text:
Acute and chronic pain affects large numbers of Americans, with approximately 100 million2 U.S. adults burdened by chronic pain alone. The annual national economic cost associated with chronic pain is estimated to be $560-635 billion. Pain is a uniquely individual and subjective experience that depends on a variety of biological, psychological, and social factors, and different population groups experience pain differentially. For many patients, treatment of pain is inadequate not just because of uncertain diagnoses and societal stigma, but also because of shortcomings in the availability of effective treatments and inadequate patient and clinician knowledge about the best ways to manage pain. Some answers will come from exciting new research opportunities, but changes in the care system also will be needed in order for patients' pain journeys to be shorter and more successful. In the committee's view, addressing the nation's enormous burden of pain will require a cultural transformation in the way pain is understood, assessed, and treated. This report provides recommendations intended to help achieve this transformation.
1This summary does not include references. Citations for the discussion presented in the summary appear in the subsequent report chapters.
2 Because of a computational error, the initial publication of the report Relieving Pain in America contained an erroneous estimate of the number of adults who experience chronic pain in the United States. A re-analysis of the study by Tsang and colleagues (2008), as well as the independent assessment by Gaskins and Richards (Appendix C), yield an estimate of approximately 100 million U.S. adults who experience chronic pain and not 116 million as stated in the original report. The text of the report has been revised to show this corrected estimate.
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Acute and chronic pain affects large numbers of Americans, with ap-
proximately 100 million2 U.S. adults burdened by chronic pain alone. The
annual national economic cost associated with chronic pain is estimated
to be $560-635 billion. Pain is a uniquely individual and subjective expe-
rience that depends on a variety of biological, psychological, and social
factors, and different population groups experience pain differentially. For
many patients, treatment of pain is inadequate not just because of uncertain
diagnoses and societal stigma, but also because of shortcomings in the
availability of effective treatments and inadequate patient and clinician
knowledge about the best ways to manage pain. Some answers will come
from exciting new research opportunities, but changes in the care system
also will be needed in order for patients' pain journeys to be shorter and
more successful. In the committee's view, addressing the nation's enormous
burden of pain will require a cultural transformation in the way pain is
understood, assessed, and treated. This report provides recommendations
intended to help achieve this transformation.
1This summary does not include references. Citations for the discussion presented in the summary
appear in the subsequent report chapters.
2 Because of a computational error, the initial publication of the report Relieving Pain in America
contained an erroneous estimate of the number of adults who experience chronic pain in the United
States. A re-analysis of the study by Tsang and colleagues (2008), as well as the independent assess -
ment by Gaskins and Richards (Appendix C), yield an estimate of approximately 100 million U.S.
adults who experience chronic pain and not 116 million as stated in the original report. The text of
the report has been revised to show this corrected estimate.
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Pain is a universal experience. Common chronic pain conditions affect ap-
proximately 100 million U.S. adults at a cost of $560-635 billion annually in
direct medical treatment costs and lost productivity. Pain's occurrence, severity,
duration, response to treatment, and disabling consequences vary from person to
person because pain, like other severe chronic conditions, is much more than a
biological phenomenon and has profound emotional and cognitive effects. Pain
can be mild and easily handled with over-the-counter medications; it can be acute
and recede with treatment; it can be recurrent over months or years; or it can be
chronic and debilitating, requiring almost constant attention and accommodation.
Many shortfalls in pain assessment and treatment persist despite humanity's
intimate familiarity with pain throughout history, modern appreciation for the
complexity of its origins and the diversity of its effects, and the not insubstantial
risk that any one person may have serious or chronic pain at some point. In gen -
eral, these shortfalls arise through gaps in policy, treatment, attitudes, education,
and research. Why and how these gaps might be remedied was the focus of the
Institute of Medicine's (IOM's) Committee on Advancing Pain Research, Care,
and Education.
Section 4305 of the 2010 Patient Protection and Affordable Care Act required
the Secretary, Department of Health and Human Services (HHS), to enter into
an agreement with the IOM for activities "to increase the recognition of pain
as a significant public health problem in the United States." Accordingly, HHS,
through the National Institutes of Health (NIH), requested that the IOM conduct
a study to assess the state of the science regarding pain research, care, and edu -
cation and to make recommendations to advance the field (see Chapter 1 for the
committee's statement of task).
This report responds to the committee's charge by providing a blueprint
for transforming the way pain is understood, assessed, treated, and prevented. It
provides recommendations for improving the care of people who experience pain,
the training of clinicians who treat them, and the collection of data on pain in the
United States. The report does not provide an exhaustive review of the literature
examining the science of pain and its diagnosis and treatment. Nor does the report
present a clinical algorithm for the diagnosis and treatment of patients with pain.
Rather, it describes the scope of the problem of pain and provides an overview of
needs for care, education, and research. The committee's recommendations are
based on both scientific evidence and expert judgment.
Several important underlying principles informed the committee's approach
to its charge. These principles are presented in Box S-1.
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Underlying Principles
• moral imperative. Effective pain management is a moral imperative, a
professional responsibility, and the duty of people in the healing professions.
• hronic pain can be a disease in itself. Chronic pain has a distinct pathology,
causing changes throughout the nervous system that often worsen over time.
It has significant psychological and cognitive correlates and can constitute a
serious, separate disease entity.
• alue of comprehensive treatment. Pain results from a combination of bio-
logical, psychological, and social factors and often requires comprehensive
approaches to prevention and management.
• eed for interdisciplinary approaches. Given chronic pain's diverse effects,
interdisciplinary assessment and treatment may produce the best results for
people with the most severe and persistent pain problems.
• mportance of prevention. Chronic pain has such severe impacts on all
aspects of the lives of its sufferers that every effort should be made to achieve
both primary prevention (e.g., in surgery for a broken hip) and secondary
prevention (of the transition from the acute to the chronic state) through early
• ider use of existing knowledge. While there is much more to be learned
about pain and its treatment, even existing knowledge is not always used
effectively, and thus substantial numbers of people suffer unnecessarily.
• he conundrum of opioids. The committee recognizes the serious problem
of diversion and abuse of opioid drugs, as well as questions about their long-
term usefulness. However, the committee believes that when opioids are used
as prescribed and appropriately monitored, they can be safe and effective,
especially for acute, postoperative, and procedural pain, as well as for patients
near the end of life who desire more pain relief.
• oles for patients and clinicians. The effectiveness of pain treatments de-
pends greatly on the strength of the clinician–patient relationship; pain treat-
ment is never about the clinician's intervention alone, but about the clinician
and patient (and family) working together.
• alue of a public health and community-based approach. Many features
of the problem of pain lend themselves to public health approaches—concern
about the large number of people affected, disparities in occurrence and treat-
ment, and the goal of prevention cited above. Public health education can help
counter the myths, misunderstandings, stereotypes, and stigma that hinder
better care.
