text:
Informatics-Supported Cancer Research Endeavors
• Cloud-based informatics platforms aim to simplify interaction and information sharing between scientists and oncologists so that targeted treatments can begin faster; can manage billions of data points generated per patient; and can reduce time for data mapping and analysis from months to days to create a real-time, growing body of knowledge.
• The National Comprehensive Cancer Network (NCCN) outcomes database is one example of a collaborative data collection system that is relevant to both clinical practice and robust clinical outcomes research.
• Web-based EHR systems can facilitate real-time alerts, decision support capability, and multiple user applications.
• Patient-centered outcomes empower providers to make tailored recommendations to the individual patient based on data from other patients most like them.
• Secondary use of data that were collected for a different primary purpose generally involves some sort of adaptation or compromise. The challenge is to identify how this secondary use can best complement and extend the primary use of the data, for example, for generation of new hypotheses.
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Cancer Research Endeavors
� loud-based informatics platforms aim to simplify interaction
and information sharing between scientists and oncologists so
that targeted treatments can begin faster; can manage billions
of data points generated per patient; and can reduce time for
data mapping and analysis from months to days to create a
real-time, growing body of knowledge.
� The National Comprehensive Cancer Network (NCCN) out-
comes database is one example of a collaborative data collec-
tion system that is relevant to both clinical practice and robust
clinical outcomes research.
� Web-based EHR systems can facilitate real-time alerts, deci-
sion support capability, and multiple user applications.
� Patient-centered outcomes empower providers to make
tailored recommendations to the individual patient based on
data from other patients most like them.
� Secondary use of data that were collected for a different pri-
mary purpose generally involves some sort of adaptation or
compromise. The challenge is to identify how this secondary
use can best complement and extend the primary use of the
data, for example, for generation of new hypotheses.
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� rust is the core underlying issue for concerns regarding con-
sent, data privacy and security, accountability, and data owner-
ship. Consumers and patients want their data to be protected,
and they want medicine and health care to be advanced.
In this session, four cancer use cases were presented as examples of
successful informatics-supported approaches to managing large, complex
datasets. Panelists discussed data collection, storage, and retrieval; data
analysis and reporting; and data sharing.
CASE EXAMPLE: DELL-TGen CLOUD COMPUTING
Spyro Mousses, vice president in the Office of Innovation and director
of the Center for BioIntelligence at the Translational Genomics Research
Institute (TGen), described a clinical trial using molecularly guided individ-
ualized therapy in pediatric cancer as a case example of successful alignment
of biomedical science and informatics. To begin, Mousses described what he
called "the evolution from evidence-based medicine to information-enabled
medicine to intelligence-based medicine" and TGen's "N = 1" approach to
drug development (Figure 4-1).
An N = 1 Approach to Clinical Research
When seeking to develop a drug for a deadly disease such as cancer,
investigators generally start with a broad target population from which they
select a representative study cohort for a clinical trial comparing one thera-
peutic option against another. Evidence-based decisions on treatment are
informed by statistical outcomes of the trial. For example, if the data indicate
a 30 percent response rate to therapeutic option 1 and a 20 percent response
rate to option 2, then therapeutic option 1 would be the drug of choice to
be developed for all patients in the original target population (Figure 4-1A).
Such a statistical approach is not ideal when dealing with a disease or condi-
tion that is clinically heterogeneous and molecularly complex, Mousses said.
Moving beyond basic evidence-based medicine, information-enabled
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Evidence-based Information-enabled Intelligence-based
medicine medicine medicine
Target population Therapeutic option 1
Selection of representative Therapeutic option 1
study cohort Drug of choice for
30% Response rate
EVERYONE in target
Therapeutic option 2 Option 2 is not
approved for this
Clinical trial 20% Response rate
Target population
Figure 4-1 A (top panel).eps
option 1
option 2
Good-outcome Poor-outcome
Selection of representative patients patients
study cohort
Association of molecular feature
to phenotype/response
Figure 4-1 B (middle panel).eps
N=1 100s of options
Selection of an
Individualized interpretation The key question is:
information (understanding) How do we do that ?
FIGURE 4-1 The evolution from evidence-based medicine (A) to information-enabled
medicine (B) to intelligence-based medicine (C).
SOURCE: Mousses presentation (February 27, 2012).
Figure 4-1 C (bottom panel).eps
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medicine takes into account more detailed characteristics of the disease,
such as expression of tumor markers or measurement of biomarkers. This
approach also starts with a target population and the selection of a represen-
tative cohort for a clinical trial, but the cohort is then further stratified based
on the association of a molecular feature with a phenotype or response. This
stratification can allow one to determine that patient A would benefit more
from therapeutic option 1, while patient B would be better treated with
therapeutic option 2 (Figure 4-1B). Still, there are affected individuals who
do not respond to either drug A or drug B.
To help address these concerns, TGen has been experimenting with an
N of 1 approach where the focus is not on finding a representative popula-
tion in which to test an investigative compound, but rather on finding a
drug that meets the needs of a single individual based on his or her molecu-
lar profile (Figure 4-1C). This approach requires intelligent interpretation of
individualized information and a mechanistic understanding of the disease
to allow for predictions about which therapy is most appropriate. About a
decade ago, TGen started to take the fundamental steps in the direction of
molecular-based cancer treatments and has been using technologies ranging
from simple gene expression and chemical assays to whole-genome sequenc-
ing to identify targets, Mousses said.
Molecularly Guided Individualized Cancer Therapy
As an example of the N of 1 approach to drug development, Mousses
described an ongoing pediatric neuroblastoma clinical trial. To make the
most of its molecular technologies, TGen needed innovative IT infrastruc-
ture. Through a collaboration with Dell, it created a cloud-based comput-
ing system that would both support the workflow of the trial and aid in
repurposing the data. It is both a cloud to support personalized medicine,
Mousses explained, and a repository to support translational research. As a
result, the trial will be expanding to other pediatric and young adult cancers.
The process starts with clinical trial design, working within the frame-
work of the regulatory agencies and in accordance with the IRBs. Following
consent and enrollment of the patients, biopsies are collected and molecular
profiling is done using next-generation sequencing technologies. Mousses
noted that the collaboration with Dell has allowed faster and deeper profil-
ing for each child and faster and improved data and clinical communica-
tion. A personalized treatment plan is then devised based on the profiling.
This model for personalized medicine clinical trials, using molecularly
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guided treatment and the Dell IT infrastructure and TGen cloud, is also
being used for a new melanoma trial.
These types of trials are necessary experiments, Mousses said, to help
define the IT requirements for intelligence-based personalized medicine
using cloud-based informatics. The molecular profiling presents the first
IT challenge, requiring high-performance computing and storage for
200 billion data points generated per patient. Another IT challenge is to
match the patient profile to known information about therapeutic concepts,
pathway concepts, and cellular processes, for example. This requires very
large knowledge databases (e.g., pharmacogenomic databases) and presents
numerous challenges. How should these complex, heterogeneous data be
presented and processed? How can they be shared and exchanged across
sites? There are also issues of security and privacy in the cloud. One of
the models TGen is exploring is a hybrid cloud, where each clinical center
would be able to warehouse its own data, keeping the patient data secure
within the confines of the health care enterprise.
Opportunities in the Cloud
The TGen model for personalized medicine clinical trials facilitates
intelligent use of the data to help each individual patient, Mousses said, but
it does not yet allow for repurposing the data for secondary studies. TGen's
future vision is to provide a system that effectively links the pediatric oncol-
ogy community, including software, hardware, and protocols that support
data exchanges so that they are secure. Infrastructure for communication
and collaboration is critical, Mousses said, and the system would include
scientific, clinical, and community web portals. The goal is for the wider
oncology community to have access to the network and be able to manage,
analyze, and link patient data to pharmacological knowledge to identify
potential treatment options. Information about the prediction and the
outcome should feed into the model to create a real-time growing body of
knowledge, not just about what is working, but about what is not working
as well.
August Calhoun, vice president at Dell Healthcare and Life Sciences
Services, added that the cloud increases computation and collaboration
capacity by 1,200 percent and reduces the time needed for data mapping
and analysis from months to days. The cloud is a shared resource that will
be accessed over the Internet to do the complex analyses required to make
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better-informed decisions about care and to share information in a con-
sented and secure manner, he said.
NCCN is an affiliation of 21 leading cancer centers throughout the
United States. The overarching mission of the network, explained Kimary
Kulig, vice president of clinical and translational outcomes research at
NCCN, is to improve the quality, effectiveness, and efficiency of oncology
practice so that patients can live better lives. NCCN seeks to enhance care
through information resources, outcomes research, and clinical trials, and
to develop information resources that are valuable to patients and other
stakeholders within the health care delivery system.
NCCN Guidelines
To aid in fulfilling its mission, NCCN issues comprehensive oncology
clinical practice guidelines that include clinical algorithms and supporting
documentation for various tumor types. There are currently 56 individual
guidelines covering 97 percent of all malignant diseases. Guidelines are
developed and continually updated in collaboration with the 21 NCCN
member institutions and efforts that involve more than 18,000 volunteer-
hours per year from 900 clinicians who participate on guideline panels.
Guidelines are categorized according to both level of evidence and degree
of consensus among panel members.
NCCN Oncology Outcomes Database
To understand the extent to which NCCN member institutions
adhered to the guidelines they helped to develop, NCCN launched an out-
comes database. In addition to the primary goals of monitoring and bench-
marking concordance with the guidelines, the database was also intended to
be used to describe patterns and outcomes of care under the guidelines and
to create a feedback loop to the physicians, institutions, and guideline panel
members. Kulig noted that the outcomes database has also become a major
data repository for research, aided by the fact that it is based on a common
data dictionary and thus serves as a platform for multi-institutional health
services research.
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The first database, launched in 1997, was focused on breast cancer
and currently includes data on close to 54,000 patients who are followed
actively throughout their entire course of treatment until death. There are
17 institutions actively participating in this database. With the architecture
in place, databases for other tumor types were subsequently launched,
including non-Hodgkin's lymphoma, colorectal cancer, non-small-cell lung
cancer, and ovarian cancer.
Structure and Operations
The NCCN outcomes database is governed by the Scientific Office,
a virtual office that includes investigators who are chairs of each of the
tumor-specific databases. The data coordinating center is housed at the City
of Hope Cancer Center in Los Angeles, California, and clinical research
associates at each participating center abstract and de-identify the data for
submission to a centralized, web-based database. Kulig noted that this is
done under an IRB-approved protocol in every site and that most of the
IRBs now have a waiver of consent unless the patient's data are linked to
specimen collection protocols. The patients included in the database have
received all or most of their care at an NCCN institution, and each patient
is followed longitudinally throughout the course of care (Kulig added that
outside medical records are unfortunately not accessed for abstraction in
this database). The NCCN main office in Fort Washington, Pennsylvania,
employs project managers, quality assurance managers, statisticians, and
analysts who work with the aggregate data from all of the databases and all
of the sites.
There are some unique characteristics of the NCCN outcomes data-
