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Tuberculosis disparity between US-born blacks and whites, Houston, Texas, USA.United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. during 1985-1992, the annual incidence rate of TB steadily decreased from 1993 to 2007. However, this decline recently decelerated, raising concerns that progress toward eliminating TB is slowing. In 2007, a total of 13,293 TB cases (4.4 cases per 100,000 population) were reported in the United States, representing a 4.2% decline in incidence from 2006 (1). Despite this decline, TB incidence remains higher among certain racial/ethnic minorities, i.e., blacks, Hispanics, and Asians, than for non-Hispanic whites. For instance, US-born young blacks probably account for the largest number of secondary TB cases in the country (2). In addition, TB rates for non-Hispanic blacks continue to be 8 times greater than for non-Hispanic whites (3). Hispanics and non-Hispanic blacks also accounted for nearly three quarters (73.9%) of 11,480 TB cases in children reported during 1993-2001, of which more than half occurred in children <5 years of age (4).
These findings clearly suggest recent ongoing transmission of Mycobacterium tuberculosis Mycobacterium tuberculosis
Tubercic bacillus.
Mycobacterium tuberculosis in these ethnic groups rather than reactivation reactivation
to become active after a period of quiescence or, as in bacterial and viral infections, latency.
cross reactivation of latent infection. Recently, molecular epidemiologic studies epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect , which estimate the proportion of clustered TB cases, have been used to support this hypothesis (5). For instance, a molecular epidemiologic study of TB in San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden during 1991-1992 found M. tuberculosis M. tuberculosis,
n the bacterium responsible for tuberculosis, generally a respiratory infection in man; nonrespiratory tuberculosis is considered an indicator disease for AIDS. See also tuberculosis. clustering in 191 (41%) of 471 patients studied that were distributed in 44 clusters. Hispanic ethnicity or black race, birth in the United States, and an AIDS diagnosis independently predicted clustering (6). Similarly, other population-based studies in New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. and in Tarrant and Harris counties in Texas found clustering of 36%-52% (7-9).
Molecular studies of clustering and identification of risk factors that contribute to these racial/ethnic disparities are crucial for efforts to eliminate TB in the United States. Although differences in socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. and access to the healthcare system among non-Hispanic blacks have been postulated pos·tu·late
tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates
1. To make claim for; demand.
2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument.
3. as the main barriers to TB diagnosis and treatment in this group, further information is needed (3,10). We studied the traditional and molecular epidemiology molecular epidemiology Molecular medicine An evolving field that combines the tools of standard epidemiology–case studies, questionnaires and monitoring of exposure to external factors with the tools of molecular biology–eg, restriction endonucleases, of TB in US-born blacks enrolled in the Houston Tuberculosis Initiative (HTI HTI Haiti (ISO Country code)
HTI High Tech Institute
HTI Hand Tools Institute
HTI Hamilton Island, Queensland, Australia (Airport Code)
HTI Horizontal Technology Integration ) during 1995-2004.
Materials and Methods
Study Population
The study population comprised patients recruited through HTI, a population-based active surveillance and molecular epidemiologic study that enrolls persons with TB reported to the City of Houston Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS and Harris County Public Health and Environmental Services The various combinations of scientific, technical, and advisory activities (including modification processes, i.e., the influence of manmade and natural factors) required to acquire, produce, and supply information on the past, present, and future states of space, atmospheric, . In this study, we examined data from TB patients enrolled by HTI who had been reported during October 1995-September 2004.
Study participants were interviewed by trained interviewers using a standardized questionnaire designed to gather details of participant demographics, living situation, transportation, travel and social contacts, tobacco and alcohol use, illicit drug illicit drug Street drug, see there use, sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. , history of incarceration Confinement in a jail or prison; imprisonment.
Police officers and other law enforcement officers are authorized by federal, state, and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes. , and personal medical history. Clinical information was supplemented through record review of all available inpatient, outpatient, and public health medical records.
Molecular Characterization of M. tuberculosis
We analyzed M. tuberculosis isolates with 3 molecular typing methods. First, isolates were characterized by an internationally standardized protocol of insertion sequence insertion sequence
Any of several discrete DNA sequences that repeat at various sites on a bacterial chromosome, on certain plasmids, and on bacteriophages and that can move from one site to another on the chromosome, to another plasmid in the same [IS] 6110 restriction fragment length polymorphism restriction fragment length polymorphism
n. Abbr. RFLP
Intraspecies variations in the length of DNA fragments generated by the action of restriction enzymes and caused by mutations that alter the sites at which these enzymes act, changing (RFLP RFLP
restriction fragment length polymorphism
restriction fragment length polymorphism.
RFLP ) profiling (11) and analyzed with BioImage Whole Band Analysis version 3.2 software (BioImage, Ann Arbor Ann Arbor, city (1990 pop. 109,592), seat of Washtenaw co., S Mich., on the Huron River; inc. 1851. It is a research and educational center, with a large number of government and industrial research and development firms, many in high-technology fields such as , MI, USA). Second, for isolates with <5 IS6110 copies, the spacer oligonucleotide Oligonucleotide
A deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) sequence composed of two or more covalently linked nucleotides. Oligonucleotides are classified as deoxyribooligonucleotides or ribooligonucleotides. type (spoligotype) was determined by using a commercially available kit (Isogen Bioscience BV, Maarsen, the Netherlands) according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the manufacturer's instructions. A member of the Beijing family was defined as having an octal A numbering system that uses eight digits. It is used as a shorthand method for representing binary characters that use six-bits. Each three bits (half a character) is converted into a single octal digit. Okta is Greek for 8. spoligotype pattern of 000000000003771 (previously designated as S1) (12). Third, isolates were assigned to a principal genetic group on the basis of polymorphisms at codon codon: see nucleic acid. 463 of the katG gene, which encodes catalase catalase /cat·a·lase/ (kat´ah-las) a hemoprotein enzyme that catalyzes the decomposition of hydrogen peroxide to water and oxygen, protecting cells. peroxidase peroxidase /per·ox·i·dase/ (per-ok´si-das) any of a group of iron-porphyrin enzymes that catalyze the oxidation of some organic substrates in the presence of hydrogen peroxide.
n. , and at codon 95 of the gyrA gene, which encodes the A subunit sub·u·nit
A subdivision of a larger unit.
Noun 1. subunit - a monetary unit that is valued at a fraction (usually one hundredth) of the basic monetary unit
fractional monetary unit of DNA gyrase DNA gyrase (ji´ras) a type II DNA topoisomerase. (13). Susceptibility testing was performed by using BACTEC 460 radiometric culture system (Becton Dickinson BD (NYSE: BDX), is a medical technology company that manufactures and sells medical devices, instrument systems and reagents. Founded in 1897 and headquartered in Franklin Lakes, New Jersey, BD employs 27,000 people in nearly 50 countries. , Sparks, MD, USA), at the hospital or reference laboratories supplying isolates to the HTI (14).
We assigned race/ethnicity on the basis of self-report. M. tuberculosis isolates were defined as clustering if they satisfied 1 of the following criteria: 1) [greater than or equal to]2 isolates from the same principal genetic group with identical IS6110 banding profiles containing [greater than or equal to]5 copies of IS6110 or 2) isolates with identical IS6110 banding profiles containing [less than or equal to]4 copies of IS6110 and sharing the same spoligotype and principal genetic group. We evaluated clusters H03 and H33 as a single cluster because they differ in only 1 band by IS6110 RFLP.
We defined drug-resistant TB as an isolate resistant to at least 1 drug, including isoniazid isoniazid (ī'sōnī`əzĭd), drug used to treat tuberculosis. Also known as isonicotinic acid hydrazide, isoniazid is the most effective antituberculosis drug currently available. , rifampin rifampin (rĭfăm`pĭn), antibiotic used in the treatment of tuberculosis. It is also used to eliminate the meningococcus microorganism from carriers and to treat leprosy, or Hansen's disease. , ethambutol ethambutol /etham·bu·tol/ (e-tham´bu-tol) an antibacterial, specifically effective against Mycobacterium; used with one or more other antituberculous drugs in the treatment of pulmonary tuberculosis, administered as the , pyrazinamide, or streptomycin streptomycin (strĕp'tōmī`sĭn), antibiotic produced by soil bacteria of the genus Streptomyces and active against both gram-positive and gram-negative bacteria (see Gram's stain), including species resistant to other . Multidrug-resistant TB was defined by resistance to isoniazid and rifampin, with or without resistance to other agents.
Data Analysis
Questionnaire data were entered into a longitudinal database (initially Epi Info Epi Info is a public domain statistical software for epidemiology developed by Centers for Disease Control and Prevention.
Developed by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA), Epi Info has been in existence for over 20 years and is version 6.02b, Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. , Atlanta, GA, USA; and subsequently Microsoft Access A database program for Windows, available separately or included in the Microsoft Office suite. Access is programmable using Visual Basic for Applications (VBA). Access can read Paradox, dBASE and Btrieve files, and using ODBC, Microsoft SQL Server, SYBASE SQL Server and Oracle data. , Microsoft, Redmond, WA, USA) for storage and analysis. Statistical analyses were conducted with STATA version 8.0 SE (StataCorp., College Station, TX, USA). Descriptive analysis was initially conducted, and selected demographic, social, and clinical factors were studied by univariate logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. to test for differences between US-born blacks and US-born whites. We used US-born whites, as opposed to all others, as the comparison group because of the heterogeneity in the latter group, particularly in non-US-born Hispanics and Asians. Variables with p<0.2 in the univariate analysis were considered in the elaboration of a multivariate The use of multiple variables in a forecasting model. logistic regression model to identify with factors independently associated with black race in TB patients. Covariates were not included in the model if they substantially decreased the sample size because of missing data. In our final model, we used the variable injection drug use instead of drug use because of colinearity and a strong association with the former variable. Covariates that were no longer significant after adjustment for other significant variables in the full model were dropped from the final parsimonious par·si·mo·ni·ous
Excessively sparing or frugal.
parsi·mo model.
Ethical Approval
Individual participants gave written informed consent before enrollment in the study. We obtained parental consent Parental consent laws (also known as parental involvement or parental notification laws) in some countries require that one or more parents consent to or be notified before their minor child can legally engage in certain activities. and patient assent for participants 13 to <18 years of age, and a parent served as a proxy for the interview of participants <13 years of age. Proxy permission and interview also were used for participants who had died or were not mentally capable of giving informed consent. The study was approved by the Institutional Review Board of Baylor College of Medicine Baylor College of Medicine is a private medical school located in Houston, Texas, USA on the grounds of the Texas Medical Center. It has been consistently rated the top medical school in Texas and among the best in the United States. , Houston, Texas "Houston" redirects here. For other uses, see Houston (disambiguation).
Houston (pronounced /'hjuːstən/) is the largest city in the state of Texas and the , and affiliated hospitals, and the University of Texas Health Science Center-Houston, Committee for the Protection of Human Subjects.
Study Population
A total of 4,312 persons with TB were reported in Harris County during October 1995-September 2004. Of those, 3,662 (85%) agreed to participate in the study and were interviewed by trained HTI personnel. The study population comprised 1,318 (36.0%) US-born blacks, 1,220 (33.3%) Hispanics, 545 (14.9%) US-born non-Hispanic whites, 463 (12.6%) Asians, 85 (2.3%) foreign-born blacks, 20 (0.5%) foreign-born non-Hispanic whites and 11 (0.3%) others. Of participants interviewed, 3,064 (84%) had a positive culture for M. tuberculosis; 2,806 (92%) of those isolates underwent molecular characterization. Interviewed participants were more likely to be younger, black, HIV-seropositive, and M. tuberculosis culture-positive than were persons who refused to participate or could not be located (p<0.01 for first 3 comparisons and p = 0.03 for the last comparison).
Rates of TB during the Study Period
Although the overall US incidence of TB decreased from 8.0 to 4.9 cases per 100,000 persons during 1996-2004, TB incidence in Harris County has remained fairly stable since 2000 after an initial decrease in 1996-1999 (Figure 1). Blacks consistently had the highest TB incidence in Harris County. In 2004, blacks accounted for approximately 56% of all TB cases among US-born participants despite representing only 18% of the Harris County population (Texas State Data Center and Office of the State Demographer de·mog·ra·phy
The study of the characteristics of human populations, such as size, growth, density, distribution, and vital statistics.
[French démographie : Greek , http://txsdc.utsa.edu/tpepp/txpopest.php).
US-born Blacks versus US-born Whites
US-born blacks were more likely than US-born whites to be younger, unmarried, and unemployed; have less education; reside in the inner city, earn less income; use public transportation; have renal and extrapulmonary disease; be HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. seropositive seropositive /se·ro·pos·i·tive/ (-poz´i-tiv) showing positive results on serological examination; showing a high level of antibody.
adj. , M. tuberculosis culture-positive, and part of a cluster; and have drug-resistant M. tuberculosis (Table 1).
The 614 HIV-infected TB patients in our study reflected a 28% rate of co-infection for US-born blacks and 20% for US-born whites (p<0.001). Rates of HIV co-infection were markedly lower for Hispanics and Asians (9.1% and 1.7%, respectively). Pulmonary disease was the predominant clinical presentation in the study population; however, extrapulmonary disease was reported more frequently for US-born blacks than for US-born whites (p<0.01).
Resistance to at least 1 anti-TB agent was recorded for 80 (7.3%) isolates from US-born blacks, compared with 22 (4.5%) isolates from US-born whites (p = 0.04). Multidrug-resistant TB represented only 1% of all cases. Mortality rate (i.e., death within 180 days after TB diagnosis) was [approximately equal to]10% and was similar for US-born blacks and US-born whites.
Clustering of Cases within Groups
Among all 4,312 cases reported during the study period, 3,578 (including enrolled and nonenrolled participants) had at least 1 positive M. tuberculosis culture. Isolates from 3,227 (90%) were genotyped, including 1,984 (61.5%) that matched at least 1 other isolate. A total of 242 clusters were identified, and cluster size varied from 2 to 172 patients (mean 57.2, median 27).
