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Objective. A number of state Medicaid programs, including Washington, reimburse pediatricians and other pediatric health care providers to apply fluoride varnish, a caries preventive agent, to eligible patients' teeth. Little is known about the factors that encourage or impede diffusion of fluoride varnish into primary care physicians' (PCPs') offices. The objective of this study was to perform an in-depth case study of fluoride varnish diffusion in 12 pediatric, family medicine, and nurse practitioner offices that underwent fluoride varnish training.
Methods. We conducted focus groups with providers and staff in 12 community-based medical practices that had undergone fluoride varnish training within the previous 18 months. Topics of discussion included how the office staff learned about and sought fluoride varnish training, the perceived role of PCPs in oral health, oral health problems within the practice, specific details about the training, and organizational and logistic factors that promoted or impeded adoption. Focus groups were audiotaped and professionally transcribed; content analyses of the transcripts were conducted by the 3 authors.
Results. Three major themes emerged about the fluoride varnish diffusion process; these were preexisting factors, communication, and logistics. Within preexisting factors, PCPs learned about fluoride varnish through their involvement in public health-related activities and were influenced to participate in the training by their concerns for their patients' oral health and difficulty gaining access to professional dental care. Among communication factors identified as important were qualities of the training session and the communication that occurred within the practice about fluoride varnish. When staff were included in the fluoride varnish decision-making and planning process, the practice was more likely to be successful in implementing fluoride varnish. Logistic factors included systems used to identify and capture eligible patients for fluoride varnish application. Other important logistic factors that were considered included division of labor and timing of the fluoride varnish application during the visit. Access to dental care was a persistent theme throughout the focus group discussions that had an impact on the other 3 major themes.
Conclusions. Fluoride varnish can be adopted successfully into medical practice given PCP and staff commitment and openness, training that leaves participants motivated, appropriate systems, and resources for professional dental care referral. In addition, PCP involvement with fluoride varnish provided opportunities to discuss preventive oral health with families. Specific recommendations to encourage fluoride varnish diffusion in other settings are offered for program planners and PCP offices.
Dental decay is the most common chronic disease of childhood and affects a disproportionate number of low-income and minority children.1 These vulnerable children have more dental caries than other pediatric patients and encounter greater difficulty accessing timely and appropriate dental care.1 Although the American Academy of Pediatric Dentistry recommends the first dental visit occur no later than 12 months of age,2 children who are at greatest risk for early childhood caries are those who are least likely to have access to this care. Pediatricians and other pediatric health care providers may be the only source of preventive oral health education and care for very young children and others who are unable to gain access to other sources of dental care. Acknowledging this, a number of state Medicaid programs reimburse pediatricians and other pediatric health care providers to apply fluoride varnish, a caries preventive agent, to eligible patients' teeth.
Fluoride varnish is a professionally applied, highly concentrated (22 600 ppm) fluoride product that has been widely used in Europe and Canada as a caries prevention agent for >20 years.3 In the past decade, it has become more widely available in the United States. Fluoride varnish is an attractive option for the primary care setting because it can be applied by ancillary staff in <5 minutes, is generally acceptable to patients, and does not require special preparation of the teeth or expensive equipment.3 Fluoride varnish can also reverse early caries lesions (white spot lesions).4 Applications 2 to 4 times a year have been shown to decrease caries in the permanent dentition by 38%.5
In 1998, the Medical Assistance Administration (MAA) in Washington state began reimbursing primary care physicians (PCPs) $18.18 per visit to apply fluoride varnish up to 3 times per year in children younger than 19 years. With subsequent budget cuts, reimbursement was reduced to $13.39/visit. PCPs can bill Medicaid for fluoride varnish application on a fee-for-service basis even for Medicaid-managed care enrollees.
Washington was 1 of the first states to reimburse physicians for fluoride varnish application. During the past 6 years, this strategy of involving pediatric medical providers in oral health care has expanded to at least 5 other states. Despite this, little is known about physicians' experience with fluoride varnish or about the factors associated with diffusion of fluoride varnish into PCPs offices. To address this, we performed a qualitative study of 12 pediatric, nurse practitioner, and family medicine practices in Washington that underwent fluoride varnish training.
This research project was approved by the University of Washington Human Subjects' Division. In 1998, all providers with a Medicaid provider number were sent a letter informing them of this new fluoride varnish program. Those who were interested could request a 1-hour on-site training session that covered fluoride varnish application, chart documentation, and billing procedures. Additional information was provided on identification of caries, oral health anticipatory guidance for families, and the importance of professional dental care referrals. Two main groups provided training: the University of Washington School of Dentistry in conjunction with MAA (UW/MAA) and the Spokane Regional Health District. The UW/MAA training provided for hands-on practice applying fluoride varnish to children of various ages, whereas the Spokane Regional Health District had their instructor demonstrate fluoride varnish application using 1 child.
We contacted the 12 community-based medical practices, located throughout Washington, who underwent oral health and fluoride varnish training in 1 of the above capacities in the years 2000–2001. After the study was explained, all 12 offices agreed to participate and a site visit was arranged. Sites consisted of 8 pediatric practices; 2 Indian health clinics staffed by pediatricians, family physicians, and nurse practitioners; 1 nurse practitioner practice; and 1 combined pediatric and family medicine group. The proportion of Medicaid patients within the practice varied from 15% to 100%. Eight practices were located in small or medium urban/suburban areas, and 5 were located in rural communities. The various settings and experiences allowed comparison of factors that affected fluoride varnish adoption.
There was an Access to Infant and Childhood Dentistry (ABCD) program in counties where 8 of the practices were located. ABCD is a county-level program created as a partnership among the University of Washington School of Dentistry, the Washington Dental Service Foundation, the MAA, the county public health department, and a local dental society. The program provides training and expanded reimbursement to dentists to care for children who are younger than 6 years and on Medicaid and outreach, dental referral, and case management for families.
Within each office, all staff who had participated in the fluoride varnish application process, including physicians, nurse practitioners, nurses, medical assistants, and administrative personnel, were invited to participate in the focus group. These focus groups were usually held over lunch, and the staff were invited to attend for as long as their schedules permitted. Informed consent to audiotape the discussion was obtained from all attendees. Topics discussed in the focus groups included how the office staff learned about and sought oral health and fluoride varnish training, the perceived role of PCPs in oral health, oral health problems within the practice, specific details about the training, and organizational and logistic factors that promoted or impeded adoption. The focus groups interviews were conducted and recorded by 1 investigator (C.L.).
Practices had adopted fluoride varnish to varying degrees at the time of the focus group. During or shortly after the site visit, billing staff were queried about the proportion of eligible patients who were receiving fluoride varnish. Some reported applying fluoride varnish to almost every eligible patient seen, whereas others were still waiting for supplies to arrive and had not yet applied fluoride varnish to any patients. One practice elected not to offer fluoride varnish after the training.
Audiotapes were professionally transcribed. All 3 authors independently read the transcripts and identified relevant themes. Data analysis was based on extracting themes in the forms of patterns or categories that emerged from the interviews and observations made during the on-site visits. Themes were compared between readers to reduce bias and enrich the analysis, and conflicts were resolved through discussion.
Through analysis of the interviews and extraction of themes, we developed a conceptual model (Fig 1) of fluoride varnish diffusion within medical offices that we studied. This model incorporated relevant players both within and outside the practice setting (horizontal axis of model) and themes that arose during the time course of the practices' involvement with fluoride varnish (vertical axis). Three major themes emerged through the diffusion process: preexisting factors, communication, and logistics (vertical axis of Fig 1). Access to dental care was a fourth theme that emerged throughout the focus group discussions and had an impact on the other 3 major themes.
Preexisting Factors
Preexisting Factors refers to those characteristics and conditions present within and outside the practice that influenced a practice to pursue fluoride varnish. Among the office personnel, PCPs were the first to learn about fluoride varnish and to make the decision for the practice to undergo training. PCPs interviewed seemed to be on one end of the spectrum with regard to their interest in new technology and their involvement in public health-related activities. Unprompted, some of the PCPs described themselves as early adopters. In fact, a number of PCPs first learned about fluoride varnish through participation in public health efforts related specifically to oral health: "I was on the oral health coalition here in town, where there was a group that had been brought together through public health and through [a local pediatric dentist], so that's basically where I heard about it."
Some PCPs had personal or professional experience with oral health and expressed concerns about the burden of oral health problems in their patients as being an important motivation for providing fluoride varnish: "I was very well aware of the problem before. We have a high incidence [of caries]. I just get so sad when I see this. I personally think that this (fluoride varnish) is an easy thing for pediatricians to take on."
Inevitably, availability of dental resources in the community arose during discussions about the burden of oral health problems. Virtually all participants agreed that access to dental care for Medicaid and uninsured patients was difficult in their community. Within some practices, the lack of any nearby dental resources for low-income patients motivated participation in the fluoride varnish program as a means to offer at least some preventive dental care to these patients: "We have 2 dentists locally, and neither one of them takes Medicaid. … There is the Z clinic in O City (50 mile drive), but they have a waiting list for 6 months. … Considering that they can't get dental care, we really want to be sure that they get as much protection as possible."
Other PCPs wanted to know that they would have a referral source for dental care if they identified problems in their patients, through their increased involvement in oral health: "One of my concerns initially going into it is if I'm looking at dental stuff more, and I find kids with problems, and I don't have any place to send them, then why do it? "
Other concerns held by PCPs before their participation in the fluoride varnish program included that (1) fluoride varnish would take too much time and thus not generate adequate income to cover its costs; financial factors were not identified as the primary incentive for fluoride varnish involvement, and most offices just wanted to break even doing the procedure; (2) the program would not be sustained, thus disappointing families who had come to expect it; and (3) fluoride varnish was adding yet another task to the PCPs' responsibilities at the well-child care visit, as this comment reflects: "I think one of the hard parts in general about being a primary care doctor is that each group wants us to do some screening or preventive treatment for their kids. The latest statistic was that we each spent 9.4 minutes with each patient. And, yes, oral health is important, so is smoking, so are seat belts, so is assessing for maternal depression. … It's just hard to fit it all in."
In contrast to PCPs, nursing staff were less likely to cite public health-related concerns or interest and more likely to worry about the practical aspects of adding fluoride varnish to their already busy schedules: "We are so overwhelmed with paperwork and work, that to have 1 more thing added to what we do, it just seems astronomical."
A few participants questioned whether fluoride varnish should even be within the purview of the medical office, as this nurse's comment reflects: "It's not that we don't care about infants' teeth. We do. It just seems like you're asking an ice cream parlor to make pizzas."
Others questioned why medical offices, who perceive themselves as already overwhelmed with preventive care responsibilities, rather than dental offices were asked to assume responsibility for providing fluoride varnish to low-income patients, as this PCP's comment shows: "Why aren't the dentists doing it? Why are you asking the physicians to do yet 1 more thing?"
Within this overarching theme, the focus was on communication about fluoride varnish during the training sessions and on communication between the PCPs and staff and among PCPs, staff, and families about fluoride varnish. Overall, the training sessions were perceived as being very helpful. The didactic components of the training sessions, covering the pathogenesis of caries, photographic images of the stages of tooth decay, and background on fluoride and fluoride varnish, were well received. In practices located in ABCD counties, the fluoride varnish trainings provided information about and encouraged use of the ABCD program for dental referral for Medicaid patients, thus providing an important resource for these practices and their patients.
Interviewees noted that observing an actual fluoride varnish application during the training dispelled the notion that fluoride varnish application and billing was difficult or time consuming: "We saw that it wasn't that hard to do, didn't take very long to do it, gave us the mechanics, showed us what to use and showed us the billing codes, so how we can bill for it, and that it costs us about a dollar in resources as far as the fluoride varnish."
The UW/MAA trainings had made arrangements for children of varying ages to be present so that participants could have hands-on practice. Being able to practice on a child furthered the sense that fluoride varnish application was fast, easy, and do-able. In training sessions in which fluoride varnish application was only demonstrated, participants felt less comfortable with the procedure at the end of the session and were less likely to start using the fluoride varnish afterward.
Some training sessions provided extra supplies, a "starter package," for the practice to begin fluoride varnish use shortly after the training. Doing so encouraged adoption. Practices that had been trained without receiving a starter package seemed to lose momentum as they figured out how to order supplies and then waited for their arrival.
In addition to the training, communication surrounding fluoride varnish occurred on different levels within the practice setting. This included communication about fluoride varnish between PCPs and their staff. In offices with the greatest success in adopting fluoride varnish, PCPs had considered their nurses' input and important role when deciding to pursue fluoride varnish training and to implement it in their practice: "We [the nursing staff and PCP] have an open discussion about it; it's not like I'm dictatorial about it. But they're usually pretty willing to try [new things]. I think that helps."
When communication about incorporating fluoride varnish into the practice setting and the division of labor surrounding its use were not addressed adequately, some ancillary staff expressed resentment. In these comments, the nurses are upset that the role of fluoride varnish application had been delegated to them, particularly when they thought that the PCP should do it:
R3 (respondent): "I would like to able to put some of those varnishes in each room, I would like to have the papers in each room, and I'd like to see the physician do the varnish right in the room at that time. I would like for them to take the responsibility. Do it all at the same time [when they are looking at the teeth]."
R2: "That was what the understanding was. They're already in the mouth looking at the teeth, so they should do it."
When communication between PCP and staff was not adequate, adoption of fluoride varnish was slower and implementation was less effective.