base, Kulig said, that differentiate it from other large datasets (e.g., the
Surveillance, Epidemiology, and End Results Program [SEER]) or other
institutional databases. The NCCN database has more than 300 different
data elements that track the continuum of care for each patient. There is
complete data on patient demographics, medical histories, family histories,
and comorbidities. Detailed information about sites of metastases and bio-
markers is also collected. All clinical events and interventions are collected,
including diagnostics, hospital admissions, very detailed sequencing of
therapies, and reasons for discontinuation of chemotherapy. Progression-
free and overall survival data are also captured.
Kulig contrasted this to tumor registry data, which generally contain no
information on comorbidity or diagnostic procedures and only limited data
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on treatment and outcomes (limited to recurrence and survival data). She
also drew a contrast to claims or billing data, which are not research-quality
data to begin with; which have no information on staging, pathology, or
histology; and from which treatment data can be very difficult to interpret.
There is generally no biomarker information, and the outcome end points
that can be derived from billing or claims data are usually in the form of
resource utilization to which costs can be affixed.
NCCN has rigorous data quality assurance processes in place, starting
with extensive data manager training. The system also includes online edit
checking during web-based entry, programmed logic checks (e.g., flagging
an entry if a prostate cancer patient is entered as female), quarterly quality
assurance reports, and on-site audits.
Five NCCN sites are currently using electronic data transfer for the
breast cancer database, Kulig said. This is particularly important at high-
volume sites to maximize efficiencies (e.g., eliminates the need to enter the
same data multiple times into various databases, such as the tumor registry,
the NCCN database, or any internal databases). Electronic data transfer
does need dedicated resources, including programming support to con-
form to the NCCN database requirements and changes. Lack of dedicated
resources can lead to failed audits or poor-quality data, Kulig said. The fact
that some sites are using electronic data transfer while others are not does
add complexity to the system, and every proposed change by NCCN must
be carefully considered for how it will affect electronic data transfer sites
versus manual data entry sites.
Current Use
The primary use of the NCCN outcomes database is the annual
analysis of institutional concordance to the NCCN guidelines. This is done
systematically for each tumor database, comparing the care that was actually
received in practice to the guideline that was in effect at the time the care
was delivered. (Kulig noted that any treatment received as part of a clinical
trial is considered concordant.) Each institution's care is then benchmarked
against the NCCN aggregate, and individual reports are provided to each
institution for quality-improvement purposes. Individual patient summary
reports can be generated from the database and are useful for viewing con-
cordance status, treatment information, or visit history, for example.
The database is also very conducive to comparative effectiveness research,
Kulig said, because it contains detailed information about the patient's clini-
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cal characteristics, comorbidities, and treatment. Institution-specific data are
available to NCCN sites, and aggregate data are available upon request. The
data are also available to non-NCCN entities for specific research queries, and
Kulig noted that NCCN has provided data to pharmaceutical, biotechnology,
information technology, and medical device companies.
Value of Collaborative Databases for Diverse Stakeholders
When we think of the continuum of data and how it is generated,
Kulig said, controlled clinical trial data provide the strongest evidence for
safety, efficacy, and even patient-reported outcomes. Such high-quality data
can also provide information about the predictive and prognostic value of
diagnostic testing and biomarkers.
Beyond the clinical trial, Kulig suggested, a lot of observational data
generated every day in clinical practice is often underutilized or even
ignored, including real-world safety and effectiveness data; patient-reported
preferences and outcomes; adherence to, duration of, and reasons for dis-
continuation of therapy; biomarkers and diagnostic testing; and resource
use and costs of care. A variety of stakeholders make use of real-world data
for a variety of purposes (Box 4-1).
Personalized medicine has a particular need for real-world, real-
time data. Kulig noted that lags in existing datasets, the NCCN dataset
included, do not necessarily accommodate real-time analysis or cutting-
edge b iomarker-linked outcomes research. In addition, there are large
bio specimen repositories in numerous institutions that are not necessarily
annotated or linked to clinical data.
In conclusion, Kulig said, the NCCN outcomes database is one exam-
ple of a collaborative data collection system that is relevant to both clinical
practice and robust clinical outcomes research. Observational, real-world
data hold value for key stakeholders. The promise of personalized medicine
in particular underscores the need for these types of data aggregation and
exchange systems.
Cancer costs are rising more rapidly than inflation and other health
care costs, and community cancer centers are facing more challenges than
ever, said Asif Ahmad, senior vice president for information and technology
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What Real-World Data Are Used by Whom?
� Treatment effectiveness
� Adverse events and safety
Food and Drug Administration
� Epidemiology
� Adverse events and safety
� Adverse events and safety
� Comparative effectiveness
� Resource use and costs
Patients and Caregivers
� Treatment effectiveness; real-world survival
� Adverse events and safety, symptoms and side effects, quality
of life
� Costs of care
� Epidemiology, current practice patterns, unmet medical need
� Treatment effectiveness versus comparators; real-world
� Side effects and adverse events, hospitalizations, resource use
and costs
SOURCE: Kulig presentation (February 27, 2012).
services at McKesson Specialty Health. McKesson Specialty Health partners
with community cancer care practices to help them manage increased com-
petition from hospitals and clinics, declines in reimbursement, health care
reform uncertainty, and rising health care costs. McKesson Specialty Health
is the second-largest business unit of McKesson, which is one of the l argest
distributors of specialty pharmaceuticals and biologics. The company has
long-term partnerships with about 3,000 oncologists, about 1,000 of whom
are in the U.S. Oncology Network, and 2,200 multi specialty practices.
Ahmad said that the foundation of McKesson Specialty Health is IT,
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upon which is built the robust customer-facing technology from which
analytic applications stem. The customers could be patients, pharmaceutical
manufacturers, payers, or others. The focus is on developing an efficient,
integrated technology suite built upon the core architecture.
System Design and Datasets
The cornerstone of the McKesson system is the iKnowMed Electronic
Health Record, one of the first totally hosted, web-based EHR systems,
Ahmad said. iKnowMed includes charge capture functionality, safety alerts
to help decrease errors, a cancer diagnosis and regimen library to aid point-
of-care decision making, and clinical trial support to help increase clinical
trial accruals. It integrates with other tools such as oral e-prescribing and
drug inventory management. One benefit for practices is the ability to drive
the workflow of the clinic from a single place. Another unique feature of
the system is the support for real-time decision making. Ahmad added
that all of the data feed into a common data management system that cur-
rently warehouses data for about 1.2 million patients, with 17,000 newly
diagnosed cancer patients added to the McKesson database every month.
Ahmad reiterated that the customer-facing technology is all built upon
the same structural data framework. For example, data in the common core
framework could be used for real-time clinical alerts that could inform the
clinician about a newly diagnosed patient for the purposes of clinical trial
recruitment or alert the nurse to a scheduled appointment for a patient
coming for the first dose of treatment. The same technology drives alerts
for pharmaceutical manufacturers that may include aggregate, de-identified
data regarding use of their products. The CARE, or Comprehensive Accrual
REsource, tool for clinical research is also built on the same technology and
facilitates identification of patients for personalized medicine trials. The
same data framework is used to pull up the weekly and monthly financial
reports for the practices. Rather than duplicating efforts, everything comes
from one source. That data store is fed by the EHR, practice management
tools, and patient-reported data from the patient portal. Ahmad noted
that the technology architecture is able to use data from whatever practice
management tools the practice has chosen to use.
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Supporting Clinical Outcomes and Research
Current trends in health care reform, consumerism, pay for perfor-
mance, and care delivery models are changing the landscape of medical
practice. The old model of "patient plus prescription results in payment" is
being replaced with one where demonstrated outcomes impact payment.
The McKesson system allows researchers to harness clinical data to show
cost-effectiveness of care alongside evidence for best possible outcomes.
Another feature is the ability to provide a market intelligence report to
manufacturers, which can show, for example, the penetration of a par-
ticular drug in the market compared to a competitor. The same data are
integrated with the clinical trial management system, Ahmad said; this has
facilitated the enrollment of more than 50,000 patients in various clinical
trials over the past 8 years.
Data Governance
Because no defined standards are fully implemented with regard to
EHRs, the data remain somewhat "dirty," Ahmad said. To help address
this, McKesson established a multidisciplinary data governance commit-
tee tasked with increasing stakeholder awareness of the importance of data
quality and working collaboratively with all stakeholders to ensure the
accuracy, completeness, and consistency of the clinical, administrative,
and financial data that are entered into the database. The committee will
consider data governance from a very comprehensive point of view, includ-
ing, for example, common definitions, structure and standardization, data
validation, data access and compliance with regulations, communication,
prioritization, and benchmarks.
Paul Wallace, senior vice president and director of the Center for
Comparative Effectiveness Research at The Lewin Group, a health care and
health policy consultancy in Washington, DC, began with a brief overview
of the evolution of comparative effectiveness research.
Comparative effectiveness research (CER) was defined in the Medi-
care Modernization Act of 2003 as "the conduct and synthesis of research
comparing the benefits and harms of different interventions and strategies
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to prevent, diagnose, treat and monitor health conditions in `real world'
settings." Subsequently, the Agency for Healthcare Research and Quality
(AHRQ) created programs to foster CER, and in 2009, the American
Recovery and Reinvestment Act (ARRA) provided $1.1 billion to fund
CER. The Patient Protection and Affordable Care Act of 2010 included
further provisions to foster CER, including the creation of the Patient-
Centered Outcomes Research Institute (PCORI). Chartered as an inde-
pendent, nonprofit research organization with a sustainable funding stream,
PCORI's charge is to fund research that offers patients and caregivers the
information they need to make important health care decisions.
Patient-centered outcomes research is a relatively new term, Wallace
explained, and there has been some tension as to what it is and what it is
not, as well as how it contrasts with personalized medicine. According to the
PCORI working definition, patient-centered outcomes research
helps people and their caregivers communicate and make informed health
care decisions, allowing their voices to be heard in assessing the value of health
care options. This research answers patient-centered questions such as: Given
my personal characteristics, conditions, and preferences, what should I expect
will happen to me? What are my options and what are the potential benefits
and harms of those options? What can I do to improve the outcomes that
are most important to me? How can clinicians and the care delivery systems
they work in help me make the best decisions about my health and health
care? (PCORI, 2012).
Wallace added that from a practice perspective, patient-centered outcomes
research will empower the oncologist to have more robust conversations
with an individual patient about what is known about similar patients, how
his or her situation compares and relates to others, and how the patient and
practitioner can move forward on the basis of that information.
The draft research agenda recently released by PCORI indicates that
20 percent of funding will be allocated to accelerating patient-centered out-
comes research and to methodological research, particularly for conducting
observational research, Wallace said. There has been an evolution in how
evidence is perceived (Table 4-1). Expert opinion based on case reports and
case series is still important and credible, but it is based on chart review
and clinician experience (essentially an N of 1). Evidence-based medicine
is more from the perspective of population efficacy (an N of many). Data
from clinical trials and systematic reviews are expressed as a mean, and