Isolates of 1,765 (63%) of the 2,807 enrolled persons were clustered, including 822 (82%) of 1,007 isolates from US-born blacks and 349 (77%) of 448 isolates from US-born whites (p = 0.05). Rates of clustering were significantly lower for Hispanics and Asians (52% and 28%, respectively; p<0.01), probably underscoring a higher proportion of reactivation of latent infection in these patients. Cluster size for US-born blacks was larger (mean 69.3, median 45) than for US-born whites (mean 46.7, median 14; p<0.001). TB strains belonging to the Beijing family represented 26% and 29% of isolates from US-born blacks and US-born whites, respectively (p = 0.25). Two (H03/ H33 and L16) of the 9 largest clusters containing at least 30 patients had more US-born blacks than US-born whites (Table 2, Figure 2).
Multivariate Logistic Regression Analysis
In our final model (Table 3), factors independently associated with black race among TB patients included younger age, fewer years of education, inner city residence, use of public transportation, prison history, renal disease Renal disease
Kidney disease.
Mentioned in: Glycogen Storage Diseases
hypertension High blood pressure Cardiovascular disease An abnormal ↑ systemic arterial pressure, corresponding to a systolic BP of > 160 mm Hg , and HIV seropositivity Seropositivity is the presence of a certain antibody in a blood sample. A patient with seropositivity for a particular antigen or agent is termed seropositive. . US-born blacks were significantly less likely than U.S.-born whites to report current homelessness, smoking, alcohol abuse, injection drug use, and same-sex behavior. Although male sex, not being married, M. tuberculosis culture positivity, employment, and extrapulmonary disease were significant in the univariate analysis, they were no longer significant in the full model and therefore were dropped from the final parsimonious model. Because including certain covariates significantly decreased the sample size (and the representativeness of the dataset), we developed a second model (data not shown) by adding drug resistance and clustering to the final model. In this model, drug resistance remained significantly higher for US-born blacks than for US-born whites (odds ratio [OR] 1.76; 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] 1.02-3.04, p = 0.04); however, clustering did not remain significant (OR 1.13, 95% CI 0.82-1.54, p = 0.46).
Although the incidence rate of TB in the United States during 2007 was the lowest recorded since national reporting began in 1953, the decline has slowed from an average of 7.1% per year (1993-2000) to an average of 3.8% per year (2001-2007) (1). Our population-based study of TB in a large US metropolitan city emphasized the epidemiologic, molecular, and clinical characteristics of US-born blacks. During the 9-year study period, the overall incidence of TB in Harris County, Texas Harris County is a county located in the U.S. state of Texas within the Houston–Sugar Land–Baytown metropolitan area. As of 2000 U.S. Census, the county had a population of 3.4 million (though a 2006 estimate placed the population at nearly 3. , decreased dramatically; however, the incidence among blacks remained fairly stable (22.6-25.2 cases per 100,000) over the past 5 years of the study. This incidence is 4-5x the US national TB incidence rate (1). Numerous factors have been postulated to explain the disproportionately high TB rate for blacks, including socioeconomic characteristics, biasing presence of comorbidities, and genetics (15,16).
Our evaluation of socioeconomic characteristics demonstrated that younger age, fewer years of education, use of public transportation, and inner city residence were independently associated with black race among TB patients. These associations support the concept that TB remains predominantly a disease of disadvantaged and marginalized persons (17,18). Contrary to findings recently reported (18), our population-based study showed that US-born whites with TB were more likely than US-born blacks with TB to be homeless. In addition, certain clinical conditions such as renal disease and HIV seropositivity were more likely in US-born blacks with TB.
M. tuberculosis isolates from US-born blacks were more likely to be resistant than were those from US-born whites, which was in accordance with previously reported findings (19). However, foreign-born persons, particularly Hispanics and Asians, still have the most drug-resistant TB in Houston (20). Among our study population, death from any cause within 6 months after TB diagnosis reported was [approximately equal to]10%. We found no difference in TB-associated mortality rates between US-born blacks and whites.
TB strains clustered in a high proportion of both US-born blacks and US-born whites (81.6% and 77.2%, respectively; p = 0.46). We previously demonstrated that ethnicity was not a significant covariate for strain clustering after adjustments for factors related to socioeconomic status (21). Isolates belonging to the Beijing genotype genotype (jēn`ətīp'): see genetics.
Genetic makeup of an organism. The genotype determines the hereditary potentials and limitations of an individual. family clustered in 26% and 29% of US-born blacks and US-born whites, respectively (p = 0.25). This genetically highly conserved family, reported worldwide but particularly prevalent in Asia and the territories of the former Soviet Union (22,23), is frequently associated with large TB outbreaks, increased virulence Virulence
The ability of a microorganism to cause disease. Virulence and pathogenicity are often used interchangeably, but virulence may also be used to indicate the degree of pathogenicity. , and multidrug resistance multidrug resistance,
n the adaptation of tumor cells or infectious agents to resist chemotherapeutic agents. (24,25).
One of the most striking findings of our study is the markedly large size of clusters. Previous US-based studies had reported cluster sizes not exceeding 30-78 patients each (6,8,9). We reported 9 clusters with >30 patients each and 3 clusters with >100 patients each, including 1 with a predominance of blacks. This may be due to the longer surveillance period used here, as well as to endemic spread of highly transmissible transmissible /trans·mis·si·ble/ (trans-mis´i-b'l) capable of being transmitted.
Capable of being conveyed from one person to another. strains, including several of the Beijing family. We estimated that at least 54% (1,984-242 [of 3,227]) of TB cases in Houston resulted from recent infection that had progressed to active disease during the 9-year study period (6). We believe this estimate is conservative because a strict definition of identical IS6110 RFLP bands was used for clustering, and several RFLP patterns in our study were similar but with [+ or -]1 band (Figure 2).
Several TB genotypes remain endemic to Houston, particularly in minorities such as US-born blacks. A high proportion of endemic strains of M. tuberculosis remain actively transmitted within this population. Further research on the dynamics of the disease, including possible delays in care-seeking behavior or diagnosis in this racial group, is of paramount importance to achieve the national goal for TB elimination.
This project was funded in part by the National Institute of Allergy and Infectious Diseases infectious diseases: see communicable diseases. and the National Institute of Drug Abuse, National Institutes of Health, under contracts N01-A0-02738 and DA09238.
Dr Serpa is an assistant professor of medicine in the section of Infectious Diseases at Baylor College of Medicine. His current research interests are epidemiology of tuberculosis and immunology of pneumococcal vaccine pneu·mo·coc·cal vaccine
A vaccine containing purified capsular polysaccharide antigen from the most common infectious types of Streptococcus pneumoniae, used to immunize against pneumonococcal disease. .
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members of the genus Mycobacterium.
anonymous mycobacteria
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adj. rud·di·er, rud·di·est
a. Having a healthy, reddish color.
b. Reddish; rosy.
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(25.) Glynn JR, Whiteley J, Bifani PJ, Kremer K, van Soolingen D. Worldwide occurrence of Beijing/W strains of Mycobacterium tuberculosis: a systematic review. Emerg Infect Dis. 2002;8:843-9.
DOI: 10.3201/eid1506.081617
(1) Preliminary analysis of data contained in this paper was presented at the 45th Annual Meeting of the Infectious Diseases Society of America The Infectious Diseases Society of America (IDSA) is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. , October 4-7, 2007, San Diego, California "San Diego" redirects here. For other uses, see San Diego (disambiguation).
San Diego is a coastal Southern California city located in the southwestern corner of the continental United States. As of 2006, the city has a population of 1,256,951. , USA (abstract no. 346).
Jose A. Serpa, Larry D. Teeter, James M. Musser, and Edward A. Graviss
Address for correspondence: Edward A. Graviss, Department of Pathology, The Methodist Hospital Methodist Hospital is the name of numerous medical institutions.
- Methodist Hospital of Indianapolis, Indianapolis, Indiana
- Methodist Hospital (Omaha, Nebraska)
- The Methodist Hospital, Houston, Texas
- List of hospitals in Kentucky
Author affiliations: Baylor College of Medicine, Houston, Texas, USA (J.A. Serpa, E.A. Graviss); and The Methodist Hospital Research Institute, Houston (L.D. Teeter, J.M. Musser, E.A. Graviss)
Table 1. Univariate analysis of selected epidemiologic and clinical characteristics of participants in the Houston Tuberculosis Initiative, Texas, 1995-2004 * Variable US-born black US-born white Demographics Age, y, mean (median) 42.5 (43.0) 48.2 (47.0) Male sex 938 (71.2) 429 (78.7) Not married 1,091 (82.8) 412 (75.6) Years of education, mean (median) 10.6 12.0 11.7 12.0 Employed 453 (34.4) 214 (39.3) Inner city residence ([dagger]) 538 (40.9) 198 (36.7) Household size, mean (median) 5.2 (3.0) 4.5 (2.0) Social history Income <$10K/year 554 (51.7) 161 (36.0) Use of public transportation 664 (50.4) 177 (32.5) Current homelessness 129 (9.8) 77 (14.2) Stay in a shelter ([double dagger]) 132 (10.0) 65 (11.9) Current smoking 745 (56.7) 388 (71.5) Alcohol abuse ([section]) 601 (45.8) 311 (57.4) Drug use ([double dagger]) 351 (26.7) 129 (23.7) Injection drug use ([double dagger]) 25 (1.91) 25 (4.6) Same-sex sexual behavior 129 (9.9) 91 (17.0) Commercial sex 168 (13.1) 67 (12.6) Prison history 281 (21.4) 92 (16.9) Medical history Known TB exposure 502 (38.1) 222 (40.7) Previous TB 112 (8.5) 55 (10.1) Asthma 85 (6.4) 28 (5.1) Diabetes 168 (12.7) 61 (11.2) Renal disease 76 (5.8) 15 (2.8) HIV seropositivity 364 (27.6) 109 (20.0) Diagnosis and prognosis Pulmonary TB 1,067 (81.0) 496 (91) Extrapulmonary TB 400 (30.3) 97 (17.8) Cavitation 458 (45.1) 213 (46.1) Smear-positive pulmonary TB 577 (54.2) 257 (51.9) M. tuberculosis culture positivity 1,102 (83.7) 486 (89.2) TB clustering 822 (81.6) 349 (77.2) Drug resistance 80 (7.3) 22 (4.5) Multidrug resistance 3 (0.3) 1 (0.2) Death ([paragraph]) 143 (10.8) 62 (11.4) Variable Hispanic Asian Demographics Age, y, mean (median) 36.9 (36.0) 45.1 (43.0) Male sex 783 (64.2) 257 (55.5) Not married 742 (60.8) 202 (43.6) Years of education, mean (median) 254 (20.8) 260 (56.3) Employed 501 (41.1) 209 (45.1) Inner city residence ([dagger]) 384 (31.5) 40 (8.6) Household size, mean (median) 4.7 (4.0) 5.1 (4.0) Social history Income <$10K/year 466 (46.0) 78 (18.1) Use of public transportation 363 (29.8) 40 (8.6) Current homelessness 32 (2.6) 4 (0.9) Stay in a shelter ([double dagger]) 17 (1.4) 5 (1.1) Current smoking 279 (22.9) 80 (17.3) Alcohol abuse ([section]) 251 (20.6) 50 (10.8) Drug use ([double dagger]) 110 (9.0) 4 (0.9) Injection drug use ([double dagger]) 9 (0.74) 1 (0.22) Same-sex sexual behavior 69 (5.7) 2 (0.4) Commercial sex 52 (4.3) 2 (0.4) Prison history 49 (4.0) 5 (1.1) Medical history Known TB exposure 375 (30.7) 86 (18.6) Previous TB 56 (4.6) 41 (8.9) Asthma 40 (3.3) 12 (2.6) Diabetes 224 (18.4) 62 (13.4) Renal disease 34 (2.79) 21 (4.54) HIV seropositivity 111 (9.1) 8 (1.7) Diagnosis and prognosis Pulmonary TB 966 (79.2) 341 (73.7) Extrapulmonary TB 354 (29.0) 153 (33.0) Cavitation 405 (45.0) 111 (37.1) Smear-positive pulmonary TB 473 (49.2) 132 (38.7) M. tuberculosis culture positivity 979 (80.2) 402 (86.8) TB clustering 466 (51.8) 100 (27.9) Drug resistance 105 (10.7) 79 (19.7) Multidrug resistance 15 (1.5) 9 (0.9) Death ([paragraph]) 80 (6.6) 28 (6.0) US-born black vs. Variable white, OR (p value) Demographics Age, y, mean (median) 0.98 (<0.001) Male sex 0.67 (0.001) Not married 1.56 (<0.001) Years of education, mean (median) 0.90 (<0.001) Employed 0.81 (0.045) Inner city residence ([dagger]) 1.19 (0.094) Household size, mean (median) 1.00 (0.454) Social history Income <$10K/year 1.90 (<0.001) Use of public transportation 2.11 (<0.001) Current homelessness 0.66 (0.007) Stay in a shelter ([double dagger]) 0.82 (0.222) Current smoking 0.52 (<0.001) Alcohol abuse ([section]) 0.63 (<0.001) Drug use ([double dagger]) 1.17 0.179) Injection drug use ([double dagger]) 0.40 (0.002) Same-sex sexual behavior 0.54 (<0.001) Commercial sex 1.05 (0.758) Prison history 1.34 (0.026) Medical history Known TB exposure 0.88 (0.222) Previous TB 0.83 (0.274) Asthma 1.27 (0.282) Diabetes 1.16 (0.353) Renal disease 2.16 (0.007) HIV seropositivity 1.52 (0.001) Diagnosis and prognosis Pulmonary TB 0.42 (<0.001) Extrapulmonary TB 2.01 (<0.001) Cavitation 0.96 (0.714) Smear-positive pulmonary TB 1.10 (0.405) M. tuberculosis culture positivity 0.62 (0.002) TB clustering 1.31 (0.050) Drug resistance 1.65 (0.043) Multidrug resistance 1.32 (0.808) Death ([paragraph]) 0.95 (0.741) * Stratification based on race does not include information about foreign-born blacks. Data presented as no. (%) participants except as indicated. OR, odds ratio; TB, tuberculosis; M. tuberculosis, Mycobacterium tuberculosis. ([dagger]) Defined according to specific zip codes. ([double dagger]) Within 6 months before TB diagnosis. ([section]) Drinks alcohol daily or nearly daily. ([paragraph]) Within 180 days after TB diagnosis. Table 2. Characteristics of the 9 largest Mycobacterium tuberculosis clusters, Houston Tuberculosis Initiative, Texas, 1995-2004 * IS6110 CDC spoligotype Genetic Cluster copy no. designation group H01 12 7760 3777 7760 771 3 H03/H33 20/21 0000 0000 0003 771 1 H02 13 0000 0000 0003 771 1 H15 9 0000 0000 0003 771 1 H07 10 0000 0000 0003 771 1 H16 9 7777 0375 7760 771 2 H04 6 7777 7677 7760 771 2 L08 2 7777 7677 7760 601 2 L16 3 7777 7677 7760 601 2 Participant data US-born black, US-born white, Hispanic, Cluster no. (%) no. (%) no. (%) H01 96 (9.5) 29 (6.4) 22 (2.44) H03/H33 109 (10.8) 31 (6.9) 8 (0.89) H02 77 (7.75) 28 (6.2) 20 (2.22) H15 25 (2.48) 7 (1.5) 6 (0.67) H07 46 (4.6) 22 (4.9) 11 (1.22) H16 28 (2.8) 8 (1.8) 5 (0.56) H04 12,(1.2) 50 (11.1) 10 (1.11) L08 55 (5.5) 23 (5.1) 28 (3.11) L16 26 (2.6) 2 (0.4) 4 (0.44) Participant data Asian, US-born black vs. Cluster no. (%) white, OR (p value) H01 4 (1.11) 1.54 (0.051) H03/H33 2 (0.56) 1.65 (0.018) H02 1 (0.28) 1.25 (0.322) H15 0 1.62 (0.264) H07 0 0.94 (0.802) H16 0 1.59 (0.254) H04 1 (0.28) 0.10 (<0.001) L08 2 (0.56) 1.08 (0.770) L16 0 (0.00) 5.96 (0.015) * IS, insertion sequence; OR, odds ratio. Table 3. Factors associated with black race in multivariate analysis in US-born TB patients, Houston Tuberculosis Initiative, Texas, 1995-2004 * Risk factor OR 95% CI p value Age 0.98 ([dagger]) 0.97-0.99 <0.001 Years of education 0.93 ([dagger]) 0.89-0.96 <0.001 Inner city residence 1.44 1.13-1.85 0.003 ([double dagger]) Use of public transportation 2.44 1.91-3.11 <0.001 Current homelessnes 0.48 0.33-0.68 <0.001 Current smoking 0.54 0.42-0.70 <0.001 Alcohol abuse ([section]) 0.63 0.50-0.80 0.001 Injection drug 0.3 0.16-0.57 <0.001 use ([paragraph]) Same-sex sexual behavior 0.28 0.19-0.41 <0.001 Prison history 1.42 1.06-1.91 0.020 Renal disease 2.61 1.38-4.92 0.003 HIV seropositivity 1.89 1.37-2.61 <0.001 * TB, tuberculosis; OR, odds ratio; CI, confidence interval. ([dagger]) ORs per additional year at risk. ([double dagger]) Defined according to specific zip codes. ([section]) Drinks alcohol daily or nearly daily. ([paragraph]) Within 6 months before TB diagnosis.
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November 26, 2014
June 25, 2006
The rough weather this weekend caused problems for some residents on one local street.
Weather is to blame for bringing down a tree on Azalea Drive in Charlottesville.
The branches just missed hitting power lines, but caused quite a mess in that home's front yard.
Police taped off the area just as a precaution until it can be cleaned up.
Power was not interrupted and no one in the home was injured.
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subset: commoncrawl


