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An adult 21 years or over must be present to sign for delivery of alcoholic beverages. Order tracking numbers will be emailed to you upon shipment, so you'll know when to expect delivery. We offer the following options for your convenience:
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Red wines that are more fruit-forward and lighter in tannin and body.
Medium bodied reds that go down easy, with smooth tannins and supple fruit.
Wines where earthy and/or spicy dominate the flavors – typically medium to full body.
Full bodied wines that have concentrated fruit and are higher in alcohol and/or tannins. Some need age.
The impression on the nose is immediate with aromas of fresh cherries, cinnamon, plum brandy, mocha chocolate, fennel seed and cigar box. The array of bright nuances continues on the palate with classic "Bordeaux blend" flavors of black currants, black cherries, blueberries and mint. There are also delicate hints of black pepper, brown butter and toasty oak flavors that combine with rich and juicy mouth watering balance continuing through the lengthy finish delivering yet another delicious D2 vintage.
Blend: 55% Merlot, 34% Cabernet Sauvignon, 9% Cabernet Franc, 2% Petit Verdot
"Serving as second wine to the corresponding Chaleur Estate bottling, DeLille's 2009 D2 comprises 55% Merlot, 34% Cabernet Sauvignon, 9% Cabernet Franc and 2% Petit Verdot sourced from seven different vineyards, each prestigious. Tea, mint, and pungently high-toned herbal essences swirl around scents of cassis and cherry, all of which have their counterparts on a finely-tannic, lusciously juicy palate on which nutty, lentil sprout-like, and subtly saline savor adds depth and saliva-inducement that persist into a long finish." 92 Points The Wine Advocate
DeLille Cellars produces a portfolio embracing the classic styles of Bordeaux, the Rhone and Provence. Since its creation, the goat to make the best handcrafted old world-style red and white wine in the state of Washington has been unwavering during their 20-year history. Through their commitment to varietal integrity, terroir expression and elegance in the glass, they continue...Read More About DeLille
Washington's first appellation, Yakima Valley has over one third of the state's vineyards. The rolling foothills of the Cascades give the vines a good sun angle, so grapes are well-ripened come harvest time. Merlot dominates the plantings here, creating elegant wines with complex fruit, herbs & structure. Syrah continues to grow in popularity, creating blanced wines with...Read More About Yakima Valley
Bordeaux Blends The Fab Five With so much history under its belt, it's no wonder that Bordeaux has figured out the recipe to produce amazing wines. Centuries of making (and drinking) wine led to the blend that has become synonomous with Bordeaux. Winemakers in the New World replicate this formula to create successful blends in their respective regions - you may see Bordeaux blends...Read More About Bordeaux Red Blends
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Sunday was my father-in-law's birthday. {Yes, there's a theme here lately, and it's not over folks!} To celebrate we went out to the farm to visit. A storm rolled in on our way, and set a cozy backdrop to our afternoon. As he always does, George promptly made rum gimlets for Cindy and me and a white russian for Jon. Oh my gimlets are delicious! That man sure knows how to shake a martini!
We feasted on snacks and Cindy's wonderful chili and talked politics all afternoon in front of the fire. Oh, and there was also ice cream cake! We couldn't believe how long it's been since I've been out there...since Christmas!? Can that be!? No wonder I was so excited!
{it's hard to see in the pic, but George had on the most hilarious visor with hair to cover his head!
Let's just say Jon get's his hair from his dad!}
To finish off the day, we went out to visit the animals in the barn. They have two horses of their own, 3 boarders, a donkey, a black sheep, two goats, two dogs, and a group of cats. The barn has changed so much since we had our reception there!
It was such a lovely day spent with family. We really must do it again soon.

subset: commoncrawl


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CHIEF Constable Stephen House and Vic Emery - Scottish Police Authority boss - are taking the legal route as they vie for control of finance and support staff.
SCOTLAND'S single police force was in disarray yesterday as it emerged battling bosses have turned to lawyers in a bitter turf war.
Chief Constable Stephen House complained he may not be allowed control over civilian staff.
Those powers could instead lie with Vic Emery, boss of the Scottish Police Authority, who oversee the force.
MSPs heard the men had sought legal advice to resolve the power struggle just months after Holyrood passed the legislation to set up the service.
House told parliament's justice committee: "I got legal advice after a conversation with the Strathclyde lead lawyer. He didn't believe the Act allowed the authority to delegate to me control over support staff, which is clearly a bit of a gobsmacking major problem."
Emery confirmed he'd also consulted lawyers over who will control force finances and other corporate services.
He said: "We have to get it right from the beginning. I'm not running the police, I'm running the SPA. Part of this process is to agree what finances are required, what savings and how those savings will be manifested."
The new police force will begin operating in April.
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Apple gives AppleSeed members new OS X 10.9 build, drops "Developer Preview"
Apple has seeded what could possibly be the Gold Master build of OS X Mavericks to AppleSeed members. The build, labeled "Build 13A598," comes two weeks after the last developer preview of Apple's next Mac operating system. However, this time Apple has conspicuously left off the "developer...
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I have been the happy recipient of many a meal delivered by friends in times of need, which for my family has meant mostly new babies and the occasional surgery or broken limb.
Despite my fairly extensive experience in this area–as giver and receiver–I used to find the process of preparing a meal for someone else's family intimidating. It's just dinner–right? But dinner is such a personal thing. Food is such a personal thing. What if my friends didn't like what I made? Or thought I was a bad cook? Or that I had terrible taste? What do people eat for dinner, anyway?
I finally had my lightbulb moment–and realized I needed to put the process on autopilot. So I came up with a go-to meal plan for myself. If someone needs dinner, I know–immediately and with barely a second's thought–basically what that is going to look like. How many times have I let my good intentions to help another family fall by the wayside because I couldn't decide what to make? Well, no longer, because I have already decided. Decide today what you will make, and you will be ready when the time comes.
It's because food is such a personal thing that the gift of a meal means so much to the recipient. It's just dinner–we all eat dinner–but there is something deeply personal about being involved in someone else's mealtime preparations. A delivered meal is a token of your friendship–a visual, tangible, edible one! Nevermind that it frees your friend to divert her attention away from the daily demands of life and on to the more pressing concerns of the moment.
Here is my go-to delivery meal:
- Grocery rotisserie chicken
- Mixed baby greens with cranberries, celery, blue cheese and candied pecans
- A loaf of good bread
- Barefoot Contessa Outrageous Brownies
Now let's review some of the nitty gritty.
When should I take my friend dinner?
It's a time-honored tradition to bring dinner to a family during times when all their available resources are consumed by the task at hand, such as a new baby, a death in the family, a surgery or other medical hardship, or sometimes, just a really bad day.
What should I make?
It's always a good idea to ask what the family likes to eat, and if there are any food allergies or dislikes. Beyond that, keep it simple and remember your audience. If there are kids in the family, it's a good idea to make something kid-friendly (baked ziti, lasagna, barbecue) or to include a dish or two that are kid-pleasing, like macaroni and cheese. Things that reheat or freeze well are preferable over dishes that don't.
It doesn't have to be a casserole.
Some of us hate the very idea of casseroles. There are other options! What about grilled chicken, flank steak, pizza, barbecue sandwiches, soup and salad, to name a few? (Once someone brought me grilled bacon-wrapped pork medallions, ready for re-heating….yum.)
What if I'm a terrible cook?
If the thought of actually cooking for another family is terrifying to you, consider take-out. Ask the family for some of their favorite restaurants and pick something up. I still fondly remember my friend pulling up to my house one sunny spring day with a giant bag from California Pizza Kitchen for our newly expanded family. We were delighted, and all my friend did was pick it up on her way home from work and drop it off to us.
How do I present the meal?
First, package the individual items. Disposable pans are a plus so that your friend doesn't need to wash a dish and keep track of it until she gets it back to you. The next best thing is a sturdy, easy to clean baking dish (like pyrex) marked on the bottom with your name. I frequently package things in inexpensive plastic containers and explicitly tell the recipient I don't want them returned. Some items (salad greens, rolls) can easily be packaged in gallon-size ziploc bags, while some things (like rolls or brownies) can be wrapped in foil.
Next, gather all the components of the meal together on a tray or in a sturdy bag. An insulated bag can be nice if you have one, but is not necessary in most weather conditions. Finish off your packaging with written instructions for anything that's not self-explanatory, e.g., "Bake at 350 degrees for 20 minutes or until heated through."
The Drop-off
Advance notice is desirable. Ask your friend what is convenient for her and plan a time so she's not in the shower, nursing the baby or taking a nap. If she's up for it, it's great to bring the meal at a time when you both can visit for a bit. A new mom may appreciate some adult conversation during the day if it's just her and the baby at home.
No time for dinner? You can still help.