Pain serves a vital function as a warning sign of injury or infection, but once
its warning role is over, continued pain is maladaptive. Chronic pain results in
many changes in the peripheral and central nervous systems that aid in its per-
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sistence. Because of those physiological changes, some types of chronic pain are
diseases in their own right.
All people are at risk of chronic pain. It can come about with age (e.g.,
arthritis), from genetic predisposition (e.g., migraine), as a component of another
chronic disease (e.g., cancer, heart disease), as a result of surgery (e.g., severed
nerves), or following an injury (e.g., low back pain, neck pain). Pain is a uniquely
individual, subjective experience. Why one person suffers an injury and reports
modest pain and another with a similar injury reports serious pain depends on
many factors: genetic characteristics, general health status and comorbidities,
pain experiences from childhood on, the brain's processing system, the emotional
and cognitive context in which pain occurs, and cultural and social factors.
Because pain often produces psychological and cognitive effects—anxiety,
depression, and anger among them—interdisciplinary, biopsychosocial ap-
proaches are the most promising for treating patients with persistent pain. But
for most patients (and clinicians), such care is a difficult-to-attain ideal, impeded
by numerous structural barriers—institutional, educational, organizational, and
reimbursement-related. Costly procedures often are performed when other actions
should be considered, such as prevention, counseling, and facilitation of self-care,
which are common features of successful treatment. In addition, adequate pain
treatment and follow-up may be thwarted by a mix of uncertain diagnosis and
societal stigma consciously or unconsciously applied to people reporting pain,
particularly when they do not respond readily to treatment.
In the committee's view, remediating the mismatch between current knowl-
edge and its application will require a cultural transformation in the way clinicians
and the public view pain and its treatment. Understanding chronic pain as a disease
means that it requires direct treatment, rather than being sidelined while clinicians
attempt to identify some underlying condition that may have caused it. It also
means that health professions education programs should include a substantial
amount of learning about pain and its diversity, and that people with chronic pain
should be recognized by family, employers, health insurers, and others as having
a serious condition. It means that people with chronic pain have an important role
to play in managing their disease in an informed, productive way. And finally, it
means that the biomedical research community should pursue pain research with
the same vigor expended on other serious and disabling chronic conditions.
The findings and recommendations presented in this report revolve around
a single conclusion:
Chronic pain alone affects the lives of approximately 100 million Americans,
making its control of enormous value to individuals and society. To reduce the
impact of pain and the resultant suffering will require a transformation in how
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pain is perceived and judged both by people with pain and by the health care
providers who help care for them. The overarching goal of this transformation
should be gaining a better understanding of pain of all types and improving ef -
forts to prevent, assess, and treat pain.
The committee's recommendations and the findings that support them fall
into four areas that serve to structure the main chapters of the report: pain as
a public health challenge, care of people with pain, education challenges, and
research challenges.3
Pain as a Public Health Challenge
Pain affects millions of Americans; contributes greatly to national rates of
morbidity, mortality, and disability; and is rising in prevalence. Substantial dis -
parities exist in the prevalence, seriousness, and adequate treatment of pain that
affect the vulnerable populations of traditional public health concern. Pain exacts
enormous costs both economically and in the toll it takes on people's lives. Analy-
sis performed for the committee revealed that the annual economic cost of chronic
pain in the United States is at least4 $560-635 billion. This estimate combines the
incremental cost of health care ($261-300 billion) and the cost of lost productivity
($297-336 billion) attributable to pain. The federal Medicare program bears fully
one-fourth of U.S. medical expenditures for pain; in 2008, this amounted to at
least $65.3 billion, or 14 percent of all Medicare costs. In total, federal and state
programs—including Medicare, Medicaid, the Department of Veterans Affairs,
TRICARE, workers' compensation, and others—paid out $99 billion in 2008 in
medical expenditures attributable to pain. Lost tax revenues due to productivity
losses compound that expense.
Finding 2-1. Pain is a public health problem. Pain is a significant public health
problem. Chronic pain alone affects approximately 100 million U.S. adults.
Pain reduces quality of life, affects specific population groups disparately, costs
society at least $560-635 billion annually (an amount equal to about $2,000 for
everyone living in the United States), and can be appropriately addressed through
population health-level interventions.
3 The findings and recommendations are numbered according to the chapter of the report in which
they appear. Thus, for example, recommendation 2-1 is the first recommendation in Chapter 2. Note
that some of the findings and recommendations are presented here in abbreviated form. The full ver-
sions are included in the respective chapters.
4 The $560-635 billion range is a conservative estimate because it excludes the cost of pain affecting
institutionalized individuals (including nursing home residents and corrections inmates), military
personnel, children under age 18, and personal caregivers (such as spouses who miss work while
caring for people with pain), as well as the lost productivity of workers younger than 24 and older
than 65. The estimate also excludes the emotional cost of pain.
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Finding 2-2. More consistent data on pain are needed. While it is known
that pain affects millions of Americans, the committee acknowledges the lack
of consistent data with which to describe the nature and extent of the problem
or to identify subpopulations that will benefit most from future interventions.
Improvements in state and national data are needed to (1) monitor changes in the
incidence and prevalence of acute and chronic pain; (2) document rates of treat -
ment or undertreatment of pain; (3) assess the health and societal consequences
of pain; and (4) evaluate the impact of related changes in public policy, pay -
ment, and care. Pain data need to be based on standardized questions, preferably
using existing international standards, to facilitate comparisons over time and
across populations. These data would be useful for a wide range of stakeholders,
including policy makers, health care providers, health professions educators,
professional licensing authorities, pain advocacy and awareness organizations,
and researchers.
Recommendation 2-1. Improve the collection and reporting of data
on pain. The National Center for Health Statistics, the Agency for Health-
care Research and Quality, other federal and state agencies, and private
organizations should improve and accelerate the collection and reporting
of data on pain. Data should be collected in the following domains:
• t
he incidence and prevalence of pain;
• i
nterference with activities of daily living and work, as well as dis-
ability, related to pain;
• u
tilization of clinical and social services as a result of pain;
• c
osts of pain and pain care, including indirect costs of lost employ-
ment and public- and private-sector costs for disability payments;
• t
he effectiveness of treatment in reducing pain and pain-related
disability, determined through research on the comparative effec-
tiveness of alternative treatments (including in different patient
populations), to identify people most likely to benefit (or not) from
specific treatment approaches.
Standardized questions, fields, and protocols for surveys and electronic
health records should be developed, and pain-related data should be col-
lected at regular intervals.
Finding 2-3. A population-based strategy for reducing pain and its conse -
quences is needed. The committee finds that, to effect changes that will reach
the millions of American adults living with pain, account for differences in the
experience of pain among population groups, and address selected environmental
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factors that contribute to the consequences of pain, a population health-level
strategy is needed.
