text: Chapter 6. Efficiency National Healthcare Quality Report, 2008 Few issues within American health care policy today are as extensively debated as how to obtain better value for money. The debate about how to improve efficiency is equally matched by the debate about how best to measure it. Varying perspectives and definitions of "efficiency" in the health care marketplace and the lack of consensus on what constitutes appropriate measurement of efficiency have stymied efforts to report on this area. For example, efficiency can be viewed from different perspectives, including individual patients, providers, and society as a whole.The issue of how to improve efficiency in the Nation's health care system is at the heart of the Department of Health and Human Services' (HHS) mission to increase transparency in health care through better information on quality and cost. In support of this mission, this year's National Healthcare Quality Report (NHQR) continues to look at potential information sources and findings on efficiency in the U.S. health care system.This year's NHQR outlines the varying perspectives of efficiency and offers potential methods for measuring efficiency at the national level that respond to the NHQR's mandate to provide lawmakers in Congress with information on health care performance. This chapter does not attempt to provide a definitive framework for efficiency, nor does it provide an exhaustive list of potential measures of efficiency. The examples follow the initial effort to report on efficiency in the 2007 NHQR and should still be viewed as preliminary.No conclusions about efficiency in the U.S. health care system should be drawn. Rather, the Agency for Healthcare Research and Quality (AHRQ) hopes that this chapter will stimulate further productive discussions on health care efficiency. AHRQ intends this chapter to be part of an evolving national discussion on measuring efficiency in the U.S. health care system that will be reviewed, revised, and presented in future reports. Background and MeasuresIn its landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century,1 the Institute of Medicine (IOM) presented six "aims" for the health care system: effectiveness, safety, timeliness, patient centeredness, equity, and efficiency. AHRQ, in its 2001 reauthorization legislation, was given the task of developing two national health care reports that would track quality and prevailing disparities in the Nation's health care system.IOM provided guidance2,3 on the development of these two national health care reports and suggested that the reports' framework be linked to the six aims presented in Crossing the Quality Chasm. At the same time, however, IOM stated that AHRQ should not try to address the issue of efficiency in the first national reports but should examine its inclusion in future reports or in a separate report.With guidance from an HHS Interagency Work Group brought together to advise on the reports' development, AHRQ developed the first NHQR and National Healthcare Disparities Report (NHDR) in 2003 without addressing efficiency. In 2004, the Interagency Work Group encouraged AHRQ to examine possible approaches to including efficiency in future reports. This followed advice from AHRQ's National Advisory Committee (NAC) of external experts from the private sector, academia, and the Federal sector. The NAC had, at AHRQ's request, formed a subcommittee, led by Dr. Don Berwick, that provided advice on the NHQR and NHDR. That subcommittee recommended that AHRQ develop a chapter on efficiency for the reports.To respond to the NAC and Interagency Work Group requests, AHRQ formed a subgroup of its Interagency Work Group in 2004 to address efficiency. In 2005, this subgroup held two meetings, during which it reviewed documents from previous reports and discussed possible ways to further this effort. The subgroup concluded that there was insufficient consensus to conceptualize and measure efficiency.AHRQ had previously commissioned the RAND Corporation to systematically review measures of efficiency and their potential to be tracked and reported at various levels. The efficiency subgroup therefore decided to wait until RAND submitted its report to AHRQ before developing any further plans. The final version of the RAND report summarizes the knowledge base on efficiency measures as follows:Few analyses of the reliability and validity ("scientific soundness") of published and unpublished measures have been conducted.Both the published literature measures and the vendor measures focus on intermediate outcomes (e.g., inpatient stays), not final outcomes (e.g., functional status or measures of health).Consensus has yet to emerge on which approaches constitute acceptable measures of efficiency.4The RAND report provides a typology of efficiency measures that emphasizes the multiple perspectives on efficiency and points out that measures must be considered from the standpoint of what the measuring organization is and what its goal is in assessing efficiency. The typology distinguishes between:Society as a whole (i.e., the "population" level).Health care firms (i.e., hospitals and other providers).Individuals.Another report in 2006 examined the question of efficiency from the cost of waste point of view. In that report, the authors outline another common typology for efficiency measurement: the tracking of overuse, underuse, and misuse in the health care system.5This chapter first presents a general set of trends on costs and quality levels in the U.S. health care system. Additional measures summarize information at the population and provider level. The measures used are presented to provide some insight on health care efficiency. They are:Change in expenditures and quality of care for cancer, diabetes, and heart disease (overview).Trends in avoidable hospitalizations and costs (population perspective).Rehospitalization for congestive heart failure (CHF) for selected States (population perspective).Trends in hospital efficiency (provider perspective).Because consensus has yet to emerge about the appropriate framework and acceptable measures of efficiency, the examples provided should be viewed as preliminary and designed to stimulate productive ongoing discussions about health care efficiency. FindingsChange in Expenditures and Quality of Care for Cancer, Diabetes, and Heart DiseaseData from AHRQ's Medical Expenditure Panel Survey (MEPS) are used to provide a preliminary overview and to suggest possible national trends in health care cost and quality. MEPS collects health care expenditures by all payers for nearly all types of health care utilization, including outpatient visits, hospital inpatient stays, emergency department visits, prescribed medicines, dental visits, and home health care. Data are collected for the civilian noninstitutionalized population.Summary data are presented here on the average annual rate of change from 2001 to 2005 in total annual expenditures for the general population and for people with three high-priority conditions: cancer, diabetes, and heart disease. In addition, quality data are summarized in terms of the median rate of change in the NHQR measures from 2001 to 2005 for the entire measure set and for each condition area.i Figure 6.1. Average annualized percentage changes in national health care expenditures and quality for general population and people with selected conditions,* 2001-2005 * Refer to Chapter 1, Introduction and Methods, for a discussion of how data years were selected for determining the percentage change in health care quality.Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2001 and 2005. Refer to the appendix for list of measures included in each category.Reference population: Civilian noninstitutionalized population.Note: Expenditures are payments from all sources for hospital inpatient care, ambulatory care provided in offices and hospital outpatient departments, care provided in emergency departments, and prescribed medicine purchases reported by respondents in the MEPS-Household Component. Sources include direct payments from individuals, private insurance, Medicare, Medicaid, Workers' Compensation, and other miscellaneous sources. Expenditures for 2001 are adjusted to 2005 dollars using the gross domestic product implicit price deflator (Bureau of Economic Analysis).From 2001 to 2005, total annual health care expenditures increased at a rate 4.6 times the rate of the increase in the summary measure of quality of care. Annual total health care expenditures rose 6.5% (in 2005 dollars). During this same period, quality increased at a rate of 1.4% (Figure 6.1).For heart disease, cancer, and diabetes individually, quality increased at a rate of 2.6%, 1.9%, and 0.1% annually, respectively. Expenditures increased at an annual rate of 4.4%, 9.0%, and 4.9%, respectively.Figure 6.1 may seem to suggest that improvements in overall quality are outpaced by increases in expenditures. However, such a conclusion cannot be drawn, and the statistics should be viewed with caution because these are comparisons of percentage changes in two very different measures. First, expenditures are comprehensively measured, but quality is not. Figure 6.1 presents a summary of all available quality measures in this report rather than a catalog of all clinical care for all conditions and patients. The quality measures track both processes of care and outcomes of care.The indicators selected for inclusion in the NHQR and NHDR measure set are considered the most scientifically sound and clinically important markers of whether we are achieving appropriate performance in health care. However, many aspects of care are not captured in these quality indicators. A comprehensive assessment may never be feasible, as technical aspects of care are changing more rapidly than can be captured through broad, consensus-based quality measurement vehicles, such as the NHQR.Moreover, it would be difficult to collect measures of quality for rare conditions. In addition, the summary measure of quality is composed of measures calculated on a per person basis, but total annual expenditures increase in part due to population growth. Finally, these statistics are provided without estimates of variability (i.e., without confidence intervals). Statistical testing for these sorts of comparisons is complex, and future versions of the NHQR will examine more refinements to such statistical testing.iiThe statistics illustrated above suggest many questions about efficiency. They are not provided to suggest causation between costs and quality. Providing higher quality care may cost more than providing lower quality care, and achieving increasingly higher quality goals may require even higher expenditures to reach an additional person. Some types of quality care might reduce expenditures, particularly by reducing hospitalizations. Furthermore, the factors that cause changes in expenditures may be different from the factors that cause improvements in quality. More research is needed to investigate these issues.Trends in Avoidable Hospitalizations and CostsTo address the population perspective of potentially avoidable hospitalizations and costs, data on ambulatory-care-sensitive conditions are summarized here using the AHRQ Prevention Quality Indicators (PQIs). Not all hospitalizations that the AHRQ PQIs track are preventable, but ambulatory-care-sensitive conditions are those for which good outpatient care can prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.6 The AHRQ PQIs track these conditions using hospital discharge data. For this analysis, total hospital charges were converted to costs using Healthcare Cost and Utilization Project (HCUP) cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare & Medicaid Services. Therefore, cost estimates in this section refer to hospital costs. Figure 6.2. National trends in potentially avoidable hospitalization rates, by type of hospitalization, 1997 and 2000-2005 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1997 and 2000-2005.Note: Data are for adults age 18 and over. Annual rates are adjusted for age and gender. Figure 6.3. Total national costs associated with potentially avoidable hospitalizations, 1997 and 2000-2005 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1997 and 2000-2005.Note: Data are for adults age 18 and over.From 1997 to 2005, avoidable hospitalizations for chronic conditions decreased significantly, from 1,294 per 100,000 to 1,092 per 100,000 (Figure 6.2). The rate also decreased significantly from 2000 to 2005 (1,213 per 100,000 to 1,092 per 100,000).Avoidable hospitalizations for acute conditions did not significantly change from 1997 to 2005 or from 2000 to 2005.Although avoidable hospitalization rates have decreased overall since 2000, total national costs associated with potentially avoidable hospitalizations have increased since 2000 (Figure 6.3). Hospital costs due to avoidable hospitalizations exceeded $29 billion in 2005, which was 35% greater than what these costs were in 1997 when adjusted for inflation ($21.9 billion).iiiThese figures provide some preliminary measures of the potential for improvement in one dimension of efficiency.Rehospitalization for Congestive Heart FailureTo gain further insight into the population perspective of avoiding potentially avoidable hospitalizations and costs, data on rehospitalization rates for CHF for nine States in 2004 and 2005 are summarized here (Table 6.1). Rehospitalization for CHF signals a worsened state of illness for patients and is more resource intensive than treatment as an outpatient in the community. Although not every rehospitalization for CHF is preventable, CHF is a condition for which good outpatient care and early intervention can help prevent rehospitalization.The estimates below are derived from data for nine States participating in the HCUP State Inpatient Databases. They are based on all CHF admissions from January to September of each year and allow for a 3-month timeframe for rehospitalization.iv Rehospitalizations have a principal diagnosis of CHF.Table 6.1. Rehospitalizations for congestive heart failure, per 1,000 initial admissions for CHF, 9 States, 2004 and 2005Age categoryState20042005RateSERateSEAges 18-64State A1401.001401.00State B1901.002301.00State C1801.001901.00State D2600.002700.00State E2301.002201.00State F2201.002401.00State G2301.002301.00State H2400.002500.00State I2401.002501.00Ages 65+State A1101.001101.00State B1700.001600.00State C1800.001700.00State D1900.001900.00State E2100.002000.00State F2100.002000.00State G2001.002000.00State H2100.002100.00State I2200.002100.00All ages (18+)State A1201.001201.00State B1700.001800.00State C1800.001800.00State D2100.002100.00State E2100.002000.00State F2100.002100.00State G2100.002100.00State H2200.002200.00State I2200.002200.00Key: SE = standard error.Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases, 2004 and 2005.Note: Data are for adults age 18 and over.The mean CHF rehospitalization rate for all adult patients previously admitted for CHF in the 9-State sample was 210 per 1,000 in both 2004 and 2005.The rate of State-level CHF rehospitalizations for adult patients of all ages previously admitted for CHF ranged from a low of 120 to a high of 220 per 1,000 for rehospitalizations for CHF. State A had a rehospitalization rate that was consistently lower than the other rates across both years and all reported age categories.The CHF rehospitalization rates for patients previously admitted for CHF were generally lower in the Medicare-eligible population than in those ages 18-64.It is important to note that the figures reported above are not national estimates and that no conclusions about national trends should be inferred. The States in the analysis account for about 36% of all adult discharges for CHF and provide an indication of the general trend that readmissions for CHF may be following.Trends in Hospital EfficiencySignificant attention has been paid to cost variations across providers and across the country. Yet it is often difficult to separate out costs due to differences among providers in outputs, patient burden of illness,5 or care quality. To address the provider perspective, hospital cost efficiency is examined using a technique from the field of econometrics that can account for such differences.v This analysis uses data from the American Hospital Association Annual Survey, Medicare Cost Reports, and HCUP State Inpatient Databases.Here, hospital efficiency is defined as the ratio of best practice costs to total observed costs. For example, given the types and quantities of outputs a hospital produces, the input prices it pays, its case mix, its quality, and its market characteristics, a theoretical best practice hospital might incur expenses amounting to $90 million. A comparison hospital in an identical situation with total expenses of $100 million would have an estimated cost efficiency of 90%.Cost-efficiency estimates have been converted to index numbers with a base of 100 for the year 2001 as a way to place less emphasis on the specific magnitude of estimated cost efficiency than on its general trend.This analysis controls for the following components that Elixhauser, et al. (1998) contend are part of patient burden of illness: (1) primary reason for admission to the hospital, (2) severity of the principal diagnosis, (3) iatrogenic complications, and (4) comorbidities that are unrelated to the primary diagnosis but have a substantial impact on both the resources used to treat the patient and the outcomes of the care provided.8 Figure 6.4. Average estimated relative hospital cost efficiency index for a selected sample of urban general community hospitals, 2001-2005 Source: Agency for Healthcare Research and Quality. Analysis based on 1,368 urban general community hospitals with data in the Healthcare Cost and Utilization Project, State Inpatient Databases. Go to Chapter 1, Introduction and Methods, for further details.Estimated urban hospital cost efficiency increased slightly from 2001 to 2004 but decreased slightly in 2005 for a selected sample of urban general community hospitals (Figure 6.4)The most cost-efficient hospitals (i.e., hospitals in the highest quartile of estimated cost efficiency) compared favorably with the least cost-efficient hospitals (i.e., hospitals in the lowest quartile of estimated cost efficiency) on a number of important variables. The most cost-efficient hospitals had lower costs and fewer full-time-equivalent employees per case-mix-adjusted admission, as well as a shorter average length of stay, compared with the least cost-efficient hospitals (Table 6.2).The most cost-efficient hospitals had a higher operating margin than the least cost-efficient hospitals (Table 6.2).Table 6.2. Correlates of hospital cost efficiencyMeasureEstimateStandard deviationCost per case-mix-adjusted admission:Top quartile of hospital cost efficiency$4,340$1,087Bottom quartile of hospital cost efficiency$6,241$2,350Full-time equivalent employees per case-mix-adjusted admission:Top quartile of hospital cost efficiency.0400.01Bottom quartile of hospital cost efficiency.0550.02Average length of stay (days):Top quartile of hospital cost efficiency4.881.33Bottom quartile of hospital cost efficiency5.221.80Operating margin:Top quartile of hospital cost efficiency.0330.13Bottom quartile of hospital cost efficiency-.0660.17Source: American Hospital Association Annual Survey of Hospitals and Medicare Cost Reports, 2001-2005.It is important to note that the figures reported above are not national estimates and that no conclusions about national trends should be inferred. However, the hospitals in the analysis represent about 53% of all urban general community hospitals and therefore provide an indication of the general trend that cost efficiency may be following.i This median rate of change is the same metric used in the Highlights section of this report and is explained in detail in Chapter 1, Introduction and Methods. A list of the measures used for these calculations is available in theii The creation of confidence intervals for expenditures using MEPS data is possible and was conducted for this analysis. The estimates with their confidence intervals are: (1) heart disease, 4.4% (-2.1-10.9); (2) cancer 9.0%, (0.3-17.6); and (3) diabetes, 4.9% (-1.4-11.2).iii The inflation adjustment was done using the gross domestic product implicit price deflator.iv A 3-month period (or longer) for readmissions has been used in studies of the effective management of chronic illness.7 Two-thirds of the readmissions reported above occurred within 1 month.v Stochastic frontier analysis (SFA) is the technique used in this analysis. SFA can estimate best practice costs as the value total costs would be if full efficiency were attained. The hospital-level "cost efficiency" estimates SFA produces measure whether output is obtained using the fewest inputs (i.e., technical efficiency), as well as whether output is produced using the optimal mix of inputs, given prices (i.e., allocative efficiency), the size of a hospital's operations (i.e., scale efficiency), and the range of a hospital's operations (i.e., scope efficiency), including possible overspecialization or overdiversification.9 Next Steps in Efficiency ReportingA significant amount of information about about the study of health care efficiency and its measurement is not fully developed. In addition, the relationship between health care quality and efficiency is complex and not well understood. Recent work examining variations in Medicare spending and quality shows that higher cost providers do not necessarily provide higher quality care, illustrating the potential for improvement.10 The preliminary examination of efficiency in this chapter is only an early step. Tracking efficiency in the health care system over the long term, understanding its relationship with quality, and finding ways to improve quality and efficiency will require future research commitment in these areas.The AHRQ-sponsored and commissioned report prepared by RAND, Identifying, Categorizing, and Measuring Health Care Efficiency Measures, released in April 2008, identifies several gaps in efficiency measurement.4 A number of efforts are now underway to advance our knowledge of efficiency. On May 20, 2008, AHRQ hosted the "Physician Performance Measurement and Reporting Conference," cosponsored by the Wisconsin Collaborative for Healthcare Quality. This conference included more than 40 technical experts on physician performance measurement and stakeholders representing consumers, purchasers, employers, and providers. The goal of the meeting was to identify areas of agreement across the groups and to suggest topics where future research might lead to further consensus. Topics identified as promising areas for future research include:Can standards be developed that can be applied to the diverse physician practices seen across the United States?Can a bridge between claims and clinical data be created?Will the implementation of initiatives designed to improve health care efficiency have an impact on health care quality?How can the regional variations in coding practices be addressed?How does the size of a physician practice affect the measurement of performance?The RAND report notes that efficiency measurement techniques developed in the academic literature, namely "frontier techniques," have not been applied to the policy setting. The RAND report identified these techniques, including stochastic frontier analysis, which is used to provide the population perspective in this chapter, as among the most promising approaches for measuring provider efficiency.These approaches also may inform strategies for improving the delivery of health care services. Therefore, AHRQ hosted an invitational meeting, "Translating Frontiers Into Practice: Taking the Next Steps Toward Improving Efficiency," on August 27-28, 2008. This meeting brought together policymakers, stakeholders, and leading technical experts to discuss how frontier techniques can be used most effectively to address the problems confronting the health care system and to identify how the needs of end users should shape the research community's agenda.Moreover, AHRQ sponsored the first in what will be a series of theme issues of the journal Health Services Research. This first issue, which appeared in October 2008, is called "Improving Efficiency and Value in Health Care." It provides insight into recent initiatives in health care that require efficiency measurement. These efforts range from internal quality improvement exercises to innovations in payment and public reporting. The theme issue also emphasizes the importance of organizational structures and market forces to efforts aimed at improving efficiency and increasing value.One of the primary areas on which AHRQ and its HHS partners are concentrating on improving efficiency measurement is the Secretary's Value-Driven Health Care Initiative. This initiative is an effort by Secretary Leavitt and HHS to provide public information about the quality and cost of services health care providers deliver. Such information is not widely available today; thus, there is little information to help consumers compare doctors and hospitals based on measures of quality and cost. Providers themselves have limited information for comparing their performance based on accepted standards of care. Yet such information may be crucial for delivering the best treatment and the best value in health care.As part of the Value-Driven Health Care Initiative, volunteer participants in AHRQ Chartered Value Exchanges commit to four objectives, called the "cornerstones" of value-driven health care. One cornerstone is "Measure and Publish Quality Information," whereby participants commit to public reporting on the performance of doctors, hospitals, and other providers. The other cornerstones are "Interoperable Health Information Technology," "Measure and Publish Price Information," and "Promote Quality and Efficiency of Care."For more information about the Value-Driven Health Care Initiative, visit http://www.hhs.gov/valuedriven/. ReferencesInstitute of Medicine. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.Institute of Medicine. Envisioning the National Healthcare Quality Report. Washington, DC: National Academy Press; 2001.Swift EK, ed. Institute of Medicine. Committee on Guidance for Designing a National Healthcare Disparities Report. Guidance for the National Healthcare Disparities Report. Washington, DC: National Academies Press; 2002.McGlynn E. Identifying, categorizing, and evaluating health care efficiency measures. Final Report. (Prepared by Southern California Evidence-based Practice Center" RAND Corporation under Contract No. 282-00-0005-21). Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication No. 08-0030. Available at: http://www.ahrq.gov/research/findings/final-reports/efficiency.Cost of poor quality or waste in integrated delivery system settings. Final Report. (Prepared by RTI International under Contract No. 290-00-0018-11). Rockville, MD: Agency for Healthcare Research and Quality; September 2006. Available at: http://www.ahrq.gov/research/findings/final-reports/costpqids.AHRQ Quality Indicators. Guide to Prevention Quality Indicators: hospital admission for ambulatory care sensitive conditions. Rockville, MD: Agency for Healthcare Research and Quality; March 12, 2007. Version 3.1. Available at: http://www.qualityindicators.ahrq.gov/pqi_download.htm.Fries K, Koop E, Sokolov J, et al. Beyond health promotion: reducing need and demand for medical care. Health Aff 1998;17(2):70-84.Elixhauser A, Steiner C, Harris R, et al. Comorbidity measures for use with administrative data. Med Care 1998;36:8-27.Mutter R, Rosko M, Wong H. Measuring hospital inefficiency: the effects of controlling for quality and patient burden of illness. Health Serv Res 2008;43:1992-2013. Fisher E, Wennberg D, Stukel T, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138:273-87. Current as of March 2009 Internet Citation: Chapter 6. Efficiency: National Healthcare Quality Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap6.html