Communication between families and PCPs about fluoride varnish was also important. Most interview participants agreed that PCPs were best qualified to introduce the concept of fluoride varnish to families. There were a number of comments about families' agreeing to fluoride varnish because the PCP recommended it. Fluoride varnish required an initial explanation, sometimes perceived as time consuming for a busy well-child care visit. When parents did have questions about fluoride varnish, they were generally about safety and aftercare. PCPs also used the discussion about fluoride varnish as an opportunity to encourage oral hygiene and routine professional dental care to their patients.
Within this theme, we considered the systems that were developed to provide fluoride varnish to patients and their effectiveness, as well as other implications of fluoride varnish involvement. Once training was completed, the actual incorporation of fluoride varnish application into regular, ongoing practice was the biggest challenge. When systems were not developed and instead reliance was made only on PCPs and staff to remember to use fluoride varnish, consistent use did not occur.
Identifying and capturing patients who were eligible fluoride varnish (ie, Medicaid beneficiaries) were substantial systems issues at most practices. When practices relied on nursing staff to identify eligibility, if it was not obvious at first glance of the medical chart, then fluoride varnish was often overlooked, as this comment demonstrates: "[The MDs] want [the fluoride varnish reminder] up when they go into the room … [but] we are not looking at every patient that we put down for well-child check to see whether or not they are [Medicaid] or if it's another insurance, so if we should put the fluoride varnish reminder up or not. That's how a lot of them are falling through the cracks."
Relying on PCPs to determine that a patient had Medicaid and then to request fluoride varnish without any reminders in place was not an effective method either. Most practices discovered that front office staff were best equipped to determine eligibility and to flag the chart for fluoride varnish. Different types of reminder flags were developed in the various offices and included a tooth sticker on the intake sheet and even the individual fluoride varnish dose pack clipped to the front of the patient's chart. The flag then indicated to the PCP that he or she should discuss fluoride varnish with the family and subsequently order it, preferably using an order sheet on which fluoride varnish was a preprinted option. Office staff usually documented fluoride varnish application on their record of preventive care, along with immunizations and other well-child care activities. Because MAA provides for 3 medical office claims per child per year for fluoride varnish, this allowed front office staff to ensure that a child had not already received all of his or her fluoride varnish treatments for the year.
Clinics that serve only Medicaid patients had an easier time implementing fluoride varnish because they were able to offer it to all of their patients without having to determine eligibility. However, in most practices that saw both Medicaid and non-Medicaid patients, there was interest in offering fluoride varnish to all patients. In addition to the time issues involved in identifying Medicaid beneficiaries, equity was an important consideration. Particularly in areas without community water fluoridation, interview participants expressed the belief that all of their patients, not just those on Medicaid, could potentially benefit from fluoride varnish. Practice staff were mindful that non-Medicaid patients would have to pay out of pocket, because neither private medical nor dental insurance will reimburse medical offices for fluoride varnish application. One practice advertised the availability of fluoride varnish for cash payment. "Fluoride varnish at the doctor's office" was popular in this particular community, where no dentists accepted Medicaid.
"We have some patients that aren't our patients that are coming asking about it. The word's out. And we do them on all the well-child [visits]. And sometimes you do the whole family. … Everybody I've talked to has asked for it. They say, 'We have a hard time getting dental care and it's wonderful that you can do that here.'… [Even people who are not on Medicaid have] asked about fluoride treatment. I've said, ′You know, you have to pay with cash for the visit, but it will only be $18.' And they say, 'Oh, we want to do it.' $18 three times a year, that's nothing."
Other key organizational/logistic themes that emerged included division of labor, timing of fluoride varnish application during the visit, location of supplies, adequacy of time and space, and financial impact. Application of fluoride varnish was usually done by nursing and/or ancillary staff. Although in the nurse practitioner practice, the PCP assumed responsibility for the actual fluoride varnish application, in most other practices, PCPs reported performing an oral examination, including the teeth and gums, and discussing fluoride varnish with families, but most did not apply the varnish themselves. One physician explained why he did not personally apply fluoride varnish: "The thing about the fluoride is that you have to bring [the fluoride varnish into the examination room] and you have to … know that this is a patient [who needs it], so it'd take a little bit of logistic work, and you have to glove, and [the nurses] glove anyway, because they're doing the shots. So it made more sense to me to have them do it as part of their immunizations. I mean, I think that physicians certainly could do it, but I doubt many will."
Delegating the responsibility of the fluoride varnish program to certain staff members seemed to promote more successful fluoride varnish adoption. When 1 or 2 nursing staff had "ownership" of fluoride varnish, they seemed more invested in making the program succeed in their practice. However, when it was the delegated staff person's day off, fluoride varnish could fall by the wayside.
Most offices used well-child care visits when immunizations were planned also to offer fluoride varnish. The allied staff who were responsible for vaccines usually also applied fluoride varnish because vaccinations and fluoride varnish were perceived as similar sorts of procedures that could be performed in the same physical space and time. Offices generally kept fluoride varnish in the same general location as vaccines were stored so that it was readily available. When done in conjunction with vaccination, most staff members agreed that application of fluoride varnish was best done immediately before immunizations because children were often upset and crying after their shots. Most staff avoided fluoride varnish application before the PCP had seen the child because they perceived that it would interfere with the PCP's examination, either because the child would be too upset or because the varnish on the teeth would not allow an adequate oral examination.
Although adequate time and space for fluoride varnish application were common concerns before implementing fluoride varnish, once adopted into practice, most participants reported that fluoride varnish application required minimal extra time and space, particularly when considered relative to the demands of giving immunizations: "I don't think it really adds much more time to the nurses, generally we're doing shots all the time anyway, so it's in the room doing some type of procedure. A fluoride varnish I would say doesn't even add—maybe adds 2 minutes to explain it to the parents and to put it on the child's teeth—so it's not really too time-consuming for us."
In a setting of overall declining reimbursement for increasingly involved well-child care visits, that fluoride varnish could be reimbursed was a positive motivating factor for practices. Although financial factors were not the primary reason for a practice's involvement in fluoride varnish, interview participants perceived that reimbursement allowed them to "break even" on the extra time required to explain and apply the fluoride varnish.
Implementing fluoride varnish had implications for the practices' involvement in oral health overall and their patients' access to dental care. PCPs and staff placed greater emphasis on oral health in both their clinical care and their interactions with families after undergoing training and incorporating fluoride varnish into their practice, as this PCP's comment reflects: "As I see patients, I am much more aware of their teeth [since the fluoride varnish program began]. I talk to everybody now that I see, about if they've been to the dentist and how long it's been and what kinds of concerns they might have. "
Because the trainings covered general oral health topics, including the importance of professional dental care, and provided referral resources, involvement with fluoride varnish in the medical setting was often coupled with using ABCD resources for dental referrals. ABCD was perceived as making a big difference in improving access to dental care for many of these practices' patients and provided a resource if the PCP identified dental problems through their increased involvement in oral health: "With the ABCD program … I've been able to get my patients in [to dental care], so I have a resource and that really had to be there first, before this piece [fluoride varnish in the medical office]. "
In addition, PCPs with professional or other relationships with dentists in the community believed that it was easier to make dental referrals. "Give and take" in patient care, such as doing preoperative history and physical examinations for dentists before they undertook operative dental care on a child, was considered important.
Using qualitative methods, we have described 12 Washington state PCP practices' experience with fluoride varnish. We have identified preexisting factors that influenced fluoride varnish diffusion within a practice, how communication promoted or impeded success with fluoride varnish, and the logistic consideration for fluoride varnish implementation in these practices. In addition, access to dental care was an important recurrent theme interwoven with the other 3 major themes.
Although fluoride varnish is just 1 aspect of an oral health preventive program, it provides a useful model to study diffusion of innovation and behavior change related to oral health within a medical practice. Theories on health promotion and behavior change provide frameworks to consider factors that influence this process. We have relied primarily on Everett Roger's Diffusion of Innovation6 model to understand fluoride varnish diffusion within these practices. Diffusion research was traditionally modeled on the concept of an individual's learning about new technology and making a decision for or against adoption. In these practices, a PCP or group of PCPs learned about fluoride varnish and decided to pursue it for the rest of the office staff. In general, the PCPs heard about fluoride varnish through special channels and obtained training in a relatively early stage of fluoride varnish diffusion into the medical setting. Characteristics of the PCPs interviewed are consistent with other descriptions of early adopters, which have included greater empathy, a more favorable attitude toward change, greater social interconnectedness, more change agent contact, greater exposure to mass media channels, and a greater likelihood to actively seek information.6 Our participants seemed to be on 1 end of the spectrum with regard to PCPs' involvement in public health activities and concerns about their patients' oral health and difficulties gaining access to dental care. However, diffusion research has demonstrated that successful innovations are ultimately adopted, sometimes after substantial time has passed, by those with more typical characteristics.6
After a decision has been made to adopt an innovation, the emphasis of organizations, such as these medical offices, is primarily that of implementation. As we have seen through analysis of these practices' experiences with fluoride varnish, behavior change within health care settings involves multiple players and is dependent on many factors.7 Characteristics of the PCPs and staff and their communication and logistic capabilities of the organization in which they worked determined the extent and rate of fluoride varnish implementation. Nurses who perceived themselves as already overtaxed and who did not feel included in the fluoride varnish decision-making or planning process often expressed frustration with having to do "1 more thing." Under these conditions, fluoride varnish was less widely implemented. This points to the important role of the support staff in determining a practice's success with fluoride varnish. In practices in which support staff were included in the planning and implementation process, problem solving around issues such as identifying eligible patients seemed to be more successful.
For practical reasons, most medical offices applied fluoride varnish in conjunction with immunizations. However, connecting fluoride varnish with vaccines limits opportunities for fluoride varnish application after 18 months of age, when the primary immunization series usually has been completed. We would encourage medical offices to use other visits, such as acute care visits and sports physicals, as opportunities for oral health anticipatory guidance and assessment and fluoride varnish application.
Patients and their families, as recipients of the preventive effort, and their environment could also influence this program's success. In these practices, when systems were in place such that families were offered fluoride varnish by the PCP, they seldom refused. The environment in which patients and their families live, particularly with regard to the availability of professional dental care in the community, also affected the fluoride varnish program. In 1 practice, fluoride varnish was seen as the only source of dental care in a setting where no local professional dental resources were available for low-income patients. Other PCPs wanted to know that dental resources were available if they identified dental problems in their patients.
Offices that implemented fluoride varnish in the context of promoting oral health and encouraging professional dental referral were most successful when they did so in partnership with dentists either through ABCD or informally. For example, in Spokane County, a respected pediatric dentist worked in conjunction with the Spokane Regional Health District to provide the fluoride varnish and oral health trainings to the medical offices. In doing so, he also identified himself and his colleagues as available for consultation and dental referrals and promoted the ABCD referral telephone line that connected Medicaid beneficiaries with local dentists for care. Where medical offices in this county had previously struggled to identify dental care options for their lower income patients and children with acute dental needs, they now had a confirmation of actual dental resources available to them and their patients.
Finally, characteristics of the training session and of fluoride varnish, considered collectively as "the innovation," also affected the diffusion process. Rogers6 identified 5 attributes of innovations that influence the extent and speed of their diffusion. These attributes—relative advantage, compatibility, complexity, trialability, and observability—help us to understand which factors promoted success with fluoride varnish (Table 1) and can inform certain recommendations for both program planners and PCP offices for how these results may be applied in other settings (Tables 2 and 3).
It is important to acknowledge the limitations of qualitative research. What occurred in these 12 practices in Washington may or may not be applicable in other locales. Moreover, these data were collected retrospectively and thus considered only practices that elected to pursue fluoride varnish training. Nevertheless, we believe that findings from this study can provide useful information to guide oral health programs in primary care practice.
In conclusion, diffusion of fluoride varnish into medical settings occurs over time and is dependent on a number of players and factors. Within medical practices, consideration of preexisting factors, communication, and logistics all were important as a practice attempted to adopt and implement fluoride varnish. When fluoride varnish is adopted successfully by medical offices, it offers an effective and straightforward caries prevention strategy for children who have traditionally had difficulty gaining access to professional dental care. Besides allowing PCPs and their staff to expand their clinical focus to include oral health, it provides an opportunity to emphasize further to patients and families the importance of good oral health and professional dental care.
Dr Lynch was funded by the Robert Wood Johnson Clinical Scholars Program. Dr Lewis and this project were funded by K23 DE14062-02 from the National Institute of Dental and Craniofacial Research. Additional funding for this research was provided by the Washington Dental Service Foundation and the Spokane Regional Health District.
We gratefully acknowledge advice and guidance throughout this study from David Grossman, Peter Milgrom, and Agnes Spadafora. This study could not have been done without the assistance of Michelle Vanderlinde, Karen Davis, and Ida Ovnicek from the Spokane Regional Health District and Margaret Wilson from Medical Assistance Administration of the Washington State Department of Social and Health Services. In addition, we acknowledge the invaluable research coordination and administrative assistance provided by Ann Nykamp and transcription services by Elana Epstein.
- Accepted September 1, 2004.
- Reprint requests to (C.L.) University of Washington, Box 354920, Seattle, WA 98195. E-mail: cwlewis{at}u.washington.edu
No conflict of interest declared.
- Copyright © 2005 by the American Academy of Pediatrics