Recommendation 2-2. Create a comprehensive population health-
level strategy for pain prevention, treatment, management, and
research. The Secretary of the Department of Health and Human Ser-
vices should develop a comprehensive, population health-level strategy
for pain prevention, treatment, management, education, reimbursement,
and research that includes specific goals, actions, time frames, and re -
sources. This strategy should
escribe how efforts across government agencies, including public–
private partnerships, can be established, coordinated, and integrated
to encourage population-focused research, education, communica -
tion, and community-wide approaches that can help reduce pain and
its consequences and remediate disparities in the experience of pain
among subgroups of Americans.
nclude an agenda for developing physiological, clinical, behav-
ioral, psychological, outcomes, and health services research and
appropriate links across these domains (consistent with Recom -
mendations 5-1 through 5-4).
mprove pain assessment and management programs within the
service delivery and financing programs of the federal government.
roceed in cooperation with the Interagency Pain Research Coordi-
nating Committee and the National Institutes of Health's Pain Con -
sortium and reach out to private-sector participants as appropriate.
nvolve the relevant federal agencies and departments (National
Institutes of Health, Centers for Disease Control and Prevention,
Food and Drug Administration, Centers for Medicare and Medi-
caid Services, Agency for Healthcare Research and Quality, Health
Resources and Services Administration, Indian Health Service, De -
partment of Defense, and Department of Veterans Affairs); private-
sector entities (pain advocacy and awareness organizations; health
professions associations; health care providers; health professions
educators; private insurers; and accreditation, certification, and ex -
amination organizations); and state-level entities.
nclude ongoing efforts to enhance public awareness about the ature
of chronic pain and the role of self-care in its management.
The development of this strategy should be completed by the end of 2012.
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Care of People with Pain
Currently, large numbers of Americans receive inadequate pain prevention,
assessment, and treatment, in part because of financial incentives that work
against the provision of the best, most individualized care; unrealistic patient
expectations; and a lack of valid and objective pain assessment measures. Clini-
cians' role in chronic pain care is often a matter of guiding, coaching, and assist-
ing patients with day-to-day self-management, but many health professionals lack
training in how to perform this support role, and there is little reimbursement
for their doing so. Primary care is often the first stop for patients with pain, but
primary care is organized in ways that rarely allow clinicians time to perform
comprehensive patient assessments. Sometimes patients turn to, or are referred to,
pain specialists or pain clinics, although both of these are few in number. Unfortu-
nately, patients often are not told, or do not understand, that their journey to find
the best combination of treatments for them may be long and full of uncertainty.
Finding 3-1. Pain care must be tailored to each person's experience. Pain
management takes place through self-management, primary care, specialty care,
and pain centers. However, the majority of care and management should take
place through self-management and primary care, with specialty services being
focused on recalcitrant or more complex cases. Accordingly, individualization
of pain management is necessary throughout the health care system. Health care
providers need to foster pain care that is patient-centered and, when necessary,
comprehensive and interdisciplinary. Financing, referral, records management,
and other systems need to support this flexibility.
Recommendation 3-1. Promote and enable self-management of pain.
Health care provider organizations should take the lead in developing
educational approaches and materials for people with pain and their
families that promote and enable self-management. These materials
should include information about the nature of pain; ways to use self-
help strategies to prevent, cope with, and reduce pain; and the benefits,
risks, and costs of various pain management options. Approaches and
materials should be culturally and linguistically appropriate and avail -
able in both electronic and print form.
Finding 3-2. Significant barriers to adequate pain care exist. The committee
finds that multiple and significant barriers to pain care and management exist in
the primary care setting.
nhanced continuing education and training are needed for health care
professionals to address gaps in knowledge and competencies related to
pain assessment and management, cultural attitudes about pain, negative
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and ill-informed attitudes about people with pain, and stereotyping and
biases that contribute to disparities in pain care.
ther barriers include the magnitude of the pain problem, including its
extremely high prevalence, which makes effective action difficult on a
national scale; certain provider attitudes and training, which impede the
delivery of high-quality care; insurance coverage, because fully one-
third of all Americans are uninsured or underinsured; cultural attitudes
of patients, many of whom do not recognize the need to address pain
early on; and geographic barriers, which place residents of rural com -
munities at a disadvantage.
ystem and organizational barriers, many of them driven by current re-
imbursement policies, obstruct patient-centered care. Examples of these
barriers are minimal capacity for frequent visits when necessary; lim-
ited time for conduct of comprehensive assessments; inadequate patient
education initiatives; difficulties in accessing specialty care; and lack of
reimbursement for needed specialty care services, interdisciplinary prac-
tice, psychosocial and rehabilitative services, in-depth patient interviews
and education, and time spent planning and coordinating care.
comprehensive, strategic approach can succeed in addressing these
barriers and help close the gap between empirical evidence regarding
the efficacy of pain treatments and current practice.
egulatory, legal, educational, and cultural barriers inhibit the medically
appropriate use of opioid analgesics.
Recommendation 3-2. Develop strategies for reducing barriers to pain
care. The population health-level strategy referred to in Recommendation
2-2 should include identifying and developing comprehensive approaches
to overcoming existing barriers to pain care, especially for populations
that are disproportionately affected by and undertreated for pain. Strate-
gies also should focus on ways to improve pain care for these groups.
Recommendation 3-3. Provide educational opportunities in pain as-
sessment and treatment in primary care. Health professions education
and training programs, professional associations, and other groups that
sponsor continuing education for health professionals should develop
and provide educational opportunities for primary care practitioners and
other providers to improve their knowledge and skills in pain assessment
and treatment, including safe and effective opioid prescribing.
Recommendation 3-4. Support collaboration between pain specialists
and primary care clinicians, including referral to pain centers when
appropriate. Pain specialty professional organizations and primary care
professional associations should work together to support the collabora-
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tion of pain specialists with primary care practitioners and teams when
primary care providers have exhausted their expertise and the patient's
pain persists.
Recommendation 3-5. Revise reimbursement policies to foster coor-
dinated and evidence-based pain care. Payers and health care orga-
nizations should work to align payment incentives with evidence-based
assessment and treatment of pain. Optimal care of the patient should be
the focus.
Recommendation 3-6. Provide consistent and complete pain assess-
ments. Health care providers should provide pain assessments that are
consistent and complete and documented so that patients will receive the
right care at the right place and the right time.
Education Challenges
The optimal timing, content, and goals of patient education about pain vary
with individual circumstances. Fundamental to treatment is education regarding
self-management to minimize flare-ups, decrease day-to-day discomfort, and
maximize functioning. In addition, public education about pain can be highly
beneficial in promoting
• i
ndividual and community actions to prevent injuries,
• a
dvocacy for appropriate acute and chronic pain treatment, and
• s
upport for improved pain prevention and control policies.
Educational programs for the many types of health care professionals who
play a role in pain prevention and treatment—nurses, psychologists, physicians,
dentists, pharmacists, physical therapists, and complementary and alternative
medicine practitioners—vary in the amount and quality of information on pain
they contain. In medical education, pain generally has received little attention,
which has contributed to the problem of undertreatment. The need for improved
education about pain is especially acute for primary care providers—the front-
line clinicians for most people's acute or chronic pain problems.