subgroups of people are thereby excluded. While population efficacy is
translated into a variety of practices, from performance management to
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TABLE 4-1 The Evolving Evidence Perspective
Study Type Methods Data Source/Organization Perspective
Expert � C
ase Reports � C
harts Effects on
Opinion � Case Series � Experience Patients
(N of 1)
Evidence- � R
CTs � T
rial Data & Databases Population
Based � Systematic � Meta-analysis Efficacy
Medicine Reviews � Reports & Series (N of Many)
� (Observation)
Comparative � R
CTs � rial Data & Databases
T Population
Effectiveness � Systematic � Meta-analysis
Research Reviews � Large Population Databases
(N of Many)
� Observation � Reports & Series
Patient- � R
CTs � rial Data & Databases
T Patient
Centered � Systematic � Meta-analysis
Outcomes Reviews � Large Population Databases
(Many N of 1s)
Research � Systematic � Reports & Series
Observation � Patient-Generated Data
NOTE: RCT = randomized clinical trial.
SOURCE: Wallace presentation (February 27, 2012).
guidelines, Wallace noted that there are pitfalls, not the least of which is that
the data may not be particularly applicable to the individual patient in the
room. Comparative effectiveness research uses large population databases
to consider population effectiveness (also an N of many). The key differ-
ence between evidence-based medicine and CER, Wallace suggested, is that
CER attempts to include those groups of people who were ineligible for
and excluded from clinical trials, using observational data to complement
and extend what was learned from the trial. Patient-centered outcomes
research builds on all of the previously discussed dimensions, focusing on
patient effectiveness (many N of 1s). In other words, what is the provider's
recommendation to the individual patient, based on as many people like
that patient as can be found?
Secondary Use of Data
When considering "secondary use" of data, Wallace said, it is important
to remember that this means the intended primary use was most likely for
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a different purpose and the data were collected under different rules. As a
result, secondary use of data generally involves some sort of adaptation or
compromise. The challenge is to identify how this secondary use can best
complement and extend the primary use of the data. Wallace outlined sev-
eral approaches to secondary use.
Most secondary uses have been reactive and opportunistic, making use
of any data that are already there. Wallace mentioned the Optum Natural
History of Disease (NHD) Model as an example of how data can be used for
secondary analysis. Using claims data, this application can answer questions
such as, How many people within a population are taking a particular lipid
drug and how do they differ from matched people with the same clinical
situation who are not taking the same drug? While it would take about a
year and a half to answer that question by going through charts, Wallace
said, the NHD applications could answer within minutes, making use of
big datasets that are optimally structured. Reactive secondary analysis can
be useful for forming new hypotheses or for iterative testing to refine a
A different approach is to plan for secondary use. This may involve
structured data capture, expanded common datasets outside clinical trials,
or common intervention protocols. Planning for secondary analysis can
help to answer questions that cannot be answered by classical experimental
approaches. For example, What are the drivers from the patient side for
choosing to undertake a third line of therapy? Can differences in costs and
response rates for various lines of therapy be demonstrated? How do survival
and costs for advanced cancer patients who opt not to have therapy compare
to those who are treated?
Wallace cited a variety of ongoing efforts in secondary use of data that
support CER and patient-centered outcomes research, including the FDA
Sentinel system that uses data to track the safety of products on the market
and the National Institute of Mental Health (NIMH) Registry of Individu-
als with Autism Spectrum Disorders to test hypotheses about etiology and
health services use by patients and families.
The sustainability of these projects is an ongoing challenge, Wallace
concluded. There is a necessary balance and overlap between funding and
governance, and between data sources and data users. Surrounding this are
issues regarding the use of distributed versus aggregated data, cost structure
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for participation, preservation of privacy and confidentiality, and propri-
etary and ownership issues.
Following the presentation of case examples, a reaction panel mod-
erated by Adam Clark, patient advocacy consultant at MedTran Health
Strategies, discussed further some of the cross-cutting issues for informatics-
supported cancer research and care. Panelists included Gwen Darien, direc-
tor of the Pathways Project and cancer survivor, Deven McGraw, director
of the Health Privacy Project at the Center for Democracy and Technology,
James Cimino, chief of the NIH Laboratory for Informatics Development,
and Steven Piantadosi, director of the Samuel Oschin Comprehensive Can-
cer Institute at Cedars-Sinai Medical Center.
Engaging Patients
Gwen Darien offered the patient's perspective based on both her
personal experience as a cancer survivor and input from her colleagues in
the advocacy community. The advocacy community is not as engaged in
health IT and informatics as it needs to be, she said. To create buy-in and
engagement of the survivor advocacy community, that community should
be engaged from the beginning, during the conceptualizing of the process
and parameters of information exchange (rather than simply participating
afterward). Are patients people that something is done to, she asked, or are
they active partners in the formulation and creation of value? Data are an
asset. What is the value of patients to health IT, and what do the patients
get out of sharing their data in return? Who owns the information and what
information do patients have access to?
Darien noted that a barrier to moving forward in informatics is the
broad assumptions made about "the patient." Some patients are extremely
engaged, some disengage once their treatment is over, others do not want
to know anything.
Building Trust: Privacy, Consent, and Ownership
Deven McGraw said that the end goal of privacy is not privacy itself,
but trust. The goal is to build a trusted, accountable ecosystem for using
data in ways that help individuals, communities, and populations. Privacy
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rules are structured largely around tools such as patient consent and data
minimization or de-identification. These tools are critically important,
McGraw said, but they are not the end goal. They are tools to be used to
build trust, along with other tools. It is also important to remember that
consumers and patients want their data to be protected, and they want
medicine and health care to be advanced. These competing interests need
to be considered and balanced when developing privacy policies.
McGraw also suggested that too much time is spent focusing just on
the issue of consent in lieu of addressing other important privacy protec-
tions. Consent is not the same as privacy. Consent ends up shifting the
burden for protecting privacy to the patient. That said, when surveyed,
people often say that they want to be asked before their data are used for
research purposes. There are efforts now to obtain general consent for future
research because it is not possible to define all of the potential research uses
of the data being collected today, but this does not lead to a meaningful
and informed consent for the patient, she said. Building trust in research
requires research institutions to be mindful of the sensitivity of the data, to
treat them with respect, and to make good decisions about how the data are
to be used. McGraw suggested that one of the ways to rely less on consent
and build trust is to improve transparency, both to the public at large and
to cancer patients, about how patient data are used, the typical tools that
institutions use to protect data, and oversight and accountability for those
Consent as a policy issue is also important for researchers because
their access to clinical data is based on informed consent. James Cimino
pointed out that if the data are going to be reused in de-identified form,
the original investigators are notified of reuse. This raises the issue of the
ownership of the data and goes beyond the patient or the institution to
the intellectual property of the investigators who are providing these data
for sharing.
Workshop participant Alison Smith from C-Change asked what role
additional penalties for inappropriate and irresponsible use of data played in
the trust equation. McGraw expressed her concern that imposing penalties
and creating the threat of legal liability can cause people to be unwilling to
share data, because that is the path of least risk. Regulators need to do more
than impose penalties, she said; they need to provide more guidance about
how to comply with HIPAA Privacy Rule (IOM, 2009).
OCR for page 43
Data Granularity
James Cimino highlighted several technical issues of data granularity
in databases. When repositories collect data from different sources, one of
the concerns is determining when the data collected are synonymous and
when are they not. The level of data granularity in clinical care is not neces-
sarily the same as the level of granularity in research data (e.g., noting the
patient had pain versus reporting the severity of pain on a scale of 1 to 10
and where exactly the pain was). Capturing the context of the data is also
important (e.g., was a complete blood count done because the patient had
a fever, or was it part of the protocol data collection schedule?). Another
technical aspect is the inclusion of genomic data. What is important to
index? How can the system cope with the changing methods of how these
data are being collected?
Secondary Use
Steven Piantadosi added his perspective as a clinical trialist. Expand-
ing on the comments by Wallace, he stressed that data that are intended
and designed to address a particular therapeutic question are distinct from
data that were produced for some other purpose. He urged caution when
making inferences based on data that were not collected for that purpose.
One example is when a safety signal emerges in a clinical trial designed to
consider a therapeutic question. Even in a highly structured clinical proto-
col, it can be very difficult to determine whether or not the safety signal is
real and actionable when the study was not designed specifically to study it.
These are not new issues, and for historical perspective, Piantadosi referred
participants to a 1984 article discussing the use of observational data from
registries to make treatment comparisons (Green and Byar, 1984).
Kulig added that observational data are largely underutilized because of
concerns from both a statistical and a clinical perspective. Wallace said that
just because we do not have statistically significant data does not mean we
do not make decisions. While the foundation of decision making is ideally
experimental empirical data, there are many questions for which empirical
data will not exist. Frameworks are needed that can help clinicians make
progressively better care decisions for each individual patient, even in the
absence of gold standard data. Piantadosi suggested that it is not a question
of having the perfect data source, but rather a problem of bias. These data-
bases are not unbiased sources of information on which to base definitive
statements about therapeutic decisions. Mousses concurred that we should
OCR for page 43
not be making definitive statements about something that the data were not
generated to address in the first place. The data can be mined, aggregated,
and used to identify trends and design studies to test new hypotheses, he
said. There may be bias in the data, but there may be a signal nonetheless
that could guide further study.
Engaging Private Practice and Extramural Researchers
Piantadosi noted that the majority of faculty at Cedars-Sinai are in
private practice (i.e., not employed directly by the hospital) and it is difficult
to incentivize them appropriately with regard to informatics needs. If, as was
noted earlier, 80 percent of patients are treated outside of academic centers,
we have to find ways to incentivize the private practice community to use
the tools and provide the data that are needed, he said.
Clark asked what would be needed for the governance or implementa-
tion of an interconnected system that would engage community practices in
data exchange. One solution, Piantadosi said, is to buy the practice. Inde-
pendent practices tend to see things in terms of time spent and cost, and
they do not respond well to edicts from the parent institution. Practitioners
may also be less computer savvy, either because of their background or the
nature of the practice.
Cimino said that NIH intramural investigators are being encouraged
to collaborate extramurally, and the clinical center is opening its doors to
extramural investigators to bring in their patients for studies and to make
use of some of the unique resources that NIH has. With regard to gover-
nance, there is currently no coordinated trans-institute effort to share data
within or outside NIH, other than what individual researchers choose to
do. The IT working group of an advisory council to the NIH director is
considering how to better coordinate intramural and extramural work, and
a report is expected in 2012.
Green, S. B., and D. P. Byar. 1984. Using observational data from registries to compare
treatments: The fallacy of omnimetrics. Statistics in Medicine 3(4):361-373.
IOM (Institute of Medicine). 2009. Beyond the HIPAA privacy rule: Enhancing privacy,
improving health through research. Washington, DC: The National Academies Press.
PCORI (Patient-Centered Outcomes Research Institute). 2012. Patient-centered outcomes
research. http://www.pcori.org/patient-centered-outcomes-research/ (accessed April 26,
OCR for page 43