text:
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WOONSOCKET ŌĆö Playing tight, or extra-inning, tilts is becoming quite the norm for Burrillville High.
Back on April 11, the Broncos snatched a 10-6, 10-frame affair against Central Falls, then ŌĆō the very next day ŌĆō lost to red-hot Johnston, 6-5, in nine. And, on Tuesday, it overcame an early deficit and edged North Smithfield, 10-9, with a run in the back half of the seventh.
WOONSOCKET ŌĆö Three throwing errors, three walks, some mental miscues, and a couple of squeeze bunts in the final two innings of play added up to a disappointing loss for Woonsocket on Thursday afternoon.
Visiting South Kingstown erased a 2-1 deficit by scoring five unearned runs in those frames and found themselves busing home with a 7-2 victory in this Division II crossover game at Cold Spring Park.
Leo J. Jarret
WOONSOCKET- Leo J. Jarret, 67, of Woonsocket, passed away on April 17th at home after battling Lung Cancer.
Leo is survived by his wife of 22 years Maureen A. (Boulris) Jarret. Leo was born in Woonsocket on November 29, 1944, he was the son of the late Leo & Rina (Landry) Jarret. Leo also leaves behind his children, James & Timothy Jarret, Deanna Vadnais, Kathryn Cournoyer, Johnathan & Richard E. Gagne and Tammy Angle. A brother John Jarret also 9 Grandchildren and a Great Granddaughter.
In accordance with Leo's wishes, his Funeral & Burial will be Private.
William Henry Dogan
ALABAMA- DOGAN, William Henry, age 94, recently a resident of Wetumpka and Montgomery, died on Tuesday, April 17, 2012 after a brief illness.
He was born in Manassas, Virginia, on January 27, 1918, the son of William and Frances Dogan, grew up on the family farm there, graduated from high school in nearby Haymarket, Virginia, and later joined the U.S. Navy in 1937.
North Smithfield High School students Megan Lefebvre, Emily Richards and Derek Kruzan, from left, join other freshmen in a car wash at the school this past Saturday. The car wash was held to benefit their April 27-May 1 trip to Washington, D.C. for a ŌĆśWe the People Honors GovernmentŌĆÖ national competition. The 36 freshmen in teacher Natalie O'Brien's American Government class won a statewide competition to compete in the national event ŌĆö the only freshman class in the nation to do so. They will compete with senior classes from all over the country.
CUMBERLAND ŌĆö A local company is doing its part to help veterans returning from war get back to work in the civilian job force.
Cumberland-based Jobless Warrior, a new online career enhancing service for veterans, announced this week its official nationwide launch of the service. Veterans across the country can now visit www.joblesswarrior.org to request free resume help, connect with a career coach, join a job networking group, and much more.
WOONSOCKET ŌĆō The City Council took a tentative first step this week toward trading in a hodgepodge of health care products the city offers various workers for a unified plan that will cover all classes of employees, including teachers, police, firefighters and municipal workers.
The idea was rolled out by Councilman Daniel Gendron as point of departure for continued exploration of the concept. Other members of the council quickly embraced the idea, which would, finance officials say, cut the cash-strapped cityŌĆÖs hefty health care costs.
WOONSOCKET ŌĆö Late last week, St. Raphael Academy head coach Tom ŌĆ£SaarŌĆØ Sorrentine explained to his senior ace, Nick Cesino, that he would draw the start when the Saints took on host Mount St. Charles on Wednesday morning.
He also told the righthander that the Mounties' infield contained a rather tall mound, and suggested he get to know it better over the weekend.
Cesino followed his mentor's order and threw some pitches from the foreign rubber on Sunday, and it became rather obvious as the innings passed he had become rather familiar with it.
CUMBERLAND ŌĆö Nick Zammarelli spent all game looking for his pitch ŌĆō the one he could drive.
Roland E. Jodoin
CUMBERLAND- Roland E. "Peewee" Jodoin, 82, of Cumberland, RI passed away on Sunday, April 15, 2012 at Oakland Grove Health Center. He was the beloved husband of the late Lucille G. (Bolduc) Jodoin.
Born in Bellingham, MA on December 22, 1929, he was the son of the late Willie and Antonia (Dubois) Jodoin.
He was the loving father of Gary R. Jodoin of Chepachet, RI, Linda M. Jodoin of Cumberland, RI; and his cherished grandchildren and great-grandchildren. He was the brother of Muriel Paulhus and her husband, Robert of Bellingham, MA and the late Leo Jodoin.