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The biggest challenge any organization faces from time to time is to ensure the constant level of productivity from its employees throughout the year. However, for every employee, the level of motivation varies from their hierarchy and from hour to hour forget about the year.
Shifting focus to our homes on to the homemakers or the working mothers, we do not find any major fluctuations in their level of commitment and productivity. Everyone has a mother at home or a wife for some, who handles the entire home related problems single-handedly in most of the cases.
Everyone knows that mother and mental strength go hand in hand. But more often we forget that in the end, even she is a human being. She too has a limit to handle mental pressures around her. Among mother's day gifts just add one more thing to make her feel a bit better, which is a little bit of understanding and care to showcase.
Growing children are always mother's biggest challenge and in their life's journey on the highway of life, they need expert guidance from parents. Mother's are the go to and feel good factor for every child no matter how old he/she has grown.
The daily routine starts from the early morning with preparations for breakfast, Tiffin and getting everyone ready on time. These are some of the biggest challenges that a mother faces on day to day basis without any complaint. Working mothers have a daunting task at hand to strike a right balance between professional and personal lives.
On this mother's day we have brought some tips for all the mothers, special focus on working mothers on how to balance the work, kids and maintain the mental strength:
Prepare Your Schedule And Manage Time
Time is the most critical substance at hand which never comes back and needs to be planned in a proper way. This will vary from a nuclear family to a joint family. Modern society is witnessing wider roles for mothers with add-on responsibilities on to their shoulders. Free availability of uncensored information requires constant monitoring and one on one talk with the children to save them from any wrong involvements. If you are working you need to schedule your time in such a way that you have not missed a point and are fresh even after constant work. A well winded time will ensure less physical and mental fatigue. It will also give you some time for yourself to replenish the thought process.
Eat Good To Build Immunity
Enough can be talked about the mental strength and mother but unhealthy mother means the family will suffer. Working women are exposed to lots of pollution and prospective antigens while traveling and meeting people. They need to eat good food to build their immunity to help develop resistance to any diseases. Also, a healthy mother can easily handle any family situation that may arise. Include fruits, vegetables, fibers, milk, and juices into the diet to help your body recover fast.
Exercise And Stay Fit
Gifts have a positive mental influence, especially among the ladies. As the mother's day gifts include a yoga class course for self or join the local fitness club to keep self physically fit. Just take 30 minutes walk in the park daily which will give you ample exposure to nature and oxygen to boost your fitness level. A fit and healthy body mean a happy mind.
Creating Happy Environment
A good mental health is very closely related to the degree of happiness in relations and environment you live in. Outing with the family every weekend or at least once in a month with lots of images helps create happy memories. Also, activities like family games, singing together, shopping and watching the movie together are some of the bond building methods which create a happy living environment. In office speaking to the positive people enhances the mental level and keeps your focus on important matters.
Find Your Emotional Sink
Women are bound to emotions more strongly than men. And more often they need to let the negative emotions out otherwise it interferes with their work. Friends are the best buffers for any negative emotions, however many a times they are not available on time due to their own life. One should remember that negative emotions are nothing but negative energy which needs to be properly channelized in order to neutralize its effect. The best ways are to start a new creative hobby this could be anything other than what you do in routine work. It can be drawing, sketching, photography, dancing, singing, and gardening or even visiting a park every now and then gives a clearer perspective. All these activities along with talking to anyone like the husband, in-laws, parents, friends or even children if they are grown up enough to understand.
Conclusion: At the time when the mother stops us from doing anything each one of us in our life has interrupted her with an argument that I am mature enough and know what is right. In doing so we forget that again when the time comes to show that real maturity we prefer to show our naïve side. The mother needs to be always on the alert. She cannot afford to make a mistake on any front of her life starting from office if she is working to the home where it's not about profit but about being together. All these add up to the physical and critically to a higher level of mental pressure. So this mother's day, don't just wish her happy mother's day but make each day mother's day. It is a time that each one of us realizes that we are mature enough and sit alongside our mother to tell her no matter what the situation be we love her. And when the problems come we will be together to handle them. And ladies you can always feel proud of what you have been constantly achieving with the resources at hand. The best technique to stay happy and mentally strong is to build in the positive mindset system. Never allow any negativity to influence your mind. Your positivity helps people around you to be positive which comes reciprocating back to you. So keep up the good positive vibes.
So make your mother's feel special here are some beautiful gift recommendations:
For more gift Ideas, go to Amazon by clicking this link and make your mother's feel special and Happy.