text:
1. Miranda rights are not only required when arrested, but when questioned in a "focus of suspicion". 2. There is no such thing as "shooting to wound". Not with a handgun in a close quarters combat situation- which is what you had BETTER be in if you claim self defense. You are shooting to stop the threat to your life. Not threat to your lawn, your dog, your beauty sleep, etc. 3. Shooting to stop the threat means shooting for the biggest piece of him- center body mass. Halfway between belly button and adam's apple. 4, If you shoot anybody, anywhere, for any reason, expect to be detained or arrested. 5. There are other means of control that should be attempted first. Making a threat of bodily harm is known as assualt. Get the PD involved. Go beyond the officer responding if you need to.
What we have here is... failure- to communicate.
Ok, here's what I think. 1. You stated that you have made a handful of posts, but your post toatal reads 2. 2. Free legal advice is worth what it cost you. 3. Don't believe in this day and age of camera phones with recorders that your "friend" can't get proof of threats of physical harm.... 4. BS
From C3Shooter: Skullcrusher, you are evil, sick, demented, twisted- and my hero!
People get the government they deserve.
This is our standard reply to legal questions:The FTF flunked our Bar Exam. Only a fool would take legal advice from us. Taking legal advice from a public forum is only exceeded in stupidity by the people that offer that advice!
I stayed at a Holiday Inn Express once.
I slept in the lobby!!
I am not a lawyer nor am I in in any kind of position to offer legal council. What I can offer is good ol' common sense. Something to consider is that South Carolina firearms (perticularly handgun) laws are drastically different from the rest of the southern states. That is the reason why most concealed carry permits to not reciprocate to South Carolina. I would hate to see a law abiding citizen be arrested and lose their firearm because of their own lack of knowledge of state and local laws. Additionally, you would need to have many disinterested witnesses verifying your story should anything happen and if it is in an apartment building in a not so good section of town, good luck with that. As mentioned before, an over-zealous DA will make a very convincing argument as to whether or not you planned on a confrontation with intent to kill. If you feel that strongly for her safety, try finding a better location for her to reside and/or let her be the one to confront the bad guy with a firearm. If she isn't trained in their use, take her to the range and let her learn. Additionally, if you do take it upon yourself or she takes it upon herself to gather evidence against the drug addict, make sure it is of enough quality that you can clearly identify the person making the threats. The polilce are over worked as it is and they aren't going to put much effort into catching a small fish. My 2 cents worth then is this: try finding alternate suitable living arrangements and if that isn't an option, make sure she gets proper training in the use of firearms so she can defend herself should this knucklehead ever back up his words with action.
common sense says start recording with a video camera what is happening or tape recorder and call 911. you dont need a gun to solve every problem. guns are the last ditch things to save a life. using one will often solve one problem and start several more. retain a lawyer and write down everything that occurs. getting actual legal advice from a real lawyer is a better thing to do then going gun shopping and reading replies from a gun forum. video/audio evidence and the old saying of "if you did not write it down it did not happen" is in play. go get real legal advice.