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subset: commoncrawl


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Check out the weekend fun happening in Stone Mountain and Lithonia, Dec.1-2, 2012 (like us on Facebook for any updates).
City of Lithonia Tree Lighting and Christmas on Main
When: Sunday, Dec. 2, 6-8:30 p.m. Tree lighting at Kelly Park at 6:30 p.m. There will be vendors and activities from 7-8 p.m. on Main Street.
Where: Kelly Park, in downtown Lithonia, corner of Max Cleland Boulevard and Main Street
Who's this for: Everyone
Why go: Holiday family fun, and a chance to support the city's small businesses. There will be music, dance performances, hot chocolate and cider.
How much: Free
Breakfast with Santa
When: Saturday, Dec. 1, 7-10 a.m.
Where: Stone Mountain First United Methodist Church, 5312 West Mountain Street (located at the corner of Ridge and W. Mountain Street).
Who's this for: Bring the kids, of course!
Why go: It's Santa!
How much: $6 donation requested. Proceeds benefit the food pantry in Stone Mountain.
Holiday in Smoke Rise
When: Saturday, Dec.1, 9 a.m.-4 p.m.
Where: Smoke Rise Elementary Charter School, 1991 Silver Hill Rd., Stone Mountain
Who's this for: Everyone
Why go: You can pick up some great gifts and holiday ideas as well as support small businesses and crafters/artisans at the 31st annual event.
How much: Free to enter
Recording Memories with Mini-Scrapbooks
When: Saturday, Dec. 1, 1-2:30 p.m.
Where: Salem-Panola library, 5137 Salem Rd., Lithonia
Who's this for: Ages 18 and up
Why go: It's a creative way to display photos and share memories.
How much: Free, just bring your photos. All other materials will be provided.
Kaijudo Demo Day and Giveaway
When: Saturday, Dec. 1, 5 p.m.
Where: The Dragon's Horde, 5615 Memorial Dr., Stone Mountain.
Who's this for: The first 20 kids that arrive and participate in the free game play will get sample decks.
Why go: One word - giveaway. Also, kids can watch a learn-to-play video, and catch an episode of the Kaijudo TV series.
How much: Free.
Davidson-Arabia Nature Preserve Hike with Ranger Robby
When: Sunday, Dec.2, 8-10 a.m.
Where: Davidson-Arabia Mountain Nature Preserve, 3787 Klondike Road, Lithonia, 30038.
Who's this for: Folks who can take on a 3-6 mile hike.
Why go: A fresh morning hike seems like a great way to start off the week -- and it's free! You'll learn about natural and cultural history, geology, forestry and much more.
Note: Wear long pants, close-toed shoes, bring water, and meet at the Nature Center on Klondike Road at 8 a.m. Phone: 770-848-3060; Email: firstname.lastname@example.com
How much: Free
Stone Mountain Park Christmas
When: Through January 1 (select dates)
Where: Stone Mountain Park
Who's this for: Everyone
Why go: If you're looking to usher in the holiday season, this is a dazzling way.
How much: You must buy a Christmas Adventure Pass, Snow Mountain & Christmas Combo Pass, or Mountain Membership for the Stone Mountain Park Christmas activities. Snow Mountain & Christmas Combo Family Value Pass is $199 for a family of four, plus tax, and includes meal tickets, hot chocolate and more.
Learn about Stone Mountain Park pass pricing here.
Snow Mountain at Stone Mountain Park
When: Through Feb. 18
Where: Stone Mountain Park
Who's this for: Everyone
Why go: Dash through the snow!
How much: Snow Mountain & Christmas Combo Family Value Pass is $199 for a family of four, plus tax, and includes meal tickets, hot chocolate and more.
Learn more about Snow Mountain and Stone Mountain Park Christmas combo pricing here.
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Good Practice in Recovery and Healing from Abuse: Adult Survivors is an extensive guide that gives insight on how to be creative in helping adult victims of abuse through the recovery and healing processes. The book features chapters written by practitioners and researchers involved in the different sectors of working with abuse. more »2013, Paperback: £22.99/ $36.95
Keywords: adult protection, adults, community care, counselling, domestic abuse, health care, older people, residential care, sexual abuse, social care, social work, supported living, trauma
Recording Skills in Safeguarding Adults is the comprehensive guide to keeping accurate, effective and complete records in safeguarding adults work. It covers crucial skills in recording, including how to write effectively; evidential requirements when writing statements and reports for court, minute-taking and includes examples of good recording. more »2010, Paperback: £19.99/ $36.95
Keywords: adult protection, carers, community care, elder abuse, health care, mental health, nursing, older people, residential care, risk assessment, sexual abuse, social care, social work, supported living
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This was a fascinating book. Jacob Kuisl is the hangman of the town of Schongau, some years after the infamous Schongau witch trials. When two child..Show More »
I liked "The Dark Monk" better than its predecessor, "The Hangman's Daughter." It tells a better story, and it has fewer horrific descriptions of M..Show More »
No. Both combined in immersion resd enhances both/
Not knowing much about the 1600s, this was a good insight into that era. I am relying of course on the author's research, which seems to me entirely b..Show More »