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Liberty is the better job!
I was desperately looking for a job, any job, when I came upon an add online for jobs at Liberty. I thought it would be just a job to get me through until I could find a better job but, little did I know, this was the better job. I just love working for Liberty. It is a great opportunity to meet people in my community, make new friends, and work with some great people! Not only is it income for me
Posted By:
Jacqueline Sadler
Wednesday, March 19, 2014
It's Our Company
At one point, John Hewitt had a mouse problem in his office. It was my job to set out the mousetraps and try to catch these little buggers. When I was leaving John's office, I told him, "I love working for your company." John replied, "It's our company." I've never forgotten that. Now whenever I talk about Liberty Tax Service, I say, "it's our company." And it really is.
Posted By:
Jeffrey Brown
Wednesday, March 19, 2014
The Liberty Culture Shines Through
Client came into my store 1st peak. ( We'll call him Bill). First thing he said was, "I just went to H& R Block and they wanted $99 to do my tax return... Do you believe that?" I said, "no- that's a great deal!" We discussed his tax situation and I told him that I'd never be the $99. guy, but this year I'd do it for less than Block to show him the difference. He agreed and I had a great time disc
Posted By:
Ralph Guisti
Tuesday, March 18, 2014
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- USA Table Tennis
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- Tip of the Day - Inside-Out Forehand Serve
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Tip of the Day - Inside-Out Forehand Serve
Kong Ling Xuan (CHN) at the 2013 Junior World Championships
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Inside-Out Forehand Serve
Many players use the forehand "pendulum" serve. It's the most popular serve in table tennis. Roughly speaking, the racket tip is down, and the racket moves from right to left (for a right-hander). However, at the advanced level, inside-out forehand pendulum serves are just as popular, with the racket moving the other way. Practice this serve, as even with less spin than your normal serves it is effective against most players, since the serve is so rarely seen below the advanced levels. The quickest way to learn it is to watch a top player do it. (Serves are very difficult to teach in print, even with photo sequences.)
Webmaster Note: Larry has an outstanding daily blog worth visiting regularly and bookmarking.