subset: commoncrawl


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Brenda Gilbert has been named president of British Columbia, Canada-based Bron Media Corp's Bron Animation, and she has named three new VPs to the division's leadership team.
Gilbert co-founded Bron with Aaron Gilbert in 2010, and she will continue to serve on the board of Bron Media Corp – which also has production, financing and film releasing divisions – in addition to heading up the company's animation arm. While she has been involved with various aspects of Bron since its inception, she will now be more focused on the company's animation activities.
Among the three VPs named to the Bron Animation team are Adam Wood, who has been appointed VP of creative, with Teunis de Raat named VP of digital and Luke Carrol named VP of production and development.
Wood joined Bron in 2012, hailing from Pixar Studios where he worked on films such as Toy Story 2, Finding Nemo and Monsters Inc. While at Bron, he's worked on projects such as Mighty Mighty Monsters and the studio's upcoming CGI-animated project, Henchmen.
De Raat has been in charge of production technology at Bron since 2012 and has also held senior-level positions at Pixar Canada, Disney and Image Movers.
Carol, meanwhile, has been with Bron since 2013, and he is currently serving as a producer on Henchmen. Carol's previous credits include The Weinstein Company's Escape from Planet Earth.
From Playback.


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Acupuncture is a safe and effective method of treating the arthritis. Here special body points are used for treating illness and for stimulating the energy of body.
Arthritis is has become one of the leading cause of disability worldwide. The term arthritis does not denote just 1 disease----but is a complex disorder that includes several distinct conditions. Arthritis can affect a person at any age but it is more common in the elderly. The commonest types of arthritis are----osteoarthritis and rheumatoid arthritis. Although, the cause, risk factors, and effects of various types of arthritis are different they have a common symptom—persistent joint pain.
The prescription medications used to treat arthritis are not very effective and the side effects of the medications can be problematic. Due to these limitations of the prescription medications people with arthritis often go for alternative therapies.
But a dilemma is ----whether these treatments work? And are they safe?
Can Acupuncture Help Relieve Arthritis Pain?
According to acupuncture an illness is caused by a disruption of Qi, or the flow of energy in the body. This leads to an imbalance of energy. Acupuncture by stimulation of the energy that flows along the meridians, or energy-carrying channels can correct this energy disruption and help the body to heal. Acupuncture also stimulates the body to secrete chemicals that decrease or eliminate painful sensations.
Before starting acupuncture treatment the acupuncturists will take a detailed history like ask you about your primary health concern, lifestyle habits, food habits and appetite, pain in the joints, sleep, stress, and sensitivity to temperature, and climatic changes. He or she will examine you, and make a diagnosis---- and then choose the acupuncture points for treatment.
The Acupuncture Treatment
Acupuncture points that are used to treat arthritis are found all over the body and are not located just directly over the affected area. When the needle is inserted you will feel a slight sting or prick. After the needle is inserted, you should not feel any pain. During the treatment you should feel comfortable and relaxed. Your acupuncturist can guide you regarding the number of treatments you need and how often you should come for them. Your acupuncturist may recommend use of herbs along with acupuncture.
Studies on Acupuncture and Arthritis
Studies have shown that acupuncture can be very effective at treating the pain and inflammation associated the different types of arthritis.
In a study in 25 percent of arthritis patients who were to undergo knee surgery for arthritis the operation was cancelled following acupuncture treatment---as they had considerable improvement in pain and functional ability after acupuncture treatment. This change was not noted in patients who received advice and exercise therapy. This shows that acupuncture is more effective as compared to advice and exercise in relieving pain and functional limitation in people with arthritis. In another study in elderly arthritis patients with knee pain due to arthritis showed significant improvement after acupuncture was started in addition to their standard therapy.
The Bottom Line
Acupuncture is a low-risk procedure, safe and effective procedure when performed by a properly trained and licensed practitioner. Acupuncture can be of help in people with arthritis. You can continue the use of your prescription medications along with acupuncture. Before you start acupuncture inform your regular healthcare provider.
All possible measures have been taken to ensure accuracy, reliability, timeliness and authenticity of the information; however Onlymyhealth.com does not take any liability for the same. Using any information provided by the website is solely at the viewers' discretion. In case of any medical exigencies/ persistent health issues, we advise you to seek a qualified medical practitioner before putting to use any advice/tips given by our team or any third party in form of answers/comments on the above mentioned website.