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Thoughts During a Meeting
I am literally sitting in a meeting as I type the rough draft of this post. (Don't worry; I am not an active participant. I am only monitoring this meeting because I will be involved in a later set of meetings in which I will have a greater role. Honest, I'm paying attention. Really, I am. What? Did I just get called on?)
The meetings involve discussions about our audit processes; ways we can be sure we are applying our standards while ensuring we are working in the most efficient and effective manner. Actually, a pretty good conversation. In fact, I believe every department should have similar discussions. How are you documenting? How are you achieving your objectives? How does your documentation support or inhibit quality? Are you documenting to just document? Are you empowered beyond the handcuffs of your departmental standards? All of these are questions worth revisiting on a regular basis.
But none of that is why I am typing this.
An auditor was just discussing a part of our process; a part where we may be insisting all auditors follow a procedure that does not apply in all situations. After his rather impassioned comments, he finished with "I apologize because this may be a very controversial subject."
Now, imagine someone from the outside world (the non-audit world) listening in. Controversial? Auditing??? What happened, did someone misplace a pencil?
At first, it does sound a little strange. It's funny to think that such small things are controversial. Yet, you know as well as I do that these little details can be important and become very controversial in their own tempest in a teapot way.
And, lest you think it is some mere local issue or a problem at the individual department level, allow me let you in on a dirty little international secret. You would not believe some of the discussions that go on at the International Committee level related to seemingly mundane things. I have sat in meetings where I couldn't believe we were spending time on the most trivial of subjects. (Does anyone really care what font is used? Seriph vs. sans seriph anyone?) And in other situations, I've been a driver of the digression. (Trust me; it makes all the difference in the world whether we use a comma or a semi-colon.) These examples are probably trivial. But let me try a more impactful example. Apparently, you should be in the room (I have not been, but I've heard stories) when discussions are held about simple word changes to the standards, definition of internal audit, etc. What is earth-shattering to one is a discussion of angels dancing on pinheads to another.
It is very easy to laugh at this (unless you're stuck in one of those interminable meetings), but let's go down a slightly different road. Controversy really only occurs when there is passion. You might be able to argue that it is misplaced passion (semi-colons?!! Get Real!), but passion nonetheless. And without passion, Internal Audit becomes a cold, dead, green-eye-shaded profession. And, you know what? I think I just figured out what was bothering me about my last post to this blog.
Back up. Let me explain. I've gotten some nice comments (both in the comments section and in separate e-mails and phone calls) about my previous post, but there was something about it that bothered me. I couldn't get a handle on what was wrong. And this little sidetrack during a meeting has helped me figure out what it is.
This column is titled "From the Mind of Mike Jacka", and you've just gotten a chance to watch that weird little mind at work. This is not where I meant for this posting to go. What was intended to be a quick write-up about the way others might view auditors as weird people with unusual priorities has turned into a deeper understanding of how to respond to myself from the previous post. Stick around – this posting has just become a preview of things to come. Next week – honest, I promise – I will respond to my own previous blog with a comment about passion, excellence, and a positive response to negative situations.
Posted on Sep 2, 2010 by Mike Jacka
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An online journal about visual art, the urban landscape and design. Mary Louise Schumacher, the Journal Sentinel's art and architecture critic, leads the discussion and a community of writers contribute to the dialogue.
Loch Ness sculpture artists fess up
A group of anonymous artists known by the pseudonym "The Phoenix," who created a three-piece sculpture of the Loch Ness monster and planted it in the Chippewa River, captured national media attention last week. They never imagined their stunt would "get this big."
With leftover cement and some egging on from the boss, a group of employees at Silvermine Stone in Eau Claire created the mythical "Nessie," according to the Eau Claire Leader-Telegram.
The artists figured they might as well come forward, since the cement factory is so close to the placement of the sculpture near the edge of the riverbank.
"We didn't think it would get this big," said Rich Mickelson, co-owner of the business, told the paper.
With the unexpected appearance of the sculpture, the opposition to its placement by the state's Department of Natural Resources and interest from local businesses to buy it, the story spread nationwide last week.
Mickelson figured some cement they had leftover shouldn't go to waste, so he encouraged his colleagues to make something fun. The iconic, fuzzy image of the so-called monster's silhouette in Scotland came to mind, and he thought, "Why not transplant Nessie to the Chippewa?"
They made molds for the head and tail and used half of a cement tabletop in the company shop for the body. They gave it a finishing touch, using red a Coca-Cola bottle cap for an eye. The head weighs more than 400 pounds, and the whole sculpture probably exceeds 1,000 pounds, the paper reported.
Read the entire Leader-Telegram article, including information about the fate of the Nessie sculpture and the artists' plans.
Image from the Associated Press.
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Wait 'till the DNR gets a hold of them. They live for this stuff.
A group of guys with a sense of humor, including the boss. This has been a funny feel good story from the get go. Too bad the DNR had to be such sourpusses. Sure, box stores and parking lots on a wetland are ok, but a silly little sculpture in a river, oh the horror!Hide replies
Couldn't agree more. Sure the DNR has a job to do also but as long as no punishment was handed down this is a simple matter.
You probably would feel differently if you hit it with your boat and were injured. It was a river navigation issue.
"As the river's water level rose, the concrete section forming the body of the sculpture resembling the Loch Ness Monster fell over. To keep it from being damaged in the river, the entire sculpture was removed.
The Wisconsin Department of Natural Resources asked last week that the sculpture be voluntarily removed because it was an illegal obstruction in the water. "
Reminded me of Downtown Disney in FL with the difference being only in the media. This is made of cement and that one is a Loch Ness made of legos. Nice!
i need tree fitty


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Community College Partnership Forms
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Earn your Cazenovia College degree in Human Services on the campus of Hudson Valley Community College. *
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With Fate Conspire is a Kirkus Reviews Best of 2011 Science Fiction & Fantasy title.
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"An absorbing finale to a series that has grown richer with every installment."--Kirkus Reviews (starred review) on With Fate Conspire"[A] complex and vibrant depiction of a magical Victorian era."--Publishers Weekly on With Fate Conspire"Enchanting, fearsome faerie vistas and pinpoint character delineations make Galen's absorbing quest one to savor and remember."--Publishers Weekly (starred review) on A Star Shall Fall"Splendidly mixing historical and fictional characters while carefully depicting the spirit of an age, Brennan's latest novel should delight fans of historical fantasy."--Library Journal on A Star Shall Fall
WITH FATE CONSPIRE by Marie BrennanKirkus Book ReviewsRead the Kirkus Review of WITH FATE CONSPIRE . Final entry in Brennan's historical fantasy series (A Star Shall Fall, 2010, etc.) wherein the Onyx Court, realm of the fae, lies hidden below Queen Victoria's London.- Kirkus Reviews
MARIE BRENNAN habitually pillages her background in anthropology, archaeology, and folklore for fictional purposes. She is the author of the Onyx Court series and the doppelganger duology of Warrior and Witch, as well as more than thirty short stories.
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Article Last Updated: Friday, November 30, 2012 4:41pm
Fish eggs spray out as Keith Taylor grabs a Kokanee salmon he snagged while fishing in the Dolores River. The salmon snag season started Nov. 15.
Photos by Sam Green
Dante Vallejos wades out into the icy waters of the Dolores River to retrieve his hook that is hung up on a rock. The fishermen all complain that the number of hooks lost in the snagging process is the bad part of salmon snag.
Ethan Long, Keith Taylor, Jim Koenig and Frank Muniz cast their lines out to snag Kokanee salmon in the Dolores River.
Ethan Long reaches for a Kokanee salmon he snagged in the Dolores River.
Catching their limit, salmon snaggers are able to fill their buckets as the Kokanee are making their run upstream.
Jim Koenig is delighted as he snags his 10th salmon from the Dolores River. Ten is the limit for snagging the fish.
Send announcements to firstname.lastname@example.com. Items submitted less than two weeks in advance will be less likely to be published. Entries may be edited for length and content.Tuesday, July 29The Montezuma County Fair Horticulture/Agriculture/Design Show, July 31 to Aug. 2. Classes include: Flowers, fruits and vegetables, foliage, herbs, houseplants, educational displays, and floral design. Entries accepted July 30...