subset: commoncrawl


text:
Before Shop-Eat-Surf, there were two sites I paid for premium content on. One is Surfline, the other is the Wall Street Journal. One is about all things surf, the other, the best business content site in the world. Shop-eat-surf is the intersection of those two worlds. Shop-Eat-Surf provides everything from coverage of events, people, brands and trends. However, beyond the Executive Edition "wall" is more meaty analysis and interpretation of financial statements, business models and brand philosophies; why certain brands and companies are succeeding, where others aren't. The Executive Edition is a must have read if the business of surf and action sports are on your radar screen.
- By Jeff Berg, Co-owner, Surfline"Shop-Eat-Surf" is now officially, the first stop in the morning for industry news. Accurate reporting, no sensationalism, and just the facts. Refreshing support to an incredible industry with a very bright future. Tiffany has cemented her role in the industry....the site is thought provoking, and inspirational. Learning the stories of others is incredibly useful. Great way to connect the retail community with the wholesale and financial, instantly and nationwide. ... And the Executive Edition rules.
- By Bob Hurley, Chairman, Hurley International
SIA: More on 2014 snow rep and retailer of the year awards + video recap.
SES: The monthly Credit Managers' Index dips to levels last seen during the credit crunch.
Details on Industry Insight.
Press Release:
RESTON, VA, November 29, 2011 – comScore (NASDAQ : SCOR), a leader in measuring the digital world, today reported holiday season U.S. retail e-commerce spending for the first 28 days of the November – December 2011 holiday season. For the holiday season-to-date, $15 billion has been spent online, marking a 15-percent increase versus the corresponding days last year. Cyber Monday reached $1.25 billion in online spending, up 22 percent versus year ago, representing the heaviest online spending day in history and the second day on record to surpass the billion-dollar threshold.
"Cyber Monday was yet another historic day for e-commerce, with online spending reaching a record $1.25 billion," said comScore chairman Gian Fulgoni. "It was just the second billion dollar spending day on record, following on the heels of Cyber Monday 2010. While last year saw Cyber Monday rank as the heaviest online spending day of the year for the first time ever, it will be interesting to watch the next couple of weeks to see if any future individual days in 2011 manage to leapfrog this year's highest day-to-date."
Cyber Monday's 22-percent growth in sales versus year ago was driven by an increase in both the number of buyers (up 11 percent) and the average spending per buyer (up 9 percent). Overall, 10 million people bought online on Cyber Monday, representing the first time on record that threshold has been reached in a single day. The average online buyer conducted 1.9 online transactions on Cyber Monday for a total of nearly $125 in spending.
Half of dollars spent online at U.S. Web sites originated from work computers, up slightly from last year. Buying from home comprised the majority of the remaining share (43.2 percent) while buying at U.S. Web sites from international locations accounted for 6.6 percent of sales.
"The Cyber Monday phenomenon originated from the significant spike in e-commerce activity that traditionally occurred following the Thanksgiving holiday weekend, with many consumers turning to their work computers to continue their holiday gift buying – and that pattern still exists today," added Mr. Fulgoni. "Looking forward to the balance of the season, it will be very important to continue to monitor the trend in consumer spending to determine the degree to which retailers' heavy promotional activity at the beginning of the shopping season, and consumers' encouraging response, has pulled forward consumers' future buying. When all is said and done, it will also be vital to see whether retailers' deals and price discounting, which consumers are now able to discover via so many different digital media channels, will have a negative impact on retailers' margins this holiday season."


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this wiki
This article is about a/an Sentient Mecha in Gosei Sentai Dairanger. |
Daijinryuu | |
Number: | none assigned |
Pilot: | n/a |
Sentai: | Gosei Sentai Dairanger |
First Appearance: | {{{firstepisode}}} |
Last Appearance: | {{{lastepisode}}} |
Number of Episode Appearances: | {{{numberofepisodes}}} Full list of appearances |
Length: | 500 m |
Width: | m |
Height: | 345 m |
Weight: | 50 tons |
Speed: | Mach 30 |
Daijinryuu (大神龍 Daijinryū?, Great God Dragon) is a neutral entity who was created by the universe itself to preserve the natural balance of the world. He appears when battles between the Dairangers and Gorma threaten that balance. According to Kameo, the reason of his first appearance is to destroy the Earth and return everything to nothingness to bring a balance to this world and to stop the human race's foolish conflict. Because of this neutral standpoint, he will kill people, innocent or guilty, if it means keeping the power of the cosmos in balance. During his first appearance, Daijinryuu destroyed a chunk of Tokyo and attacked the Gorma Palace as a warning to the Gorma and the Dairangers.
The Gorma fall back, but only for a little while, causing Daijinryuu to return. Daijinryuu then casts a spell to make civilians bow to it on the top of tall buildings, then jump off of them. After realizing that the Gorma were to blame for the upset of balance, he goes to destroy the Gorma palace. To restore the balance and change Daijinryuu's mind, the Lai-Lai Jewels and the Great Earth Shaking Jewel were scattered.
- There was a humanoid form of Daijinryuu in its early sketches.
See also
- Serpentera - Power Rangers counterpart in Mighty Morphin Power Rangers (Season 2). See comparison page.


text:
Kyle Eastwood Tickets
Find the Kyle Eastwood tickets you're looking for on viagogo, the world's largest ticket marketplace. Select an event to view the range of tickets available or view the Kyle Eastwood tour on a map to find an event near you. You can also sell your spare Kyle Eastwood Concert Tickets on viagogo, and listing tickets is free. All Kyle Eastwood tickets are covered by the viagogo Ticket guarantee!
Do you know of a Kyle Eastwood event we can't find? Click Here to tell us about it!


text:
The latest version of COMSOL, 5.0 is now available through the campus license distribution. Continue reading
Collaborative Qualitative Analysis Service Coming
Qualitative Analysis is an important part of many research projects that involve interviews or qualitative surveys. ICT is in the final stages of launching a new service to support qualitative research at the University of Saskatchewan. Continue reading
ownCloud service
We'd like to bring the ownCloud service to the attention of the research community. It is an exciting new feature that is part of the data storage suite that ICT offers to campus. Continue reading
MATLAB R2014b Patch Released
MathWorks has informed us that they have found and resolved a number of problems in MATLAB R2014b that could lead to files being removed.
Information about the bugs and patch is available in bug report #1184018 on MathWorks' website. In short, the most serious one is removal of files in the current directory when MATLAB exits. The others are crashes when using Simulink. The fixes are ZIP files that must be extracted in the MATLAB R2041b install directory, by a privileged user.
The main distribution from MathWorks has been patched, and installs from the ditto distribution site after the morning of January 16 will have these patches in place.
If you have any questions about these MATLAB patches, please contact Research Computing for answers. Remember to backup your files (such as the .m files) to prevent loss of data or work.
ESRI Canada Scholarship, 2015
ESRI Canada has given a scholarship to University of Saskatchewan students for the past several years. You can see previous winners on The Spatial Initiative (TSI) web site. They are offering this scholarship again this year. Details of the scholarship are available at the ESRI Canada website. (PDF file) Applications for the scholarship are to be sent via email to firstname.lastname@example.com. The deadline for application is January 24, 2015.
Applicants must have a "B+" average in their classes (i.e. a minimum 75% average), and must include a CV and a transcript. They should also note how they have used ESRI software in the past. Other information required follows below: Continue reading
Wolfram Mathematica 10.0.2 released
Wolfram Mathematica 10.0.2 is available for install on campus computers. Users are encouraged to try the new version. Continue reading
Introductory Course on High Performance Computing and Scientific Computing
High performance computing (HPC) is taking a fundamental role in scientific research around the world. Here at the University of Saskatchewan, the research computing group is making efforts to provide access to these new resources and technology to our researchers. As part of these efforts, we designed an delivered an introductory course intended for those graduate students, PDFs and researchers who want to start using HPC resources to speed up their researches.
The first offering of our course ran on September 18 and 19. During 12 hours, the 25 attendees (mostly graduate students and some staff members) reviewed the basic commands and concepts of a Linux system, and the characteristics of the different HPC systems that we have at the University (Plato, Zeno and Meton). They learned how to use efficiently these systems and which kind of problems fit better to each one: shared memory, distributed memory, GPU clusters, and large memory systems. Finally, they analyzed and solved practical examples using the systems (for more details see the course outline below).
Originally we designed the course with an aim to bring new users with no experience or little experience with Linux systems and HPC servers, to a point where they must be able to deploy HPC applications on the most suitable system depending on the problem at hand. The contents of the course could be customized, however, for future offerings according to the attendees backgrounds and interests. We are willing to offer the course again soon, with next offering potentially in January, as long as there are people interested. So, please do not hesitate to contact us at firstname.lastname@example.com with your questions and comments if you are interested in attending.
Original course outline:
1. Introduction to scientific computing
2. Linux basics
3. Compiled and interpreted languages
4. High performance computers
5. Running serial codes in a server
6. Running parallel code in distributed memory systems
7. Running parallel code in shared memory systems
8. Running code with GPU acceleration
Coast2Coast Fall Seminar Series in WestGrid Collaboration Facility: Antibody Sequencing
The University has been participating in the Coast2Coast Seminar series for a number of years. Organized out of IRMACS at Simon Fraser University, two themed seminar series are delivered per year, Fall and Spring. This term's C2C Seminar is on Antibody Sequencing, organized by Dr. Felix Breden from SFU.
The University of Saskatchewan local connection to this seminar series will be held in the WestGrid Visualization and Collaboration Facility (Agriculture 2D71). The first seminar of the series is Tuesday, September 30 at 12:30 CST Saskatoon time.
Space is limited, so please RSVP to email@example.com for each attendee.
Felix Breden describes the Seminar Series beneath the cut:
REDCap Service Launch Announcement
As pre-announced in an earlier post in this blog, REDCap hosting is being launched as a service from ICT today.
REDCap is a data collection and management tool written by a group at Vanderbilt University, and adopted by over 1100 institutions world-wide from Dunedin to Reykjavik, who form the REDCap Consortium. Researchers on campus have been requesting this tool for their research.
The University of Saskatchewan implementation is described on this service page in ICT's website. There are some restrictions on the use of the service, many having to do with the terms of our agreement signed to allow us to join the REDCap Consortium. Researchers wishing to use the service will complete a form and send that to the service support team.
We will respond with information on how to access the REDCap service and other information on its use. There is currently no charge for the service, and none are anticipated in the future.
For the REDCap service only, please contact firstname.lastname@example.com with any questions or support requests.
ESRI User Conference to be held in Saskatoon
ESRI, the makers of the ArcGIS software, is holding their user conference in Saskatoon on the 16th of September. There are early bird rates available until September 5. Details are available on the conference web site.
Attendees normally pay ~$150. However, the fee for educators/students is $35, which includes a hot lunch and reception. Please note that a valid U of S ID is required to qualify for the reduced rate.
If you are available to present your work (e.g., posters) to the GIS community, please contact André Piasta at email@example.com
After you click "Register Now" on the conference site, on the registration page you can select Educator/Student as "attendee type" which should trigger the reduced rate.
Should you have any questions, please contact André Piasta at email@example.com.