Send flowers. Bring by some treats, or a new dvd for the kids. Or chocolate. And coffee! Bring by some magazines, or a new movie. Send a cute (or funny) card. Take your friend's kids to the park for an hour. One of my friends helped me greatly by having my daughter to play every Thursday morning during the long, cold winter when my last baby was born. The most important thing is to be there for your friend.


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Notification has been published in local news papers and official website regarding the submission of online application form. Registration is already started for fellowship of 1st April/1st August 2013. For Apply Online click on the link provided here. You need to enter your details and attached passport size photograph along with scan copy of your signature in .jpg or .jpeg format.
Important Dates for KVPY 2013 Admission :-
- Sale of Application Form from : July 2nd week 2012 .
- Closing of Registration at : 7th September 2012,
- Issue of Hall Tickets/Admit Card : September last week 2012.
- Date of Entrance Exam on : 04-11-2012
Important Notes for KVPY 2012 – 2013 Registration :-
- Each subject has own application form, So please fill accordingly.
- Pay Slip or challan form will be available at official site.
- Exam fees of Rs 200 has to be deposit in nearest branch of State Bank of India (SBI) at account number "10270577392″
Official Site : KVPY 2012 - 2012 online application status, hall ticket
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BEIJING (AP) — Top-ranked Victoria Azarenka and No. 2 Maria Sharapova advanced to the second round of the China Open on Monday. Azarenka beat Alize..
TOKYO (AP) — Second-seeded Tomas Berdych defeated Benoit Paire of France 6-1, 7-6 (6) in a first-round match at the Japan Open on Monday. Berdych u..
BANGKOK (AP) — Gilles Simon upset top-seeded Janko Tipsarevic 6-4, 6-4 Saturday to set up an all-French final against Richard Gasquet at the Thailand Open. ..
KUALA LUMPUR, Malaysia (AP) — Second-seeded Juan Monaco of Argentina outlasted Kei Nishikori of Japan, 6-2, 2-6, 7-6 (4) Saturday to reach the final of the Malays..
TOKYO (AP) — Russia's Nadia Petrova beat defending champion Agnieska Radwanska 6-0, 1-6, 6-3 on Saturday to win the Pan Pacific Open. Radwanska dou..
SEOUL, South Korea (AP) — Caroline Wozniacki reached the semifinals of the Korea Open by defeating Klara Zakopalova of the Czech Republic 6-2, 6-3 Friday. ..
SEOUL, South Korea (AP) — Maria Kirilenko of Russia withdrew from a second-round match at the Korea Open on Wednesday because of a back injury. Org..
CHARLESTON, S.C. (AP) — Venus Williams helped Washington catch up, then beat Coco Vandeweghe in a last-game tiebreaker as the Kastles completed their second strai..
GIJON, Spain (AP) — John Isner and the U.S. Davis Cup team saw firsthand that Spain's dominance isn't limited to Rafael Nadal. Ferrer beat Isner 6-..
CHARLESTON, S.C. (AP) — Venus Williams lifted the undefeated Washington Kastles to the World Team Tennis final Saturday, beating Ashley Harkleroad in the evening'..
BUENOS AIRES, Argentina (AP) — Argentina's injured and emotional Juan Martin del Potro beat Radek Stepanek in the opening match, and the Czech Republic's Tomas Be..
CHICAGO (AP) — While Andy Murray basked in the glow of his first major championship, his coach celebrated the U.S. Open title with a few rounds of golf with his b..
NEW YORK (AP) — If it's true, as they say, that the toughest Grand Slam title to win is your first, then Andy Murray was right to feel relief, above all, when he ..
NEW YORK (AP) — For Andy Murray, and for Britain, this was all rather fitting. Forced into a fifth set, despite winning the first two, against defe..
NEW YORK (AP) — Given all of the setbacks Serena Williams shrugged aside over the years — on tennis courts and, more daunting, away from them — she probably s..
NEW YORK (AP) — With a potentially dangerous storm bearing down on the U.S. Open, play was suspended in the first set of defending champion Novak Djokovic's semif..
NEW YORK (AP) — Scotland's own Sean Connery and Alex Ferguson crashed Andy Murray's post-match news conference after he won his U.S. Open semifinal Saturday. ..
NEW YORK (AP) — Among the many lessons Serena Williams has learned in the 13 years since she played her first Grand Slam final is that routine is overrated. ..
NEW YORK (AP) — Among the many lessons Serena Williams has learned in the 13 years since she played her first Grand Slam final is that routine is overrated. ..
NEW YORK (AP) — Dealing with 20 mph wind that blew a changeover chair onto the U.S. Open court on one point and yanked his hat off during another, Andy Murray nav..


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Material Type: | Internet resource |
Document Type: | Book, Internet Resource |
All Authors / Contributors: |
Donald Palmer |
OCLC Number: | 813299147 |
Description: | xv, 313 p. : ill. 25 cm. |
Contents: | The Normal Organizational Wrongdoing Perspective -- Definitions, Theory Development, and Method -- A Rational Choice -- The Cultural Embeddedness Account -- Behavioral Decision Theory -- The Administrative System Account -- Situational Social Influence -- The Power Structure Account -- Accidental Wrongdoing -- The Social Control of Organizational Wrongdoing. |
Responsibility: | Donald Palmer. |
More information: |
The book provides an analysis of organizational wrongdoing explaining why individuals and groups behave unethically or illegally, using a range of different theories and case studies
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Donald Palmer has developed a provocative argument about the inevitability of organizational wrongdoing. What we have here is a critical, inclusive, sociological analysis that takes the perspective of embedded wrongdoers[The book] could easily be a basic text for organizational studies courses of any kind. Why? Basic positions are presented and compared. Ethics are not compartmentalized. Applications are not oversimplified. Readers understand more clearly why organizational participants may develop a cynical outlook. Read more...
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Sail for Sombrero Chino (Chinese Hat), named for its volcanic rock shape. View Galapagos wildlife and birds, specifically American Oystercatchers, Galapagos Penguins, and Sally-Lightfoot Crabs as they skirt across the rocks.
In the afternoon, sail for Fernandina. This island was never invaded by foreign animal species, making it one of the most pristine eco-systems in the world. Take a short hike to the Flightless Cormorant nesting site and view the volcano La Cumbre. Throughout the day, snorkle in the clear, blue waters of the Galapagos.
Head for Urbina Bay, located at the base of Alcedo Volcano, and explore its jagged coastline. View Land iguanas, hawks, coral reef, and giant tortoises. Snorkel with turtles, rays, and tropical fish.
In the afternoon, sail for Moreno Point. Hike along several lava paths which take you through tide pools and mangroves.
In the afternoon, visit Gardner Bay, the breeding site of most of the world's 12,000 pairs of Waved Albatrosses. The bay is surrounded by white sandy beaches with a myriad of sea lions.
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Originally Posted by Cyclonepride That's a really funny name you got there. Are you twice as bad as Vin Diesel? If you mean twice as bad of an actor, yes; and that is quite an achievement. Technically it is 2.333 times as bad.
Last edited by VeloClone; 01-10-2011 at 10:27 AM.
"There are five real good recruits in the state. We got three of them. One couldnt get into school, and the other went to (the University of) Iowa...which is about the same thing." - Coach Johnny Orr
A little off topic, but I wish more schools had their cameras in the same location as Duke. Watching from that high angle gives a much better view of the whole floor, much closer to watching coaches film than the way most games are shot.
I don't want to see highlights of a play from floor level. It's as bad as football highlights from ground level--you get absolutely no perspective of a great many dimensions that are invaluable.
Paul Rhoads' players never quit.
More basketball, less talk. Did anyone happen to see the NBA game on TNT last week (Thursday maybe..?) with Reggie Miller and Chris Webber doing the game? It was basically a 2 hour conversation about what they thought with some tidbits from the game thrown in afterwards. Give me the facts about the game, thats all I need. THe broadcast is supposed to be about the game not about the commentators egos. Basketball is so fast paced you don't have the time for the extra stuff like you do in between snaps in football or pitches in baseball.
Not just hoops, they do it in football when they get off on their little sidebar stories or have a guest in the booth and seem to forget about the game. My favorite was during the Seneca Wallace lead comeback against Iowa. They had Raisin Face in the booth at the start of the third quarter jabbering about Iowa Hawkeye this and that and were totally oblivious to what was happening on the field, ie: Cyclones kicking Hawkeye tail feathers. It will probably happen tonight in the big championship game when they get jibber jabbering about something and miss some big play.
