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Top Definition
a meat gazer, some one who enjoys looking at the male genetalia. Normally short and fat and resembles a short furry rodent. He is normally found in the male head looking for his next victim. Also known as Omar Angeles/ cock stalker.
So I walked into the bathroom and i saw this scallygag waiting for me to watch me pee.
de Jizzwell 24 juillet 2010
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Dental Crowns Center - Ventura, CA
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Dental Crowns
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The anatomy of a tooth can be divided into two basic parts -- the root and the crown. In a person with healthy gums and bone, the root of the tooth is covered by the gums and bone. The part of the tooth that is vi...
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- In case of Emergency, call 911
Nearby Ventura Hospitals results
- 1Aurora Vista Del Mar Hospital
801 Seneca St
Ventura, California 93001
(805) 653-643
- 2Community Memorial Hospital
147 N Brent St
Ventura, California 93003
(805) 652-501
- 3Ventura County Medical Center
3291 Loma Vista Rd
Ventura, California 93003
(805) 652-600
- 4Pacific Shores Hospital
2130 N Ventura Rd
Ventura, California 93036
(805) 604-121
- 5Saint John's Regional Med Ctr
1600 N Rose Ave
Ventura, California 93030
(805) 988-250
- 6Ojai Valley Community Hospital
1306 Maricopa Hwy
Ventura, California 93023
(805) 646-140
- 7Santa Paula Hospital
825 N 10th St
Ventura, California 93060
(805) 933-860
- 8St John's Pleasant Valley Hosp
2309 Antonio Ave
Ventura, California 93010
(805) 389-580
- 9Los Robles Medical Center
215 W Janss Rd
Ventura, California 91360
(805) 497-272
- 10Thousand Oaks Surgical Hospital
401 Rolling Oaks Dr
Ventura, California 91361
(805) 777-775
- 11Santa Barbara Cottage Hospital
400 W Pueblo St
Ventura, California 93105
(805) 682-711
- 12Cottage Rehabilitation Hospital
2415 De La Vina St
Ventura, California 93105
(805) 682-711
- 13Psychiatric Health Facility
315 Camino Del Remedio
Ventura, California 93110
(805) 681-524
- 14Goleta Valley Cottage Hospital
351 S Patterson Ave
Ventura, California 93111
(805) 967-341
- 15Simi Valley Hospital
2975 Sycamore Dr
Ventura, California 93065
(805) 955-600
- 16Devereux California
6980 Falberg Way
Ventura, California 93117
(805) 968-252
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subset: commoncrawl


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A Weld County jury convicted a man on Wednesday of operating a pole-barn building scam while he was serving a work-release sentence in Larimer County.
Arthur John Radebaugh, 39, was incarcerated in a community corrections program in 2011 when he was doing business through BNA Agri Consulting, according to a news release from the Weld District Attorney's Office. Although he wasn't allowed to run a business while serving his sentence, Radebaugh contracted with residents, including senior citizens, to build pole barns.
He failed to get building permits, inflated prices, failed to deliver materials and left unfinished construction sites from January through September of 2011, according to the release.
The release states that the jury convicted Radebaugh of defrauding clients of more than $16,000. He was found guilty of four felony and three misdemeanor charges: one count of theft of $500 or more from an at-risk adult, three counts of theft — $1,000-$20,000, two counts of theft — $500-$1,000 and one count of theft less than $500, according to the release.
Because of Radebaugh's criminal history, District Attorney Ken Buck is seeking to have him classified as a habitual criminal. That designation would substantially increase the length of each possible sentence.
His next hearing has not yet been scheduled.


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on October 4, 2012 - 12:01 AM
, updated October 4, 2012 at 9:13 AM
My favorite college admissions adage is: "A good essay can heal the sick, but can't raise the dead."
A strong essay has the power to move a teetering applicant into the "yes" pile, but it's not a miracle drug that will assure an acceptance letter to a less-than-qualified student.
The essay has taken center stage in the application process for a variety of reasons. With so many students applying to many more colleges than in the past, the essays are really the best way for students to set themselves apart.
Since interviews are no longer standard, the essay introduces the student and helps the admissions committee get to know them.
Perhaps this is why high school seniors are feeling particularly stressed. What's worse is that the advice from colleges is so general that it's hard for students to know how to respond.
Here are some of the do's and don'ts from colleges:
• "Be authentic, show us who you really are."
• "Share your passion; write about what's important to you."
• "Make it memorable."
• "Write what you think we want to hear."
• "Tell us what we already know about you."
• "Forget to proofread."
Was that helpful? Maybe, but what most students really want to know is, how do I pick my topic? How do I figure out what to write about that shares something about me and is still interesting and insightful?
When I'm working with a student to brainstorm essays, I ask a variety of questions to tease out the best potential topics. Here are a few:
• What are your favorite subjects? Why?
• What are your greatest strengths/talents?
• What are your weaknesses?
• How are you different than most of your friends?
• What are your relationships like with your family (siblings, parents and grandparents)?
• What is important to you/what do you care about?
• How do you spend your time outside of school?
• What is your greatest achievement/most unusual thing you've ever done?
• Have you learned any "life lessons"? What? From whom?
• How would someone that knows you well describe you?
After answering these and other questions, the topic typically, and almost magically, begins to reveal itself.
Lee Bierer is an independent college adviser based in Charlotte, N.C. For more information, visit www.collegeadmissionsstrategies.com.


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Tuesday, July 23, 2013
Each week, the Moultrie News and Mount Pleasant Recreation Department will feature local track and field athletes participating in the department.