Finding 4-1. Education is a central part of the necessary cultural transforma -
tion of the approach to pain. The committee finds that the federal government is
in a position to contribute to substantial improvements in patient and professional
education about pain.
Recommendation 4-1. Expand and redesign education programs
to transform the understanding of pain. Federal agencies and other
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relevant stakeholders should expand education programs to transform
patient and public understanding of pain. In concert with Recommenda-
tion 2-2, federal agencies, in partnership with health professions asso -
ciations, payers, pain advocacy and awareness organizations, and other
relevant stakeholders, should develop education programs for patients,
the public, and health care providers that are designed to promote a
transformation in their expectations, beliefs, and understanding about
pain, its consequences, its management, and its prevention.
Recommendation 4-2. Improve curriculum and education for health
care professionals. The Centers for Medicare and Medicaid Services,
the Health Resources and Services Administration, accrediting or-
ganizations, and undergraduate and graduate health professions train -
ing programs should improve pain education curricula for health care
Recommendation 4-3. Increase the number of health profession-
als with advanced expertise in pain care. Educational programs for
medical, dental, nursing, mental health, physical therapy, pharmacy, and
other health professionals who will participate in the delivery of pain
care should have increased capacity to train providers who can offer
advanced pain care.
Research Challenges
In recent years, biomedical research has made remarkable strides in under-
standing of the basic biological and psychological underpinnings of pain. A
principal current opportunity may be to use what has been learned across a broad
spectrum of fields—from genomic and cellular through behavioral mechanisms—
to develop innovative therapies that are simultaneously more targeted to the
individual and more comprehensive in meeting patient needs.
From a scientific standpoint, the future of pain research is exciting because
of advances in a number of relevant and diverse research fields and the devel-
opment of new research techniques. This excitement is tempered, however, by
knowledge that federal research dollars to address the problem of pain are in short
supply and likely to decrease. Pain is a topic of interest to virtually every NIH
institute and center, but not a central concern of any one of them. The committee
believes one of the existing NIH institutes should be designated the lead institute
for pain. The committee further believes that the NIH Pain Consortium needs to
take a stronger leadership role in effecting the necessary transformation in how
pain research is conducted by fostering coordination across institutes and centers,
by ensuring that study section decision making on pain proposals is improved,
and by exploring a range of potential public–private initiatives.
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Pain research should not be confined to NIH. As this report details, pain-
related research is needed across public health entities, involving, for example,
the Centers for Disease Control and Prevention's epidemiological and public
education expertise, the Agency for Healthcare Research and Quality's quality
improvement initiatives, the Health Resources and Services Administration's ex -
pertise in professional education and service delivery for vulnerable populations,
and the Centers for Medicare and Medicaid Services' research and demonstration
programs related to reimbursement policies.
Finding 5-1. Research to translate advances into effective therapies for pain is
a continuing need. The committee finds that significant advances have been made
in understanding the basic mechanisms of nociception and pain, leading to new
potential targets for future pain assessment and treatment strategies. Furthermore,
recent advances in the neurosciences, biomarkers, and the behavioral sciences have
validated a comprehensive approach to the management of pain that includes the
individual's inherent biology, behavior, and psychological makeup and reactions,
as well as environmental influences. However, data and knowledge gaps in pain
research remain that have prevented such research advances from being translated
into safe and effective therapies. Addressing these gaps will require a cultural
transformation in the view of and approach to pain research, involving basic,
translational, and clinical researchers; federal funding and regulatory agencies;
and private organizations. This cultural transformation is reflected in the following
Recommendation 5-1. Designate a lead institute at the National
Institutes of Health responsible for moving pain research forward,
and increase the support for and scope of the Pain Consortium.
The National Institutes of Health should designate a specific institute to
lead efforts in advancing pain research. At the same time, the National
Institutes of Health should increase financial resources and staffing
support for and broaden the scope of the Pain Consortium and engage
higher-level staff from the institutes and centers in the consortium's
efforts. The Pain Consortium should exert more proactive leadership in
effecting the necessary transformation in how pain research is conducted
and funded.
Recommendation 5-2. Improve the process for developing new agents
for pain control. Academia and industry should develop novel agents for
the control of pain. This does not mean simply recycling current drugs.
What is required is basic and clinical science research to discover new
classes of pain therapeutics and more efficient ways of developing them.
Also required is that regulatory agencies, especially the Food and Drug
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Administration, develop new and expeditious ways to evaluate and ap-
prove new pain therapies.
Recommendation 5-3. Increase support for interdisciplinary re-
search in pain. Federal agencies, such as the National Institutes of
Health, Agency for Healthcare Research and Quality, Centers for Dis -
ease Control and Prevention, Department of Defense, and Department
of Veterans Affairs, as well as private funders of pain research, should
increase support for interdisciplinary research and research training—
across agencies and professions—on pain-related diseases and the defi-
ciencies noted in Finding 5-1.
Recommendation 5-4. Increase the conduct of longitudinal research
in pain. Public and private funders should increase support for longitu-
dinal research in pain, including comparative effectiveness research and
novel randomized controlled trials, to help ensure that patients receive
care that works best in both the short and long terms.
Recommendation 5-5. Increase the training of pain researchers. With
the support of training grants from the National Institutes of Health,
academic institutions should increase the training of basic, translational,
behavioral, population, and clinical pain researchers. This training should
recognize the interdisciplinary benefits of research on pain and pain man-
agement. Agencies such as the National Center for Health Statistics, the
Agency for Healthcare Research and Quality, and the Centers for Medi-
care and Medicaid Services should support the training of researchers
interested in secondary analysis of pain-related data collected by these
With the goal of providing relief for pain in America, the committee
concludes this report by offering a blueprint for action toward transforming
prevention, care, education, and research (Chapter 6 and Table S-1 below).
This blueprint organizes the committee's recommendations into two categories.
Recommendations categorized as immediate are those the committee believes
should be initiated now and completed before the end of 2012. Recommenda -
tions categorized as near-term and enduring build on these immediate actions,
should be completed before the end of 2015, and should be maintained as on -
going efforts. The comprehensive population health-based strategy set forth in
Recommendation 2-2 should inform actions taken in response to, or consistent
with, all of the other recommendations.