Yes, it has gotten gradually worse. I watched ISU-Nebraska on ESPN3 --- I think it was fed from Nebraska network via FSN Midwest(?) -- but that was the worst case of the cutaway/miss live action I've ever seen in an ISU game, perhaps ever (there may be other examples just as bad, but I would probably notice more during an ISU game). I hate having to guess whether a free throw was made or missed based on audio crowd reaction. That happened at least five times. I can understand occasional "goofs" cutting to a replay during presumed dead space, when the action actually continued sooner than expected (or a "video booth gaffe," when someone picks the wrong camera). But if I know damn well the ball is in play and we get an extended shot of a coach or the crowd, that's a joke. We don't need a cutaway to the crowd after a big basket in non-dead-ball sequence, either. Most viewers can tell it was a huge basket, just by, you know, watching the game. Then again, maybe we didn't actually see the play.
Best in local news satire: Bass Lake Beacon
Originally Posted by VeloClone I just wanted to get the feel of how most people feel about how a director directs the coverage of a BB game. Over the last couple of decades I have seen the definition of what is important in a BB game apparently change. When I first started watching college BB they would cover the action on the court anytime the ball was live. Replays, highlight packages and crowd/bench/player shots were saved for a deadball situations and timeouts. Anymore (since the emergence of ESPN?) directors seem to be so enthralled with making themselves look good that they forget that they fail anytime their viewers miss action on the court. Personally it frustrates me no end when we are forced to watch a player celebrate or the head coaches wife cheer while the team is pressing the end bounds pass. We miss how the turnover and basket happens because we need a honey shot? We miss an inbounds play and score because we have to see the previous play three times and they aren't done when the ball is inbounded. We come back from a commercial break and have to look at a stat graphic while the action on the court has already started. Show stats before the action or put a condensed version across the bottom of the screen. Anybody else think that sports coverage is getting too cute and forgetting what it is all about? I always thought the whole point was the game... Am I alone in getting upset with missing out on part of the game? What if the coach's wife it a hottie? I love watching Syracuse basketball.
Originally Posted by 2020cy I agree with Tube1. Sweeeeeeet...
Originally Posted by tube1 What if the coach's wife it a hottie? I love watching Syracuse basketball. I have no issues with seeing the head coach's hot wife. Please show me her during a timeout.
I imagine a day in the not too distant future when all broadcasts are delivered through internet streams where each camera is delivered indpendently and users on their computer or web enabled TV are allowed on an individual basis to select the camera(s) they want to watch and sync any audio feed of the game to the video broadcast. Let the users pick when they switch cameras and let them rewind when they want to. Let users choose to watch the camera that is focused on the hot wife all game if they want or watch a typical broadcast version put together by the network. Not only does this give users a MUCH better experience, but the network gets N times as much advertising slots to sell (where N is the number of cameras at a game). Until this happens, I'm sure I'll continue to be disappointed.
Originally Posted by synapticwave I imagine a day in the not too distant future when all broadcasts are delivered through internet streams where each camera is delivered indpendently and users on their computer or web enabled TV are allowed on an individual basis to select the camera(s) they want to watch ........ Imagine there's no heaven, it's easy if you try ....
Originally Posted by psi Imagine there's no heaven, it's easy if you try .... I love Forrest Gump references.
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Presented at the Society for Academic Emergency Medicine annual meeting, Phoenix, AZ, June 2010.
Hospital-reported Data on the Pneumonia Quality Measure "Time to First Antibiotic Dose" Are Not Associated With Inpatient Mortality: Results of a Nationwide Cross-sectional Analysis
Article first published online: 5 MAY 2011
DOI: 10.1111/j.1553-2712.2011.01053.x
© 2011 by the Society for Academic Emergency Medicine
Additional Information
How to Cite
Quattromani, E., Powell, E. S., Khare, R. K., Cheema, N., Sauser, K., Periyanayagam, U., Pirotte, M. J., Feinglass, J. and Mark Courtney, D. (2011), Hospital-reported Data on the Pneumonia Quality Measure "Time to First Antibiotic Dose" Are Not Associated With Inpatient Mortality: Results of a Nationwide Cross-sectional Analysis. Academic Emergency Medicine, 18: 496–503. doi: 10.1111/j.1553-2712.2011.01053.x
Dr. Powell and Dr. Khare are supported by a National Research Service Award postdoctoral fellowship grant through the Institute for Healthcare Studies at Northwestern University under institutional awards from AHRQ (T-32 HS 000078 and F-32 HS 17876-01). Dr. Courtney was supported by grant 5K23HL077404-04 from the National Heart, Lung, and Blood Institute.
The authors have no relevant financial information or potential conflicts of interest to disclose.
Supervising Editor: Christopher R. Carpenter, MD.
Publication History
- Issue published online: 13 MAY 2011
- Article first published online: 5 MAY 2011
- Received September 7, 2010; revisions received October 21 and November 14, 2010; accepted November 19, 2010.
- Abstract
- Article
- References
- Cited By
ACADEMIC EMERGENCY MEDICINE 2011; 18:496–503 © 2011 by the Society for Academic Emergency Medicine
Objectives: Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality.
Methods: This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance.
Results: Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th–75th interquartile range = 2–11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05).
Conclusions: In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.
Pneumonia is a significant cause of mortality in the United States.1,2 It accounts for 4.3% of all emergency department (ED) admissions, and the cost of treating community-acquired pneumonia is estimated at $10 billion per year, with 92% of costs occurring in the inpatient setting.3–5
The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) have defined standardized quality measures that hospitals are required to publicly report and are evaluated on.6 One such quality measure relating to pneumonia is the time to first antibiotic dose (TFAD), with the current requirement that the initial antibiotic is given within 6 hours of hospital arrival (increased from 4 hours in April 2008).7
There has been significant debate regarding the appropriateness of the TFAD measure.8–11 In holding hospitals to this standard, it is reasonable to expect that achieving this goal would correlate with improved outcome and decreased inpatient mortality. The evidence for the TFAD measure originated in two studies of Medicare patients that demonstrated mortality benefit with earlier initiation of antibiotic therapy,12,13 but since implementation of the quality measure, subsequent studies have failed to reproduce this mortality benefit.14–16 Furthermore, there is the potential for unintended consequences of enforcing this quality measure, such as antibiotic overuse, antibiotic misuse, misdiagnosis, and misprioritization of patients.8,9,17–23 The objective of this study was to determine whether hospital performance on the TFAD quality measure for patients admitted from the ED with a principal diagnosis of pneumonia is associated with decreased inpatient mortality.
Study Design
We performed a cross-sectional analysis of the 2007 Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS). The Northwestern University institutional review board found this study of deidentified data exempt from informed consent requirements.
Study Setting and Population
The NIS is the largest publicly available all-payer inpatient database in the United States and is provided by the U.S. Agency for Healthcare Research and Quality. Data are weighted to result in a sample that is representative of all admissions to nonfederal United States hospitals on an annual basis. Additional detail on the NIS can be found on the HCUP website (http://www.hcup-us.ahrq.gov/). We linked this data set with the publicly available 2007 CMS Hospital Compare hospital scores for the TFAD measure. The Hospital Compare data report the percentage of pneumonia admissions that achieved TFAD within the quality measure goal of 4 hours. The ability to link patient-level data from NIS to hospital-level data from Hospital Compare was possible by using the American Hospital Association (AHA) identification number provided within the NIS data set.
The 2007 NIS data set contains 8,043,415 inpatient discharge records from 1,044 hospitals located in 40 states. Admissions for pneumonia were identified based on principal diagnosis International Classification of Disease-9th revision (ICD-9) codes. We used similar ICD-9 codes to those found in other large pneumonia studies.13,24 The study sample included patients 18 years or older with an ICD-9 principal discharge diagnosis of 480, 480.0–480.3, 480.8–480.9, 481, 482, 482.0–482.4, 482.8–482.9, 483, 483.0- 483.1, 438.8, 484, 484.0–484.1, 484.3, 484.5–484.8, 485, 486, or 487. Because we wanted to focus on the acute identification and diagnosis of pneumonia, patients were excluded from the analysis if the admission was from a source other than the ED. The AHA identification number linked the NIS patient records to the 2007 CMS Hospital Compare TFAD measure. Therefore, records were excluded if the AHA identification number was not included in the NIS or if the hospital of admission did not report the TFAD quality measure.
Study Protocol
Patient and Hospital Variables: NIS. NIS data included admission source, discharge status (alive or dead), sex, age (divided into quintiles), and race and ethnicity (black, Hispanic, white, other, or missing). Race and ethnicity data were missing for 26.0% of study patients from states where this information was not mandated, and therefore this demographic information was not included in the multivariate analysis. NIS data also included length of stay (LOS), weekend admission, primary payer source, and patient zip code median income (divided into quartiles). Individual income level was not available from the NIS. However, we coded patients with a primary payer status of Medicaid or self-pay (uninsured) into a single category as an additional proxy for lower socioeconomic status.