text:
Powder on my chest,
from 2 Chainz – I Feel Good Lyrics on Genius
This is a reference to 'Zoom' by Lil Boosie.
The powder could be cocaine or baby powder (getting fresh after a shower).
To help improve the quality of the lyrics, visit 2 Chainz – I Feel Good Lyrics and leave a suggestion at the bottom of the page


text:
Perl: the Markov chain saw | |
PerlMonks |
Re^3: Cross-platform GUI for UNIX based scriptsby RichardK (Priest) |
on May 23, 2013 at 17:12 UTC ( #1034991=note: print w/ replies, xml ) | Need Help?? |
Yes, run the web app on the server where you want to service to run, then the users can point their browsers to its URL.
In Section
Seekers of Perl Wisdom


text:
commercial property for rent or lease in Nolan (TX), Industrial Space For Lease.
Nolan commercial real estate for lease, rent, and leased investments.
Find Nolan industrial buildings for lease, retail rentals, & Nolan shops. Locate a Nolan warehouse lease and any real estate for lease / investment, including industrial properties to rent and sale.
Most companies have a business plan which encompasses a companys real estate requirements. Nolan commercial lease options should be considered for the foreseeable future and as such business leaders should attempt to anticipate the future expansion, if any, of the business. Its worth considering that when presented with the initial lease this will represent the ideal situation for the landlord. If details are not addressed prior to signing then issues that may arise may lead to unforeseen difficulties in the future.
commercial space listings
Sylvester (Fisher), Novice (Coleman), Trent (Taylor), Roscoe (Nolan), Loraine (Mitchell), Iraan (Pecos), Fort Stockton, Imperial
in Nolan Texas (TX) (Nolan)


text:
Viral infections can be the trigger that initiates this auto-immune disease. As a result from the circumstance that some carbohydrates tend to be easier to become digested by enzymes in the digestive tract than the others, which some carbohydrates in foods will be more susceptible to digestion inside the stomach, this allows the need for a powerful index to measure the results on our blood glucose levels of food, in an endeavor to avert the effect of diabetes, any indications of diabetes, or diabetic symptoms requiring the necessity for a Glycemic index of Foods. The herb leaves are when combined other herbs described above to have good results. Today, insulin comes in oral or tablet form, that may be useful in dealing with all kinds of diabetes. The truth is, most food, causing all of the carbohydrates you consume, are broken down into its simplest structure, glucose.
This condition also known as AGE abbreviated includes coronary heart, vascular disease, blindness, kidney disease, retinopathy (blindness) and decrease of feeling within the hands along with the feet (peripheral neuropathy) among others. Eye Complications Diabetes might cause eye problems and may lead to blindness. Lifestyle plays an essential part in determining who gets diabetes. Macular edema or retinal thickening is a vital manifestation of NPDR and represents the leading cause of decreased vision in diabetics. To live normal life patient has to take insulin and take physical exercise and has healthy diet plan.
<img width=400 height=300 src="http://paleodiethouston.files.wordpress.com/2011/01/1_diabetes_sff4.jpg" />
Most of those factors relate to social occupational and diet programs. Foot and Skin Care - High blood sugar levels and decreased blood flow to the limbs may cause severe nerve damage and decrease of feeling. Allium seeds porridge ("Qian Jin Yi Fang"): Allium sub 10g fry, rice 50g, taking porridge for diabetic patients with impotence. Symptoms of Diabetes - The most common symptoms of diabetes include:excessive urination including frequent trips towards the bathroomincreased thirstincreased appetiteblurred visionunusual weight lossincreased fatigueirritability - Complications from Diabetes - Diabetes can lead to many disabling and life threatening complications. It is additionally the leading reason for new cases of blindness among adults 20-74 years old.
To determine one's blood sugar a test called Fasting Blood Glucose has being conducted. Generally those with diabetes desire to keep their blood pressure less than 130/80. Kudzu powder porridge ("Tai Ping Sheng Hui Fang"): Kudzu powder 30g, rice 50g, taking an overall of porridge. Type II results from the condition the place that the body does not properly use insulin. As much as possible, experts would advice proper medication and treatment to avoid certain unexpected complications throughout the human system.
But exercise makes your cells more receptive to insulin, making it easier for the hormone to complete its job. Patients will notice a slight loss and/or blur in vision. Presence of a advanced of insulin in the body can increase hunger, which is why some diabetic patients can start consuming more. It is brought on by hormones linked to pregnancy and a shortage of insulin. Sugar should be eaten within a meal, and it can be consumed inside forms of fruit pies, pudding, or frozen yogurt.
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text:
From $950 / week
Hide Property Details
- 3 bedrooms
- 2 bathrooms
- Sleeps 6
- House
Description from the manager
Tropical Daze
Lower Bay, Bequia
St. Vincent & The Grenadines
The ideal location
Tropical Daze is just a few foot steps away from the white, pristine sands of the stunning Lower Bay Beach. Privacy and shade is given to this lovely vacation base by the tall trees in the garden.
Living & Relaxing Space
The living room at Tropical Daze is a simple space, with sofas, TV and DVD player. There are also books, radio and CD player to entertain you. The kitchen is very well equipped, with oven and grill, fridge / freezer. Other amenities include toaster, coffee maker, blender and all cooking utensils are provided. There is a lovely dining area that accommodates ...Read more
Tropical Daze - Bequia
Lower Bay, Bequia, Saint Vincent and the Grenadines
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text:
Great Baby Gift!
My 1st Wood Block Wagon is a nice way to start an infant with Holgate wood toys. Six pastel colored smooth edged wood blocks fit into this 8" long wooden wagon. Sweet little Teddy Bears dance along the side of the wooden wagon, making an excellent addition to any child's room. Pastel colored blocks..
This item can be personalized!
Wood Wagon measures: 8-1/2" long x 4-1/4" wide x 3-1/2" high. Wood Blocks are 2-1/4" square x 1-1/8" thick.
Ages 9 months and up.


text:
Decimal Degrees: Latitude: 35.819285 Longitude: -82.1923425
Share your comments and photos of South Estatoe Church, a Church in Yancey County, NC
(Optional) Upload a photo taken at this location:
Cemetery: Autrey Cemetery , Carroway Cemetery , Robinson Cemetery , Patton Cemetery , Robinson Cemetery
Church: South Estatoe Church
Civil: Township of South Toe
Populated Place: Celo , Hamrick
Ridge: Clear Creek Ridge
Stream: Roaring Spout Branch , Locust Creek , Shuford Creek
13 Places found nearby
New! Tell others about this location or share a photo!
Time to build: 0.1090 Secs | Cached: 02-Mar-15 08:07 PM


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Carbonates in Slovenia
Carbonates in Slovenia
Published: April 2014
Publisher: Euromonitor International
Product ref: 206569
Pages: 29
Format: PDF
Delivery: Immediate download
Together with rising health awareness, increased price sensitivity among Slovenian consumers amidst worsening economic conditions continued to depress demand for carbonates in 2013. The decline in total carbonates volume sales was markedly slower than that recorded in 2012, however, and also well below the average rate of decline for the entire review period. Similarly, after declining in 2012, total current value sales grew by 1% in 2013. This modest improvement was partly due to more frequent...
Euromonitor International's Carbonates in Slovenia report offers a comprehensive guide to the size and shape of the market at a national level. It provides the latest retail sales data (2009-2013), allowing you to identify the sectors driving growth. It identifies the leading companies, the leading brands and offers strategic analysis of key factors influencing the market – be they legislative, distribution, packaging or pricing issues. Forecasts to 2018 illustrate how the market is set to change.
Product coverage: Cola Carbonates, Non-Cola Carbonates.
Data coverage: market sizes (historic and forecasts), company shares, brand shares and distribution data.
Why buy this report?
- Get a detailed picture of the Carbonates market;
- Pinpoint growth sectors and identify factors driving change;
- Understand the competitive environment, the market's major players and leading brands;
- Use five-year forecasts to assess how the market is predicted to develop.
Euromonitor International has over 40 years' experience of publishing market research reports, business reference books and online information systems. With offices in London, Chicago, Singapore, Shanghai, Vilnius, Dubai, Cape Town, Santiago, Sydney, Tokyo and Bangalore and a network of over 800 analysts worldwide, Euromonitor International has a unique capability to develop reliable information resources to help drive informed strategic planning.
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Five portion grill 19180
Item No.3250030799
This 19180 grill from George Foreman cooks up to five portions and has a floating hinge for when extra headroom is required. The ready to cook indicator light is perfect for getting the right temperature, while the plates channel the fat and grease into a separate drip tray, for easy cleaning.
This item is available for
UK Home Delivery Free (UK orders over £30) or £3.99
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Full Delivery details
- Model: 19180
- Cooks up to 5 portions
- Grill channels fat and grease in to separate drip tray
- Non-stick finish on grill plates
- Extended chrome handle for ease of use
- Floating hinge enables cooking of extra thick food
- Ready to cook indicator light
- Drip tray included
- Up to a 3 year guarantee (when you register your product online)
- Metallic red with Chrome handle
- Weight: 2.468 kg
- HWD: 13.2 x 33 x 32.5 cm