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Name: Randy Altschuler
Hometown: St. James
Party: Republican
Bio: Randy Altschuler, 41, is a businessman who grew up in New York City. He narrowly lost to five-term incumbent Tim Bishop in 2010 by a slim 593 votes, after nearly 200,000 ballots were cast.
Upon graduation from Harvard Business School, Altschuler worked in the financial services industry, and started Office Tiger with a former classmate in 1999. Office Tiger created 4,000 jobs worldwide, including 750 in America, and specialized in business process outsourcing – contracting business operations overseas – and was purchased by RR Donnelly for $250 million seven years after it launched.
Altschuler also co-founded CloudBlue in 2001. CloudBlue focuses on managing electronic waste, and employs over 400 Americans.
He has lived in St. James since 2007 with his wife, son and daughter.
After the 2010 Congressional race, Altschuler screened for the Republican nomination for Suffolk County Executive – a race County Treasurer and Republican Angie Carpenter eventually lost to Steve Bellone – though bowed out so he could run again for Congress.
Altschuler picked up the Independence Party nomination for the 2012 race, in addition to the Republican and Conservative lines he held in 2010.
Education: Altschuler earned his Bachelor's degree from Princeton University and his Master's degree in business administration from Harvard University Business School.
Opponent: Rep. Tim Bishop
Congressional District: New York's First Congressional District, covering eastern Long Island, will change starting in the 2012 race. Its western boundary will change to cover all of Hauppauge, some of Commack, and less of Kings Park. Click here for a map to compare.


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LEED for Homes is a green building rating system with over 50,000 units certified and 120,000 units registered world wide. The program can be applied to mixed-use multi-family buildings, as well as single-family homes. This course provides an introduction to the LEED for Homes rating system and delivery model. The course addresses the intents and requirements of prerequisites and key credits within the rating system while providing real world examples of strategies to meet them. The course also identifies the roles and responsibilities of key stakeholders on a LEED for Homes project and is designed to prepare the professional to plan for key considerations and requirements for the LEED certification process.
Learn how to apply the LEED for Homes rating system to a real project that you are working on by walking through the phases of a typical project and the key decisions that project teams must make, including key stakeholder considerations. Engage in interactive, case-based activities that enable you to work hands-on with LEED implementation strategies and rating system tools.
Course Outcomes
* Pre construction Plan Draft Checklist Completed
* Knowledge of LEED for Homes Process
* Meet Requirements for LEED AP Homes Credential
* Know Steps to take your Exam
Continuing Education for the entire series.
8 NARI Green
8 Local & State Contractor & Architect Licence may be applicable (MI confirmed)
Part 1
- Introduction to LEED for Homes & Green Home Certifications
- Quick Review – LEED V4
- LEED for Provider & Green Rater – What and who are they?
- Understanding the Materials Resource (MR) of the LEED for Homes 2008
Part 2
- Location & Linkages (LL)
- Sustainable Sites (SS)
- Water Efficiency (WE)
Part 3
- Energy & Atmosphere (EA)
- Indoor Environmental Quality (IEQ)
Part 4
- Innovation and Design (ID)
- Awareness & Education (AE)
- LEED for Homes Version 4 Introduction
- LEED Checklist Navigation
- LEED registration and Submittal Process How to
- Submit a checklist with the Materials & Resources section completed*
* Either on Box.com or email to [email protected]
- Identify the types of projects which are eligible for LEED for homes
- Recognize the roles and responsibilities of key stakeholders in the LEED certification process
- Recognize goals, intents, and requirements of prerequisites and key credits in Energy & Atmosphere & Indoor & Environmental Quality, and strategies to meet them
- Identify synergies between LEED credits
This course is a part of the following series:
Implementing LEED for Homes on Your Next Project
- Intermediate
Created by
Jason LaFleur is a LEED Accredited Professional with Homes speciality (LEED AP Homes)
Jason LaFleurRegional Director Alliance for Environmental Sustainability
Brett Little made 2 contributions in the last 6 months
Brett Little is a member of


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It's not exactly "Night of the Living Dead," but there are apparently nearly 2,000 so-called "zombie houses" in the East Bay right now.
The real estate website Realty Trac recently came out with a study of zombie houses across the country.
These are homes that are in foreclosure where the occupants have either disappeared or have moved, leaving the homes vacant before they have been sold.
Is there a zombie home near you in Walnut Creek? Let us know in the comments section.
Realty Trac estimates Contra Costa County has 1,178 zombie houses. That total ranks as 7th highest among California's 58 counties. Contra Costa is the 9th largest in total population.
The website says there are 748 zombie homes in Alameda County. The total ranks as 11th in the state. Alameda County has the 7th largest total population.County Total Foreclosures Total Zombies Zombie Percentage Alameda County 3,490 748 21 percent Contra Costa County 3,812 1,178 31 percent California 106,135 28,821 27 percent
The problem zombie homes sometimes present is they become run-down or even vandalized, becoming eyesores in their neighborhood.
Jay Gallagher, the broker/owner of HomesMax HomeSellers, said zombie homes are bigger problems in urban areas such as Richmond and Oakland, where the sheer numbers and a lack of resources make code enforcement difficult.
In suburban areas, zombie homes can hurt property values and make it difficult for agents to sell nearby houses.
Gallagher said neighbors and even real estate agents have been known to mow the lawn of a zombie home to keep up the neighborhood's appearance.
Gallagher added new accounting rules sometimes discourage banks from foreclosing on a home. They don't need to list these homes as liabilities or losses until they foreclose, so sometimes they let these houses sit there.
"Many homeowners have left their homes expecting the bank to take possession," said Gallagher. "Years can pass before the homeowner realizes that the property is still in their name and they are still legally responsible for the property."


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Saturday, March 13, 2010
Valparaiso's scheduled Horizon League opener in women's tennis set for Saturday afternoon in Tampa, Fla. has been postponed, and will be rescheduled for next Saturday, March 20, in Green Bay, Wis.
A combination of weather and travel difficulties by the Phoenix necessitated the postponement. The Crusaders have now wrapped up their spring trip in Florida, and will return to action next Saturday in Green Bay.
|Copyright ©2014 Valparaiso University Athletics. All Rights Reserved.


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When we talk about Black Hat SEO, we're not talking about wizardry and witchcraft. However, we are talking about a spammy way to place more keywords on your website. Rather than following proper SEO guidelines, several websites will try to squeeze in as many keywords as they can in order to improve their search engine rankings.
We often come across websites that have hundreds of keywords hidden in the source code, or worse yet, visible at the bottom of the page. These companies think they have beat the system, but Google knows better than that. Nowadays, when Google indexes a website, they will interpret these bundles of keywords as spam, and will not reward you with any search engine rankings. No matter how good your content or Meta Data is, Google will still view that chunk of keywords as harmful information to your website.
Often times, specifically with eCommerce websites, your web template will automatically lay the keywords of all of your products onto the bottom of your page. This can easily be remedied, but if gone unnoticed, can essentially hurt all of those rankings that you have built up over the years.
So how do we avoid Black Hat SEO? We create original content with a limited amount of keywords. Linking these keywords to relevant pages on your website also helps Google recognize the importance of each search term in regards to your domain. Improving your Meta Data with these keywords is a also a way to work SEO magic behind the scenes. Just make sure you steer clear of that black magic….


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Tonawanda News — A state and local partnership aimed at investigating unemployment insurance fraud recovered almost $2 million in stolen funds in 2012, including sums of $132,000 and $135,000 from Erie and Monroe counties, respectively.
Those two are among the top 10 counties in the state to return the largest portions of recovered funds stolen from the state's unemployment insurance fund, according to statistics provided by the department of labor and cooperating district attorneys statewide.
Leading the pack are Orange and Queens counties downstate, where $178,000 and $153,000 in stolen funds were recouped in 2012, respectively, followed by Monroe County, which is so far the top ranked District Attorney's Office in securing convictions in unemployment prosecutions.
So far this year, the county has secured $92,081.
"Unemployment insurance fraud drives up costs for honest businesses and jeopardizes the benefits of the workers who rely on this vital safety net," Gov. Andrew Cuomo said in a prepared statement.
"Such criminal activity should be prosecuted to the fullest extent of the law and I applaud our local partners who pursue these cases for their vital help in returning these stolen funds."
Restitution in such criminal cases is paid back to the labor department before being added to a trust fund set up to help workers who have lost their jobs due to downsizing or other factors.
The funds are in turn used to prevent additional costs from accruing to employers because of the trust fund's ability to pay benefits, even while the same employers pay into the fund.
"When the fund is forced to pay out because of a fraudulent claim, employers have to pay more — and that means consumers will be paying more as well," Cuomo's statement reads.
New York state operates one of the largest unemployment insurance systems in the country. In 2012, the state paid out nearly $7.1 billion in total unemployment benefits to 1.13 million people. At the height of the recession in 2009, the state paid out $9.2 billion to 1.2 million people.