To account for confounding due to comorbid conditions present on admission that may have influenced mortality, we used the Elixhauser ICD-9 secondary diagnosis codes to identify concurrent admission conditions. This comorbid condition coding scheme has often been used in previously published mortality models to adjust for severity of preexisting illness for critically ill patients.25–27 The comorbidities included in the Elixhauser index are very similar to those of other risk-adjustment schemes, such as the scheme used by Hospital Compare to account for deaths unrelated to hospital care for their quality measure analysis. The NIS classified patients as having or not having each of 30 Elixhauser chronic comorbid conditions. For the purpose of our analysis, patients were then categorized by the number of concurrent conditions present at admission (0, 1, 2, 3, 4, 5+).
Hospital-level data in the NIS included bed size (categorized by NIS as small, medium, or large; based on the number of short-term acute beds in the hospital and specific to the hospital region, location, and teaching status), teaching status (member of the Council of Teaching Hospitals or not), and location (rural versus urban). To assess whether TFAD performance was an independent predictor of mortality, these hospital characteristics were also included in multivariate models of inpatient mortality.
TFAD Measure. The 2007 CMS Hospital Compare data reported the TFAD measure as the mean percentage of admissions for pneumonia where the first dose of antibiotics was received within 4 hours of arrival at the hospital. The CMS Hospital Compare also reported the AHA hospital identifier, and this was used to link the mean percentage score to each admission record in the NIS. Records were then divided into balanced quartiles based on mean TFAD percentage. Further information on the 2007 CMS Hospital Compare report is available at http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=13224.
Key Outcome Measure
The key outcome measure in this study was overall all-cause inpatient mortality.
Data Analysis
Analyses were conducted with STATA version 10.0 (StataCorp, College Station, TX). Patient and hospital characteristic data were evaluated across TFAD performance quartiles with chi-square tests for categorical variables, and the analysis of variance (ANOVA) for continuous measures. The unadjusted association of TFAD performance with mortality was evaluated continuously with a t-test and by quartiles with the chi-square test. Significance between TFAD quartiles was conducted by one-way ANOVAs with post-hoc Bonferroni tests. A population-averaged logistic regression model with an exchangeable working correlation matrix was used to analyze the simultaneous effects of age, sex, number of comorbid conditions, weekend admission, payer status, income level, hospital size, location, teaching status, and TFAD performance on inpatient mortality. This approach accounted for nesting of admissions within hospitals.28 Forward censoring was not used in developing this regression model. This multilevel statistical modeling takes into account both individual and hospital-level variables and adjusts for "nesting of admissions" or similarity of patients presenting to one hospital compared to another hospital. Results are reported as odds ratios (ORs) and 95% confidence intervals (95% CI). Significant associations were interpreted as p < 0.05.
The ED Pneumonia Patient Sample
The final study population included 95,705 patients from 530 hospitals (Figure 1). The overall inpatient mortality for this nationwide sample of admitted patients with acute pneumonia was 4.1% (95% CI = 3.9% to 4.2%). Median time to death was 5 days (25–75th interquartile range = 2 to 11 days). Overall, hospital-reported data suggested a relatively high percentage of admissions meeting the TFAD within 4 hours. The mean TFAD performance score across all hospitals was 77.7% (95% CI = 77.6% to 77.8%). The TFAD performance quartiles were: highest performing quartile 86% to 100%, second highest performing quartile 79% to 85%, third highest performing quartile 72% to 78%, and lowest performing quartile 0 to 71%.
Unadjusted Patient and Hospital Characteristics Across TFAD Performance Quartiles
Table 1 displays patient and hospital characteristics for the 2007 ED pneumonia admission sample across TFAD performance quartiles. The mean age of the study sample was 69.3 years (95% CI = 69.2 to 69.4 years). There was a significant trend toward older patients being more represented in the higher performing quartiles in a post hoc analysis (p < 0.001). Just over half of the population was female (52.1%). The mean LOS was 5.59 days (95% CI = 5.56 to 5.63 days). The highest performing hospitals had a mean LOS of 5.2 (95% CI = 5.14 to 5.26 days) and the lowest performing hospitals had a mean LOS of 5.84 (95% CI = 5.76 to 5.92 days).
Overall Sample | Antibiotic Compliance | ||||
1st Quartile | 2nd Quartile | 3rd Quartile | 4th Quartile | ||
| |||||
Patient characteristics | |||||
Age (yr)* | 69.3 | 67.2 | 68.8 | 70.3 | 70.9 |
Hospital LOS (days) | 5.59 | 5.84 | 5.72 | 5.61 | 5.20 |
Race | |||||
Missing† | 26.08 | 17.40 | 24.82 | 30.88 | 30.96 |
White | 58.70 | 59.29 | 57.90 | 56.79 | 60.90 |
Black or African American | 8.18 | 11.63 | 9.62 | 7.45 | 4.09 |
Hispanic | 7.04 | 11.68 | 7.66 | 4.88 | 4.06 |
Sex | |||||
Male | 47.88 | 48.14 | 47.61 | 47.28 | 48.49 |
Female | 52.12 | 51.86 | 52.39 | 52.72 | 51.51 |
Number of comorbid conditions | |||||
0 | 3.92 | 4.31 | 3.90 | 3.57 | 3.91 |
1 | 12.62 | 13.19 | 11.95 | 12.47 | 12.82 |
2 | 20.98 | 20.77 | 20.74 | 20.79 | 21.62 |
3 | 23.53 | 22.96 | 23.28 | 23.79 | 24.09 |
4 | 18.70 | 18.15 | 18.67 | 19.44 | 18.51 |
5+ | 20.24 | 20.61 | 21.46 | 19.95 | 19.05 |
Median income | |||||
1st quartile (lowest) | 28.13 | 34.44 | 27.28 | 29.20 | 21.46 |
2nd quartile | 26.01 | 26.57 | 28.25 | 23.46 | 26.12 |
3rd quartile | 24.20 | 21.42 | 25.53 | 24.33 | 24.57 |
4th quartile (highest) | 21.66 | 17.57 | 18.94 | 22.01 | 27.85 |
Medicaid/uninsured | |||||
No | 87.24 | 83.61 | 85.84 | 88.58 | 90.83 |
Yes | 12.76 | 16.39 | 14.16 | 11.42 | 9.17 |
Hospital characteristics | |||||
Rural | |||||
No | 83.04 | 90.95 | 91.61 | 81.03 | 69.22 |
Yes | 16.96 | 9.05 | 8.39 | 18.97 | 30.78 |
Region | |||||
Northeast | 26.58 | 21.29 | 24.23 | 29.08 | 31.48 |
Midwest | 14.38 | 7.06 | 12.06 | 20.08 | 21.90 |
South | 29.06 | 40.09 | 33.91 | 24.85 | 17.84 |
West | 28.96 | 31.55 | 29.80 | 26.00 | 28.78 |
Teaching status | |||||
No | 62.34 | 47.92 | 59.95 | 66.81 | 74.47 |
Yes | 37.66 | 52.08 | 40.05 | 33.19 | 25.53 |
Hospital size | |||||
Small | 14.94 | 6.60 | 10.68 | 20.27 | 21.68 |
Medium | 25.46 | 21.08 | 29.95 | 20.39 | 31.20 |
Large | 59.60 | 72.32 | 59.37 | 59.34 | 47.12 |
For states with available data on race and ethnicity (74.0% of the sample), we found a predominantly white population (58.7%), with 8.2% being black and 7.0% being Hispanic. There were a greater proportion of black and Hispanic patients in the lower performing hospitals when compared to higher performing hospitals (p < 0.001). The majority of the population (62.5%) had three or more Elixhauser comorbid conditions present on admission. There was a heterogeneous mix of median income levels for the patient sample, and lower performing hospitals had a greater proportion of low-income patients. Furthermore, higher performing hospitals had significantly fewer patients with Medicaid or without insurance.
Of the sample, 83.0% were from urban hospitals and 59.6% were from large bed–size hospitals. Over half of ED admissions for pneumonia were to nonteaching hospitals (62.3%). There were a greater proportion of urban hospitals in the two lowest performing quartiles compared with the two highest performing quartiles. The lowest performing quartile also included a significantly higher percentage of large bed–size hospitals (73.3% vs. 47.1% in the highest quartile, p < 0.001). Finally, the highest performing quartile hospitals were more likely to be nonteaching hospitals (74.5% vs. 47.9% in the lowest quartile, p < 0.001).
Unadjusted Association of TFAD Performance Quartiles and Mortality
There was no significant difference in inpatient mortality between hospitals across the four TFAD performance quartiles, with mortality ranging from 4.01% to 4.08% (p = 0.98; Figure 2). Mean hospital compliance with the TFAD measure did not significantly differ between patients who died and those who survived their hospital admission (77.7% and 77.8%, respectively; p = 0.71).
