting up; people are getting fed up; people are losing interest in democracy because the benefits of democracy are not getting to them."
He said he led the campaign of the NDC in 2008 across the country, assuring Ghanaians that things would be different if the party came to power.
"Is there a difference"? he asked.


text:
Hemorrhoids Tests
Hemorrhoids need to be examined by a doctor. Without proper treatment, hemorrhoids easily become a more severe problem. If you are afflicted with hemorrhoids, it is important to get them diagnosed. It is also advisable know what to expect from the tests and evaluation procedures. Your doctor are going to be able help you determine if blood loss and irritation are a result of hemorrhoids or something more serious. He or she will then be able to help you find the proper treatment for it. If you are having problems with hemorrhoids, a thorough doctor's examination is imperative. Prior to administering any tests, an examination can make the process easier for you and the doctor. Your doctor will be in a position give you an exact diagnosis and reduce your hemorrhoid-related pain.
An Anoscope is the First Type of Commonly-Used Test for Hemorrhoids
The doctor will use the anoscope to make verify that hemorrhoids are the problem. The anoscope, essentially a short hollow tube with a light on the end of it, is introduced approximately two inches to the anal canal. The light will allow the doctor to be able to see the blood vessels, if they are swollen and to what degree. It is not necessary to quick before this procedure.
Proctoscopy is the Second Test Used for Hemorrhoid Diagnosis
A proctoscope is much like the anoscope. Additionally, it consists of a hollow tube that is inserted into the colon. The light at the end, however, extends farther into the rectal area. This is usually required if you having problems with inside hemorrhoids. That allows the physician to ascertain whether the bleeding is through hemorrhoids or is actually resultant from other digestive problems.
How To Shrink Hemorrhoids Naturally And Hemorrhoids Herbal Remedies
Learn How To Cure Hemorrhoids Naturally in 2 Days! Get Rid Of Hemorrhoids Permanently Without Surgery. CLICK HERE ▻▻▻ http://www.
Third Type of Test is Called a Sigmoidoscopy
With this specific type of test, as with the two previous, there will be a hollow tube together with a light on the end that is inserted into the rectal area. The actual sigmoidoscope is more flexible and allows the doctor to look at additional to the rectal area. During the course of a sigmoidoscopy, the doctor will not only be able to look at the rectal area, but also remove any growth taking place in your gastrointestinal system that may be causing the hemorrhoids.
The main reason a doctor would opt for a sigmoidoscope would be to bend around the colon to see the edges that may have the hemorrhoids attached to them. With a sigmoidoscopy, it is important that the colon is empty. In order to clean out the colon, you may be required to take a laxative, use an enema or both, depending on your needs. This allows them better identify problems within the digestive tract or even in the rectal area.


text:
Christmas has come early at 2onthewing as we've just been awarded Best International Travel Feature at the Sabah Tourism awards ceremony held in Kota Kinabalu, Sabah, East Malaysia. The winning article, Reefs, Wrecks and Barracudas was published in Silkwinds, the inflight magazine of Silk Air and as it's the season of good will, we'd like to share it with you…… Just click on the link below and dive into some of Sabah's beautiful islands.
Tags: Sabah Tourism, Sabah's dive islands, Silk Air, Silkwinds magazine, top scuba diving islands