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The form of United's midfielders has not only given Sir Alex selection headaches, it's also inspired threads on our message board. Like this one on Giggs and Scholes...
"Ryan and Paul have been and still are important players to the squad. They have got vast experience, the character, the nerves and composure needed in big games. But I'd suggest the duo start more often on the bench, while the ever-consistent Anderson and speed merchant Nani are in the starting line-up."
"I think SAF knows how to use the squad and the players. We will need Giggs and Scholes when it comes to the later stages of the season. Their experience will help us in Europe. I agree they should not always play but they're still important players."
"I agree that Giggs and Scholes are not as fast as maybe the newcomers but pace is not the only quality you need in a side. I think the reason why the young lads like Anderson and Nani are playing so well is because they have these players to look up to. It must be amazing to train with players who've done it all. Also, Scholes is not 100% fit either. He needs a few more games to get back, let's not forget that. Speed was never a feature in his play to be honest. It's his cleverness in the final third and his trickery that often goes unnoticed. The bottom line is that Giggs and Scholes can mix it with the best of them."
Read the full thread and add your comments at www.manutd.com/messageboard.


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7 Things You Don't Need to Buy
10 Engagement Photos That Will Make You Completely Jealous
Why You Should Never Wash Your Jeans
11 Money Moves to Make Before You Turn 40
8 Exercises to Get Rid of Back Fat
10 Genius Tips for Organizing Your Closet
Kate Middleton Shatters Her Fashion Comfort Zone
5 Rules: Becoming a Millionaire by 40
Guys Dig Women in High Heels: Science
8 Hairstyles Every Girl Should Know
The Last Thing Guys Are Looking At
Don't Fall for Outlet Store Tricks!
Will This $0.50 Stock Hit $6.00? 3 Reasons We Think So!
Why It's Okay That You'll Never Have The Thigh Gap
14 Fun Ways to Wear Knee High Boots
What's The Best Sleeping Position For Your Relationship?
The Fierce New Way To Wear Rain Boots
Stunningly Iconic White Wedding Dresses
Your Guide to Deciphering Your Body Type
The Worst Jeans For Girls With Big Butts
Amazing Wedding Dresses That Aren't White
10 Tricks to Instantly Look More Attractive in Photos
The Genius Way to Organize Your Jewelry
The Healthiest and Most Efficient Ways to Lose Pounds
6 Hints That Will Help You Make New Friends
Find The Perfect Lingerie For Your Wedding Night
7 Things to Keep in Mind While Being Photographed
Dating a Boy vs. Dating a Man
15 Fabulous Long Winter Coats For a Dreamy Winter Look
Christian Grey's 5 Steps to Follow