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TABLE S-1a Blueprint for Transforming Pain Prevention, Care, Education,
and Research
IMMEDIATE: Start now and complete before the end of 2012
Recommendation Actors Key Elements of Recommendation
2-2. Create a Secretary of Health and Involve multiple federal, state, and
comprehensive Human Services (HHS) private-sector entities, such as the
population health- National Institutes of Health (NIH),
level strategy for Food and Drug Administration
pain prevention, (FDA), Centers for Disease Control
treatment, and Prevention (CDC), Agency for
management, and Healthcare Research and Quality
research (AHRQ), Health Resources and
Services Administration (HRSA),
Centers for Medicare and Medicaid
Services (CMS), Department of
Defense (DoD), Department of
Veterans Affairs (VA), outcomes
research community and other
researchers, credentialing organizations,
pain advocacy and awareness
organizations, health professions
associations (including pain specialty
professional organizations), private
insurers, health care providers,
state health departments, Medicaid
programs, and workers' compensation
3-2. Develop HHS Secretary, AHRQ, CMS, Key part of the strategy envisioned in
strategies for HRSA, Surgeon General, Recommendation 2-2
reducing barriers to Office of Minority Health,
pain care Indian Health Service, VA,
DoD, large health care
providers (e.g., accountable
care organizations)
3-4. Support CMS, VA, DoD, health care The pain specialist role includes
collaboration between providers, pain specialists, serving as a resource for primary care
pain specialists pain centers, primary care practitioners
and primary care practitioners, pain specialty
clinicians, including professional organizations,
referral to pain primary care professional
centers when associations, private insurers
OCR for page 1
TABLE S-1 Continued
Recommendation Actors Key Elements of Recommendation
5-1. Designate a NIH Involve pain advocacy and awareness
lead institute at the organizations; foster public–private
National Institutes of partnerships
Health responsible
for moving pain
research forward,
and increase the
support for and
scope of the Pain
NEAR-TERM AND ENDURING: Build on immediate recommendations,
complete before the end of 2015, and maintain as ongoing efforts
Recommendation Actors Key Elements of Recommendation
2-1. Improve the National Center for Health Based on Recommendation 2-2; foster
collection and Statistics (NCHS) (part public–private partnerships; includes
reporting of data on of CDC), AHRQ, CMS, subpopulations at risk for pain and
pain VA, DoD, state and local undertreatment of pain, characteristics
health departments, private of acute and chronic pain, and health
insurers, outcomes research consequences of pain (morbidity,
community, other researchers, mortality, disability, related trends)
large health care providers,
designers of electronic
medical records
3-1. Promote Health professions Requires the development of better and
and enable self- associations (including more evidence-based patient education
management of pain pain specialty professional products
organizations), pain advocacy
and awareness organizations,
health care providers
3-3. Provide CMS, VA, DoD, graduate Improved health professions education
educational medical education (GME) requires a stronger evidence base
opportunities in and continuing medical on clinical effectiveness and more
pain assessment and education (CME) primary interdisciplinary training and care
treatment in primary care programs (backed by
care accreditation, licensure,
and certification authorities
and examiners), nurse
practitioner and physician
assistant training programs,
researchers, health care
OCR for page 1
TABLE S-1 Continued
Recommendation Actors Key Elements of Recommendation
3-5. Revise CMS, VA, DoD, Medicaid Requires the development of more
reimbursement programs, private insurers, evidence on clinical effectiveness and
policies to foster health care providers, health collaboration between payers and
coordinated and professions associations providers
evidence-based pain (including pain specialty
care professional organizations),
pain advocacy and awareness
3-6. Provide Health care providers, WHO should add pain to the
consistent and primary care practitioners, International Classification of
complete pain pain specialists, other health Diseases, Tenth Edition (ICD-10)
assessments professions, pain clinics
and programs, World Health
Organization (WHO)
4-1. Expand and FDA, CDC, AHRQ, CMS, Focus is on patient education and
redesign education Surgeon General, DoD, VA, public education; includes pain
programs to pain advocacy and awareness prevention
transform the organizations, health
understanding of professions associations
pain (including pain specialty
professional organizations),
private insurers, health care
4-2. Improve CMS, HRSA Bureau CMS's role is that of payer for GME;
curriculum and of Health Professions, include interdisciplinary training
accrediting organizations,b
education for health
care professionals undergraduate and graduate
health professions training
programs (backed by
licensure and certification
authorities and examiners)
4-3. Increase the Pain medicine fellowship Requires more effort to attract young
number of health programs and graduate health professionals to pain programs;
professionals with education programs in also requires collaboration between
advanced expertise in dentistry, nursing, psychology educators and clinicians
pain care and other mental health
fields, rehabilitation therapies,
pharmacy, and other health
OCR for page 1
TABLE S-1 Continued
Recommendation Actors Key Elements of Recommendation
5-2. Improve FDA, NIH, pharmaceutical Based on Recommendation 5-1;
the process for manufacturing and research involves developing new and faster
developing new industry, academically ways to evaluate and approve new pain
agents for pain based biomedical research therapies, e.g., novel forms of patient
control community, private funders of stratification in clinical trials and novel
pain research investigative endpoints
5-3. Increase support NIH, AHRQ, CDC, DoD, Based on Recommendation 5-1; basic,
for interdisciplinary VA, pharmaceutical translational, and clinical studies
research in pain manufacturing and research should involve multiple agencies and
industry, private funders of disciplines; focus on knowledge gaps
pain research, academically
based biomedical research
community, pain advocacy
and awareness organizations
5-4. Increase NIH, AHRQ, CDC, DoD, Based on Recommendation 5-1;
the conduct of VA, pharmaceutical includes translational, population
longitudinal research manufacturing and research health, and behavioral aspects of pain
in pain industry, Patient-Centered care (social and multimodal aspects,
Outcomes Research Institute, not just medications and other single
private funders of pain modalities); focus is on real-world
research, academically situations (comparative effectiveness,
based biomedical research not just efficacy); foster public–private
community, outcomes partnerships
research community, pain
advocacy and awareness
5-5. Increase the NIH, NCHS, AHRQ, CMS, Includes more interdisciplinary training
training of pain academic medical institutions
a The committee prepared this table based on the recommendations but with a focus on their imple -
mentation. The table lists a range of potential actors and key elements of each recommendation.
b Accrediting organizations include the Liaison Committee on Medical Education, Commission on
Osteopathic College Accreditation, Accreditation Council for Graduate Medical Education, Com -
mission on Dental Accreditation, Commission on Collegiate Nursing Education, National League for
Nursing Accreditation Commission, American Psychological Association Committee on Accredita -
tion, Council on Education for Public Health, Council on Social Work Education, and Council for
Higher Education Accreditation (Perez et al., 2007).
OCR for page 1


text:
Listen to Radio web62.com
Marcus Robinson - wide receiver
Born in a year of the rabbit, WR Marcus Robinson had his greatest year in the Rabbit year 1999, which ended with a 4-year contract worth $ 14,5 million.
Unlike his colleague Lawrence Phillips, who only had the chance to impress European fans, Marcus Robinson did meet a smart coach at the Bears, who realized his feel and talent for super smooth action.
Being also an expert on billiard tables reveals the great sensitivity of Marcus Robinson, who had entered the Bears only as the fourth WR and is now most likely to become MVP 99.
All Rhein Fire fans and also the organization love to remember the days when Marcus had been around.
Marcus Robinson had played a great season for Rhein Fire in 1998, when he was a major factor on the field in particular during the World Bowl in Frankfurt with his 74 yards which had helped a lot to defeat the Galaxy and to win the very first title.
In fact Marcus Robinson stands for the most receiving yards at Rhein fire with a proud 811 during that awesome season.