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Blichmann Engineering has done it again! Their line of Fermenator conical stainless steel fermentors are the pinnacle of form and function for today's homebrewer. This is the 7 gallon tri-clamp model, which comes complete with tri-clamp fittings.
These fittings for the bottom dump and racking arm offer unparalleled cleaning and sanitation advantages over its NPT brother. The tri-clamps can be broken down and taken apart with ease, as the seals are made via o-rings, not threaded joints. No need to wrap and rewrap with pipe thread! Blichmann takes pride in using only 304 stainless steel, and the interior all-weldless construction can't be found anywhere else on the market today!
Perfect for up to 5.5 gallon finished batch sizes of beer, or 6 gallons of wine, cider, or any other fermented beverage!
Minimum interior refrigerator dimensions:
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The New BMW Motorrad Navigator V. The State-of-the-art, Safe And Reliable Guide
The new BMW Motorrad Navigator V. The state-of-the-art, safe and reliable guide – Sep 24, 2013– Munich, Germany (AutoReleased) – BMW Motorrad presents the new Navigator V featuring a large and bright 5″ TFT Display as well as functions precisely tailored to the rider's needs. The premium-class, Bluetooth capable GPS navigation system is not only a reliable guide on and off the roads of Europe, but also when not in use on the motorcycle. With an automobile mounting kit the powerful GPS unit can also be used as a navigator in the car. The navigation system can be used as a hands-free speaker phone for Bluetooth mobiles thanks to the loudspeaker and microphone integrated into the holder.
The navigation unit is available either with preinstalled map data of Europe, North America or without preinstalled maps. If a customer decides on the version with preinstalled maps, he receives lifelong access to map updates (Lifetime Map Updates – LMU). In order to plan routes, the user can download the Base Camp tour planning software free of charge at www.garmin.com or install it directly from the installation file on the navigation device itself. Memory capacity of the Navigator V can be expanded to up to 64 GB using an additional SD card slot.
The new trip technology featured by the Navigator 5 defines the state of the art with regard to route planning and routing. It allows the user to create longer and more detailed tours with up to 3,750 shaping points per trip. The navigation instructions – e.g. via Bluetooth using the BMW Motorrad communication system –are partially spoken using Real Directions. For this the route is described using clearly visible points of orientation. Instead of saying "turn left in 100 metres" the system instructs: "turn left at the yellow church". For safe offroad navigation, the Navigator V displays a large compass.
Map zooming is finely graduated and offers many comfort features such as a lane assistant and 3D building display in many cities. One of the many other options the Navigator V offers to the rider is PhotoNavigation: Geo-coded pictures stored in the device can be clicked on to start navigating towards that location. The unit features a fully-fledged travel computer, a home function for fast routing to the home address and beeline offroad waypoint navigation.
The Garmin Smartphone Link is optionally available and provides a lot of useful information during the tour. The free Smartphone Link app is available from the Google Play store and the iOS app store. After pairing the smartphone with the Navigator V, freely available contents can be called up such as basic weather as well as live services (subject to a charge) such as real-time traffic congestion information and detailed weather reports. The Navigator V is compatible with the free Garmin BaseCamp route planning software. This can be used to easily create routes, waypoints and tracks and transfer them to the navigation device.
Thanks to the 4-button mount cradle, the waterproof and petrol-resistant housing of the Navigator V can be fixed safely to the motorcycle and easily operated, even using gloves while riding. On the R 1200 GS and K 1600 GT / GTL models many functions can also be controlled directly using the multi-controller on the left of the handlebars.
The BMW Motorrad Navigator V is powered by an integrated and exchangeable lithium ion battery which supplies up to four hours of power. While riding, the battery is charged via the motorcycles on-board power system. It can also be charged via mini USB at the computer or using an optional charging unit.
The BMW Motorrad Navigator V is supplied with a micro USB cable, a practical carrier bag, screw driver and lifelong map updates (only applies to the Europe and North America version).
Unit dimensions: 136 x 83.4 x 24 mm
Display: 5″ TFT, 800 x 480 pixels, 65,000 colours
Weight: 288 g


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2015's Dec 24 is commemorated as the birth of Muhammad (PBUH), while the next day, Dec 25, is Christmas – originated from the words "Cristes moesse" or 'the mass or festival of Christ'- a celebration of the birth of Christ.
The birth of two great individuals of all time, commemorated side by side. This sends a strong message to the Universe. And to me, the message is the (re)birth of Peace.
The word birth in latin is nascent, which means "just coming into existence and beginning to display signs of future potential." The potential that is exemplified and re-emphasised by the beloved Prophet Muhammad and Jesus Christ (peace be upon them).
The potential, that is, to truly be human being. To be muslim – someone who is in complete submission and therefore an expression of Peace of Perfection and Mercy to the universe. To be christian – someone who says with Saint Paul 'I live; yet not I, but Christ liveth in me', and hence is the 'peacemaker par excellence'. The potential to be Peace, or rather, for Peace to be. The potential for us to be peacemakers.
But peace can only be when self is not. And self remains as long as there is inner-movement (in the mind). Hence for a self to not be, one needs to stay (still), without any commentaries or analysis of what is happening, without looking any other way. In the words of the Qur'an (QS 6:91), one simply needs to "Say: "God!" – and then leave them to play at their vain talk." By "saying", it means expressing, manifesting.
Thus one needs to "say God", that is, to allow – with complete awareness and submission – God and only God to express. To stay (with Him), without commentaries or analysis. To stay, until there is fana' (i.e. the passing away from self). To stay, until salaam (Peace) radiantly manifests, enveloping all four corners of the universes.
As Saint Gregory of Nyssa so beautifully puts it, "Peace is indeed the greatest of joy-giving things; and this He wishes each of us to have in such measure as to keep it not only for himself, but to be able to dispense from the overflow of his abundance also to others. For He says, 'Blessed are the peacemakers'.
Now a peacemaker is one who gives peace to another; but one cannot give to another what one does not possess oneself. Hence the Lord wants you first to be yourself filled with the blessings of peace, and then to communicate it to those who have need of it."
It is high time for Peace to yet again shine forth in this world. It is starting to do so. Peacemakers are emerging all over the world. Restlessness – which is the other end of the peace spectrum – is growing, gaining momentum for the pendulum to swing the other way.
The commemoration of the birth of the two Great Ones is but good news of such potential. It is an invitation to Peace. It is a call for action to anyone who can and is willing to hear to be peacemaker, first to oneself, then to fellow beings, and then to the whole universes.
Can we hear? Are we willing? Are we staying?
God knows best and He guides the Way.


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By Cory Phare
From Dracula to Nosferatu to Edward Cullen, our obsession with vampires spans centuries and archetypes.
So, what is it about these bloodsuckers that makes them so compelling to us mortal day-dwellers?
"Part of the attraction of vampires is the age-old promise of eternal life, and blood has been associated with life as far back as Leviticus," said James Aubrey, Ph.D., professor of English at Metropolitan State University of Denver. "Vampires also appeal to the common wish for more power over one's environment, including over other humans."
Aubrey isn't just another fan – he's an expert currently teaching a section of the University's popular Vampire Films course. Here are his picks for six vampire flicks that are sure to leave you dead – and loving it.
Let the Right One In (2008)
This is the story of two lonely 12-year-old kids in Stockholm learning to love each other. One is being bullied at school, and the other is a child vampire, with the classic line "I've been 12 for a long time." Oskar is infatuated with everliving Eli, but this is more than a schoolhouse melodrama with no parents in sight – the mood is as dark as Sweden's long winter nights. If the plot feels familiar, it's because this flick was remade in the U.S. as "Let Me In," but the original Swedish version is more creepily, sneakily engaging.
Byzantium (2012)
"This medieval saga follows a vampire mother-daughter duo on the run from a male-only vampire society seeking to rid the world of these upstart females. Although set in a seedy town on the English Channel, the vampires originate from Ireland (coincidentally, on that same rocky island where Luke Skywalker was found in The Last Jedi). Gemma Arterton and Saoirse Ronan are terrific as the ruthlessly protective mother and her sensitive daughter, the latter of whom becomes romantically interested in a local boy between mercy killings."
Cronos (1993)
Director Guillermo del Toro's first film is set in Mexico City where an aging billionaire's search for eternal life leads him to a magical device, dubbed Cronos, that grants his wish – but also gives him a lust for blood. As in del Toro's "Pan's Labyrinth," an important character in the movie is a brave 10-year-old girl whose grandfather first discovers Cronos inside an antique statue in his shop.
Near Dark (1987)
A nomadic family of vampires travels around in a sun-proofed RV, "the Winnebago from Hell," as director Kathryn Bigelow has called it. They are extremely violent and don't adjust easily to a new family member, abducted by their daughter from a farm in Oklahoma. The movie has been called a "vampire western" but it's too beautifully lighted and filmed to fit readily into either genre. This was Bigelow's first movie as solo director before going on to become the first woman to win an Oscar for Best Director for "The Hurt Locker."
Da Sweet Blood of Jesus (2014)
This Spike Lee Joint focuses initially on Dr. Hess Green, a wealthy African-American man who collects ancient artifacts, including a mysterious ceremonial knife. He develops a thirst for blood after his valet stabs him with the knife – and then shoots himself. When valet's wife, named Ganja, comes looking for her husband, she and Green fall in love, and he turns her to a vampire as well. Problems arise when Ganja finds herself attracted to a would-be victim they have invited to – and for – dinner. Lee's film, set in Brooklyn and Martha's Vineyard and scored by Bruce Hornsby, is a remake of Ganja and Hess, a 1970s indie flick that drew raves at the Cannes Film Festival.
What We Do in the Shadows (2014)
This mockumentary by the creators of Flight of the Conchords follows four vampires from different historical periods, each with different quirks, all sharing an apartment in New Zealand. A flat meeting devolves into hilarious arguments over housekeeping chores, including who will do the bloody dishes that have been piling up. For the 18th-century vampire-dandy, getting ready for a night out at the club is a particular challenge when he can't see his reflection in a mirror. Then there's the local gang of werewolves – problems, problems.
©Copyright 2019 by Metropolitan State University of Denver. All rights reserved.
MSU Denver Office of Marketing and Communications


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PLEASE NOTE: THE BEST BEFORE DATE IS END OF July 2020 (SEE T&C)
About SiS Protein Bars – Chocolate & Peanut Flavour
SiS Protein Bars contain a blend of easily digestible proteins (20 grams per bar) in the form of whey, casein and soy protein. It is important to consume protein in close proximity to training sessions (i.e. before or after training) in order to maximize training adaptations.
Protein intake is often overlooked by endurance athletes. SiS Protein Bars provide an appropriate quantity of high quality protein for before or immediately post exercise.
Benefits of SiS Protein Bars
Adapting to the demands of endurance training is facilitated by increased muscle protein synthesis whereby new proteins are made in our muscles after each training session. The muscle becomes reconditioned so that it can better withstand the physical demands during the next training session.
For optimal protein synthesis to occur, it is crucial that we consume high quality protein given that protein contains amino acids that make new proteins. SiS Protein Bars contain a blend of easily digestible, quality proteins that act as a trigger to stimulate protein synthesis.
Key Features
- High protein formula to promote training, adaptation and recovery
- Each bar contains 20 grams of easily digestible protein
- A high quality blend of whey, casein and soy protein
- Promotes the rebuild of muscle following exercise
- Contains Peanuts, Milk, Soya, Gluten
Informed Sport Registered: Our complete product range is developed using a world-class approach to banned substance testing, providing assurance for athletes.