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Inspections, Compliance, Enforcement, and Criminal Investigations
Mt. Clemens General Hospital 09-May-02
DEPARTMENT OF HEALTH & HUMAN SERVICESFood and Drug Administration
Detroit District
1580 East Jefferson Avenue
Detroit, MI 48207-3179
Telephone: 313-226-6260
May 9, 2002
Michele Blair, DO
Lead Interpreting Physician
Mt. Clemens General Hospital
1000 Harrington
Mt. Clemens, MI 48043
Dear Dr. Blair:
We are writing you because on April 16, 2002, your facility was inspected by a representative of the State of Michigan acting on behalf of the Food & Drug Administration (FDA). The inspection revealed that your facility failed to comply with the Mammography Quality Standards Act of 1992 (MQSA) and certain Quality Standards for Mammography as specified in Title 21, Code of Federal Regulations (CFR), Part 900.12. These requirements help protect the health of women by assuring that a facility can perform quality mammography.
The recent inspection at your facility revealed the following Level I findings:
1. Processor Quality Control (QC) records were missing for at least 30% of the operating days during the month of July, 2001. This is in violation of Title 21 Code of Federal Regulations 900.12 (e) (I).
2. Phantom QC records were missing for at least four (4) weeks since your previous MQSA inspection. This is in violation of Title 21 Code of Federal Regulations Q 900.12 (e) (2).
3. The system to communicate results of diagnostic mammograms was inadequate because:
a) There was no system in place to provide timely medical reports to the referring physicians.
b) There was no system in place to provide timely lay summaries of the reports to the patients.
c) There was no system in place to communicate serious or highly suggestive cases to the patients and referring physicians as soon as possible.
This is in violation of Title 21 Code of Federal Regulations 900.12 (c).
The specific problems noted above appeared on your MQSA Facility Inspection Report (copy enclosed), which was issued at the close of the inspection. These problems are identified as Level 1 because they identify a failure to meet significant MQSA requirements.
Because these conditions may be symptomatic of serious underlying problems that could compromise the quality of mammography at your facility, they represent a serious violation of the law which may result in FDA taking regulatory action without further notice to you. These actions include, but are not limited to, placing your facility under a Directed Plan of Correction, charging your facility for the cost of on-site monitoring, imposing civil money penalties, suspending or revoking your facility?s FDA certificate, or obtaining a court injunction prohibiting any further mammography activity that constitutes a serious risk to human health.
In addition, you should also address the following Level 2 findings that were listed on the inspection report provided to your staff at the close of the inspection.
1. Your facility has not specified adequate procedures to be followed for infection control including a system to record disinfection of equipment when such equipment may have come into contact with blood or other potentially infectious material. This is in violation of Title 21 Code of Federal Regulations 900.12 (e) (13).
2. Your facility has not specified written procedures for the collection and resolution of consumer complaints. This is in violation of Title 21 Code of Federal Regulations 900.12(h)(1).
3. There was no evidence of corrective actions for processor QC failures on at least one occasion. This is in violation of Title 21 Code of Federal Regulations 900.12 (e)(8).
4. Processor QC records were missing on at least two, but less than five, consecutive days of operation. This is in violation of Title 21 Code of Federal Regulations 900.12 (e)(1).
5. There was no evidence of corrective action, before further exams, when the phantom image failed either the image score or had a background density or density difference that was outside of regulatory limits. This is in violation of Title 21 Code of Federal Regulations 900.12 (e)(8).
6. There is no system in place to track all positive diagnostic mammography exams, including the correlation of positive mammograms with biopsy results.
This is in violation of Title 21 Code of Federal Regulations 900.12 (f).
7. A medical audit and outcome analysis is not conducted on an annual basis to include data individually and collectively for all of the interpreting physicians at your facility. This is in violation of Title 21 Code of Federal Regulations 900.12 (f).
It is necessary for you to act on this matter immediately. It is your responsibility to ensure adherence to each requirement of the MQSA and FDA?s regulations.
You are responsible for investigating and determining the causes of the deficiencies that the inspection identifies and promptly initiating permanent corrective actions.
Please explain to this office in writing within fifteen (15) working days from the date you receive this letter:
- the specific steps you have taken to correct the Level 1 and 2 violations noted in this letter;
- each step your facility is taking to prevent the recurrence of similar violations;
- the sample records that demonstrate proper record keeping procedures, if the findings relate to quality control or other records (Note: Patient names or identification should be deleted from any copies submitted).
If your facility is unable to complete the corrective action within 15 working days, you should state the reason for the delay and the time within which corrections will be completed. Please submit your response to:Mr. David M. Kaszubski
Director Compliance Branch
U. S. Food & Drug Administration
1560 East Jefferson Ave.
Detroit, MI 48207-3179
Please note that FDA regulations do not preclude a State from enforcing its own State mammography laws and regulations. In some cases, these requirements may be more stringent than FDA?s. When you plan your corrective actions, you should consider the more stringent State requirements, if any. You should also send a copy of your response to the State of Michigan radiation control office that conducted the inspection referenced in this letter. You may choose to address both the FDA and any additional State requirements in your response.
There are many FDA requirements pertaining to mammography. This letter only concerns the findings of your recent inspection and does not necessarily address other obligations you have under the law. You may obtain general information about all of FDA?s requirements for mammography facilities by contacting the Mammography Quality Assurance Program, Food and Drug Administration, P.O. Box 6057, Columbia, MD 21045-6057 (1-800-838-7715) or through the Internet at http://www.fda.gov/cdrh/mammography.
If you have any questions regarding this letter or how to ensure that you are meeting MQSA standards, please call Mr. Dennis E. Swat-k, Radiological Health Expert, at 313-226-6260 Ext.155.
Joann Givens
District Director
Detroit District Office


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Show Me The Way Back To Your Heart Lyrics - Brian Mcknight
Review The Song (2)
I remember days and nights were never cold
Had you in my life, I had you there to hold
And I remember love warm as a summer day
But I lost you
And I lost my way
Now I'm in the rain
Begging you please, please
Baby, won't you show me the way back to your heart
Let me see a sign to know if I'm close or far
Lead me back to the road
That leads back to your arms
Every night another lonely street
I walk down alone
Searching for a light
Your light to lead me home
Leave a candle in the window
And let it shine for me
Take my hand and take these tears away
I can't take the pain
I'm on my knees begging you please
Take my hand
Take me in your arms
I'm out in the dark
Down on my knees, begging you please
Click here to submit the Corrections of Show Me The Way Back To Your Heart Lyrics
Please Click Here to Print Show Me The Way Back To Your Heart Lyrics
Thanks to Maurice Freedom, email@example.com for submitting Show Me The Way Back To Your Heart Lyrics.
This is a great song | Reviewer: EHarrison | 5/16/12
The lyrics are powerful and truthful of a person that is hurting and begging for one more chance. If you can sing and about to lose selfone sing this song to them. If they do not respond let the go because it is too late. This song is will move most people if song well and with feeling.
The Songs is Great | Reviewer: maricel manatac | 9/20/07
The songs is really great...the way Brian McKnight sing the song really reveals what the songs is really all about. It is really highly recommended to people wanted to bring back their love ones...i have the copy of the song everytime i heard it melts my heart...great melody...music and lyrics the best
The following area is only for review, if you want to submit the lyrics or the corrections of the lyrics, please click the link at the end of Show Me The Way Back To Your Heart Lyrics.


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Vans Syndicate x Sean Cliver Authentics pay tribute to skateboarding's premier graphic designer, Sean Cliver. Available exclusively at select independent skateboard retailers, Vans Syndicate celebrates the diverse heritage of ideas, attitudes and influences that make up skateboarding's unique lifestyle.
Vans Syndicate x Sean Cliver Authentic Shoes
Skate Warehouse is excited to announce that the Vans Syndicate x Sean Cliver Authentic shoes will be online on 6/28. Check out our full selection of Vans until then!
DGK Homage Series – Decks & Tees
DGK just released a series of decks and tees paying homage to some classic skate graphics of the 80's. This new DGK Homage Series recycles the art of Jim Phillips, John Lucero, Sean Cliver and Scott Obradovich into pro boards for Stevie Williams, Lenny Rivas, Keelan Dadd, Marcus McBride and Josh Kalis.