Adjusted Analysis: Patient and Hospital Factors and Mortality
Results from adjusted analysis identified increasing age, female sex, and increasing number of comorbid conditions as predictor variables independently associated with increasing odds of inpatient mortality (Table 2). Patients over the age of 85 were over seven times more likely to die than those 18 to 44 years of age (OR = 7.60; 95% CI = 5.98 to 9.65 years). Those with five or more comorbid conditions were over two times more likely to die than those with no comorbid conditions (OR = 2.4; 95% CI = 1.88 to 3.18).
Inpatient Mortality | ||
| ||
Patient characteristics | ||
Age (yr) | ||
18–44 | Reference | |
45–64 | 2.27 | 1.79–2.88 |
65–84 | 4.18 | 3.30–5.29 |
>84 | 7.60 | 5.98–9.65 |
Female | 0.82 | 0.77–0.88 |
Number of comorbid conditions | ||
0 | Reference | |
1 | 1.11 | 0.84–1.47 |
2 | 1.38 | 1.06–1.80 |
3 | 1.51 | 1.16–1.97 |
4 | 1.72 | 1.32–2.25 |
5+ | 2.44 | 1.88–3.18 |
Median income | ||
1st quartile | Reference | |
2nd quartile | 0.99 | 0.90–1.09 |
3rd quartile | 1.05 | 0.95–1.16 |
4th quartile (highest) | 1.04 | 0.93–1.16 |
Medicaid/self-pay | 1.06 | 0.92–1.22 |
Hospital characteristics | ||
Rural | 1.10 | 0.97–1.24 |
Teaching hospital | 0.98 | 0.88–1.08 |
Hospital size | ||
Small | Reference | |
Medium | 1.10 | 0.96–1.27 |
Large | 1.06 | 0.93–1.21 |
Weekend admission | 1.04 | 0.97–1.12 |
TFAD quality performance | ||
Lowest performing quartile | Reference | |
3rd highest performing quartile | 0.91 | 0.79–1.05 |
2nd highest performing quartile | 0.94 | 0.82–1.08 |
Highest performing quartile | 0.89 | 0.77–1.02 |
None of the hospital characteristics were significant as independent predictors of inpatient mortality. Specifically, hospital compliance with antibiotic timeline guidelines did not predict inpatient mortality. The highest performing TFAD hospital quartile had an OR of 0.89 (95% CI = 0.77 to 1.02) compared to the lowest performing TFAD hospital quartile. The second and third highest quartiles had ORs of 0.94 (95% CI = 0.82 to 1.08) and 0.91 (95% CI = 0.79 to 1.05), respectively.
This is the first work to demonstrate a lack of an association between hospital compliance with the time to first antibiotic dose for pneumonia and inpatient mortality in a large cohort of adult patients admitted from EDs across the United States. We demonstrated no significant mortality difference between ED admissions from hospitals performing in the highest performing quartile and ED admissions from hospitals performing in the lowest performing quartile for the TFAD quality performance measure. Furthermore, there was no significant difference in mean hospital compliance with the TFAD measure among patients who died and those who survived their pneumonia hospital admission. There was a statistically significant relationship between hospital LOS and hospital performance on the TFAD quality measure. However, the clinical significance of 5.20 versus 5.84 days is uncertain and may not help clarify conflicting evidence on the impact of this secondary outcome.10
There were several similarities between our study and previous studies. We demonstrated a clear trend toward higher inpatient mortality from pneumonia with increasing age.15,29–32 We further demonstrated higher inpatient mortality with increasing burden of comorbid disease.30 Our finding that larger hospital bed size and teaching hospitals were associated with lower hospital performance on the TFAD measure is consistent with results of other studies investigating pneumonia quality measures and hospital characteristics.33,34 It is possible that the larger, urban, teaching hospitals care for sicker, more complex patients who have not been captured by our analysis if pneumonia was a secondary diagnosis after sepsis or respiratory failure, thus giving these hospitals a deflated representation of their quality measure performance. In addition, these hospitals generally have much longer wait times than smaller, community hospitals, which could influence their TFAD if compliance with the quality measure does not have a high priority. We also demonstrated that females have a significantly decreased inpatient pneumonia mortality compared to males. The basis of the relationship between sex and inpatient pneumonia mortality has not been specifically investigated in prior studies that we are aware of, but studies have demonstrated sex disparity with the diagnosis of pneumonia.35,36 Further evaluation of the relationship between sex and inpatient pneumonia mortality should be pursued.
Previous studies have demonstrated mixed associations between the TFAD quality measure and mortality as reviewed by Yu and Wyer10 in a meta-analysis of studies comparing inpatient or 30-day mortality among patients receiving early versus delayed antibiotics. Many time-to-antibiotic studies have been limited by small sample sizes, were limited to the Medicare population, or included only patients over the age of 65 years.12,13,16,30,37,38 The CMS/TJC quality measure was originally based on studies performed by Houck et al.12 and Meehan et al.,13 which were limited to a Medicare population of adults over the age of 65 years. In practice, the TFAD quality measure is applied to all patients over the age of 18 years, as was included in this study. Our results from a decade after the original study on TFAD quality measure, however, add to the body of literature supporting the fact that there is no association between performance on the TFAD measure and mortality in a general adult population.10,15,16,30
The TFAD measure has been called a "flawed performance measure."9 Evidence in the literature suggesting possible unintended or harmful consequences of strategizing ED care specifically toward the TFAD quality measure is substantial and growing. Problems have been identified, including misdiagnosis, flawed triage, lack of cost-effectiveness, and inappropriate delivery of antibiotics.8,9,11,17–23 In 2009, the American Academy of Emergency Medicine issued a literature review and concluded that the TFAD measure should be discontinued as a performance measure.11
Although this study does not investigate the reason for lack of survival improvement with TFAD, we can speculate why we reached different outcomes than the original studies that demonstrated such an improvement. It is possible that there was a much larger disparity in timing of antibiotic delivery to pneumonia patients during the period before and just after the initiation of the quality measure. This wide disparity in care may have led to significant mortality outcome differences in patients as reported in the original studies leading to the quality measure. However, there is now a more uniform time delivery of antibiotics among hospitals, and the pendulum may have swung the opposite direction so that the negative consequences of implementing the TFAD quality measure have superseded any negligible mortality improvements. Implementation of quality measures may require repeated evaluation of their benefit to ensure original intent of the measure is indeed consistent with ongoing medical practice.
There were several limitations to this study, many of which are inherent to secondary data analysis of population-based hospital discharge data sets. We selected patients on the basis of principal discharge diagnosis, which relies on accuracy of internal hospital reporting and coding, similar to how patients are presently identified for quality measure performance. The principal diagnosis is generally defined as the diagnosis chiefly responsible for admission to the hospital, but we were unable to confirm that each patient was treated for pneumonia in the ED.39 Moreover, because we relied on discharge diagnosis and wanted to best capture patients with the primary diagnosis of pneumonia admitted through the ED, we did not include the ICD-9 codes with a primary diagnosis of "respiratory failure" or "sepsis" and a secondary diagnosis of pneumonia, since we believe that this would incorporate too many patients who developed pneumonia after admission.
Similarly, the hospital-level data we abstracted from the CMS Hospital Compare website are self-reported data, which may contribute to the narrow range of overall hospital compliance with the quality measure. If all hospitals are reporting similar compliance, the mean performance may have been too uniform to demonstrate an effect on mortality. Furthermore, there may be unmeasured confounding hospital-level data that could influence outcome. We also cannot account for the uniformity of data collection between, and even within, hospitals reporting to Hospital Compare.
We were limited by the data provided through the NIS. We were unable to adjust for severity of the specific pneumonia illness, as data required for standard risk stratification means, such as the Pneumonia Severity Index Score's laboratory and vital sign data, were not available.40
Our study was a comparison of hospital-level data on TFAD performance and patient-level inpatient mortality. This may somewhat limit the extent to which our findings can be applied to an individual patient; however, it much more accurately approximates the administration of the current performance measure, which is also reported as hospital-level data. We are not able to comment on the association, or lack of association, between the timing of antibiotic administration for pneumonia in a particular patient and individual inpatient mortality. We are also not able to analyze or comment on further outcome measures beyond inpatient mortality, such as 30-day mortality or morbidity measures secondary to delayed antibiotic administration or inappropriate antibiotic administration. Furthermore, although we are able to identify those patients with inpatient mortality, we are unable to identify cause of inpatient death and if it was a direct result of pneumonia or involved withdrawal of care.
Despite these limitations, we feel that the large sample size and associated power allow for the evaluation of even a small effect size and provide meaningful data calling into question nationwide application of the TFAD quality measure for pneumonia as a way to improve nationwide pneumonia mortality. Further work in other yearly samples after the change to the 6-hour time frame could confirm our findings, as could investigating relationships between quality measure performance data and other meaningful outcomes, such as hospital resource utilization and cost or patient morbidity.
In this large heterogeneous nationwide sample, there was no association between hospital-reported time to first antibiotic dose quality measure performance and inpatient mortality for patients admitted through the ED for pneumonia. These results raise questions about the quality measure as a benchmark for hospital quality of care in acute pneumonia.