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Mazda BT-50 aftermarket performance upgrade kit. Turn your utility into a mini sports truck with power to burn and superior economy.
- MB Diesel Cool Tubes Intercooler systems are fully manufactured in Australia to the highest standards.
- K&N performance Cotton air filter. K & N filters offer superior flow over standard elements, excellent dust and debris retention, fully serviceable for the life of the engine.
-Unichip Programable Engine Management System. Fully adjustable depending on modifications made to the vehicle. Not just a 'fuel chip', the Unichip can control Injection Timing, Injection Quantity, Boost Level and Torque limiting valves all the while reading sensors such as water temperature, air temperature, engine speed and engine load to allow the most accurate tuning possible on a diesel common rail engine.
What does this mean for you? Simply put ,Better economy, safer power and a piece of mind that your investment is well protected.
- MB Diesel 2.5″ Torque Tubes, Mandrel bent performance exhaust system including metallic catalytic converter. Get that sweet note, improved performance with no drone.
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Oct. 24 Premarket Briefing: 10 Things You Should Know
NEW YORK (TheStreet) -- Here are 10 things you should know for Thursday, Oct. 24:
1.-- U.S. stock futures were rising Thursday following a report that said manufacturing in China rose to a seven-month high in October.
European stocks were trading higher. Asian shares ended Thursday's session mostly lower but Japan's Nikkei 225 index bucked the trend and rose 0.4%.
2.-- The economic calendar in the U.S. Thursday includes weekly initial jobless claims at 8:30 a.m. EDT, the trade balance for August at 8:30 a.m., and new-home sales for September at 10 a.m.
3.--U.S. stocks closed lower Wednesday as Caterpillar (CAT), the construction and mining equipment leader, posted earnings that fell short of expectations and China, the world's second-largest economy, revealed a spate of bad business loans.
4.-- Amazon.com (AMZN - Get Report), the world's largest online retailer, is expected by analysts after Thursday's closing bell to report a third-quarter loss of 9 cents a share on revenue of $16.76 billion.
Amazon posted a year-earlier loss of $274 million, or 60 cents a share, which included a loss of 37 cents related to its investment in LivingSocial.
5.-- AT&T's
(T - Get Report) third-quarter earnings topped Wall Street earnings estimates, aided by the strength in smartphone sales.
AT&T earned 66 cents a share on revenue of $32.16 billion, excluding gains from spectrum sales. Analysts were expecting profit of 65 cents a share on sales of $32.19 billion.
McKesson signed an agreement Thursday with German company Haniel to acquire its 50.01% stake in Celesio and is making an offer to other shareholders at 23 euros a share. The offer represents a 5.8% premium to Celesio's closing share price on Wednesday. Celesio of Stuttgart, Germany, has about 38,000 employees, operates in 14 countries, runs 2,200 pharmacies and posted revenue of 22.3 billion euros (about $29.5 billion) in 2012. 10.-- The Boston Red Sox topped the St. Louis Cardinals, 8-1, in the first game of the World Series. Game 2 is Thursday night. -- Written by Joseph Woelfel To contact the writer of this article, click here:Joseph Woelfel To submit a news tip, send an email to:firstname.lastname@example.com.
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We saw a lot of action in the document management world recently, with Facebook closing the door on its much ignored email service, a rebranded Web Apps from Microsoft and a new Service Pack released by AvePoint aimed at improving data governance. Accusoft kept busy with the upgrade of its Prizm document viewer, while WatchDox offered a free document editor to its users.
Facebook Quashes Email
It's been a busy couple of weeks for Facebook. With all the hoopla around the WhatsApp acquisition and the difficulties people have had getting their head around the amount of money involved, most haven't been paying much attention to any of the other announcements from Facebook. One of those involved the end of its @facebook.com email service.
The announcement, which should have landed in the mail box of those that actually used the system, explained that after three years it is finally calling it a day on the service.
If the announcement only started filtering out onto the web very slowly, it's only because the service didn't have a huge number of users and, according to the announcement, Facebook wants to enable its account holders to keep all their mails in one place.
What will happen in the future is that emails sent to email@example.com addressees will, moving forward, be sent to the OTHER address you provided when first setting up a Facebook account.
It could be, though, that trying to make a buck out of WhatsApp and developing its email service at the same time was just one social bridge too far. Facebook also told users that it is giving up the service to focus on improving mobile messaging services for everyone.
The @facebook.com address never gathered any traction — I can't ever remember having received an email from a facebook.com address — and if its launch was met with a lukewarm response initially three years ago, that was soon replaced by pure loathing after Facebook judiciously decided in 2012 to replace default email addresses listed on users' profiles with @facebook.com.
That was a step too far for most and the reaction forced it to change its policy soon afterwards. The aftermath is that now it has been suppressed completely and will never come back to haunt users again. Did we say never?! Never is a very long time, so lets just say goodbye for now.
Microsoft, Google Slug it Out
Another big announcement over the past couple of weeks came from Microsoft and the rebranding of its Web Apps under the global banner of Office.com.
Realistically, there wasn't a huge amount of IT meat to chew on here, but according to a blog post from Microsoft, many people were confused about the apps, what they are, and where they can be found. Microsoft has resolved it all by placing everything in Office.com.
That this makes it easier to use these apps, and offers an easy-to-use alternative to Google Drive was missed by few, especially given that two have been beating each over the head with their respective productivity offerings for years as they vie for market dominance. Will it work? Who can say, but if you're interested in more check it out here.
AvePoint's New Service Pack
Meanwhile, AvePoint has also been busy on issues of compliance and information governance with the release of AvePoint Compliance Guardian Service Pack (SP) 2.
The new Service Pack not only protects and governs enterprise's information, it also makes information available to the people that need it when they need it.
With it, enterprises can put into effect comprehensive risk management policies, document them and implement measures to ensure they conform to whatever security regimes that are in force in a given enterprise.
While we are familiar with AvePoint's compliance products and features, this one is also offering support for social platforms, cloud computing, improved incident tracking and management, as well as additional features like encryption and redaction in order to help organizations proactively protect IT environments.
In fact, there is a whole pile of new features and enhancements with this release, which we can't cover here, but the bottom line is secured, discoverable and agile information use, wherever that information is located.
Continue reading this article:
- Microsoft Leaks Offer a Glimpse of SharePoint 2016
view comments - Discussion Point: Who Has the Best Digital Marketing Hub?
view comments - 5 Predictions About Marketing Technology
view comments - 10 Collaboration Trends for 2015
view comments - 8 Tech Trends You Need To Know
view comments - Why You Should Be Worried (and Angry) About Lenovo
view comments - Keeping SharePoint In Check with Information Governance
view comments