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Chill out on hot summer days with the fresh flavors of this cool tomato-cucumber salad.
Southern Living JUNE 2008
1. Stir together cucumber, onion, and tomatoes. Add oil-and-vinegar dressing, lemon zest, lemon juice, and salt and pepper to taste. Toss to coat.
Tip: Grape or cherry tomatoes, halved, may be substituted .
Note: For testing purposes only, we used Campari tomatoes and Newman's Own Olive Oil & Vinegar Salad Dressing.
Go to Full Version of


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Become a Friend of the Fatherhood Institute by donating £20 per month or more by direct debit - and get free entry to our Annual Fatherhood Lecture (starting January 2015)
A father-inclusive approach to supporting couple relationships and the co-parenting team
In partnership with the Tavistock Centre for Couple Relationships and 4Children, we are offering local authorities the chance to access a free training package for early years practitioners and managers, to help them engage with couple/parental relationships and ensure a more father-inclusive approach.
Schools – boost your results by becoming a FRED provider
'When I see my children at the weekend they say, "We don't want to go to McDonald's – can we read stories instead?".'
You probably already know how important dads can be to their children's learning – and if you don't, you can find out here.
Creating father-inclusive health and social services: one-day course
The government's Healthy Child programme says:
"The contribution that fathers make to their children's development, health and wellbeing is important, but services do not do enough to recognise or support them.
Bringing Fathers In: helping global activists embrace 'dad power'
The Fatherhood Institute and MenCare are launching a package of practical resources for health, education and social care professionals, policy makers, programme managers and designers, researchers and evaluators, to mark International Men's Day (Nov 19), Universal Children's Day (Nov 20) and International Day to Eradicate Violence Against Women/White Ribbon Day (Nov 25).
New right to attend antenatal appointments is welcome, but it should be paid
Jeremy Davies writes:
The Fatherhood Institute welcomes expectant dads' new right to take time off for antenatal appointments, which starts today.
Parenting programmes ignore dads and waste money, say FI and Yale
Including dads could boost child outcomes and save taxpayers' money, says global research review
The Fatherhood Institute and leading experts from US and UK universities say a 'game change' is needed in the commissioning, design and evaluation of parenting programmes, to get fathers more involved and thus improve child outcomes and value-for-money.
Supporting Teenage and Young Parents Conference
Wednesday 10 DecemberCentral London


text: The evidence is in. The bulk of race or ethnicity related threads are initiated by the righties. I searched for various key words and looked at only the first page of the search results. (I would have provided the links to the search results, but I think those links fail rather quickly. At any rate, you can do the same searches. Do "Search Titles Only.") I searched for the word "Muslim": - Muslim Threats force out disabled teacher with dog. cupofjoe1962 - McCain is a Muslim. Wildo7 - Obama backed Muslim extremist cousin in Kenya. FreeTedWilliams - Muslim riots in France turn barbaric. Real World - Muslim Award. Harry Boy - Muslim Fascists--God--Mary--Jesus. Harry Boy - Radical Muslim gets job at Andrews AFB. FreeTedWilliams - A Muslim 'Mafia'? patsfan13 - Another Scumbag Muslim Heard From. QuiGon I searched for the word "race": - This thread. Patters - Here Comes The Race Card. Harry Boy - Imus in trouble again for race comments. cupofjoe1962 - Obama Wouldn't Be Where He Is But For Race. a.paul - BOOK: WRONG ON RACE ... The Democratic Party's Buried Past. F.B.N. - Bronx students discuss Obama's race speech. weswelker#83 - Supreme Court Throws out Death Row Verdict Race and issue. GJAJ15 - More KKKlinton Race Baiting. QuiGon - Barack Obama's Race Problem: White Liberals. F.B.N. - Media Reporting and Race. Real World - Race. wistahpatsfan - Race Riot. Harry Boy I also searched for "black," "racist," "homosexual," "gays," and got similar results. Knowing that I posted a handful of threads, I also searched for Christians, religion, and even Cosby, as well as several other terms that are often divisive. It certainly appears that the righties see the world as us vs. them. It's the righties who bring race and ethnicity into the conversation, and we can expect them to do the same in the General Election. Obama's right on this one.


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My Blog
By Egon von Greyerz Founder Matterhorn Asset Management
January 31 (King World News) - World Financial System & Economy At Dangerous Break Point
In the late 1960s when I started my working life in Switzerland we paid Swiss francs (CHF) 4.30 for every dollar. Today one dollar costs us 90 Swiss cents. Thus, in the last 45 years the dollar has fallen 80% against the Swiss franc. This is of course not what we would expect from the world's reserve currency. But we all know that the US has abused its reserve currency status and increasingly lived above its means since 1971, thereby creating a massive debt and current account deficit....
Continue reading the Egon von Greyerz piece below...
To hear which company investors and institutions around the globe are flocking to
that has one of the best gold & silver purchase & storage platforms
in the world click on the logo:
The trend of the dollar against the Swiss franc is unlikely to change in the next few years (see chart below). The next projected level for the USD/CHF exchange rate is CHF 0.40 – 0.50. Thus I would expect another 50% fall in the dollar in the next few years.
Let us instead look at the CHF/USD rate which is the inverse of the above (see chart below courtesy of goldchartsrus). Back in 1970, one Swiss franc was worth $ 0.23. Today you get $1.11 for one Swiss franc, or an an almost 5-times appreciation. During the same period, gold in Swiss francs has gone from CHF 150 per ounce, to CHF 1,125 per ounce, or up 7.5-times. Remember that gold in dollars went from $35 in 1971, to $1,250 today, which is a 35-fold increase.
Thus gold has been a better investment than Swiss francs over the last 40 odd years, but virtually anything is better than the US dollar which is being totally destroyed by endless deficits, debts and money printing.
What most holders of dollars don't realize is that their currency is being totally debased in real terms by falling 97% against gold in the last 43 years, and 80% against the Swiss franc. It is totally amazing that anyone outside the US wants to hold dollars. And even the Americans would be much better off to dump their own currency.
So will the Swiss franc continue to be almost as good as gold and a safe haven currency? Based on my projection above, the dollar should fall another 50% against the Swiss franc. But that doesn't necessarily mean the Swiss franc will appreciate in real terms. The problem for the Swiss franc is that the Swiss banking system is too big for the country -- being 7-times GDP, which is in line with Cyprus. And since there is a risk that the banking system will have problems worldwide, the Swiss would have to print an awful lot of money to try to save their banks.
So even if Swiss francs will be better to hold than dollars in the next few years, there is still a risk just like there is with most paper currencies. With the world financial and economic situation being at a very dangerous breaking point, for investors there is of course nothing safer than holding real physical gold and storing it outside the banking system."
© 2014 by King World News®. All Rights Reserved. This material may not be published, broadcast, rewritten, or redistributed. However, linking directly to the blog page is permitted and encouraged.
IMPORTANT - KWN will be releasing interviews all day today and this weekend with former US Treasury official Dr. Paul Craig Roberts, Egon von Greyerz, Andrew Maguire, John Ing and many others.
UPDATE: Egon von Greyerz' incredible audio interview is available now, you can listen to it by CLICKING HERE.
The audio interviews with Egon von Greyerz, Dr. Paul Craig Roberts, Nigel Farage, James Dines, Gerald Celente, Michael Pento, Eric Sprott, Andrew Maguire, Rob Arnott, William Kaye, David Stockman, Art Cashin and Dr. Marc Faber are available now. Other recent KWN interviews include Jim Grant and Felix Zulauf -- to listen CLICK HERE.
Eric King
World Financial System & Economy At Dangerous Break Point
On the heels of continued pressure on global stock markets, today a 42-year market veteran warned King World News that the world financial system and economy is now at a dangerous breaking point. Egon von Greyerz, who is founder of Matterhorn Asset Management out of Switzerland, also included two fantastic charts to go along with his tremendous and exclusive KWN piece.
© 2014 by King World News®. All Rights Reserved. This material may not be published, broadcast,
rewritten, or redistributed. However, linking directly to the blog page is permitted and encouraged.
January 31, 2014


text:
I downloaded this at Midnight. So far this is what I have:
My town is named "HighHill"
My neighbours are: Peck, Midge, Knox Egbert and
As you can see, I have alot of birds living in my town.
I'm also getting Nibbles the squirrel tomorrow.
I was pretty lucky on my first day, finding 2 Diplo Skulls and a Birdwing Butterfly
Also the 3D in the game is nice. I wouldn't call it the best, but it sure is nice and offers more to the experience.