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Twins Should Strike While Stove is Hot
by, 12-13-2012 at 10:03 PM (1282 Views)
As the slow early weeks of this offseason dragged on, we kept hearing the same refrain:
Just wait until Zack Greinke signs. Then all of the dominoes will begin to fall.
True story. We're seeing it now. On Monday, the Dodgers announced they'd signed the game's premier free agent to a monstrous six-year, $147 million deal. In the days since, other top names have begun to quickly come off the board.
On Thursday, the Angels landed Josh Hamilton with a five-year, $125 million offer. Shortly after that came to light, Bob Nightengale reported that Anibal Sanchez the consensus No. 2 free agent pitcher had signed a five-year, $75 million contract with the Cubs, though he later backtracked. Sanchez is now playing Chicago against Detroit, and his price will likely be driven up. It's pretty compelling stuff, really.
Overshadowed by those huge headlines was Ryan Dempster's signing with the Red Sox. The right-hander agreed to terms on a two-year, $26.5 million deal that looks downright reasonable in comparison to some of these other sums being thrown around.
According to Doogie Wolfson's source, the Twins "kicked the tires" on Dempster but "never made a formal offer." Terry Ryan's done a whole lot of tire-kicking this winter, but appears content to walk away with nothing but scuffed shoes and empty hands, at least when it comes to the middle tier of starters.
We've heard the Twins connected to names like Joe Saunders, John Lannan, Francisco Liriano and Joe Blanton, but there's been no steam with higher-grade options such as Shaun Marcum and Edwin Jackson. Why not take a shot at Dempster? The Twins could have outbid the Red Sox and still been comfortably short of last year's budget.
Dempster has his warts, for sure. He'll turn 36 in May, and he got knocked around a bit after being traded to the AL this year. With the Rangers, he still averaged a strikeout per inning and pitched well after a couple early clunkers so I wouldn't worry too much about it. He has posted an ERA of 3.85 or below in four of the past five years and has averaged 200 innings over that span. He's a very solid starter, and his addition would send a message to fans that the Twins are truly committed to improving, now and in the future.
Some might say that Boston is a more attractive destination for Dempster, which brings us to the theory that free agents flat-out don't want to sign in Minnesota. But the Sox have been more of a mess than the Twins over the last two seasons and Fenway is a pretty treacherous pitching environment, which matters for a guy who might try to score one more contract after this one.
Apparently Ryan never made a serious bid, so it all becomes a moot point.
Even if the Twins were low on Dempster, why not get legitimately involved with the likes of a Marcum or Jackson? The money is ostensibly there, and even if contention in the next year or two is unlikely, they need to get better. They need to keep playing meaningful games past the middle of July to counteract the attendance drain that has been hitting them in the late months. They need a proven veteran to lead a young and inexperienced staff, and the current senior Kevin Correia is not a credible candidate.
Up to this point the Twins have essentially added no payroll for 2013. The Correia signing brings them back near even after they unloaded Denard Span's salary. With the big free agent names off the board, this is where Ryan should become active. These are the pitchers he should be in on.
He might have to pay more than he'd like in order to play that game. In fact, he definitely will. But failing to even participate in the bidding would be a disservice to fans, as well as plain-old bad team-building. The current starting stable is completely devoid of reliable assets Ryan admitted as much when surprisingly acknowledging that "there's no guarantee [Correia] will strengthen the group" and that's just no way to proceed, even if the ultimate goal is to make a push further down the line.
There is not a team in the league that should be more desperate for quality pitching than the Twins. Perhaps they should start acting like it.


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Celebrating 20 Years of Innovation, Madden NFL 09 delivers its most fun and exciting football package ever for the PSP and NDS, combining Wi-Fi multiplayer games and Rec Room minigames with all-new EA SPORTS� Family Play, featuring an easy-to-use game control system. With an all-new tri-level playcalling system, plus the new Last-Minute Miracle mini-game, the franchise takes its next leap in bringing you the greatest football experience on the go with Madden NFL 09.
Madden NFL 09 is a Sports/Football video game for PlayStation 3 developed by Electronic Arts and published by EA Sports on August 12, 2008. It's rated Everyone by the ESRB and 186 of our users have voted it 4.4 out of 5 stars.
Our newest cheats for Madden NFL 09 were added January 23, 2011. We also have the game available on PlayStation 2, Xbox, Nintendo DS, PSP, in addition to PS3.
Unlock ring 5 to fight in play now mode.
In order to get the rings faster, especially the 4th one which you need to get the freak option in superstar mode, just start a new franchise and select every team. Now simulate everything for a bunch of seasons and the points will add up, getting you the rings much easier.
Go to the game settings and turn the offsides setting to zero doin this will allow you to get to the quaterback or runnig back a whole lot quicker.
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Your speed can be 100 if you get a 3. 77 has your 40-yard dash on superstar.
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Information contained on this page is provided by an independent third-party content provider. WorldNow and this Station make no warranties or representations in connection therewith. If you have any questions or comments about this page please contact email@example.com.
SOURCE Kinetic Physical Therapy
CEO & Co-Founder of Kinetic Physical Therapy Presents Five Seminars to Participants of the 'Lighten Up Ramsey' Weight Loss Challenge
RAMSEY, N.J., May 6, 2014 /PRNewswire/ -- Kinetic PT has partnered with the Ramsey Board of Health to present educational seminars that support the participants of the Lighten Up Ramsey Weight Loss Challenge. "It has been our pleasure to contribute to this important health initiative for the Ramsey Community and offer professional assistance and education to these motivated participants through seminars and personal training," notes Evan M. Chait, CEO and Co-Founder of Kinetic Physical Therapy.
Chait has developed a series of five seminars that have demystified the myths associated with metabolism and weight loss, as well as education around the proper food supplements and diet. These individual seminar topics are as follows: Hidden Factors to a Sluggish Metabolism, Flatten Your Abs Forever, Are Your Supplements Making You Fat?, Minerals and Beyond and 40, Fit, and Fabulous. These informative ninety minute seminars have had great attendance and interest and are being presented at the offices of Terrie O'Connor Real Estate School in Ramsey, another local business who has contributed to the program.
"We have been extremely pleased that Kinetic PT has partnered with us to help support and educate our participants. We are excited to meet and exceed our weight loss goal of 600 lbs.," says Donna Sprunger-Madar, Co-Chair of the Lighten Up Ramsey Weight Loss Challenge Program.
If you are interested in learning more about the content from these seminars, please call 201.327.1990 to schedule a consultation.
About Kinetic Physical Therapy
Our mission at Kinetic PT is to deliver results by providing highly specialized and customized treatment and training regimens for our patients and clients in order to cultivate a future of health and well-being. Kinetic PT is "Bridging the Gap Between Physical Therapy and Personal Training"™ through education, knowledge and an experienced team. Our team has the tools to rehabilitate, enhance athletic performance, promote weight loss and most importantly, prevent injury. Kinetic PT is headquartered at 171 Lake Street, Ramsey, NJ 07446 with a second facility located at 182 Kinderkamack Road, Park Ridge, NJ 07656. Learn more online at www.KineticPT.com.
©2012 PR Newswire. All Rights Reserved.


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Fulfillment of the doctoral program requires that the student complete between 136 and 162 course units. The exact course-unit requirement is dependent upon the student's prior preparation in business technologies.
Listed below is a selection of courses offered in the Business Technologies program.
• 47-951 BT PhD seminar I
• 47-952 BT PhD seminar II
• 47-953 BT PhD seminar III
• 47-954 BT PhD seminar IV
• 45-870 Management of Information Systems
• 45-872 Information Resources Management
• 45-873 Telecommunications for Business
• 45-877 Strategic Uses of Information Technology
• 45-878 Developing and Sourcing Information Systems
• 45-914 Information Technology Management
The Tepper School of Business has defined several concentration areas within Business Technologies for students to develop, in consultation with their advisors. Students wishing to concentrate in Business Technologies have the opportunity to examine problems of theoretical and practical importance to management and the research community.
Among the more popular concentrations in Business Technologies are the modeling of individual and organizational responses to new information technologies, the economic evaluation of information systems, electronic commerce, software productivity and quality, and business value of Internet technologies.


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1801 Industrial Way
San Benito, TX 78586
Visit Gillman Honda San Benito and experience world class service. Our knowledgeable and experienced staff is committed to your satisfaction, and we strive to exceed your expectations. We are a greater Rio Grande Valley, San Benito, Brownsville, Harlingen and McAllen area Honda dealer with inventory and pricing that will get you into your dream car today. Schedule a test drive by contacting our friendly sales staff at 866-607-9034, or come see us in person by following our step by step directions. Our Honda dealership is about 5 miles away from the center of Harlingen, and less than an hour from McAllen, Texas.
Choose from all of the most popular Honda models at Gillman Honda San Benito. Visit our San Benito new Honda dealership and check out the Accord, CR-Z, Civic, Odyssey and Pilot, and more. Our sales team is ready to answer questions you have about any 2014 or 2015 Honda model. For everyday low prices and a great selection of cars in San Benito, visit Gillman Honda today.
Get a well-maintained, competitively-priced, used car in Harlingen at Gillman Honda San Benito. Our auto repair technicians perform a detailed inspection on every used car at our auto dealership. Gillman Honda San Benito is an excellent location for a used car in San Benito, TX. Need to locate a specific new or used car in the Harlingen area? Complete our Car Finder form and we will alert you when your dream vehicle arrives at our dealership.
Gillman Honda San Benito offers a variety of automotive services at one convenient location. Visit our auto finance department and let our professional finance team review available car loan and lease options with you. We work with a variety of financial institutions and can get you an affordable car loan or lease in greater Harlingen. Fill out Gillman Honda San Benito's online finance application and begin the auto loan process from the comfort of your own home.
At Gillman Honda San Benito we want you to get the most out of your new or used car; which is why we offer services to keep your vehicle in top condition. Our San Benito Honda service and auto repair center features some of the area's most skilled mechanics. Gillman Honda San Benito also stocks a comprehensive inventory of Honda auto parts and accessories. Our car parts specialists are standing by to help you locate Honda accessories or car parts in San Benito. For added convenience, place your Honda parts order right now by completing our online order form.
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For 2014 Honda Accord Plug-In Hybrid, 115 combined miles per gallon of gasoline-equivalent (MPGe) electric rating; 47 city/46 highway/46 combined MPG gasoline only rating. 13 mile maximum EV mode driving range rating. 570 mile combined gas-electric driving range rating. Based on 2014 EPA mileage and driving range ratings. Use for comparison purposes only. Your MPGe/MPG and driving range will vary depending on driving conditions, how you drive and maintain your vehicle, lithium-ion battery age/condition, and other factors. For additional information about EPA ratings, visit http://www.fueleconomy.gov/feg/label/learn-more-PHEV-label.shtml.