The authors thank the Northwestern University Emergency Medicine Research College members for their time and dedication in the preparation of the manuscript.
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- 2 , , , et al.
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- 7The Joint Commission. Performance Measure Initiatives: Pneumonia Core Measure Set. Available at: http://www.jointcommission.org/assets/1/6/Pneumonia.pdf. Accessed Mar 3, 2011.
- 8Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule. Chest. 2007; 131:1865–9., , , .
- 9Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008; 149:29–32., , , .
- 10Evidence-based emergency medicine/critically appraised topic. Evidence behind the 4-hour rule for initiation of antibiotic therapy in community-acquired pneumonia. Ann Emerg Med. 2008; 51:651–62., .
- 11The measurement of time to first antibiotic dose for pneumonia in the emergency department: a white paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2009; 37:335–40., , .
- 12Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med. 2004; 164:637–44., , , , .
- 13Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA. 1997; 278:2080–4., , , et al.
- 14Processes of care, illness severity, and outcomes in the management of community-acquired pneumonia at academic hospitals. Arch Intern Med. 2001; 161:2099–104., , , , .
- 15Factors influencing in-hospital mortality in community-acquired pneumonia: a prospective study of patients not initially admitted to the ICU. Chest. 2005; 127:1260–70., .
- 16Early administration of antibiotics does not shorten time to clinical stability in patients with moderate-to-severe community-acquired pneumonia. Chest. 2003; 124:1798–804., , , et al.
- 17 , , .
- 18JCAHO/CMS core measures for community-acquired pneumonia [letter]. Ann Emerg Med. 2006; 47:505., , , , , .
- 19Identification of 90% of patients ultimately diagnosed with community-acquired pneumonia within four hours of emergency department arrival may not be feasible. Ann Emerg Med. 2007; 49:553–9., .
- 20The Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures lead to unnecessary antibiotic administration by emergency physicians. Acad Emerg Med. 2009; 16:184–87., , .
- 21Profiles in patient safety: Antibiotic timing in pneumonia and pay-for-performance. Acad Emerg Med. 2006; 13:787–90..
- 22Emergency department operational changes in response to pay-for-performance and antibiotic timing in pneumonia. Acad Emerg Med. 2007; 14:545–8., , , , , .
- 23Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med. 2008; 168:351–6., , .
- 24Racial and ethnic disparities in pneumonia treatment and mortality. Med Care. 2009; 47:1009–17., , , et al.
- 25Comorbidity measures for use with administrative data. Med Care. 1998; 36:8–27., , , .
- 26Comparison of different comorbidity measures for use with administrative data in predicting short- and long-term mortality. BMC Health Serv Res. 2010; 10:e140., , .
- 27Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data. Med Care. 2004; 42:355–60., , .
- 28Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986; 42:121–30., .
- 29Delayed administration of antibiotics and mortality in patients with community-acquired pneumonia. Ann Emerg Med. 2009; 53:618–24., .
- 30Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia. Chest. 2006; 130:11–5., , .
- 31Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med. 1997; 157:1453–9., , , et al.
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- 40A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997; 336:243–50., , , et al.


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Autoroute Tolls in France
Autoroutes are at the heart of the French road network.
Autoroutes are the French equivalent of motorways, but rather than being owned by the government and paid for by taxes they are owned by different companies who charge vehicles a toll; if you're driving a long way you can expect to have to pay several different tolls on your journey.
Most autoroutes are toll roads, but a few are free, particularly in the Brittany region, where most of the autoroutes still belong to the government.
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Toll autoroutes are signalled with the word péage (toll) and a blue sign, whereas free roads have a green sign.
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You can pay by cash or credit card, or if you're planning to spend a lot of time on the roads you could invest in an electronic Telepeage badge. If you put it on your dashboard or on your windscreen it automatically raises the barrier without you having to lean over to the left window. It keeps a record of all your journeys then bills you at the end of your holiday. Sanef have recently set up a new operation in the UK that allows UK residents to pay for a Liber-t tag from a UK bank account. More information is available from Sanef, the UK representatives of French autoroutes - click here for more information.
Autoroute Toll Charges
Tolls are subject to change so it's wise to check just before you leave or make sure you're carrying extra cash when driving through France, just in case. And don't forget that different vehicles pay different prices.
Please check online before you travel at www.autoroutes.fr.


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India's EXIM Bank for project development company with AfDB
March 11, 2014
India and US can accomplish a lot together: Obama
March 11, 2014
London to host meeting over sanctions on Russia
March 11, 2014
Energy surplus northeast can power rest of India
March 11, 2014
20 troopers killed in Chhattisgarh Maoist attack
March 11, 2014
Zimbabwe invites Indian companies to partner in agriculture
March 11, 2014
Storm in Shiv Sena over MNS support to BJP
March 11, 2014
The Additional Secretary, Ministry of Culture, K. K. Mittal witnessing the exchange of signed documents of the Implementation Protocol
March 11, 2014
Goliath Modi vs David Kejriwal: 9 DAYS WILL SHAPE OR SHAKE INDIA…
March 11, 2014
Stage set for India Aviation 2014 in Hyderabad
March 11, 2014
Cloudy day ahead in Delhi
March 11, 2014
Traffic hit, Delhi Metro shuts two stations due to protest
March 11, 2014
Domestic car sales up 1.39 percent in February
March 11, 2014
'Indian private sector can partner Republic of Congo economy'
March 11, 2014
New Zealand to put 'colonial' flag to referendum
March 11, 2014
US lawmakers ask Pentagon to welcome Sikhs in military
March 11, 2014
World bank to give $3 billion to Ukraine
March 11, 2014
Russia views US proposals on Ukraine questionable
March 11, 2014
US to beef up air operations in Poland
March 11, 2014
US economy poised for gains in 2014
March 11, 2014
Nepal to introduce air crash investigation regulation
March 11, 2014
Australia offers $9 mn aid for Somalia
March 11, 2014
India, Africa should form working group on healthcare: Experts
March 11, 2014
Sangma announces return to national politics
March 11, 2014
Samajwadi Party may not field candidates against Sonia, Rahul
March 11, 2014
Court says judges are not caged parrots
March 11, 2014
The Minister of Industry of the Republic of Sudan, Al Simah Al Siddiq Al Nour meeting the Minister for New and Renewable Energy, Dr. Farooq Abdullah
March 11, 2014
The Minister for Commerce & Industry, Anand Sharma with the PM of Kingdom of Lesotho, Dr. Motsoahae Thomas Thabane
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Gagan Will Help Save $10 million worth fuel – Civil Aviation Secretary
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Indian envoy S. Jaishankar presents credentials to President Obama
March 10, 2014
News Archives
December 2011
« Nov
Jan »
» Archive for December 13th, 2011
Cabinet defers food bill as discussions inconclusive
New Delhi, Dec 13 The cabinet Tuesday deferred a decision on the proposed food security bill as talks on the legislation remained inconclusive, with Agriculture Minister Sharad Pawar raising the issue of high subsidies involved in implementing the measure. "Discussions...
Steel Minister Beni Prasad Verma at the foundation stone laying ceremony
NTPC and EGCB ink Contract Agreement in Bangladesh
Dhaka, Dec 13 NTPC Limited, India's largest State owned power generator, signed a Contract Agreement with Electricity Generation Company of Bangladesh Ltd (EGCB) today for providing Operation and Maintenance Services for 2×120 MW Gas based...
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?? ??????, 13 ???????, 2011? ????? ??? ????? ????????? ???? ???????? ????? ???? ?? ??? ???????? ?? ?? ?????? ?? ??????? ??? ??? ????????????? ??. ?????? ???? ?????? ???????? ????????? ??????? ??? ???????? ?? ??????? ??? ????? ?? ?????? ???? ??? ???? ?????...
Cabinet approves National Electricity Fund
New Delhi, Dec 13 The cabinet Tuesday approved the creation of a National Electricity Fund (NEF) to provide interest subsidy of Rs.8,466 crore for electricity distribution projects for a period of 14 years. "The National Electricity Fund is being...
Kerala wants defence ministry to buy coir geotextiles
Thiruvananthapuram, Dec 13 The Kerala government proposes to ask the defence ministry to buy coir geotextiles produced in the government and the cooperative sectors in the state. "We will approach the defence ministry to buy geotextiles from the...
Petroleum sector contributes Rs.192,577 crore to exchequers
New Delhi, Dec 13 The petroleum and natural gas sector has contributed Rs.136,497 crore to the national exchequer and Rs.88,997 crore to the state coffers last fiscal, the government said Tuesday. The sector's contributions were through cess, royalty,...