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The first Three Musketeers 3D teaser trailer has landed and it's filled with all the ridiculous action one comes to expect from Paul W.S. Anderson these days. Far from being a bad thing, the action packed style shows off how fun this version of the story can be.
Yeah, looks like crazy fun to me. I know it's going to be mindless, but at the same time I kind of like that. Not every film has to be an Inception on the cerebral level. Sometimes you just need sword fighting and shit blowing up.


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We love women, the older the better!
Sorry. We say that because roughly 70% of our bookings come from women and 70% of bookings are 60+ years old. This has given us the mantra: "The old are more adventurous than the young, and women more adventurous than men". Come on young man, prove me wrong!
If you are considering a trip with me you may have questions or doubts about your suitability for an off the beaten track trip in some of Africa's lesser known regions. But I have learnt that the only adaptation seniors need is to have a chair to sit on in the evening and portable stool with a loo seat for those unforseen moments in the bush! You will know your limitations and we can work any trip around your requirements. All of our staff and every community we pass through are always willing to lend a hand.
My benchmark is my Mum, who test drives all of my trips and so far she has not complained. perhaps she is biased, so ...
Some words from my senior clients:
Freda Fleischer was born in 1921 in Vienna. She is Jewish. At the age of 18 she escaped from Nazi Austria to England and became a nurse during the war, a doctor after the war, and was a published travel writer. I took her to Timbuktu at the age of 90.
The names of two places have always spelt Magic for me and my partner. One was Bokhara, the other Timbuktu. We did get to Bokhara in 1977 and were not disappointed but somehow Timbuktu eluded us. Finally I went on my own.
My only worry was whether my age would be an obstacle. One travel agency had been very hesitant and wanted me to find a companion! I found Guy on the Internet and he fitted the bill. To my great surprise he had no reservation when I told him my age.
I am lucky since I am very fit and actually never think of age, accepting that I have slowed down and do require help under certain circumstances. I did not expect 'luxury' but wanted to get a feel of the country and its people and this was exactly what happened. Anyone who is eager to visit a country like Mali, which is poor on material things but rich in every other aspect, should go with Guy. He and his staff care and will look after you. You will not be disappointed.
Freda Fleischer (90)
Irene and her husband Gabriel are both veterans of the second world war. Gabriel flew in Halifax bombers and Irene was a wren.
Thank you for a wonderful exciting and unique journey in Mali. It was not only the "sights" we saw but the opportunity to see the lives of families and especially their children in their surroundings following their own way of life - not at all a show put on for tourists. I loved their friendliness and smiling faces towards us as we travelled. The Dogon valley and its people were especially of interest and I'd like to learn more about their history and culture. The first camp site on the Niger gets into my list of the 6 best camp sites in the world. Many many thanks for an amazing journey.
Irene Aitman (85). Bespoke trip to Mali, January 2010
Ann Gover Ann is in her 70s. She is an artist from Bristol, UK.
A wonderful trip giving westerners an opportunity to experience the vibrancy of Africa, meet African people and see something of their lives. Best wishes, and thank you for all the trouble you took to make the trip such a success.
Ann Gover
Val and Geoff Mead, both in their seventies, came on the same trip as Ann, Irene and Gabriel - they made up my first trip with only senior travellers (the average age being 78). Geoff was worried about a long standing back problem, worried most about the Dogon trekking. We adapted the route we took and if he needed to stop walking we had a vehicle ready for him; in the end though, Geoff managed the climb up the Dogon escarpment and I don't think he ever took the vehicle option!
We have travelled widely in Africa and elsewhere, but the Mali experience was unique. From Here 2 Timbuktu made sure that we saw all the major attractions, and the strange and colourful culture of the Dogon people, in particular, will long remain in our memory.
Val and Geoff Mead


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When you check out Nex 2 Nu Auto Sales to search for a car, you will be happy with the selection you have made. Our dedicated sales associates are knowledgeable, and here to assist you find the best vehicle to suit your needs. You'll find a large selection of vehicles to pick from, we also have cars in order to suit any budget. Nex 2 Nu Auto Sales is now Rocky Mount's best place to get a used vehicle. With incredible customer care, and competitive prices, you won't ever need to go anywhere else for your auto buying needs. So stop by Nex 2 Nu Auto Sales at 2412 Sunset Ave, Rocky Mount, North Carolina 27804 and let us to show our world class service. So come check out Nex 2 Nu Auto Sales of Rocky Mount at 2412 Sunset Ave, Rocky Mount, North Carolina 27804 and let us assist you in getting the car you've always wanted.