The extremely fast wide receiver had finished the season as Offense MVP of the 1998 NFL Europe and as a member of the allstars team with 884 yards in 10 games.
Marcus Robinson had scored 43 TDs in his wonderful career.
Video interview with Marcus Roninson's former coach Mike Jones
Peace to the crew and trouble for any defense.
Rhein Fire Home Cheerleaders
CoachesAlvin HarperBart AndrusEd O'NeilGalen HallGuy McIntyreJim TomsulaMike JonesPete Kuharcheck

subset: commoncrawl


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How Will My Product(s) Be Delivered?When purchasing a large appliance from AppliancesConnection, a representative will contact you 48 hours prior to arriving to your location to schedule a delivery date and a 4 hour time window. Upon delivery, your product will be unloaded and ready for you to open and inspect. If you have chosen White Glove service, the item will be placed in your room of choice and the debris will be removed.
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Ambella Home Verona Towel Cabinet.Part of the Verona Collection of Bathroom Furniture, this towel cabinet comes with ample storage space and style.


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Tennessee Gov. Bill Haslam says he isn't counting votes in the Tennessee legislature just yet for his Insure Tennessee Medicaid expansion proposal.
At least he's not counting hard votes for the upcoming Feb. 2 special legislative session as he holds a series of nine public forums across the state.
The Booksellers at Laurelwood will host "Gone Dead Train" author Lisa Turner for a discussion and signing Tuesday, July 22, at 6 p.m. at the bookstore, 387 Perkins Road Extended. Visit thebooksellersatlaurelwood.com.
The National Association of Women Business Owners, Memphis Chapter will hold "Meet Shelby County Women Candidates," an after-hours nonpartisan reception, Monday, July 21, from 4 p.m. to 6 p.m. at Salsa, 6150 Poplar Ave., suite 129. For more information and to RSVP, visit nawbomemphis.org.
"What you don't know won't hurt you" is a popular saying today. While that may be true in some cases, when it comes to your health, the opposite is true. Speaking from personal experience, I can tell you that when it comes to kidney disease, what you don't know can actually put your health in grave danger.
Memphis City Council member Lee Harris is challenging Democratic state Sen. Ophelia Ford in the August primary for District 29, the Senate seat held by a member of the Ford family since 1975.
Memphis civil rights icon Maxine Smith died Thursday evening at her South Memphis home at the age of 83.
After much speculation about resistance from other parts of the state to lifting the statewide ban on special school districts statewide, the bill to do that sailed through the Tennessee House and Senate Monday, April 15.
NASHVILLE (AP) – A Tennessee House committee on Tuesday recommended passing a bill that would dock the welfare payments of parents of children who fail at a school despite Republican Gov. Bill Haslam's opposition to the measure.
NASHVILLE (AP) – A proposal to eliminate hotel allowances for some Tennessee lawmakers passed the House on Monday despite concerns that it might hurt those who use the excess to defray other unreimbursed expenses.
The Soulsville arrows beneath the Bellevue Boulevard railroad overpasses near Walker Avenue point north and south. It is the first indication that you are in an area where several possibilities can coexist.
Maxine Smith pointed out that the wheelchair she used to enter the Benjamin L. Hooks Central Library was borrowed – and she also made a point of walking from the doorway of the Memphis and Shelby County Room at the library to her seat in the room.
The Tennessee State Senate will vote Monday, April 30, on the bill that would permit suburban towns and cities in Shelby County to hold referendums this year on forming their own municipal school districts.
The August elections were already going to be more complex than usual. There are the changes from this year's drawing of new district lines for the Tennessee Legislature and the U.S. House of Representatives.
If Democrats have their way, the Tennessee General Assembly would meet only every second year, lawmakers' daily expenses would be capped and bill sponsors would have to divulge if their legislation originated with national groups.
NASHVILLE – The organizer of a trip by 15 state legislators to China this summer says he returned with a "verbal commitment" from Chinese officials to match up to $5 million in state money for establishing educational ties between the nation and Tennessee.
On the night of the worst civic tragedy in West Memphis' history, blues stood up and did its thing.
The "Blues Trail to Chicago" concert was briefly canceled before officials decided to go with the show in honor of the two second-generation law enforcement officers who were shot and killed earlier Thursday.
The stage is set for the county's most anticipated political showdown in the Aug. 5 state and federal primary elections.
Noon today is the deadline for candidates in the primaries, as well as those vying for nonpartisan seats on the Shelby County school board and the three judicial positions, to file their qualifying petitions for the ballot.
NASHVILLE, Tenn. (AP) - A constitutional amendment to guarantee the right to hunt and fish in Tennessee will go before voters in November's general election.
The House voted 90-1 in favor of the proposal sponsored by Republican Rep. Joe McCord of Maryville.
The newest member of the Shelby County legislative delegation to Nashville should take the oath of office in the Tennessee Legislature by the weekend.
Mark White won Tuesday's special election for the state House District 83 seat representing parts of East Memphis and Eastern Shelby County.
Mark White is the newest member of the Shelby County legislative delegation to Nashville. The Republican business owner won Tuesday's special election for the State House District 83 seat representing parts of East Memphis and Eastern Shelby County.
John Pellicciotti is pursuing his master's degree in political science from the University of Memphis. He's writing his thesis. And this week, after trying several times for several years, the small-business owner and consultant got some real-world experience in his degree area.
Shelby County Commissioners took several rounds to do it, but got through the last two appointments left from the busy 2009 political year.
At the group's first meeting of 2010, Republican John Pellicciotti was appointed to the District 4 Position 3 seat vacated in December by Democrat Matt Kuhn. Kuhn resigned to become a policy adviser to interim Shelby County Mayor Joe Ford.
Shelby County Commissioners will begin the new year with some familiar chores.
Today's meeting begins at 1:30 p.m. at the County Administration Building.
It includes the appointment of a new commissioner for District 4 Position 3. And the commission will appoint an interim state representative for District 85.
Today is Election Day for voters in parts of East Memphis, Bartlett, Cordova and Germantown. Polls in those areas are open today from 7 a.m. to 7 p.m.
On the ballot are the last two elections of 2009 and the latest in a series of changes to the Shelby County Legislative Delegation and to the Tennessee Legislature.
The Public Relations Society of America's Memphis chapter has named Memphis City Schools superintendent Carol Johnson as its Communicator of the Year for 2005. Johnson accepted the honor at the organization's January chapter meeting. PRSA presents the award annually to a respected member of the community who invests time or talent in communicating a specific message to public audiences. Johnson replaced superintendent Johnnie Watson after his retirement in 2003. She had served as superintendent of Minneapolis Public Schools since 1997.


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Winter in Hellas Basin
October 9, 2009
This image was collected during southern winter when the usually cloudy Hellas Basin is relatively free from clouds. Even though there is little cloud cover, the atmosphere is still much thicker due to the deeper basin compared to elsewhere on Mars, making image details not as crisp as when viewed through thinner atmosphere. In the center of the image are several dark streaks which originate from the side of a higher standing butte. The dark material is likely being eroded from a single layer within the cliff face. Wind has moved some of the eroded dark material to form the streaks.