Savanna Adams, 10, participates in the 400-meter, 800-meter and mini javelin events with the Mount Pleasant Track Club. Marshall Coppage, pictured next to Savanna, did not return his questionnaire.
Question: If you could be anyone for a day, who would you be?
Savanna Adams: Taylor Swift.
Q: What is your favorite Mount Pleasant restaurant?
SA: Locklear's Lowcountry Grill.
Q: What is the best moment in your athletic career?
SA: When I got athlete of the week for the first week.
Q: What is the best advice you have gotten from a coach?
SA: "Don't speed out; follow the pack."
Q: What do you look forward to the most about being an adult?
SA: Having a family.
Q: What do you think are the most difficult and most fun aspects of track?
SA: Most difficult: practice. Most fun: meet.
Q: What is your favorite movie and TV show?
SA: Movie: "101 Dalmatians" and TV show: "Modern Family."
Q: If you could have dinner with any three people who would you choose?
SA: Taylor Swift, Steve Jobs and Ben Mackay.
Go online to www.MoultrieNews.com to sign up for our free weekly e-newsletter to receive a top story, police blotter, weekend event and "On Vacation" photo emailed directly to you every Thursday.
© 2016 Moultrie News an Evening Post Industries company. All Rights Reserved.
Registration on or use of this site constitutes acceptance of our Terms of Service, Privacy Policy and Parental Consent Form.


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CORVALLIS, Ore. - Liquid crystal display screens - LCDs - are integral to TVs, smart phones and other consumer electronics.
A new startup in Corvallis born from research at Oregon State University wants a share of the $120 billion flat-panel TV industry.
Tucked away in a corner of Owen Hall on the OSU campus is headquarters for Amorphyx, a company focused on backplanes.
Backplanes are sort of like dimmer switches controlling the light that goes through pixels on your screen.
The team at Amorphyx has found a way to make backplanes for 40 percent less cost than current technology. The process uses amorphous metals - metallic glass instead of crystaline metal - which are less expensive than the current materials used to make backplanes, according to the company.
"It's a simpler structure, simpler device, simpler materials, easier to build, lower cost," said John Brewer, the company's CEO.
The test chip was fabricated in the clean room at Owen Hall. The technology is an outgrowth of research at the university.
Dr. Bill Cowell showed KVAL News a small prototype chip based on the new technology. "It's pretty exciting to be able to start something from a very base, research level and see it grow into something with tremendous commercial opportunity," said Cowell, technical officer for Amorphyx.
Amorphyx was nominated for a grant from at the Willamette Angel Conference but didn't receive funding. The company is still seeking capital to set up a production plant in Corvallis and produce LCD backplanes to seel to customers in Asia.
"We think we'll completely change the cost of the next generation of high-performance, high quality television," Brewer said.
CORVALLIS, Ore. - Liquid crystal display screens - LCDs - are integral to TVs, smart phones and other consumer electronics.


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Top Definition
When a woman puts on nail polish and doesn't bother removing it or adding to it making it look worn out and bad.
she went out the other night with her boyfriend and hasn't replaced it, yeah she totally has vintage nail polish!
автор: murninman 3 марта 2011
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a gunngle is a person who thinks they are everything. when really they belong in a cage. they are often associated with grebs and weiners. they copy people rather frequently in tests and exams. not caring about the consequences.
esther, you are a greb and a gunngle. go crawl back into your cage!
av iizfromwizbeklyk. 26 april 2011
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When considering a sports vehicle traveling at speeds easily passing the 100 mile per hour (160 KM/h) mark, every part of the car must be finely tuned and properly calibrated, from the aerodynamics to the engine and power train.
STAR-CCM+ can cover your every one of your needs for designing the next big sports car, especially in the following areas:
External Aerodynamics
Our CFD package makes it easy to quickly analyze the entire aerodynamic profile, including spoiler wings to help offset the car's lift and aerodynamic calculations to reduce drag. Our tools can analyze and assist with optimization of the aerodynamics of a single part or the car as a whole, allowing designers to test variations and positions of each part and choose the most efficient one.
Engine simulation and combustion
STAR-CCM+ has a full combustion simulation package called DARS, in addition to standard Fluid flow packages, allowing the full simulation of the combustion cycle of an engine. In addition, STAR-CD and es-ice are the industry leaders in simulation of full engines, including faithful simulation of the moving parts, such as engine pistons, allowing for the complete simulation and analysis of a car engine. CD-adapco has all the tools you need to optimize engine performance while minimizing weight.
Thermal management
STAR-CCM+ is ideal for all Thermal analysis and management needs, able to take time sensitive thermal data from STAR-CD and es-ice to create a model for doing thermal management analysis. STAR-CCM+ is the industry leader in all CFD related simulations, and you can count on it to help improve and optimize your thermal flow quickly, efficiently, and easily.


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Serves 8 |
Prep Time 25 minutes |
Cook Time 35 minutes
3 Tbsp Eden Extra Virgin Olive Oil
2 cloves garlic, minced
1/2 cup Eden Sliced Shiitake Mushrooms, soaked 10 minutes in 1/2 cup warm water, reserve soaking water
1/4 cup Eden Maitake Mushrooms, soaked 20 minutes in 1/2 cup hot water, reserve soaking water
5 cups vegetable stock, see Eden's recipe, reserved mushroom soaking waters includedor water
14 1/2 ounces Eden Diced Tomatoes w/Green Chilies, do not drain
15 ounces Eden Cannellini (White Kidney) Beans, do not drain
1 Tbsp fresh rosemary, choppedor 1 tsp. dried rosemary
1/4 tsp crushed red pepper flakes
1 tsp Eden Sea Salt, or to taste
8 slices whole grain sourdough bread
1/4 cup fresh parsley, minced
Remove the shiitake and maitake from the soaking water, while reserving the soaking water. Finely chop the maitake and coarsely chop the shiitake. Heat the oil in a large soup pot. Sauté the garlic, shiitake and maitake for 2 to 3 minutes. Add the mushroom soaking water, vegetable stock, tomatoes, beans, rosemary, crushed red pepper and sea salt. Mix, taste and adjust seasoning by adding more sea salt, if desired. Cover and bring to a boil. Reduce the flame to medium low and simmer for 25 to 30 minutes.