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Your are here: Home // Posts Tagged With Anna Suarez
LV unable to dig out road victory
The women's volleyball team lost 3-1 to Claremont-Mudd-Scripps Saturday at Ducey Gymnasium.
La Verne spiked by Pomona-Pitzer
The Leopards fell short in a 3-1 loss against Pomona-Pitzer Tuesday after the women broke under pressure in the fourth set.
La Verne goes 2-2 at Leopard Invitational tournament
The Frantz Athletic Court stands were full of excitement as fans cheered on their fellow Leopards during the women's volleyball Leopard Invitational games last Friday and Saturday.
The women's volleyball team ended the tournament 2-2.


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Natal is a coastal city in the northeastern state of Rio Grande do Norte, Brazil.
From the Natal Travel Guide
Average cheapest prices by month for budget accommodation in Natal
Todo OK ... more
You should check this place, because some information you give on this page is NOT true. the reception is closed at 10pm, they do not have a bar, the location is horrible, after 8pm you can not go out because it is dangerous, THIS KIND OF PLACES ARE NOT GOOD FOR YOUR PAGE, IT DOES NOT HELP YOUR REPUTATION. ... more
Natal (brazil) january-feb. 2004
hi! i m going to natal in january and i d like to know if anyone knows the right places to go, what to do besides going to the beach, and if anyone would like to meet, since i m going alone! any info is more than welcome, i ve been told it s paradise, so i expect no less!!! thanx, Luz ...
Hi, just asking about the weather in September for Rio, Buenos Aires, Santiago, Iguzau falls, & Natal. Not sure what to pack! Hope someone can help me. ...
budget accommodation in Puerto Natales in January
Can anyone recommend a nice, quiet and clean hostel in Puerto Natales where an over 50 couple can find a private room for 5 nights in January? We are also having trouble finding similar accommodation in El Chalten so any help will be greatly appreciated. ...
degrees and raining. That was it, we were going to Natal on the North East coast and it was going on Dee ...
Posted in South America by oharridge
Puerto Natales
Het is zo´n zes uur met de bus van El Calafate in Argentinië naar Puerto Natales in Chili. Het ...
Posted in Capibara by capibara
To Puerto Natales
to Puerto Natales, the gateway to Torres Del Paine. It is beautifully situated on an inlet surrounded ...
Posted in The Rooster's Solo Adventure by solorooster
What's more important to you?Price Popularity
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Hard to know if people are on edge and jittery, or more aware and diligent about looking after their neighbors given the rash of burglaries that have occurred in Rancho Santa Margarita.
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A local resident thought he saw a couple of males who may have been responsible for more than a half-dozen recent thefts, many between the 241 toll road and Antonio Parkway in the north end of town.
The informant contacted the Orange County Sheriff's Department on Friday, 3:01 p.m., to report a burglary in progress on Via Solano—in an area that has been popular with the burglar(s).
The informant spotted two men in a van who parked in the driveway of a neighbor's house. Both men were wearing backpacks. One man went to the back of the house and then the other went through the front door.
Deputies arrived on the scene only to report that there was no burglary taking place. One of the suspicious subjects was a resident at the home.
In addition to watching out for the neighbors, which is recommended by police, it might be a good idea to get to know them, too.


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KEXP faves First Aid Kit have announced the follow-up to their beloved release, 2012′s The Lion's Roar. The Swedish folk sisters will release the full-length Stay Gold on June 10th via Columbia Records, produced by Bright Eyes producer Mike Mogis. Sample the single "My Silver Lining" below. The girls are playing Saturday, May 24th atRead more...
All In! KEXP's Music Match!
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University of Washington
iTunes and KEXPYou can now find KEXP under "Eclectic" in iTunes after the demise of the "Public" category, to better represent the diversity of our daytime variety shows and numerous specialty programs.
KEXP Suggests


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The basic case against New York Mayor Michael Bloomberg's latest crusade — to outlaw the sale of extra-large sugared soft drinks — is Libertarianism 101: In a free country, people should have the right to do what they want, even if it's bad for them.
The major exceptions and complications to this basic principle don't seem to apply. Unlike secondhand smoke, my consumption of a Pepsi does no direct harm to anyone else. Unlike marijuana, sugary drinks have a perfectly adequate and legal substitute: sugar-free drinks. (Even if you can tell the difference between Coke and Diet Coke, you can't claim that the difference is very large.) And unlike a regulated pharmaceutical drug, a single dose of Coca-Cola won't kill you.


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NX Camera 52mm C-PL Filter
LF52PLTake your pictures to a new level of creativity and professionalism with the help of the Samsung C-PL Filter. By reducing reflections, haze and sunlight glare, the easy-to-use filter ensures that your photos are as clear as possible. If you want to explore your creativity, the filter comes with an adjustable rotation mechanism, which allows you to alter the lighting effect. This is also useful when lighting conditions change rapidly, as you can quickly alter your filter settings to take the best shot. With the Samsung C-PL Filter, you can enjoy much more control over your photography. 0 5 0 reviews
Recycling Batteries Responsibly
The European Directive on Batteries and Accumulators aims to minimise the impact of batteries on the environment and encourage the recovery of the materials they contain. In the UK, regulations on the recycling of batteries and accumulators (rechargeable batteries) were Introduced in 2009. The Waste Batteries Regulations aim to significantly increase UK collection and recycling of used portable batteries from 3% in 2007 to 25% by 2012, rising to at least 45% in 2016.
The battery symbol on a product or on its packaging indicates that the product must not be disposed of with general household waste. Instead, it is the consumer's responsibility to dispose of their waste batteries at a designated collection point so that they can be recycled. The separate collection and recycling of batteries at the time of dispo sal will help to conserve natural resources and ensure that they are recycled in a manner that protects human health and the environment. A comprehensive list of battery recycling centres can be obtained from: www.recycle-more.co.uk
All Samsung products that are subject to the Batteries Directive are compliant with the UK battery and accumulator Requirements. In accordance with national law, SAMSUNG Electronics (UK) Ltd is a member of an approved batteries producer compliance scheme. This scheme collects, treats and disposes of batteries on Samsung's behalf.
- Reduce reflections, haze and glare for clearer photos
- Adjust the lighting effects easily and quickly
- Use the filter with a range of Samsung NX cameras
- Carry it with you thanks to ultraportable design
Rotate filter enhanced effects
Enjoy clearer pictures with less reflection
- NameLF52PL
- Filter DiameterФ52mm
- Filter TypeCPL Filter
- FeatureReduces reflections
Physical Specification
- Weight15g
Compatible Models
- Compatible ModelsNX Series Camera
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Your opinions about this product can be helpful to us and to anyone thinking about buying one.