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Quality Inn & Suites Near Fairgrounds Casino 10007 Princess Palm Avenue Tampa, FL 33619 Phone: (813) 622-8557 Fax: (888) 519-3178 |
»Downtown Ybor City
Tampa's Ybor City, began its intriguing history when cigar makers settled here after a disastrous fire that drove the industry north from Key West. Today it is a National Historic Landmark District lined with old buildings and historic sites. Today's Ybor is a lively and popular shopping, dining and entertainment district featuring everything from museums to flamenco dancing and of course, plenty of cigars. The area really comes alive when the sun sets with a bevy of nightlife options. Do not miss the annual Halloween Parade, known as the Mama Guava Stumble or Guava-ween!
»Adventure Island
Located right across the street from Busch Gardens Tampa Bay, Adventure Island's 30 acres of water-drenched fun in the sun features the ultimate combination of high-speed thrills and tropical, tranquil surroundings for guests of all ages. Within a soothing Key West atmosphere await slides, corkscrews, water falls, a wave pool, children's water playground and other family attractions.
»Trout Creek Park
Open daily from sunrise to sunset, Trout Creek Park is the perfect place for a relaxing stroll by the river, leisurely jog throughout the park, or a group picnic. Trout Creek has numerous picnic tables located along the trail with convenient access to parking. For larger groups, there are several pavilions equipped with electricity and grills. The park is popular with local residents for canoeing, boating, and fishing excursions on the Hillsborough River. Within the park, visitors have access to easy hiking trails, primitive trails, and off-road cycling trails. The park is pet friendly and equipped with water fountains, restroom facilities, pay phone. - Vickie Ferguson
»Busch Gardens
At Busch Gardens, animals roam free and you are the outsider. You can see the park by monorail, cable car or train. Roller coasters, wild animals, entertaining shows, rides, food, shopping, sightseeing, bird shows, exotic flowers, train rides, Serengeti adventures, river rapids...the list goes merrily on. Wear comfy walking shoes and spend the day at this 300-acre park. You can even taste the Anheuser Busch brew that started it all. Busch Gardens is open year-round with varying schedules. Call or see website for details.
»Statue of Roland Manteiga
The Roland Manteiga statue is the statue of an editor of the La Gaceta weekly newspaper that was the only trilingual newspaper in the U.S. started by his father. This statue stands as a replica of Roland Manteiga reading his own newspaper on the streets of Tampa. The statue is a great attraction to the tourists as well as locals that speaks of a lot of stories about Roland and his father. One can surely visit this statue and gain knowledge about the history of the trilingual newspaper as well click some pictures while one stands along with the statue.
Created as the ultimate entertainment destination for people of all ages, this unique venue combines the best games, attractions, music, video, and technology in a dynamic environment. The Jax Grill and the HopScotch Lounge are on site for a complete entertainment experience, as well as over 180 games for all ages.
»Lettuce Lake Park
A hub for outdoor activities, this Tampa park offers visitors the opportunity to hike, fish, kayak, and more. The little ones can let loose on the playground structure and the picnic tables and barbecue's are perfect for a summer gathering. A nature center informs visitors on the local flora and fauna along with the extensive hiking trail information.
»Busch Gardens Adventure Park
The ultimate family adventure park, this amusement park offers an array of fascinating attractions based on exotic encounters with the African continent including a unique blend of thrilling rides, one of the country's premier zoos complete with over 2,700 animals, live shows, restaurants, shops, and interactive games.
»The Florida Aquarium
The Florida Aquarium gives visitors an all-access pass to the mysteries of the deep. Observe seahorses, lobsters, colorful fish, moray eels, gators, river otters, Australian sea dragons and many more. If you're feeling truly adventurous, take advantage of the "Swim with the Fishes" or "Dive with the Sharks" programs (advance reservations required). Kids will love the wide range of colorful and fun-filled interactive displays. The aquarium also sponsors ecotours aboard a 64-foot catamaran, affording patrons an opportunity to get even more up-close-and-personal with the sea. See website for complete list of attractions, calendar of events and more.
»Morris Bridge Park
Morris Bridge Park, located near the University of South Florida, provides 106 acres of native Florida landscaping along the Hillsborough River. The park is a thriving ecosystem of wetlands, forest, and swamp, giving hikers, bicyclists, joggers and nature lovers an intriguing respite for relaxation. The park provides a boat dock and ramp, canoe launch area, fishing docks, covered shelters and restroom facilities. Anglers have the option of fishing from a boardwalk or along primitive trails. Several trails meander throughout the park and take hikers past scenic cypress trees, picnic areas and pavilions. Morris Bridge Park is open 365 days a year from sunrise to sunset.
»Yacht StarShip Dining Cruises
The StarShip Yacht provides two-hour dining cruises along with 4-star menu selections prepared daily by the ship's chef. Enjoy the Sunday Brunch Buffet Cruise featuring breakfast and lunch selections or the Lunch Cruise, which offers a 3-course meal including appetizer, entree and dessert. While cruising the waters of Tampa Bay, a narration of historical points of interest is provided on both cruises. For an evening of fun, the Dinner Cruise offers a 3-course meal, live music, bar and dancing under the moonlight. Throughout the year, special cruises have been scheduled for holidays and special events. Reservations required. Price: Brunch and Lunch Adults: $44.95 Child: $31.95 Dinner Adults: $79.95 Child: $44.95
»Tampa Bay Lightning
When the Lightning began playing hockey in Tampa in 1992, quite a few residents were baffled by this fast, exciting sport. Since then, the Bolts have become one of Tampa's most popular past times with a state-of-the-art home at the Ice Palace. Games can get rowdy, as snowbirds try to cheer their home teams louder than the hometown fans. Games are usually in the evenings, but some afternoon games are scheduled on weekends and holidays. Tickets range in price from swank luxury box seats to nosebleeds.


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Why it's every wife's duty to make other men fancy her: Angela Epstein's provocative take on married life
Standing in front of the bedroom mirror, I give my reflection one last appreciative glance. I've got a night out with some female colleagues at a swanky new bar, and I'm determined to look my very best.
Arrogant as it may sound, I'm happy with what I see: freshly blow-dried hair, carefully applied lipstick, a pair of leg-stretching killer heels and a dress that manages to be both sexy and elegant.
All that's needed is a final spritz of perfume — just enough to entice, not too much to overpower — and I grab my clutch and keys and head for the door.
Glamorous: Angela Epstein likes to make the effort to look good for her husband, Martin
Tonight, I want to attract a man. Not because I'm some predatory divorcee out to bag a scalp, nor because I'm a mistress-in-waiting looking for a little extra-curricular activity.
No, I am a happily married woman, with no interest in any man other than my lovely husband of 20 years, Martin, the father of our four children.
But that doesn't stop me from making sure that whenever I'm 'on show', be it at a social event with Martin, a work engagement or — in the case of tonight — out with a few girlfriends, I dress in a way that will attract male attention.
A recipe for trouble? I don't think so. It's critical for a married woman, however happy she is, to make herself desirable to other men.
And before all those sour-faced, school-run mums with their hands up a chicken or their elbows in a twin tub start hurling their curlers at me, let me explain.
Some women dress to impress other women — so they'll pass the brutal, look-you-up-and-down appraisal routine practised by all judgemental ladies.
But I'm not interested in what other women think. Men are the barometer by which my attractiveness to my husband can be measured, ensuring I never take his interest in me for granted.
It's easy, after years of marriage, to assume your husband will fancy you no matter how you look. And at the end of a busy day, with four children to take care of, it can take a lot of effort to — well — make an effort.
Improvement: If men notice, your husband is likely to remember how much he fancied you in the first place
Unsexy: A stressed, scruffy woman with messy hair and a baggy shirt is not the stuff of male dreams
Bad habits set in... not bothering with make-up when you both go to the cinema (who's going to notice your sallow complexion in the dark?)... ditching your contact lenses for your pebble-thick glasses if it's just a quick supper at the local gastropub...
I see married women all the time in their ugly shoes or with their badly concealed baby weight, tagging alongside an uninterested spouse.
These women are, I'm afraid, inviting their man to stray. For, reprehensible as it is for any man to cheat, a woman who no longer values her own sexiness is compounding any potential weakness on her husband's part.
The way to keep him interested is to make him insecure — show him that other men are interested in you, so he'd better value what he's got.
I realise that mine isn't a popular view. The other evening, I went for a drink with a female work friend. I was in tight-fitting jeans, full make-up and high heels; her notion of dressing up was to take off her apron.
I explained my theory, only for her to snarl: 'If my husband's seen me give birth, he can cope with me in an old top and jeans.'
But that's precisely the point. Your spouse remembers only too well watching his beautiful bride transformed into an enormous, foul-mouthed harpy on the delivery table.
He knows how you look in the morning with last night's make-up landsliding down your face and hair matted like the bottom of a cat basket.
If that's all you ever show him, it's simply inevitable that he'll take you for granted. Sure, he may love you — but when you stop showing him your desirable side, his attraction to you will become as tired and routine as the weekend shop.
Romance: Making the most of yourself makes you feel better and keeps your marriage in good shape
Beware: Scruffy women are more likely to fall prey to cheating husbands says Angela
That's why you have to remind him that other men find you sexy — otherwise you dent his delicate male ego by suggesting he's not worth scrubbing up for.
Remember, if he married you, he must have fancied you (once). I'm a hard-working, multi-tasking, mother-of-four battling encroaching age and fatigue. I would describe my looks — without some clever M&S upholstery and a load of cosmetics — as utterly ordinary. But that just makes me work even harder.
My husband is, at best, bemused by my theory. The other night, as I was wiggling up and down the bedroom in a clingy cream frock and fretting over which heels to team it with before we headed out to a charity do together, he commented: 'Does it really matter? Who really cares, apart from me?'
Ah, but at the function, when one of the male organisers told me I looked 'rather hot', he bristled and threw a proprietorial arm around my shoulder. Hurrah! Result!
Working hard so other men notice you triggers a Neanderthal response in your man. It takes him back to those bygone days when males, high on pheromones, would prowl round for potential mates.
Nothing is more guaranteed to drag him away from checking football scores at a party and place him firmly back by your side than the appreciative glance of a lusty competitor.
And the greater the status of the man who notices you, the greater the impact on your other half. It will reinforce his pride in the fact that you are his.
It works the other way, too. Nothing reignites my interest in my husband more than the flutter of another woman's eyelashes in his direction.
I buy him beautiful clothes for his birthday, even though they might court the sort of female attention that I know raises my hackles. It's all part of keeping the spark alive.
Does it get me into trouble? Occasionally, yes. There will always be men for whom a reasonably-presented woman will seem fair game.
This is why turning heads has to be done with a restrained hand. Men are simplistic about smoke signals.
If you're heavy handed with the hair-flicking, pouting and skirt-hitching they automatically assume this is semaphore for 'there's a Travelodge around the corner'. When I sense there is any danger of that, I can't get back to my lovely man fast enough.
Ultimately, I still fancy my husband and want to do everything I can to ensure he still fancies me too.
But even if he put a ring on my finger, it doesn't hurt to keep him on his toes too.
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Dizzy Over Decimals: Multiplication #3
This math practice sheet is chock-full of decimal multiplication problems that are guaranteed to help your child get more comfortable with his schoolwork. The more he works on these tricky problems, the easier they'll get.
If he still needs a little more practice, don't forget to check out the rest of the series here.
Common Core:
Updated on Aug 16, 2010
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