Toast the slices of sourdough bread and place one slice in each individual serving bowl. Set aside until the soup is done.
When the soup is done, turn the flame off and stir in the parsley. Ladle the soup over the toasted bread and serve.
Beans, Condiments, Good/High Fiber, Good/High Protein, Italian, Japanese Food, No Sweetener Added, Oils, Soup, Chili & Stews, Tomatoes, Vegan, Whole Grain


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Cleopatra mocks Antony (1.3.83-5) in J. P. Kemble's Covent Garden staging, 1813
As seen here, ladies' costumes on stage were by this time a little less distracting and less obviously anachronistic than Augustan ones, but William Hazlitt still considered Faucit's performance as merely "the affected levity of a modern lady" (Morning Chronicle, 16 Nov. 1813). She was known variously as Harriet Elizabeth Diddear, later Mrs. John Saville Faucit and then as the second Mrs. William Farren the younger.
Samuel De Wilde (Painter); Henry Cook (Engraver); 1814. Courtesy of the H. Beard Collection, Victoria and Albert Museum.


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Lisbon Area Amateur Radio Association
We are an amateur Radio group, those meetings are on the third tuesday of the month at 6:00pm with anyone interested to attent. the purpose of are group is to promote amateur radio for the advancement of the radio art, and to prepare for emergency's and technical expertise. any amateur radio operator is welcome to come to are meetings. we are now taking apllication for membership to the association. along with training for Skywarn that the EMA director sets up for us. we are also a non-profit group, help people. so come out to see us at the Emergency management agency third tuesday of month at 6:00pm.
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Author Affiliations: Mental Health Institute, Second Xiangya Hospital (Drs X. Guo, Zhai, Liu, Fang, Wu, Xue, Chen, and Zhao), and State Key Laboratory of Medical Genetics of China (Dr Zhao), Central South University, Changsha, Hunan; Jining Medical College, Jining, Shandong, China (Dr Zhai); Chongqing Mental Health Centre, Chongqing, China (Dr B. Wang); Beijing Anding Hospital Affiliated to Capital Medical University, Beijing, China (Dr C. Wang); Psychiatric Hospital of Jiangxi Province, Nanchang, Jiangxi, China (Dr Hu); Mental Health Center of West China Hospital, Sichuan University, Chengdu, Sichuan (Dr Sun); Mental Hospital of Henan Province, Xinxiang, Henan, China (Dr Lv); Shanghai Mental Health Centre, Shanghai, China (Dr Lu); Guangzhou Brain Hospital, Guangzhou, Guangdong, China (Drs Ma and He); Hunan Brain Hospital, Changsha, Hunan, China (Dr T. Guo); Nanjing Brain Hospital, Nanjing, Jiangsu, China (Dr Xie); and Department of Psychiatry, University of California, San Diego (Drs Twamley and Jin).
Antipsychotic drugs are limited in their ability to improve the overall outcome of schizophrenia. Adding psychosocial treatment may produce greater improvement in functional outcome than does medication treatment alone.
To evaluate the effectiveness of antipsychotic medication alone vs combined with psychosocial intervention on outcomes of early-stage schizophrenia.
Randomized controlled trial.
Ten clinical sites in China.
Clinical sample of 1268 patients with early-stage schizophrenia treated from January 1, 2005, through October 31, 2007.
Patients were randomly assigned to receive antipsychotic medication treatment only or antipsychotic medication plus 12 months of psychosocial intervention consisting of psychoeducation, family intervention, skills training, and cognitive behavior therapy administered during 48 group sessions.
Main Outcome Measures
The rate of treatment discontinuation or change due to any cause, relapse or remission, and assessments of insight, treatment adherence, quality of life, and social functioning.
The rates of treatment discontinuation or change due to any cause were 32.8% in the combined treatment group and 46.8% in the medication-alone group. Comparisons with medication treatment alone showed lower risk of any-cause discontinuation with combined treatment (hazard ratio, 0.62; 95% confidence interval, 0.52-0.74; P < .001) and lower risk of relapse with combined treatment (0.57; 0.44-0.74; P < .001). The combined treatment group exhibited greater improvement in insight (P < .001), social functioning (P = .002), activities of daily living (P < .001), and 4 domains of quality of life as measured by the Medical Outcomes Study 36-Item Short Form Health Survey (all P ≤ .02). Furthermore, a significantly higher proportion of patients receiving combined treatment obtained employment or accessed education (P = .001).
Compared with those receiving medication only, patients with early-stage schizophrenia receiving medication and psychosocial intervention have a lower rate of treatment discontinuation or change, a lower risk of relapse, and improved insight, quality of life, and social functioning.