text:
Contech Eat Better & Drink Better Bowls
Contech DrinkBetter Medium Blue Water Bowl by. Contech Electronics Inc.
The Drink Better pet bowl encourages dogs to drink at a slower, healthier rate, and makes less mess while they're at it. Many dogs instinctively drink too fast.
Besides making a wet mess, this habit can contribute to digestive problems such as indigestion and vomiting, and light-haired dogs may experience staining of the muzzle (from chlorinated water).
The Drink Better bowl uses a floating obstacle to control the flow of water, encouraging dogs to drink slower and take only as much as they need, without soaking their ears and muzzles or slopping water around the feeding area.


text:
There is dew in one flower and not in another, because one opens its cup and takes it in, while the other closes itself and the drop runs off. So God rains goodness and mercy as wide as the dew, and if we lack them, it is because we do not open our hearts to receive them.
- James H. Aughey
44.848171 -93.443316


text:
November 26, 2014
PARIS (AP) - When the French Open starts Sunday, Roger Federer will be in his 54th consecutive Grand Slam tournament.
That run dates to January 2000 and is the longest among active players. If he enters Wimbledon and the U.S. Open later this year, he'll tie the record of 56 in a row set by Wayne Ferreira from 1991-2004.
Federer says it reflects great stamina and an injury-free career. He's not simply showing up, of course: Federer has reached at the least the quarterfinals at the past 35 majors, winning a record 17 titles.
Rafael Nadal, meanwhile, is returning to Grand Slam action at Roland Garros after nearly a year's absence, while past U.S. Open champions Andy Murray and Juan Martin del Potro both withdrew from the French Open because of health issues.
Copyright 2014 Associated Press. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or email@example.com.


text:
|Total (w/tax)
|Total (w/tax)
Book Description:
This best-selling guide to Prolog and Artificial Intelligence, which has been updated to include key developments in the field, concentrates on the art of using the basic mechanisms of Prolog to solve interesting AI problems. Combined approach to Prolog and AI allows flexibility for learning and teaching. Provides a thorough representation of AI, emphasizing practical techniques and Prolog implementations. Prolog programs for use in projects and research are available for download from the companion website http://www.pearsoned.co.uk/bratko
Tags: Reference,


text:
Obama And Romney Tied In Nation's First Results
By Diane Sweet November 6, 2012 11:00 am -
For over fifty years, the tiny New Hampshire village of Dixville Notch has been the source of Election Day's first official result, and this year was no different. For the first time in Dixville Notch history, all 10 of the township's
We welcome relevant, respectful comments. Please refer to our Terms of Service for information on our posting policy.
Paul Ryan Reminds Homeless People They Did This To Themselves
Obama Replies To 10-Year-Old's Letter About Her Two Dads


text:
You must log in to access this feature. Sign in with Twellow or Facebook to get started.
By signing in to Twellow, you indicate your agreement to our terms of service.
Simply connect with Facebook and kiss those password blues away,
or go here to reset your password.
I use twitter like a two way radio to communicate with coworkers


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|Sign in With Your Burrp Id!
|Register With Burrp!
|Sign in With Your Burrp Id!
|Register With Burrp!
Home > Bangalore Bakery Shops > South Bangalore > Banashankari Bakery Shops > Miras Dial A Cake
5 Reviews / 5 Ratings
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June 10,2014
June 28,2013
Can't Stop Eating These Cakes
The Cakes are phenomenal. I have ordered around 7 times in last 6 months and each time got it delivered on the dot and the cakes are simply Yummmmmmmmmmmmmmmmmmmm.
Can't stop eating when I get the cake. I actually avoid calling my friends home when I order the cake. I don't mind paying a little more than other places, it is worth it.
I now order from them for mine and my friend's parties.
November 17,2012
Amazing cake and party
I ordered Tom & Jerry cake for my son and asked them to help me in making party arrangements too.
The cake was beautiful and super Yummy. My little prince and his friends were ecstatic. They helped me to make all the arrangement for party the decoration, games, food. It was amazing, we all enjoyed thanks to Miras Dial a Cake.
Amazing people and amazing cakes.
May 19,2012
Excellent Cakes & On-time Delivery
We ordered 2 cakes (Pineapple, Chocolate with Fruits), 8 Swiss Rolls (Strawberry, Blueberry) & 6 Chocolate Cup Cakes.
They are very fresh & tasted perfect. They used absolutely fresh ingredients & fruits.
And they delivered exactly 5 minutes before the said time. Impressed.
A bit expensive when compared to cakes in various shops, but quality was excellent, so I did not mind the rates.
Strongly recommended for special occasions.
February 01,2012
A divine indulgence
Am lucky to have chanced upon this place through Snapdeal. Since then, I have ordered quite a few cakes form them, the latest being muffins for my daughter's birthday. I must say evn the eggless versions are so very fresh and divine ... That one cannot stop craving to have more. The way they go about understanding the order, customize it as required and delivery is very professional. Slightly high on the pricing, but worth the try. Go for it Bengaluru, you will definitely not want to miss out on Mira's fresh bakes. Well, the ones I tried were fresh strawberry gâteau, red velvet muffins, crispy crusty brownie and the heavenly banana walnut. Each of them were excellent
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Never was a real big fan of April Fools' Day. Maybe because I'm pretty much of a fool 365 days a year – 366 once every four, when I vote in a presidential election. So all those "funny" April Fools' stories? They're not getting linked here. You have to find them yourself. For real stories, read on.
• It took us awhile, but we finally figured out all the stories coming out of Eugene weren't of the April Fools' variety. They had just enough weirdness to make you wonder. After all, who takes a job that pays almost a million a year and then doesn't have a contract? Besides Mike Price, we mean. But that seems to be the case with Mike Bellotti as AD at Oregon. And, as you read this, it's obvious there was plenty of time to get one done. … The whole thing stinks to one Oregonian columnist. … Nike's Phil Knight has his say about the basketball coach search. … St. John's hired former UCLA coach Steve Lavin and at least one person didn't think it was great idea. … OK, back to spring football, with UCLA starting practice today looking to figure out some things and ASU in the middle of its time, looking to utilize the tight end more.
• That's all for this morning. We'll be back after practice this afternoon – my understanding is there will be no pads – with our usual report. Until then …
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by Associated Press
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NASHVILLE — A Powerball ticket sold in Tennessee barely missed winning a share of an estimated $590.5 million prize. But the ticket has a nice consolation prize worth $1 million.
Officials say the Powerball ticket worth $1 million was sold in Chattanooga.
There's no word yet on who won.
A Powerball ticket sold at a supermarket in Zephyrhills, Fla., matched all six numbers selected Saturday night for the estimated $590.5 million prize. It's the highest Powerball jackpot in history.
The winning numbers were 10, 13, 14, 22 and 52, with a Powerball of 11.
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The Associated Press


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Goodwin Village Monash
Operator Goodwin Aged Care Services Ltd
Location 27 Cockcroft Ave, Monash ACT 2904
Phone (02) 6175 5601 · Fax (02) 6175 5620 DPS id 12860
Government subsidised aged care
162 beds. 7 are respite beds. 16 beds cater for secure dementia. 84 are extra service beds.
These services are operated by Goodwin Aged Care Services Ltd.
No vacancies listed
If you're interested in any services, please refer to the "Send Enquiry" area to ask about availability.
Australia's largest selection of vacancies
Take a look at the huge selection in the vacancies area:
Email Enquiry option is not provided by this organisation
Please contact Goodwin Village Monash by phone on (02) 6175 5601 and mention DPS Guide as the referral source.