Rupee recovers from record low but outlook gloomy
Mumbai, Dec 13 The Indian rupee, which Tuesday slipped to a new low of 53.50 to a US dollar intra-day, recovered a bit, but weakness in the currency persisted as demand for the green-back from importers and banks rose amid global uncertainty. A depreciating...
Parliament attack recalled
New Delhi, Dec 13 The nation Tuesday paid homage to the martyrs of the Parliament House terrorist strike 10 years ago that led to a flare-up on the India-Pakistan borders, while families of the victims demanded expeditious execution of Afzal Guru, the...
Israel seeks closer education, tech ties with India
New Delhi, Dec 13 Israel Tuesday pitched for greater collaboration with India in fields of education, technology and academic research. "Education and R&D are the comparative advantage of both Israel and India. Collaboration in these fields...
'Economic impact of inadequate sanitation is Rs 2.44 tn'
New Delhi, Dec 13 The country is paying a heavy price for inadequate sanitation, with its impact on the economy estimated at Rs.2.44 trillion a year, parliament was informed Tuesday. This amount is equivalent to 6.4 percent of the country's GDP...
Himachal gets Rs.171.22 crore loan for rural projects
Shimla, Dec 13 The National Bank for Agriculture and Rural Development (NABARD) has sanctioned a Rs.171.22 crore loan to Himachal Pradesh for creation of rural infrastructure, an official statement said here Tuesday. The amount would be spent for the...
Iran dismisses request for return of US drone
Tehran, Dec 13 Iran has dismissed a request from the US that Tehran return a spy drone that crashed in the country. Iran announced Dec 4 it had downed an RQ-170 Sentinel drone of the US in the Tabas desert in the country's eastern region. Tehran...
Low-carb diets better for easing weight: Study
London, Dec 13 A low-carb diet is better than a standard, calorie-restricted one for cutting down weight and lowering blood levels of cancer-promoting hormone insulin, a British study has found. Researchers at Genesis Prevention Centre at University Hospital...
Canada pulls out of Kyoto accord
Ottawa, Dec 13 Canada has withdrawn from the Kyoto Protocol, thereby saving about $14 billion in penalties, Environment Minister Peter Kent announced Monday. Kent blamed the "incompetent Liberal government" of former prime minister Jean Chretien...
US to freeze $700 mn aid to Pakistan
Washington, Dec 13 (IANS) In the midst of a tense standoff with Islamabad, a Congressional panel has agreed to freeze $700 million in US aid to Pakistan unless it helps in the fight against homemade bombs in Afghanistan. The freeze on US aid was agreed...
Congress core group meets ahead of UPA meeting
New Delhi, Dec 13 The Congress core group met here to discuss the Lokpal bill ahead of a meeting of (UPA) leaders Tuesday evening, party sources said. The one-hour meeting at the parliament house office of Prime Minister Manmohan Singh at noon was attended...
No policy paralysis, Indian economy will bounce back, says Pranab
New Delhi, Dec 13 Blaming the weakness in the global economy for the recent slowdown in India's industrial output and economic growth, Finance Minister Pranab Mukherjee said Tuesday the government was not suffering from any policy paralysis and...
If Fire In Govt Hospital…..: WILL MANTRIS TOO BE ARRESTED?…
If Fire In Govt Hospital….. WILL MANTRIS TOO BE ARRESTED? By Poonam I Kaushish New Delhi, Dec 13: "What's the use of coming now? He is already dead. All are dead. The Administration is hopeless, useless," angrily shouted Pradeep...
PM Manmohan Singh paying tributes to the martyrs of the Parliament attack
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"I love this e-reader. It is a remarkable product!"
3.5 starson by HarryGagaPros: The e-ink screen is so easy to read anywhere; on a plane, in my dark dorm room, and even in broad daylight. I like the text-to-speech for my young cousins so that they can "read" in my car. The page turns are so fast as well.
Cons: If you don't purchase a cover you can get your Kindle pretty dirty and a little scratched up. Also, sometimes my Kindle freezes for about 20 seconds. The 3G doesn't catch in certain places but that's with every 3G device.
Summary: The Kindle has an amazing body but there are a few things that could be improved. The back has this rubbery feel to it so if you scratch it, you can easily rub it off but if you scratch the front, it's scratched. The buttons for the keyboard rub off easily after much use but they have a grip on them that allows a better push. Also the cursor is amazing for small fingers. Bigger fingers might have a problem with navigations.
The e-ink screen is the brightest gray, white, and black's that I've ever seen. It doesn't really matter that it doesn't have color because it's primary use is for reading, not for searching the web. That's why browser is still under experimental. Also, the page turns can be a tad slow at times. Sometimes the Kindle will freeze up but that does not happen a lot. The details used in the sleeping state in the pictures are magnificent. You can barely see any pixelating in the Kindle at all!
The store is very accessible as well. It's right on your Kindle! When you press the Menu button and then you press "Go to My Kindle Store" it will immediately take you there. There it gives you suggestions of books depending on the books you have previously bought. You can also buy magazines, New York Times Bestsellers, and many others. I was a bit dissapointed in some of the books that are not available on the Kindle but most of that is the author's fault as not wanting their books to be pirated.
For some reason, I have read soooo many books on the Kindle in such a short amount of time. I've read six books in the matter of two weeks. It kind of blows my mind.
The Kindle is beautiful inside and out and is a perfect gift for anyone! My grandmother, my younger cousin, and even my best friend are all getting Kindle's because they are so jealous of mine.


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A full slate of matches is on tap this weekend as the American National Rugby League moves into business end of the 2011 season. A heatwave in the northeast will set the scene for some tense action that will be highlighted by a doubleheader in Philadelphia with the hometown Aston Bulls hosting the New York Knights and the Bucks County Sharks visiting the Delaware Vipers. The Knights (4-1) have moved five points clear of the second-placed Sharks at the top of the standings and will be looking to cement their spot when they tackle the Bulls (2-3), who are in fifth place. Since dropping their season opener to the Connecticut Wildcats, the New Yorkers have been perfect in gaining maximum points from every match and will be warm favorites going into Saturday's contest. The likes of Xavier Lozinguez, Sean Taylor and Nigel Millgate have been dominant as head coach Guillaume Cieutat has his charges firing on all cylinders and executing his game plans to a tee.
The second game of the doubleheader will see the Sharks (3-3) looking to bounce back from their shock loss to the Bulls last week when they face off against the winless Vipers (0-4). Bucks County started the season with a bang, but lately they have dropped off the pace and with the AMNRL's annual War at the Shore showpiece event just a week away, they will be wanting to rediscover their winning form.
In the other game of the round, the Northern Raiders (3-3) are away at the Wildcats (3-1) in Norwalk, CT, in what promises to be a very competitive encounter. After several seasons as the league's cellar dwellers, the Raiders are currently enjoying their best run in years. They recruited well in the offseason and their Australian imports have been combining well with their homegrown talent including Paulo Reis and Tony Kalamas. The Cats, on the other hand, are having somewhat of a resurgence of their own this season meaning this one could go down to the wire.
Out west in the Pacific Conference, the action will continue after last weekends high performance camp and inter island challenge between Maui and Oahu which was evaluated by USA Tomahawks Head Coach Matthew Elliott. A number of dynamic new players such as Jayson Rego and Josh Rice (former University of Hawaii footballers) Apelu So'oalu (USA Eagles U/20), Uale Rae, Drake Miller, and Dustin Umeyda performed well along with USA Tomahawks representatives Vaka Manupuna, Mike Tuala, Pila Taufa, and Andrew Malafu.


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At Newton-Upon-Rawcliffe, Pickering
SECOND SATURDAY in AUGUST
By kind permission of the Woodmansey Family
Next AGM Tuesday 4th March 2014 Newton-upon-Rawcliffe Village Hall 8pm
The Boon Hill Show Committee would like to thank everyone who contributed to making this year's show another success and raising:
£2,500 for Yorkshire Air Ambulance, £2,500 for Scarborough Hospital Special Baby Unit and a small donation to other local charities.
Results and Photographs to follow shortly.
Boon Hill Show is a community run country show and has over 50 years of proud traditional history! Everyone is made to feel welcome and get a taste of country life.
Unaffiliated Open Show Jumping Amateur Gundog Scurry
NEW In-Hand Mountain &Moorland Pony Gymkhana
Companion Dog Show Riding Classes
Terrier Show and Racing Coloured Horse Classes
Vintage Tractors NEW Ridden Veteran
Scarecrow Class Clear Round Show Jump
Tack & Turnout Open Produce Classes
Handicrafts Open Cookery Classes
Photography Classes Hound Trails
Horse and Pony entries in advance or double on the day. Licensed bar – provided by Howard Hebron of the Blacksmith Arms, Hartoft and The Coach House Inn, Rosedale Also, home made refreshments, tombola, grand raffle, auction of various items and other exhibitions including wood sculptures by Karl Barker will be on show
Lurcher & terrier qualifying show for Cock of the North, Pride of the Peaks and Egremont Crab Fair
Admission £4.00 per person, children £1.00, free car park, show field parking £3.00 extra


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"The long anticipated fight between Manny Pacquiao, 51-3-2, 38 KO's and Floyd Mayweather, JR., 41-0, 25 KO's is a done deal with only signatures needed on the printed contract" said a very reliable inside source close to Team Mayweather who has just contacted RSR. This inside source went on to say, "Floyd is very happy that both sides could work out issues that he always felt could be talked out." Floyd is anticipating on making well over 50 million dollars with Manny making almost the same. Tentative dates being kicked around for an HBO PPV is the middle to end of November 2010 and if this does happen there is no doubt that this fight will be the biggest grossing in history.