Environment, Mars, Astronomy, Planetary science, Arabia Terra, Hellas Planitia, Planetary geology, Cloud


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Traditions Linens
This beautifully bright bandana sheet set brings a dash of color and fun to your bed. Made from incredibly soft cotton, the sheets in this set are generously sized to fit today's oversized mattresses.
Drawing inspiration from great design and the world around us, Traditions Linens creates bedding and bath collections that layer texture, color and pattern in all-natural fibers.


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Consultation for Use of Program Design Logic Models
OP&A is offering a one-hour free consultation on the use of logic models in program design every Tuesday morning at 10:00am on a first-come, first-served basis. Contact Deborah Earl to schedule a session.
The Office of Policy and Analysis conducts various training programs with other units within the Institution as well as organizations across the nation and around the globe. From regularly hosting visiting scholars and interns, to providing consultations for other organizations, to leading seminars and workshops or to delivering lectures in our offices in Washington or at offsite facilities, OP&A helps forward the Smithsonian's mission: "the increase and diffusion of knowledge."
OP&A has hosted visiting scholars, interns, and fellows from around the world, including participants from: Austria, Azerbaijan, Canada, Gabon, Georgia, Japan, Korea, Turkey, and other nations. Visits vary in length from a few days to a year or more. Long term visitors generally undertake projects under the guidance of OP&A senior researchers and/or participate in the design and the execution of OP&A projects. OP&A also draws upon experts in diverse disciplines Institution-wide who add to and enrich participants' understanding.
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text: Index: documentation/manual/en/module_specs/Zend_Validate-Hostname.xml =================================================================== --- documentation/manual/en/module_specs/Zend_Validate-Hostname.xml (revision 24569) +++ documentation/manual/en/module_specs/Zend_Validate-Hostname.xml (working copy) @@ -94,18 +94,21 @@ The Zend_Validate_Hostname constants are: ALLOW_DNS to allow only DNS hostnames, ALLOW_IP to allow IP addresses, - ALLOW_LOCAL to allow local network names, and - ALLOW_ALL to allow all three above types. + ALLOW_LOCAL to allow local network names, + ALLOW_URI to allow + RFC3986-compliant addresses, + and ALLOW_ALL to allow all four above types. - - Additionally there is ALLOW_URI which allows to check hostnames - according to RFC3986. These - are registered names which are used by WINS, NetInfo and also local - hostnames like those defined within your .hosts file. For security - reasons ALLOW_URI is not contained within - ALLOW_ALL. - + + Additional Information on ALLOW_URI + + ALLOW_URI allows to check hostnames + according to RFC3986. These + are registered names which are used by WINS, NetInfo and also local + hostnames like those defined within your .hosts file. + + To just check for IP addresses you can use the example below:


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Sandi Sieger:
I'm in the business of celebrating Australia every day. Being Editor-In-Chief of this magazine means I see, do, taste and feel so much of this great land every day of the week. So when I sat down to think about the meaning of Australia Day, I was a little stuck. It's just another day, after all.
Sure, there'll be a lot of stereos beating to the sound of Triple J's Hottest 100. There'll be a lot of barbeques sizzling with snags and steaks, and tops being twisted off bottles, and corks being popped. There'll be Australian flags emblazoned on windows and cars and tattooed on the shoulders and backs of the citizens of this country. But what about it should matter?
I'm not sure that I can offer a brilliant, all-inclusive answer. I know that many people baulk at the Australian flag and despise it as a symbol of celebration. That vegetarians don't really care for Sam Kekovich or his lamb ads. That middle-class Australia loves to point the finger at bogans and tut. That we are not a Republic. That we have a history – a flawed, problematic history. I know all that. And I know many other people do to, and they refer to it, and laugh at it, and bring it up as a means to rip apart all the good things there are about this country, and the people that inhabit it.
And there are so many good things. So many beautiful places, and wonderful, lovely people, and talented artists, and creative ventures, and sporting achievements, and medical geniuses, and innovative educators – so many people so devoted to greatness.
And that it's the people that tut and vomit opinions that really need to think about Australia Day and its meaning. Because it's not just another day. It's a day to celebrate and honour our country.
I've always admired Americans for their unabashed love for their country – the way they hold their hand to their heart and honour their flag. Perhaps there is something we can learn from them.
Australia is a young country. One that, might I add, considering its youth, has not only kept up with but surpassed most other countries in the world in most industries. There's not that many of us and we're really good at what we do – period.
Australia may have made wrongs, but it has also made many rights. The time has come to stop focusing on the past – we must now focus on the future.
We may be jovial, and a country of larrikins, but that doesn't mean we can't be proud. It doesn't mean we can't be grateful. It doesn't mean we can't wave a flag in seriousness.
Our core – of mateship, and loyalty, of humour, and intelligence, of inclusion, and culture – should be a marker of solidarity and celebration – not separation.
The thing I've realised is that I may celebrate Australia every day, but not enough other people do. It's their opinions and generalisations and complete ignorance that hold them back from seeing Australia clearly.
So, to be clear, we live in the best country in the world – one that values so many things that other countries do not, one that is caring and loving, one that is stunning and inspiring, one that we should be proud of. And, most definitely, one that we shouldn't have to keep defending or defining.
Wave your flag proudly this Australia Day, turn the music up, eat your sausage in bread with sauce, feel the sand beneath your toes, rub red dust off your face, wear your bikini down the street with thongs on your feet, laugh, clink glasses with friends, soak in the views and say thank you; that not only can you do all of that freely, but that you can do it proudly.
Happy Australia Day.
Please enjoy the reflections and observations below that some of the Onya Team have put together for you.
Above: Fashion Editor Sarah Kempson hangs the Australian flag at last year's Onya Aid
Bianca Villarosa:
Summer in Australia is all about family barbeques, catching up with friends, white sandy beaches, tennis, cricket, fish and chips, ice-cream, Moonlight cinema and my new (and cute) Sass & Bide shorts.
Relaxing on Australia Day with the people you love the most and enjoying Triple J's Hottest 100 is also worthy of a mention.
However, we don't need just one day to realise how lucky we are. We should be celebrating the best country in the world every day.
There are hundreds more reasons as to why I love Australia…but the most important is FREEDOM.
Glenn Dunks:
Australia Day is such a curious event on this antipodean nation's calendar. It's a day where some people act far more patriotic than they normally would, whilst at the same time there are those who act far more unpatriotic than they normally would. Personally, I love Australia – of course I do, I couldn't write for Onya Magazine if I didn't – but I don't celebrate 26 January any more than I normally would. This Australia Day I will be working several hours before attending a barbecue in the park where the (uh-oh, will this get me into trouble?) rather awful sounds of the Triple J Hottest 100 will be blaring out of a portable stereo. It's merely another day in which I get to spend with glorious people in this glorious country. There may also be dancing. Oh yes, there may.