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Cookies & Privacy
Cookies Policy
Our website uses cookies to distinguish you from other users of our website. This helps us to provide you with a good experience when you browse our website and also allows us to improve our site. By continuing to browse the site, you are agreeing to our use of cookies. A cookie is a small file of letters and numbers that we store on your browser or the hard drive of your computer if you agree. Cookies contain information that is transferred to your computer's hard drive.
We use the following cookies:
- Strictly necessary cookies. These are cookies that are required for the operation of our website. They include, for example, cookies that enable you to log into secure areas of our website, use a shopping cart or make use of e-billing services.
- Analytical/performance cookies. They allow us to recognise and count the number of visitors and to see how visitors move around our website when they are using it. This helps us to improve the way our website works, for example, by ensuring that users are finding what they are looking for easily.
- Functionality cookies. These are used to recognise you when you return to our website. This enables us to personalise our content for you, greet you by name and remember your preferences (for example, your choice of language or region).
- Targeting cookies. These cookies record your visit to our website, the pages you have visited and the links you have followed. We will use this information to make our website and the advertising displayed on it more relevant to your interests. We may also share this information with third parties for this purpose.
Privacy Policy
Ternion LTD respects your privacy and is committed to protecting your personal data. This privacy notice will inform you as to how we look after your personal data when you visit our website (regardless of where you visit it from) and tell you about your privacy rights and how the law protects you. Please also use the Glossary at the bottom of this Privacy Notice to understand the meaning of some of the terms used in this privacy notice.
1. Important information and who we are
Purpose of this privacy notice
This privacy notice aims to give you information on how Ternion collects and processes your personal data through your use of this website, including any data you may provide through this website when you sign up to receive information or updates about our business.
This website is not intended for children and we do not knowingly collect data relating to children. It is important that you read this privacy notice together with any other privacy notice or fair processing notice we may provide on specific occasions when we are collecting or processing personal data about you so that you are fully aware of how and why we are using your data.
This privacy notice supplements the other notices and is not intended to override them.Controller
Ternion LTD is the controller and responsible for your personal data (referred to as, "we", "us" or "our" in this privacy notice).
If you have any questions about this privacy notice, including any requests to exercise your legal rights please contact us using the details set out below.Contact details
Full name of legal entity: Ternion LTD
Registered Address: Hunkins Waterfront Plaza, Suite 556, Mainstreet, Charlestown, Nevis
We comply with the General Data Protection Regulation that has entered into force on May 25, 2018.
We establish the necessary safeguards to ensure and protect confidentiality, integrity and accessibility of the Personal Data. The safeguards will prevent the unauthorized use of or unauthorized access to the Personal Data or prevent a personal data breach (security incident) in accordance with relevant policies and applicable Data Protection Legislation.Third-party links
This website may include links to third-party websites, plug-ins and applications. Clicking on those links or enabling those connections may allow third parties to collect or share data about you. We do not control these third-party websites and are not responsible for their privacy statements. When you leave our website, we encourage you to read the privacy notice of every website you visit.
2. The data we collect about you
Personal data, or personal information, means any information about an individual from which that person can be identified. It does not include data where the identity has been removed (anonymous data).
We may collect, use, store and transfer different kinds of personal data about you which we have grouped together follows:
- Identity Data includes [first name, last name, username or similar identifier].
- Contact Data includes [email address and telephone numbers].
- Technical Data includes [internet protocol (IP) address, your login data, browser type and version, time zone setting and location, browser plug-in types and versions, operating system and platform and other technology on the devices you use to access this website].
- Marketing and Communications Data includes [your preferences in receiving marketing from us and our third parties and your communication preferences].
We also collect, use and share Aggregated Data such as statistical or demographic data for any purpose. Aggregated Data may be derived from your personal data but is not considered personal data in law as this data does not directly or indirectly reveal your identity. For example, we may aggregate your Usage Data to calculate the percentage of users accessing a specific website feature. However, if we combine or connect Aggregated Data with your personal data so that it can directly or indirectly identify you, we treat the combined data as personal data which will be used in accordance with this privacy notice.
We do not collect any Special Categories of Personal Data about you (this includes details about your race or ethnicity, religious or philosophical beliefs, sex life, sexual orientation, political opinions, trade union membership, information about your health and genetic and biometric data). Nor do we collect any information about criminal convictions and offences.
If you fail to provide personal data You are not obliged to provide us with personal data by law, or under the terms of any contract. The provision of personal data by you is entirely voluntary and at your discretion. If however you decide not to provide us personal data that will mean that we are unable to provide you with details of our business.
3. How is your personal data collected?
We use different methods to collect data from and about you include:
• Direct interactions. You may give us your Identity, and Contact Data by filling in forms or by corresponding with us by post, phone, email or otherwise. This includes personal data you provide when you:
• fill out a form or create an account on our website;
• request marketing to be sent to you;
• or give us some feedback.
• Automated technologies or interactions. As you interact with our website, we may automatically collect Technical Data about your equipment, browsing actions and patterns. We collect this personal data by using cookies, server logs and other similar technologies. Pleaseseeourcookiepolicyforfurtherdetails.
4. How we use your personal data
We will only use your personal data when the law allows us to. Most commonly, we will use your personal data in the following circumstances:
• Where it is necessary for our legitimate interests (or those of a third party) and your interests and fundamental rights do not override those interests.
• Where you have given us your consent to do so.
• Where we need to comply with a legal or regulatory obligation.
• Where we rely on consent as a legal basis for processing your personal data (for example in order to send direct marketing communications to you via email).
Purposes for which we will use your personal data
We have set out below, in a table format, a description of all the ways we plan to use your personal data, and which of the legal bases we rely on to do so. We have also identified what our legitimate interests are where appropriate.
Note that we may process your personal data for more than one lawful ground depending on the specific purpose for which we are using your data.
Purpose/Activity Typeofdata Lawful basis for processing including basis of legitimate interest
To provide you with information that you request about our business.
(a) Identity
(b) Contact
(c) Marketing and Communications Consent
To manage our relationship with you which will include notifying you about changes to our terms or privacy policy.
(a) Identity
(b) Contact Necessary to comply with a legal obligation
To administer and protect our business and this website (including troubleshooting, data analysis, testing, system maintenance, support, reporting and hosting of data)
(a) Identity
(b) Contact
(c) Technical
(a) Necessary for our legitimate interests (for running our business, provision of administration and IT services, network security, to prevent fraud and in the context of a business reorganisation or group restructuring exercise)
(b) Necessary to comply with a legal obligation
We strive to provide you with choices regarding certain personal data uses, particularly around marketing and advertising and we will not send you any marketing emails or allow your data to be used to send marketing emails or other communications unless you have expressly consented (opted-in) to that.
Opting out
You can ask us or third parties to stop sending you marketing messages at any time by following the opt-out links on any marketing message sent to you or by contacting us at any time.
You can set your browser to refuse all or some browser cookies, or to alert you when websites set or access cookies. If you disable or refuse cookies, please note that some parts of this website may become inaccessible or not function properly. For more information about the cookies we use, please see our cookie policy
Change of purpose
We will only use your personal data for the purposes for which we collected it, unless we reasonably consider that we need to use it for another reason and that reason is compatible with the original purpose.
If we need to use your personal data for an unrelated purpose, we will notify you and we will explain the legal basis which allows us to do so.
Please note that we may process your personal data without your knowledge or consent, in compliance with the above rules, where this is required or permitted by law.
5. Disclosures of your personal data
We may have to share your personal data with the parties set out below for the purposes set out in the table in paragraph 4 above.
• Internal Third Parties as set out in the Glossary.
• External Third Parties as set out in the Glossary.
• Third parties to whom we may choose to sell, transfer, or merge parts of our business or our assets.
Alternatively, we may seek to acquire other businesses or merge with them. If a change happens to our business, then the new owners may use your personal data in the same way as set out in this privacy notice. We require all third parties to respect the security of your personal data and to treat it in accordance with the law. We do not allow our third-party service providers to use your personal data for their own purposes and only permit them to process your personal data for specified purposes and in accordance with our instructions.
6. International transfers
Many of our external third parties are based outside the European Economic Area (EEA) so their processing of your personal data will involve a transfer of data outside the EEA.
Whenever we transfer your personal data out of the EEA, we ensure a similar degree of protection is afforded to it by ensuring at least one of the following safeguards is implemented:
• We will only transfer your personal data to countries that have been deemed to provide an adequate level of protection for personal data by the European Commission. For further details, see European Commission: Adequacy of the protection of personal data in non- EU countries.
• Where we use certain service providers, we may use specific contracts approved by the European Commission which give personal data the same protection it has in Europe. For further details, see European Commission: Model contracts for the transfer of personal data to third countries.
• Where we use providers based in the US, we may transfer data to them if they are part of the Privacy Shield which requires them to provide similar protection to personal data shared between the Europe and the US. For further details, see European Commission: EU-US Privacy Shield.
7. Data security
We have put in place appropriate security measures to prevent your personal data from being accidentally lost, used or accessed in an unauthorised way, altered or disclosed. In addition, we limit access to your personal data to those employees, agents, contractors and other third parties who have a business need to know. They will only process your personal data on our instructions and they are subject to a duty of confidentiality.
We have put in place procedures to deal with any suspected personal data breach and will notify you and any applicable regulator of a breach where we are legally required to do so.
8. Data retention
How long will you store my personal data for?
We will only retain your personal data for as long as necessary to fulfil the purposes we collected it for, including for the purposes of satisfying any legal, accounting, or reporting requirements.
To determine the appropriate retention period for personal data, we consider the amount, nature, and sensitivity of the personal data, the potential risk of harm from unauthorised use or disclosure of your personal data, the purposes for which we process your personal data and whether we can achieve those purposes through other means, and the applicable legal requirements.
9. Your legal rights
Under certain circumstances, you have rights under data protection laws in relation to your personal data. These rights include the right to: Request access to your personal data (commonly known as a "data subject access request"). This enables you to receive a copy of the personal data we hold about you and to check that we are lawfully processing it.
Request correction of the personal data that we hold about you. This enables you to have any incomplete or inaccurate data we hold about you corrected, though we may need to verify the accuracy of the new data you provide to us.
Request erasure of your personal data. This enables you to ask us to delete or remove personal data where there is no good reason for us continuing to process it. You also have the right to ask us to delete or remove your personal data where you have successfully exercised your right to object to processing (see below), where we may have processed your information unlawfully or where we are required to erase your personal data to comply with local law. Note, however, that we may not always be able to comply with your request of erasure for specific legal reasons which will be notified to you, if applicable, at the time of your request.
Object to processing of your personal data where we are relying on a legitimate interest (or those of a third party) and there is something about your particular situation which makes you want to object to processing on this ground as you feel it impacts on your fundamental rights and freedoms. You also have the right to object where we are processing your personal data for direct marketing purposes. In some cases, we may demonstrate that we have compelling legitimate grounds to process your information which override your rights and freedoms.
Request restriction of processing of your personal data. This enables you to ask us to suspend the processing of your personal data in the following scenarios: (a) if you want us to establish the data's accuracy; (b) where our use of the data is unlawful but you do not want us to erase it; (c) where you need us to hold the data even if we no longer require it as you need it to establish, exercise or defend legal claims; or (d) you have objected to our use of your data but we need to verify whether we have overriding legitimate grounds to use it.
Request the transfer of your personal data to you or to a third party. We will provide to you, or a third party you have chosen, your personal data in a structured, commonly used, machine- readable format. Note that this right only applies to automated information which you initially provided consent for us to use or where we used the information to perform a contract with you.
Withdraw consent at any time where we are relying on consent to process your personal data. However, this will not affect the lawfulness of any processing carried out before you withdraw your consent. If you withdraw your consent, we may not be able to provide certain products or services to you. We will advise you if this is the case at the time you withdraw your consent.
You will not have to pay a fee to access your personal data (or to exercise any of the other rights). However, we may charge a reasonable fee if your request is clearly unfounded, repetitive or excessive. Alternatively, we may refuse to comply with your request in these circumstances. What we may need from you
We may need to request specific information from you to help us confirm your identity and ensure your right to access your personal data (or to exercise any of your other rights). This is a security measure to ensure that personal data is not disclosed to any person who has no right to receive it. We may also contact you to ask you for further information in relation to your request to speed up our response.
Time limit to respond
We try to respond to all legitimate requests within one month. Occasionally it may take us longer than a month if your request is particularly complex or you have made a number of requests. In this case, we will notify you and keep you updated.
10. Glossary
Legitimate Interest means the interest of our business in conducting and managing our business. We make sure we consider and balance any potential impact on you (both positive and negative) and your rights before we process your personal data for our legitimate interests. We do not use your personal data for activities where our interests are overridden by the impact on you (unless we have your consent or are otherwise required or permitted to by law). You can obtain further information about how we assess our legitimate interests against any potential impact on you in respect of specific activities by contacting us.
Comply with a legal or regulatory obligation means processing your personal data where it is necessary for compliance with a legal or regulatory obligation that we are subject to.
• Service providers acting as processors who provide IT and system administration services.
• Professional advisers acting as processors or joint controllers including lawyers, bankers, auditors and insurers who provide consultancy, banking, legal, insurance and accounting services
• Legal authorities acting as processors or joint controllers who require reporting of processing activities in certain circumstances.
If you feel that we have not addressed your questions satisfactorily, you may contact a data controller.