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This ancient cheese, with its delicate, slightly sour flavour and distinctive moist, flaky texture is made from pasteurised cows' milk. Wensleydale is available in two varieties: the common white sort, which is sold very young, and the rarer blue-veined Wensleydale, which has a mellow, rather savoury character, and a firm texture.
The only Wensleydale still made in the valley itself is that from the Hawes Creamery, which uses locally-sourced milk. also makes a blue version. Their cheeses are sold under the name 'Real Yorkshire Wensleydale'.
White Wensleydale is often enjoyed with fruitcake in its Yorkshire homeland. Wensleydale was made with ewes' milk up until the 17th century, but now it is made exclusively with cows' milk.
Article by Felicity Cloake
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and minerals which could be toxic, such as vitamin a,d, the b's, calcium and iron, for example. I take 2 multivitamins, opticean, and the vitamins and minerals I get from foods. Am I at risk for toxicity and what are the warning signs that you might be over-doing the vitamins and minerals the body stores?
Not a great resource, but here's the wikipedia entry http://en.wikipedia.org/wiki/Vitamin_poisoning
It says that deaths in the US are rare, typically zero.
That question would be tough to say yes to because it takes a lot of vitamins and minerals to actually make you ill. From the little bit of research I did, it looks like you would have to try pretty hard to get poisoned.
How much do you weigh? If you are truly concerned, you could take 1 less multivitamin.
Hmmm! Interesting I was wondering the same thing too. I read a lot about this in my nutrition class.
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It's pretty hard to get toxic levels of minerals and vitamins. Usually if you get too much of a mineral, diarrhea happens. As long as you keep stuff in balance, such as balancing calcium and magnesium, you can get high amounts of these.
Vitamin wise, the water soluble are easily excreted in urine. Some can be toxic but it requires very very high level, most likely your multi doesn't have them. Fat-soluble tends to be more toxic, but multivitamins rarely include them in big amounts. They prefer to include the very cheap beta-carotene, which is not toxic because your body control its conversion to vitamin A. Vitamin D, most likely they don't put much. The RDA is very low for that vitamin and they're basing their dosages off that. You already get a lot of vitamin D whenever you tan, so the only common way to get vit D toxicity is to combine sun exposure with cod liver oil.
Some of them might have long term negative impacts though. Care should be taken with iron and copper supplementation, as both of them are heavy metals that the body doesn't handle as easily and can increase oxidative stress in too high amounts.
So in general you are pretty safe, although at your place I'd cut at least 1 multi and replace it with more meat, veggies or nuts.
Oh and the secret is: balance.
Last edited by Max Thunder; 12-06-2006 at 09:18 PM.
The secret? Stop taking vitamins. If you diet is good you won't need them.
That's a picture of Scarlett Johansson.
i believe every person who is serious about thier healt should take a multi-vitamin
you dont need to cut back at all 2 a day wont hurt you unless it has unbeliveably high levels of certain vitamins which i doubt it does
Way down this road, in a gym far away, a young man was once heard to say, "I've repped high and I've repped low, No matter what I do my legs won't grow."
He tried leg extensions, leg curls, and leg presses, too. Trying to cheat these sissy workouts he'd do. From the corner of the gym where the big men train, Through a cloud of chalk and the midst of pain.
Where the big iron rides high and threatens lives, Where the noise is made with big forty fives. A deep voice bellowed as he wrapped his knees, A very big man with legs like trees.
Laughing as he snatched another plate from the stack, Chalking his hands and monstrous back, Said "Boy stop lying and don't say you've forgotten, Trouble with you is you ain't been SQUATTIN"


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He'Brew Messiah Nut Brown Ale - Shmaltz Brewing Company
Displayed for educational use only; do not reuse.
Ratings: 313 | Reviews: 68 | Display Reviews Only:
New York
3.5/5 rDev -2.5%
07-30-2014 16:29:55 | More by civicm87
3.5/5 rDev -2.5%
look: 3.5 | smell: 3.5 | taste: 3.5 | feel: 3.5 | overall: 3.5
Tasted from bottle at City Taco in Evansville, IN, to accompany some gourmet fish and shrimp tacos. Appearance unknown, as this was not served in glassware.
Nose malty and nutty, so pretty much typical for the style.
Taste more roasty and nutty. Hint of citrusy hops follows, and this one drinks very smooth, without too much cloying sweetness as can be the case with some brown ales. Smooth and easy drinking. A non-craft beer friend accompanying me had the same beer, and he also enjoyed it. No problems here with this solid and faithful nut brown ale.
Serving type: bottle
07-28-2014 15:37:01 | More by secondtooth
3.5/5 rDev -2.5%
07-24-2014 12:28:45 | More by Keene
Alberta (Canada)
3/5 rDev -16.4%
07-20-2014 19:43:46 | More by Howlader
3/5 rDev -16.4%
07-20-2014 04:51:48 | More by ygtbsm94
3.5/5 rDev -2.5%
07-19-2014 05:55:06 | More by Cloaked_Phantom
3.25/5 rDev -9.5%
07-15-2014 19:55:09 | More by AndyBSound
3/5 rDev -16.4%
07-10-2014 23:02:54 | More by AlexDSM
3.5/5 rDev -2.5%
07-10-2014 01:47:17 | More by scripna
3.7/5 rDev +3.1%
look: 4.5 | smell: 4 | taste: 3.5 | feel: 3.5 | overall: 3.75
I feel as though I am Hercules, left to clean out the Aegean Stables when it comes to my backlog of bottles. I am not trying to be disparaging of bottled beers, but when I am the creator of The CANQuest (TM) and I am swimming in bottles, something is wrong.
From the bottle: "Silver Medal World Beer Championships"; "MALTS: specialty 2-Row, Carapils, Dark Crystal, Chocolate, CaraMunich 60, Kiln Amber HOPS: Warrior, Cascade, Liberty"; "Born: SF 1996 Reborn: NY 2013"; "The Chosen Beer Brewed in New York L'Chaim! To Life!"; "Kosher Certified Rabbi Approved"; "Why is this beer different from all other beers? As commanded, we at HE'BREW Beer have been fruitful and multiplied our offerings. Tradition teaches that the Messiah's name is Shalom - Peace. With your first sip of this rich, dark, and delicious libation, we hope to offer a momentary taste of microbrewed bliss. If you feel the sudden urge to beat your swords into ploughshares (Isaiah 2:4) or to picnic with the lion and the lamb (Is. 11:6) ... Rejoice! Now, our award-winning brewers can't claim supernatural powers - simply a fanatical commitment to brewing world-class beers: A truly scrumptious mitzvah (good deed)! May your cups runneth over with the blessings of great beer and great shtick. To Life ... L'Chaim! [undersigned] Jeremy Cowan, Proprietor".
I was slightly anxious to get started, so my pour was nearly inverted, which does not work well when dealing with a bottle. Once things slowed down, a great pseudo-cascade took place, resulting in two fingers of dense, light-brown head with good retention. Color was a deep-brown with garnet highlights (SRM = > 27, < 34) and NE-quality clarity. Nose smelled of chocolate, coffee, tobacco and caramel. Mouthfeel was medium and it was not as sweet as I had girded myself for, based on the nose. It tasted more like cocoa than outright chocolate and the tobacco taste helped to also reduce some of the inherent sweetness of the style. Finish was semi-sweet and left me with an unusual dried tobacco flavor in my mouth. Not bad, but just not really my bag.
Serving type: bottle
07-09-2014 22:16:37 | More by woodychandler
3.5/5 rDev -2.5%
07-07-2014 19:00:20 | More by Albert_is
4/5 rDev +11.4%
07-06-2014 00:29:34 | More by drinkin-beeers
3.8/5 rDev +5.8%
look: 4 | smell: 3.25 | taste: 4 | feel: 4 | overall: 3.75
Starts with a large head but settles to a narrow layer of light tan bubbles. Good set of streaky spots and webs of lace. Brown color where light shines through easily. Appears to be clear.
Dark caramel aroma--sweet with a bit of toast (with cinnamon sugar). A bit cloy.
The flavor is an improvement because the flavor is dryer than the smell indicates. Strong crystal and caramel malts. The swallow features a very good hop presence, more than most brown ales. The body is also above average.
Serving type: bottle
07-03-2014 03:34:36 | More by smcolw
New York
3.75/5 rDev +4.5%
07-02-2014 21:20:17 | More by smithj4
3.5/5 rDev -2.5%
06-27-2014 02:26:22 | More by JDeming
3.75/5 rDev +4.5%
06-26-2014 06:12:03 | More by Stephen_Purdue
3.75/5 rDev +4.5%
06-24-2014 02:42:49 | More by sunilmallya
3.75/5 rDev +4.5%
06-22-2014 01:31:23 | More by dmorgan310
3.25/5 rDev -9.5%
06-19-2014 00:45:19 | More by PTEdelman
3.85/5 rDev +7.2%
look: 3.5 | smell: 3.5 | taste: 4 | feel: 3.75 | overall: 4
Rustic red-brown color with a coarse head. Looks like a winter warmer.
Nutty nose with English toffee and tempered malts. Light kiln bitterness, mostly Maillard Effect in full swing. Earthy hops, herbal notes, and combustible sugars.
Very tasty nut brown. Rugged malt toast, dry toffee, barley, breakfast coffee, and finishing alkali-pressed cocoa. Herbal and caramelized. Absolutely awesome.
Slick body with medium viscosity. Carbonation is mild. Nice prickle. Very good.
Kickass nut brown. Among my favorites.
Serving type: on-tap
06-18-2014 04:47:10 | More by thecheapies
3.75/5 rDev +4.5%
06-08-2014 18:29:57 | More by rspauldi
3.5/5 rDev -2.5%
06-01-2014 13:35:55 | More by TEdubbaD
3.5/5 rDev -2.5%
05-30-2014 21:15:59 | More by Durandal_777
3/5 rDev -16.4%
05-29-2014 23:20:20 | More by neckbracesub
New Jersey
3.5/5 rDev -2.5%
05-24-2014 18:25:47 | More by Latarnik
He'Brew Messiah Nut Brown Ale from Shmaltz Brewing Company
81 out of 100 based on 313 ratings.


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Associated Press
ABILENE, Texas —
Police are investigating the Texas child protection agency for its alleged mishandling of a case in which a 22-month-old girl died after her mother claimed her military husband's deployment overseas left her too stressed to care for their three children.
Abilene police Chief Stan Standridge says the department is investigating the local Child Protective Services office after a new supervisor closed the case six days before the child's death on Aug. 28.
Agency spokesman Patrick Crimmins says the mother's two other children are in foster care.
Crimmins says the supervisor didn't follow agency guidelines in closing the case. There was no required final visit and no one approved closing the case.
Standridge declined to say Monday what charge the department was investigating.
Abilene is about 185 miles west of Dallas.


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