Trial Registration
clinicaltrials.gov Identifier: NCT00654576
Antipsychotic drugs have been shown to be effective against psychotic symptoms, and they are now the mainstay of therapy for patients with schizophrenia.1,2 However, long-term therapy with antipsychotics is associated with a range of adverse effects, poor adherence, and high rates of medication discontinuation.2- 4 Most patients, even those with a good response to medication, continue to experience disabling residual symptoms, impaired social and occupational functioning, and a high risk of relapse. Certain psychosocial treatments have been shown to have beneficial effects on clinical and functional outcomes.5- 9 For instance, family intervention reduces relapse rate,5 cognitive behavior therapy reduces positive symptoms,5,8 and social skills training improves social competence.7 The combination of pharmacotherapy and psychosocial intervention has been recommended for treatment of schizophrenia by practice guidelines for psychiatrists.10 Psycho social interventions can be best implemented when acute symptoms have been reduced and the patient can be successfully engaged in treatment. The goals of intervention are to reduce stress on the patient, provide support to minimize the likelihood of relapse, enhance the patient's adaptation to life in the community, and facilitate continued reduction in symptoms and consolidation of remission.10 However, the effectiveness of psychosocial intervention approaches has been considered separately. Each intervention has been directed toward one of the components of the problem: the patient's symptoms, relapse, or social skills. Few comprehensive psychosocial intervention packages have been developed that can address several problems simultaneously in schizophrenia.
Early illness course is an important predictive factor for the long-term outcome; intervention during this critical period is considered important.11 As with the published literature on chronic schizophrenia treatment, studies of first-episode and early schizophrenia samples have shown that they benefit from medication management integrated with a variety of psychosocial treatments. For example, the OPUS trial used an intensive early-intervention approach combining assertive community treatment, family psychoeducation, and social skills training, with positive effects on hospitalization rates, living independence, symptom severity, and family burden.12,13 Integrated treatment with medication, skills training, and cognitive behavior therapy is another approach that has been used, with positive effects on symptom severity.14 Finally, medication has also been integrated with cognitive behavior therapy, family support, and vocational services, with positive effects on hospital readmission, functioning, and medication adherence.15,16
In this article, we report on the Antipsychotic Combination With Psychosocial Intervention on the Outcome of Schizophrenia Study (funded by the Ministry of Science and Technology of China), a 1-year randomized clinical trial that tested the effect of medication combined with a group psychosocial intervention vs medication treatment alone on outcomes of patients with early-stage schizophrenia.17 The outcomes measured included the rate of treatment discontinuation or change due to any cause, relapse or remission, and assessments of insight, treatment adherence, quality of life, and social functioning. We hypothesized that combined medication and comprehensive psychosocial treatment would result in lower rates of treatment discontinuation or relapse than would medication treatment alone, which would reflect variations in efficacy, insight and adherence, quality of life, social outcome, and adverse effects.
The study was conducted between January 1, 2005, and October 31, 2007, at 10 clinical sites in China (6 university clinics and 4 province mental health agencies). All patients were enrolled from outpatient psychiatric clinics and were under maintenance treatment. Eligible patients were those 16 to 50 years of age who met the following enrollment criteria: (1) DSM-IV diagnosis of schizophrenia or schizophreniform disorder within the past 5 years, as determined by the Structured Clinical Interview for DSM-IV Axis I Disorders–Clinician Version18 administered by study investigators or trained staff; (2) living with family members who could be involved in the patient's care; (3) Positive and Negative Syndrome Scale (PANSS)19 total score of 60 or less; (4) receiving maintenance treatment with one of the following 7 oral antipsychotics: chlorpromazine hydrochloride, sulpiride, clozapine, risperidone, olanzapine, quetiapine fumarate, or aripiprazole. We selected these 7 antipsychotics because more than 90% of schizophrenic patients in China were prescribed one of these antipsychotics.20 Patients were excluded if they were (1) prescribed 2 or more antipsychotics or long-acting injectable antipsychotics, (2) participating in other therapy programs, (3) pregnant or breastfeeding, or (4) diagnosed as having a serious and unstable medical condition. This study was approved by the institutional review board at each site, and written informed consent was obtained from the patients or their legal guardians.
After baseline assessment, participants were randomly assigned to receive combined medication and psychosocial treatment or medication treatment alone and were monitored for up to 12 months or until medication treatment was discontinued for any reason. Group assignment was based on a 1:1 randomization scheme balanced by sites and medication prescribed. All medication visits and interventions took place in the outpatient psychiatric clinics in these participating institutes. Members of both study groups came to medication management visits once a month, and the therapy was given on the same day for the combined treatment group. The family members had to bring the patient to each appointment, regardless of treatment group. All patients and their family members from both study groups came to the clinic once a month and received the same compensation for participating in the study. No transportation, outreach, or other logistic supports were provided by this study. In both groups, patients and family members could ask medication- or treatment-related questions of the treating clinicians during their 30-minute visit as standard of outpatient care for medication management. To better keep the assessors and clinicians blinded, the psychotherapy rooms, clinicians' offices, and assessors' offices were isolated from each other; patients and family members were reminded at enrollment and follow-up visits not to discuss treatment assignment with their clinicians and assessors; and investigators and staff were restricted in the discussion of patients within research teams. Further detail about the study rationale, design, and methods have been described previously.17
Because all patients were receiving maintenance treatment, we encouraged clinicians to try to keep patients on the same medication regimen for 3 to 6 months to gauge treatment efficacy and minimize early discontinuation. However, medications could be changed at any time during the course of the study if the change was clinically warranted. If a patient's medication was stopped or switched, patients were classified as discontinued and were terminated from the study. No further assessments were required for these patients. Mood stabilizers, benzodiazepines, antidepressants, and anticholinergic medications were permitted, and daily doses of all medications were recorded throughout the study.