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2015 Philadelphia Black Political Summit
On Saturday, April 11, 2015 from 9am-5pm and Sunday, April 12, 2015 from 12:30pm-4pm, The Philadelphia Black Political Coalition will host The Philadelphia Black Political Summit at Dobbins CTE High School at 2150 Lehigh Avenue. The Summit is open to all individuals and organizations in the Black community interested in participating in the development of a collective Black agenda.
The agenda topics will include:
- Education
- Economic Development
- Housing
- Criminal Justice
For additional event details, click here to retrieve the flyer.


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Z Ancestris
(Utworzył nową stronę "What are the differences between Ancestris and another genealogy program? Its features. __TOC__ ==100% gedcom compliant== {{TwoColumns|column1= Ancestris respec...")
Wersja z 19:16, 15 kwi 2016
What are the differences between Ancestris and another genealogy program? Its features.
Spis treści
100% gedcom compliant
Ancestris respects the gedcom specifications. It's very very rare a program which is compliant with the gedcom specs, Ancestris is one the few available on the market. And you know what? Ancestris is free. It's an opensource project developped by people found of genealogy.
Read more about GEDCOM...
Your data are preserved
Ancestris works on the gedcom file itself. It's easy to see the advantages of such a thing. A gedcom file is a text file, so it can be opened using a simple editor as notepad for windows, or gedit for linux, etc...
Ancestris will never modify your datas when it reads your gedcom file, even if your datas come from another genealogy program which is not 100% gedcom compliant. It will "respect" the mistakes made by the other genealogy programs. You will be advised of those mistakes, but your gedcom file won't be modify at all. It means if you want to read your gedcom file by your previous genealogy program, it won't complain about your data as it will find again its records.
Same program for all operating systems
The same program can be run on different operating systems, as Windows, Linux, and MacOs.
What does it mean? No need to export your data. No need to transform your data to be read, update, etc, on another operating system your friend, a member of your family can run. You run Windows. Your nephew has a MacOS computer. You will be able to exchange your data with a sureness of the integrity of your data. He updates your genealogy and sends it to you? 100% of what he has done will be read by you on your computer.
Very powerful
Ancestris comes with a gedcom editor. With it you will be able to add all tags you can find in the gedcom specifications. Of course, you won't have a very sofisticated GUI (Graphical User Interface), but it's the key for such forcefulness.
Heavy development
Our team works hard for Ancestris. Once an official release is out, no new feature won't be added to secure your work. If a bug is reported it will be fixed very quickly. On the other side, updates for our development releases are available weekly and sometimes daily.
Plugins. Yes, you can extend the capabilities of Ancestris using plugins.
Following this link you will see some screenshots we have made. Maybe the actual version is a little bit different from what you can see there, but development goes on, and we want to improve Ancestris according to what you need, to what you expect.


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|what's new
|photo gallery
|for sale
|data explorer
|picture search
|order our book
|photo submit
|1990 25th Anniversary Mustang
Saleen 7up Mustang
Only 12, 1990 Deep Emerald Green 7-Up Mustangs were converted to Saleens. These Saleen 7up Anniversary Mustangs actually started life at the ford factory as coupes even though their model code is still P44 for Mustang LX convertible.
|Examples of a 1990 25th Anniversary Mustang
|No Examples at this time, but if you have one, consider submitting photos to us


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Leaving a gift to the hospice in your Will is not just a donation… it's your continued support.
Making your Will is an important way to remember the friends, family and causes you care about after your death. A donation in your Will to the Dougie Mac costs you nothing during your lifetime but can offer comfort, care and support to local patients and families.
A gift in your Will can keep a person as well as possible for as long as possible. No matter the size of your donation, it will certainly make a difference. As an independent local charity, we rely on gifts in Wills to be able to continue to provide our services both at the Hospice and within our community.
To make it easier for you, our dedicated Legacy team can offer you friendly and confidential advice, and in addition, we hold our annual Make a Will Month in May where a local solicitor can write a basic Will, waiving their usual fee.
Writing a Will doesn't have to be expensive or complicated. It can provide you with peace of mind to know that following your death your family & loved ones will be looked after and your wishes are followed.
To assist you, please find an information booklet for you to download, or you can contact us for us to send you one in the post.
we have attached further details below of a List of Solicitors who support the DougieMac plus a Will making pack for you to download.
To make it even easier for you to get started with planning for your future, every May we hold "Make a Will Month". During May, a team of local solicitors will make your Will and waive their normal fee. For further information on Make a Will Month and to receive your free information pack, please email email@example.com or call 01782 344308.
Our dedicated Legacy Team can offer you friendly and confidential advice or send you a pack in the post to give you more information about Making your Will and also leaving a Gift to charity.
For further information please contact us on 01782 344308 or complete a contact form and one of the team will be in touch soon.
Gifts in Wills are important to local people like Rosalind & David…
Rosalind Hancox cares for husband David, who attends Dougie Mac's Day Therapy Unit weekly.
Here she explains the importance of making a Will and considering leaving a gift to the hospice: "Everyone knows someone who has received support from Dougie Mac. They were wonderful in supporting my brother, James Watson and his wife Sue during his illness. He was cared for on the Inpatient Unit as he battled a brain tumour and lung cancer, and sadly passed on Christmas morning.
Not so many people know about the Day Therapy Unit for people with life limiting illnesses. My husband Dave goes every Tuesday and receives not only medical care from the doctors and nurses, but also emotional support. He loves his time at Dougie Mac where he can enjoy social interaction which he would otherwise miss due to his condition which can make him feel quite isolated. The support they give us both is amazing. We are so lucky to have the Dougie Mac locally. We can't praise them enough. They support us all and we need to support them by leaving a gift in our Wills. Having a Will prepared has given us both a sense of relief.
We've documented exactly what we want to happen and it means that there will be no disagreements with family members. And it's so easy to do too; the Will writing process is not at all time consuming and a friendly professional walks through everything with you."


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Cork English College is excited to announce the introduction of an OET preparation course in 2019. OET is the internationally-recognised English language test that assesses the language skills of healthcare professionals seeking to register and practise in an English-speaking environment.
The OET qualification is recognised by the major regulatory bodies for health professionals in Ireland (Medical Council, Nursing & Midwifery Board of Ireland, Dental Council of Ireland, The Pharmaceutical Society of Ireland, as well as Ireland's multi profession healthy regulator CORU). The qualification is also recognised in the UK, Australia, New Zealand, Ukraine, Dubai, Singapore and Namibia.
The OET exam is currently available in the CEC exam centre each month, so students who take the course will be able to sit the exam at the school. CEC is one of only two OET testing centres in Ireland. The new exam further reinforces CEC's position as a premier preparation and testing centre in Ireland.
The exam preparation course will have an emphasis on exam techniques and practice. As the exam is based on real healthcare scenarios the course content will also be focused on this. Students can opt to take 1 to 1 classes if they require extra individual tuition before the exam.
For information on course and exam dates please contact the school.


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EGF R (pTyr845) antibody
Product Details
- Target Species
- Human
- Western Blotting
- Mouse anti EGF receptor (pTyr845) detects a band of approximately 175 kDa in pervanadate-treated A431 (treated lysate) cell lysates
- Product Form
- Purified IgG - Liquid
- Preparation
- Mouse monoclonal antibody purified by thiophillic adsorption and size exclusion chromatography from tissue culture supernatant
- Buffer Solution
- Phosphate buffered saline
- Preservative Stabilisers
- 0.09% Sodium Azide
PEG & Sucrose
- Immunogen
- Phosphopeptide conjugated to KLH
Storage Information
- Storage
- Store undiluted at -20°C, avoiding repeated freeze thaw cycles
- Guarantee
- 12 months from date of despatch
More Information
- UniProt
- Entrez Gene
- Acknowledgements
- PrecisionAb is a trademark of Bio-Rad Laboratories.
- Regulatory
- For research purposes only
Applications of EGF R (pTyr845) antibody
|Application Name
|Min Dilution
|Max Dilution
|Western Blotting
The PrecisionAb label is reserved for antibodies that meet the defined performance criteria within Bio-Rad's ongoing antibody validation programme. Click here to learn how we validate our PrecisionAb range. Where this product has not been tested for use in a particular technique this does not necessarily exclude its use in such procedures. Further optimization may be required dependent on sample type.
Secondary Antibodies Available
|Product Code
|Pack Size
|List Price
|Goat anti Mouse IgG (H/L):HRP
|2 ml