Manny Pacquiao & Floyd Mayweather, JR Agree to Fight – Signatures Only Thing Needed on Finalized ContractMerchant was later informed that Affliction was the actual promoter of the event and not just a sponsor courting De La Hoya as he had earlier ascertained from his conversation with Schaefer. "This is hard for someone with my experience to compute. When somebody says '$5 million sponsorship,' I have a different interpretation," said Merchant. "This never even occurred to me that Affliction was the guys behind this and that Golden Boy was just putting its brand on it and was not taking any risk and would make money on the end. This is a whole new financial model from what I've known in boxing."
Sherdog.com This explains it. Larry Merchant wasn't misinformed, he was almost completely uninformed. But it takes a man to own up to a mistake, and Larry's done that.Bruce Binkow, Golden Boy's Chief Marketing Officer, took Merchant's comments in stride. "It's ridiculous [to say] that there was a $5 million dollar fee paid [for de La Hoya's attendance]," said Binkow. "There's a financial commitment obviously that Affliction made, and Oscar felt an obligation through his partners at Affliction [to attend]. I don't know how more simple it can be and why it's any more complicated than that." And while Merchant might be questioning de La Hoya's lack of allegiance to the sport that made him a star, Binkow said the former champion's decision to grace "Day of Reckoning" was strictly business. "The [Affliction] pay-per-view date was set long before the boxing event, and Oscar didn't feel right about offending his commitment to our partners in Affliction," said Binkow. "I think it was a great night for both sports. There was packed houses at the Staples Center and the Honda Center, so we were thrilled with both events."
Loretta Hunt at SherdogDe La Hoya hasn't been a real fighter for years. You can't fault the guy because he has been a great fighter in the past and made so much money from the sport. But, realistically, he has been a part-time boxer for years. That showed last weekend against Pacquiao who was so hungry to win that fight. Unfortunately for De La Hoya he just fell apart at the hinges after the first few rounds. He just didn't have anything there. So hopefully that was his last fight, I don't think he is going to fight again.
Joe Calzaghe weighs in on Oscar de la HoyaWe'll email you a reset link.
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Pennsylvania Governor Corbett Proclaims March 4-10 as Agriculture Week
HARRISBURG, Pa., March 1, 2012 /PRNewswire-USNewswire/ — Governor Tom Corbett today proclaimed March 4-10 as "Agriculture Week" in Pennsylvania to celebrate the many contributions of the state's leading industry.
"Pennsylvania was built on fertile fields and hard work and this week we take time to celebrate our nationally respected agriculture industry," said Governor Corbett. "From our more than 63,000 farm families who produce quality agricultural commodities, to the thousands of jobs connected to the industry and the estimated $57 billion in economic impact."
Pennsylvania is a national leader in the production of many agricultural commodities, including apples, chickens, Christmas trees, eggs, grapes, milk, mushrooms, oats, peaches, pears, pumpkins and trout.
Consumers can ensure they are buying products made or grown in Pennsylvania by purchasing PA Preferred(TM) items.
"Pennsylvania is home to an abundant and diverse food supply," said Agriculture Secretary George Greig. "Buying PA Preferred products helps support our farmers and local businesses, while making investments in local economies and keeping Pennsylvania growing. PA Preferred makes a difference."
The PA Preferred program identifies agricultural products grown and processed in Pennsylvania to consumers and major retail, wholesale and distribution chains interested in supporting local farmers and businesses.
The program's trademark is a gold checkmark inside a blue keystone. It can be found on products year-round at farmers markets, restaurants, food processors, grocery chains, craft breweries and wineries.
The Department of Agriculture is celebrating Agriculture Week with events:
- Monday, March 5 – Greig will visit Masonic Village Farm in Elizabethtown, Lancaster County. The farm recently earned national recognition for environmental stewardship.
- Tuesday, March 6 – Greig will present a Berks County homeschooler who won the 2012 Farm Show Detectives program with free ice cream for a year and an ice cream party for 80 fellow homeschoolers at the Fleetwood Bible Church, sponsored by Turkey Hill.
- Thursday, March 8 – Greig will teach students from Steelton-Highspire Elementary School in Dauphin County how to make PA Preferred pizzas and how popular food items are grown.
For more information, visit www.agriculture.state.pa.us.
Media contacts:
Samantha Krepps, Dept. of Agriculture; 717-787-5085
Kirsten Page, Governor's Office; 717-783-1116
Editor's Note: The text of Governor Corbett's proclamation follows:
AGRICULTURE WEEK – March 4-10, 2012
WHEREAS, Agriculture is Pennsylvania's leading industry, generating $5.7 billion in cash receipts and an estimated $57 billion in economic impact, making it the cornerstone of Pennsylvania's economy; and
WHEREAS, local farm businesses support on-farm and farm-related jobs, with one in seven jobs relating to the state's agriculture industry; and
WHEREAS, the state's more than 63,000 farm families are using new technologies and practices to become more efficient, making it possible for each farmer to feed 155 people, while meeting the demands of an increasingly quality- and environmentally-conscious world; and
WHEREAS, Pennsylvania's farm families and businesses work to lead the way in the production of agricultural commodities, including apples, chickens, Christmas trees, eggs, grapes, milk, mushrooms, oats, peaches, pears, pumpkins and trout. Farmers throughout the state have established an outstanding reputation as leading suppliers of these quality products throughout the world; and
WHEREAS, many of the state's farm families are preparing the way for their operations to remain viable in perpetuity by establishing new markets, preserving valuable farmland for future agricultural production, being good stewards of the land and engaging the next generation of agriculturalists; and
WHEREAS, Pennsylvania is home to innovative programs like PA Preferred(TM), the official branding program of Pennsylvania's diverse agricultural commodities that helps farmers and processors market their products and helps consumers locate products grown or processed in the state.
THEREFORE, in special recognition of Pennsylvania agriculture, I, Tom Corbett, Governor of the Commonwealth of Pennsylvania, do hereby proclaim the week of March 4-10, 2012 as AGRICULTURE WEEK and encourage all citizens to pay tribute to the extraordinary efforts of the men and women who provide us with an abundance of safe food, fiber and energy, and to recognize the vital contribution they make to the quality of life within the Commonwealth of Pennsylvania, the United States of America and the world.
Tom Corbett, Governor
SOURCE Pennsylvania Office of the Governor


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Took this picture using my tripod in my Mum's back garden.
great combo as always... |
nice shoes! :) |
So in love with the details of this my dear! That braid around the waist and those lovely shoes and that shawl is just too pretty <3 |
The blending of colors is amazing! Hyped! ♥ |
LOOVE it! :D
stunning! its so luxurious and regal looking |
love it! |
beautiful! i really love the skirt! btw I have a pashmina which is similar to that! +1 |
Nadia Sabrina R. @rnadiasabrina i love the scarf and the skirt much! :) |
oh so good!


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From the Publisher
"Rich and warm and funny and varied ... beautifully written."-- Los Angeles Times, on The Sign in Sidney Brustein's Window"One of a handful of great American plays -- it belongs in the inner circle, along with Death of a Salesman, Long Day's Journey Into Night and The Glass Menagerie."--Washington Post, on A Raisin in the Sun


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Bread Day
Every Tuesday and Friday, starting at 9:30AM. The Salvation Army offers FREE bread and other items from local retailers, farmers, and bakeries within our community. This service is open to all in the community
Items vary from week to week, and may even include vegetables, salads, fruits, pizza, etc�
For The Tri City Corps to maintain this program, we ask that when you leave the gym with your bags full of goodies, please inform the person at the door of how many items will be taking home with you.
Factoid about BREAD DAY:
The Salvation Army Tri City Corps in 2011 served 18,439 individuals with bread distribution, and 43,221 items (bread, baked good, produce, etc...) are given away to those in the community. Yay!!
'Daily Bread' distribution on a weekly basis would not happen without the support of donors.
Blue Goose -- St. Charles
Norton Farm -- St. Charles
Costco --- St. Charles
Starbucks -- St. Charles and Geneva
Caribou -- Geneva
Hosanna Lutheran Church
Lazarus House