Patients assigned to the combined treatment group received medication treatment and were enrolled in a psychosocial intervention program. The psychosocial intervention strictly followed a detailed treatment manual designed by the principal investigators (Drs X. Guo, Liu, and Zhao) and included 4 evidence-based practices: psychoeducation, family intervention, skills training, and cognitive behavior therapy.21 Participants receiving psychosocial intervention were seen 12 times (once per month for 12 months), receiving each of the 4 group treatments on the same day, for a total of 48 one-hour sessions (see Table 1 for topics covered). A lunch break and 2 half-hour breaks were provided to maintain engagement and attention. We designed this comprehensive psychosocial intervention to be delivered on the same day once a month mainly owing to the care structure in China, the potential time and cost burden to patients and their family members, and the feasibility of adoption by other care settings. In China, most patients with schizophrenia live with their family members because of limited social welfare for severely mentally ill patients. Many of these family members also work full time, so it is not convenient for them to take time off every week and bring the patients for therapy. In addition, all our psychosocial interventions were group based, so having many patients and their family members come in once a week at the same time was not feasible or practical. Weekly intervention visits also would have increased the costs of transportation and therapist time, making the overall cost of the psychosocial intervention higher. Finally, psychosocial interventions have become more popular in recent decades in China, but the number of well-trained therapists remains limited in many Chinese psychiatric settings. More frequent therapy sessions could be not only difficult for patients and family members but also hard for many psychiatric settings to adopt.
Psychoeducation included teaching patients and caregivers about the symptoms, treatment, and course of mental illness and afforded patients and family members the opportunity to ask questions about psychiatric disorders and treatment options. This group provided a forum in which to discuss concerns and obtain support from the group to reduce the stigma of mental illness. The purpose of psychoeducation was to increase patients' and caregivers' knowledge and understanding of the illness and treatment.22- 24
Family intervention included developing collaboration with the family, socializing about non–illness-related topics, monthly updates on each family's situation, enhancing family communication, teaching patients and their families to cope with stressful situations and the illness, and teaching patients and their families to detect signs of relapse and intervene in crises.22,25,26
Skills training included modules on medication management and symptom self-management, dealing with stigma, social problem solving, and independent living skills. The training included teaching complex interpersonal skills by breaking down the targeted behaviors into component steps and systematically using modeling, behavioral rehearsal, positive and corrective feedback, and in vivo practice to shape the acquisition and generalization of skills.7,27- 29
Cognitive behavior therapy involved treatment of auditory hallucinations, delusions, and associated symptoms and problems (ie, anxiety, depression, and self-esteem); prevention of relapse; and enhancement of medication adherence. Treatment included an assessment and engagement phase, education, and building a therapeutic alliance; functional analysis of key symptoms, leading to formulation of a problem list; development of a normalizing rationale for the patients' psychotic experiences; and exploration and enhancement of coping strategies. Concomitant affective symptoms were addressed by means of relaxation training.30,31
Therapists who had at least 2 years of clinical experience after earning an MD or PhD or at least 5 years of experience after earning a masters degree in clinical psychology delivered the psychosocial intervention. They attended training workshops until they had mastered all treatment procedures. Treatment fidelity was maintained by having the therapists' supervisors assess adherence to the treatment manual after each monthly session by reviewing videotapes.
All subjects were assessed monthly by the study psychiatrists and every 2 weeks by a research assistant who had instructions to contact the psychiatrist if medication discontinuation, relapse, or other problems were suspected. The psychiatrists assessed patients mainly for medication management purposes, evaluating for clinical response to medications, medication adherence, and major adverse effects. The research assistants assessed patients, patients' caregivers, and other sources every 2 weeks by telephone for any hospitalizations, relapses, or other causes of treatment discontinuation. The research assistants also administered the symptom and functioning rating scales at scheduled intervals. The primary measure was rate of treatment discontinuation or change and time to treatment discontinuation. Once a patient discontinued the study, no further assessments were completed. Our criteria for treatment discontinuation or change were somewhat broader than those of the Clinical Antipsychotic Trials of Intervention Effectiveness study2 and included (1) clinical relapse/hospital admission; (2) loss to follow-up or patient's refusal; (3) nonadherence, defined as taking less than 70% of prescribed medications, detected by either the treating psychiatrist or research assistants during follow-up assessments; (4) changing or stopping of the initial antipsychotic medication by physician or patient request; and (5) intolerability, defined as severe adverse effects that caused the treating psychiatrists to stop the medication.
Clinical relapse was defined by any one of the following32: (1) psychiatric hospitalization; (2) an increase in the level of psychiatric care (eg, from clinic visits to day treatment) and a 25% or more increase in the PANSS total score (or 10 points if the initial score was ≤40); (3) a Clinical Global Impressions Scale score of "much worse" or "very much worse"33(pp218-222); (4) deliberate self-injury; (5) emergence of clinically significant suicidal or homicidal ideation; or (6) violent behavior resulting in significant injury to another person or significant property damage.
Secondary outcomes further assessed treatment effectiveness by measuring symptom severity (PANSS), insight (Insight and Treatment Attitudes Questionnaire [ITAQ]),34 treatment adherence (appointment adherence), quality of life (Medical Outcomes Study 36-Item Short Form Health Survey [SF-36]),35,36 and social functioning on the Global Assessment Scale (GAS)37 and the Activities of Daily Living Scale (ADL).38,39 The SF-36 consists of 8 domains that assess bodily pain, general health, general mental health, physical functioning, role-emotional, role-physical, social functioning, and vitality. The GAS is a single-item rating scale for evaluation of overall patient functioning.37 The 14-item independent ADL assesses a person's ability to perform basic (eg, dressing, walking, and bathing) and instrumental (eg, using a telephone, doing laundry, and handling finances) activities of daily living.38,39 This scale has been widely used and has demonstrated validity in studies of medically ill and dementia populations in China.40,41 The rate of obtained work or education during the 12 months was also used to assess role functioning and community integration. The physical examination and the effect of antipsychotic treatment on weight gain were recorded regularly. The Treatment Emergent Symptom Scale33(pp341-350) was used for monitoring adverse effects.
All interviewers trained and received reassessments of interrater reliability on the basis of videotaped demonstration interviews. Agreement among the raters was high for the PANSS, ITAQ, GAS, and ADL (Pearson correlation coefficient, 0.78-0.86) at baseline and every 6 months.
Analyses were performed according to the intention-to-treat principle. Randomized patients who had at least 1 assessment during treatment made up the intention-to-treat population. The sample sizes were selected to make possible the detection of a 15% difference in discontinuation rates after 1 year with 85% power and a 2-tailed α level of significance of .05.
Baseline characteristics were compared between the 2 groups by analysis of variance, Pearson χ2 test, or Fisher exact test, as appropriate. We used Kaplan-Meier survival curves to estimate the time to discontinuation of treatment in the sample. Factors associated with treatment discontinuation were determined by multivariate analysis using a Cox proportional hazards model with stepwise reduction and a log-rank test with control for site.42 Data were presented as hazard ratios (HRs) and 95% confidence intervals (CIs). Time course and treatment differences for change in the PANSS, ITAQ, SF-36 domain scores, GAS, and ADL were analyzed by means of a mixed-effects model for repeated-measures analyses with effects of treatment, time, and treatment × time interaction with unrestricted covariance of baseline scores.43 Time was classified into months (baseline and 3, 6, 9, and 12 months). Other categorical outcomes (including data regarding adverse events) were compared with the use of Pearson χ2 test or Fisher exact test. All statistical tests were 2-tailed.
A total of 1563 potentially eligible subjects were screened. Of these subjects, 1268 patients completed the baseline assessment and underwent randomization; 633 were assigned to receive antipsychotics combined with psychosocial intervention (of whom 29 refused the psychosocial intervention and were excluded from analysis) and 635 to receive antipsychotics alone. Overall, 744 patients (60.0%) completed the 1-year follow-up: 406 (67.2%) in the combined intervention group and 338 (53.2%) in the antipsychotics-alone group (Figure 1).
Figure 1. Study flowchart showing the numbers of patients screened for potential inclusion, the reasons for exclusions from randomization, and primary outcome in 1-year follow-up. *These patients were excluded from the final analysis because their follow-up was not carried out.
There were no significant differences between study groups with respect to baseline demographic and clinical characteristics. The mean age was 26 years; 55.0% of the patients were male and most patients (84.6%) had a diagnosis of schizophrenia (Table 2).
Among the 406 combined-treatment participants who completed the study, the mean (SD) number of sessions attended was 44.2 (4.4) (92.1% of the 48 total sessions), whereas among the 198 combined-treatment participants who discontinued or changed treatment, the mean number was 18.1 (4.9) (37.7% of total sessions).
Forty percent of patients in the final analysis (495 of 1239) discontinued their treatment during the 12-month treatment period (32.8% of patients in the combined treatment group and 46.8% of patients in the medication-alone group). The difference between groups in treatment discontinuation for any cause was significant (HR, 0.62; 95% CI, 0.52-0.74; P < .001) (Table 3 and Figure 2).
Figure 2. Time to treatment discontinuation because of any cause (A) or relapse (B). A, Kaplan-Meier survival analysis showed a significant difference between the medication treatment group and the combined medication and psychosocial intervention group (log-rank test: χ21 = 28.85; P < .001). B, Kaplan-Meier survival analysis showed a significant difference between the medication treatment group and the combined medication and psychosocial intervention group (log-rank test: χ21 = 18.12; P < .001).
Relapses occurred in 14.6% of patients in the combined treatment group and 22.5% of patients in the medication-alone group. The risk of relapse was lower among patients assigned to combined treatment (HR, 0.57; 95% CI, 0.44-0.74; P < .001) (Table 3 and Figure 2). Nonadherence was noted in 2.8% of patients in the combined treatment group and 5.7% of patients in the medication-alone group; rates of these events were lower among patients assigned to combined treatment (HR, 0.45; 95% CI, 0.25-0.79; P = .006). Readmission occurred in 6.5% of patients in the combined treatment group and 11.2% of patients in the medication-alone group. The risk of readmission was substantially lower among patients assigned to combined treatment (HR, 0.50; 95% CI, 0.34-0.74; P = .007).
We also analyzed all causes of discontinuation for poor outcomes only by excluding intolerance and changing medication (because these events do not always indicate poor outcomes). The results showed that 29.1% in the combined treatment group and 42.4% in the medication-alone group discontinued treatment because of poor outcomes; this difference was statistically significant (HR, 0.57; 95% CI, 0.46-0.70; P < .001).
The results of the mixed-effects model for repeated-measures analyses of change in psychopathologic behavior and daily functioning assessments between the 2 treatment groups are presented in Table 4. Although the analyses used data from the baseline and 3-, 6-, 9-, and 12-month assessments, we present only the baseline and 6- and 12-month mean scores in the table. Analyses showed a significant improvement in total PANSS and ITAQ scores over time in both groups (both F > 89.67; both P < .001); however, the change in total ITAQ scores was greater in the combined treatment group than in the medication-alone group (F = 25.94; P < .001). Improvements in GAS (F = 4.33; P = .002) and ADL (F = 12.70; P < .001) scores were also greater over time for the combined treatment group than for the medication-only group. Compared with those in the medication-alone group, those receiving combined treatment showed significantly greater improvement on 4 domains of the SF-36 (role-physical, general health, vitality, and role-emotional; all F ≥ 3.98; all P ≤ .02).
In addition, a significantly higher proportion of patients receiving combined treatment obtained employment or accessed education (30.1% in the combined treatment group vs 22.2% in the medication-alone group; χ2 = 10.09; P = .001).
There were no significant differences in the frequency and types of adverse events reported between the 2 groups (all P > .05; Table 5). The treatment group effect at the end of treatment (determined by analysis of variance with the baseline value as a covariate) was not significant for the dose of antipsychotic medication (P = .55). There were no differences between the 2 groups in the rates or types of medications added during the study (all P > .05; Table 5).
Treatment of schizophrenia should focus on improving real-world effectiveness outcomes, including functional capacity and health-related quality of life. This study was designed to provide information on the effect of psychosocial intervention on outcome in early-stage schizophrenia, in particular on functional outcome in real-world practice. We found that combined treatment improved medication adherence, risk of relapse and hospital admission, insight, quality of life, and social/occupational functioning.
Treatment discontinuation in patients with schizophrenia is strikingly common; the Clinical Antipsychotic Trials of Intervention Effectiveness study reported that 74% of patients discontinued their medications during the 18-month study,2 and the European First Episode Schizophrenia Trial reported that an average of 42% had discontinued their medications at 1-year follow-up.44 Discontinuing medication is associated with symptom exacerbation, relapse, increased hospitalization, and poor long-term course of illness.45,46 Our study showed a lower rate of medication discontinuation than the above-mentioned studies. One reason could be that our psychosocial intervention reduced the risk of treatment discontinuation and improved insight and medication adherence; another reason could be that family members are more involved in patients' care in China, similar to other Asian or developing countries. This kind of family involvement and support could further reduce medication discontinuation rates and subsequently improve outcomes. Another potential reason for better outcomes in the combined treatment group is that medication and psychosocial treatments occurred on the same day each month for patients, allowing the psychiatrists and other care providers to reinforce the importance of participation in all components of treatment.
Prevention of relapse is the cornerstone to improving all areas of long-term outcome and achieving long-term improvements in quality of life and level of functioning. The risks of relapse and hospital admission were significantly lower in the combined treatment group than in the medication-alone group in this study.
Improvements in quality of life represent evidence of a good treatment outcome for patients with schizophrenia.47,48 After 12 months of treatment, more improvements in quality of life were seen in patients who received combined treatment. Better quality of life outcomes in the combined treatment group were demonstrated not only in mental health domains but also in physical health domains, suggesting that combined treatment may afford the best combination of effectiveness and improved quality of life.
Social outcomes reflect how patients live, function in society, and perform their various roles (eg, having a job, going to school, or having friends). Our study showed that a significantly higher proportion of patients receiving combined treatment obtained employment or accessed education. Thus, the findings support the results from previous studies that patients with schizophrenia receiving combined treatment had better outcomes.12,13,49- 52 In particular, integrating a comprehensive therapy with medication treatment in patients with early-stage schizophrenia before the disease becomes chronic and disabling could improve long-term outcomes.
Psychoeducation, family intervention, skills training, and cognitive behavior therapy have proved to be effective in treating people with schizophrenia.5,7- 10,31,52 To our knowledge, this is one of a very few studies to take this integrated intervention approach and address outcome as a whole, with the goal of improving overall outcome in patients with early-stage schizophrenia. Our once-monthly comprehensive psychosocial intervention approach is different from the common therapy model used in the United States and other western countries. Although this study cannot indicate whether this intensive therapy model can be applied in other countries, it did provide evidence that the model was practical and showed better efficacy than medications alone in improving overall outcome for patients with early-stage schizophrenia. This result may be particularly informative to Asian, African, or Latin American countries, where patients with schizophrenia tend to live with their families and family members are often involved in patient care.
This study has several limitations. First, this was a 12-month trial; a longer-term randomized clinical trial would contribute substantially to understanding the longer-term effects of psychosocial intervention on outcomes. Second, although measures were taken to maintain the blinding, it is not known how effective the blinding was. However, several outcome measures were not vulnerable to bias, such as rehospitalization, loss to follow-up, and treatment nonadherence. Third, although the combined psychosocial intervention showed better overall efficacy than medications alone, we do not know whether the effects of the combined intervention were equally attributable to all the modules.
In summary, our study suggests that combined treatment in patients with early-stage schizophrenia reduces the rate of treatment discontinuation and risk of relapse. It also improves insight, adherence to treatment, quality of life, and social functioning. Integrating comprehensive therapy with medication treatment in the early stage of schizophrenia is critically important and should be recommended as the standard of care.
Correspondence: Jingping Zhao, MD, PhD, Mental Health Institute, Second Xiangya Hospital, Central South University, 139 Renmin Middle Rd, Changsha 410011, Hunan, China (firstname.lastname@example.com); and Hua Jin, MD, Department of Psychiatry, University of California, San Diego, San Diego VA Healthcare, 3350 La Jolla Village Dr, Mail Code 116A-1, La Jolla, CA 92161 (email@example.com).
Submitted for Publication: May 10, 2009; final revision received January 9, 2010; accepted March 5, 2010.
Author Contributions: Drs X. Guo and Zhai contributed equally to the study. Dr Zhao had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This research was supported by grant 2004BA720A22 from the National Key Technologies R&D Program in the 10th 5-year plan of China, grant 30630062 from the National Natural Science Foundation of China, and grant 2010CB529601 from the National Basic Research Program of China.
Role of the Sponsor: The funding organizations played no role in the design, conduct, analysis, or interpretation of the research or in any aspect of preparation or approval of the manuscript.
Additional Contributions: The following individuals collected data at participating sites: Yan Yu, MD, Zhanchou Zhang, PhD, Mental Health Institute of the Second Xiangya Hospital, Central South University; Jianchu Zhou, MD, Jie Ning, MD, Juhong Qiu, PhD, Chongqing Mental Health Centre; Qi Chen, MD, Ying Wang, MD, Qing Huang, PhD, Beijing Anding Hospital Affiliated to Capital Medical University; Fajin Gong, MD, Fang Yu, MD, Shuiquan Xu, MD, Psychiatric Hospital of Jiangxi Province; Hong Deng, MD, Qinglan Tao, MD, Yun Wan, PhD, Mental Health Center of West China Hospital, Sichuan University; Ruiling Zhang, MD, Yingli Zhang, MD, Chuansheng Wang, MD, Mental Hospital of Henan Province; Na Liu, MD, Jie Zhang, MD, Jun Cai, MD, Shanghai Mental Health Centre; Ting Li, MD, Guiying Mai, MD, Guangzhou Brain Hospital; Xiyan Zhang, PhD, Xuejun Liu, MD, Hunan Brain Hospital; and Xiaofang Shang, MD, Yu Cheng, MD, Min Zhou, PhD, Nanjing Brain Hospital. Statistical support was provided by Zhenqiu Sun, PhD, School of Public Health, Central South University.
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It's time for District 4 to change seeding process
February 4, 2013
The system is broke. Actually, it has been broken for years and changes desperately are needed....
Let's base the seedings on the color of the uniforms. You can only beat who you play. Keep the seedings based on record--strength of schedule leaves so much open to subjectivity. If a team really is the best, they'll win.
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Hello, does anybody else get this? Basketball is not the only D4 sport plagued by this seeding strategy; D4 soccer teams feel the same pain. Doesn't D4 football have a seeding plan based on strength of schedule? Seems like a simple fix, but for some reason it appears that the D4 powers are resistant to change. Chris please keep the pressure on, it's time for change. RIP JFH.
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College students provide defensive patent publications on diverse topics
Defensive patent publications establish the existence of prior art in any field
It bothers many of us everytime we hear about yet another non-obvious, overreaching, and abusive patent—particularly a software patent that is getting in the way of innovation and creativity. Additionally, there is an overwhelming sense of frustration when a regular citizen can't do much to change the current, sad state of affairs.
There is however, at our reach, a tool that can change it all: defensive patent publications. Any one can submit one to the US Patent Office to officially establish the existence of prior art in any field.
A defensive publication makes it clear that the idea is currently known to a "person having ordinary skill in the art", PHOSITA, and is a formal way of establishing prior art in such a way that the patent office will not award future patents for inventions on that pre-existing idea. Defensive patent publications are very easy to write, usually only about two pages long, and are not subject to the requirements that the idea has to be new, useful, or non-obvious. On the contrary, the publication is stating that the idea is a trivial one for a person with background in the field.
In Fall 2012, the Linux Defenders, from the Open Invention Network (OIN), teamed with the students of the Open Source Software Practices class at Rensselaer Polytechnic Institute (in Troy, NY) to write a set of defensive patent publications.
The students in the class first went through four lectures on the history and nature of patents, one of them given directly by Andrea Casillas, director of the Linux Defenders program at OIN. After this training, each one of the students wrote a defensive patent publication on a topic close to a class project that they were already working on.
Members of OIN guided the students at every step of the process, providing instructions on how to write the publications and leading them to the finished product that was ready to be submitted to the US Patent Office.
The topics were very diverse, including for example:
- relativistic time keeping
- multiple copy pasting
- multi-factor authentication
- storing arrays for expedient lookup
- remote delegation of credentials
The exercise was done as a homework assignment and only took two days. From a group of 27 students, this exercise resulted in 14 defensive patent publications actually being submitted to the US Patent Office through the IP.com system.
Coursework in colleges and universities
We advance that we could scale this approach to all the Computer Science and Software Engineering college programs in the country, by encouraging or requiring that engineering students do at least one defensive patent publication in the topic of their major during their college training.
This form of community service would achieve a dual purpose:
- students will learn about the nature of patents and the economic balance that should be examined before the government awards 20-year long monopolies
- a solid body of prior art will be established in every field, that will protect the continuous availability of public domain knowledge for the students to build upon nurture the creativity of the next generation
This action of self-defense requires a very low level of effort and can scale to have major influence in curtailing the damaging affects of the floods of trivial patents that the US Patent Office is awarding every year. Also, it is an active way of protecting the public domain, making it possible for the next generation to have a space in which they can cultivate innovation and creativity.
8 Comments
Interesting post! I briefly searched the European Patent Office (http://www.epo.org) if such defensive patent registration is possible but could not find anything.
What about an existing patent that never should have been issued due to prior art, published, in english, a decade beforehand?
Is there an inexpensive way to draw into the attention of the eyes of the USA patent office the published prior art?
Thanks for considering this,
I write what I want on my keyboard.
I do not have to "search for prior art".
This is ridiculous.
"Note that the action of compiling and linking an executable, and combining it with a computer, (under the current legal precedents) can infringe on a Patent."
Sorry, but when I give instructions to a machine, it involves that the machine follows what I told her to do.
Freedom of expression is not limited to "source code on a piece of paper."
And creating executable is just a mathematical transformation of information, I can do it with a pen and paper and produce the binary myself without a computer.
Patent attorneys do not understand that, when programmers wants to respect patent law, they ***have to*** restrict their freedom of expression. And that is not constitutional for sure.