I don't subscribe to the idea that I have to wear Australian flag paraphernalia, nor do I have much time for the Sam Kekovich school of thought that to be a true man one must eat lamb. I'll stick with snags in bread with tomato sauce, okay? No, I think to embrace Australia Day is to embrace multiculturalism, not spout hate speech (that goes for you, Margaret Court) and to reflect on how lucky we are as individuals whilst maybe taking a swig from a bottle of beer or diving into some beachside fish and chips. It will be a change of pace from last year when I, along with the rest of the Onya crew, helped raise money for flood-stricken Australians, but they'll be in my mind no less. As the Film Editor it is my job to write about movies for you dear Onya readers, but one needn't watch our stories on screen to see this great nation writ large. Just look around and you'll see how great it is.
Jessica Barlow:
I love being Australian because there is simply so much to love about this weirdly shaped place. Despite the breathtaking scenery (think Lake Eyre, Coober Pedy and the great Aussie sunsets), it isn't what first comes to mind when I think about what makes me feel Australian. Instead, I see the places I go to see friends and family, to work and to relax. I hear jokes and fun conversation and remember nights with family around the BBQ. The Aussie spirit is imbued into each of them, as well as myself. That laughing, loving, fighting, loyal and adventurous spirit carries me to work and home again and occasionally, away on a great holiday. Whenever I go overseas, that spirit is what calls me back again. It is something I cannot live without and is what makes me truly Australian.
Kait O'Callahan:
"Patriotism is the belief that your country is superior to all other countries because you were born in it."
When I first read these words by George Bernard Shaw, I committed them to memory so I had someone wise to recite when I was asked yet again why I wasn't supporting the All Blacks. Turns out, I should have Googled 'patriotism is…' earlier; a lot of famous old guys shared this same view. Due to my lack of loyalty, I support the sports teams I like the best, not the ones that share my accent, and I'm not ashamed to say I moved to Australia because I think it suits me better. It also means I don't really like Australia Day and its hysterical pride in being Aussie. What I can say is that since moving to Melbourne I've been welcomed with wide-open arms. I've met people through writing, through Twitter, and through tennis. I've been invited to events where I've known no one, but walked out knowing everyone. I'm not an outrageously social person, but I've had no problems making friends. That is the sign of a happy country. I also enjoy the weather, the sport, and the chocolate chip cookies at the supermarket. I'm not a patriot, and I wasn't born here, but I love Australia anyway. And I know you guys are cool with that.
Lee Zachariah:
Oh, Australia Day. I love you so much. Other countries may have national holidays, and birthdays, and Thanksgivings, and annual reminders of that time they wrestled their independence back from the USSR, but no other country does it with quite the same swagger as we.
How many other countries would treat a day – less than month after the Christmas/New Year's break – as a well-deserved holiday from the work they only returned to the week previous? It's like a collective sigh has been let out by those of already feeling oppressed by the seven or eight days we've already had to work this year. That sigh is almost always followed by a conspiratorial giggle at the conniving way we always manage to turn the nominatively singular Australia Day into a four-day holiday. Five, if we call in sick on Monday, which, between the enduring hangover and traditional sunburn, we almost certainly will.
Every Australia Day we gather at a friend's house to eat BBQ, drink beer, watch the cricket, and listen to Triple J's countdown of the best 100 songs from the previous year, as studiously voted by us. This is not something we do instead of a solemn religious observance: this is our religious observance! What better than barbecued cow, not-quite-cold-enough beers, a qualitatively eclectic mix of indie pop hits, and – let's be honest – the most boring sport in the world, to remind us what it means to be Australian? And the fact that we do it on the very day most of our ancestors invaded this country is the kind of dick move that actually suits the mood of the holiday.
Why is Australia Day better than any other country's national holiday? Because ours celebrates the absolute best and worst of this country, as scored by the inconsistent standard of music we all decided was best representative of the previous year, which was itself (in true Dickensian fashion) the best and the worst year we'd ever had. We're never satisfied, but we're always pretty happy.
A joyous and happy birthday, current iteration of Australia!
Rebecca Jade McGuire:
Australia Day means thongs, sunscreen, and sausages. Such a cliché, but the truth. Triple J in the background, a stinking hot lunch, followed by a gargantuan storm to cool. It also means a fabulous display of my backyard cricket skills, including this conversation:
Family: "You have to bowl, you can't peg the ball."
Me: "I'm allowed to peg, it's only backyard cricket."
Family: "But it's still cricket, and cricketers bowl, not peg."
Me: "Well sorry, I'm not a cricketer, and last time I checked you weren't part of the Australian cricket team either, so I win. Pegging now."
So basically, Australia Day means family and friends, and backyard cricket rules discussions. We wouldn't want it any other way.
Rosanna Beatrice Stevens:
We hold such a frightening and exciting responsibility to sustain the environments we hold as part of Australian iconography. Because when we claimed this land as ours, and we made National parks into places that were protected from not only ourselves, but the Indigenous people's intrinsically respectful practices, we put our hands up to say, 'We'll answer to extinction, erosion and salination. We will walk places and we won't buy new Jeeps for a ridiculously cheap $25K. We will regenerate bushland. We will keep our cigarette butts and Maccas wrapping in our cars. And we will share our backyards with possums and brown snakes alike.' As Australians — as democratically involved citizens of a free nation — we are told each of us make a difference.
You have to celebrate the difference you make.
Sarah Kempson:
I have lived in Australia my entire life, yet it is only recently that I have truly begun to appreciate the magical nature of our country. Two years ago, I met an American girl who had come to Australia for love and could see no reason why she would ever want to leave. While the love didn't last, her love for Australia did and now she faces an uphill legal struggle to stay in Australia where she has made a life for the past four years.
I think we often get complacent about how lucky we are to live in a country as wonderful as Australia, but watching my friend lay in limbo as to whether she will be permitted an extended visa or residency really drives home the message for me.
We are all very lucky to live in a country that is so special and provides amazing weather (most of the time), beaches, countryside and people. I talk about travelling the world and living in another country, but at the end of the day, I will always come back home, to Australia.
Tom Valcanis:
No matter where you go, there's a common thread that binds us all. Spending time in Brisbane away from my native Melbourne, there is certain foreignness to navigating a new city; new sights, new sounds and unexplored places only those who call it home know about. But no matter if you're in Adelaide or Wagga, our cheeky and ambitious spirit shines through – it's almost ineffable, but to stand amongst Australians both that have made it home and have called it home right from the start, is an inimitable experience which others can observe and perhaps understand but never quite appreciate in its entirety. My grandparents arrived from Macedonia after a bitter march out of a warzone in 1951 – they know all too well the "never say die" attitude of Australia and are proud to call it home, thankful for the opportunities, peace and comfort it has afforded them for the better part of their lives.
We have tamed the land over two hundred years – for better or worse – but as we sweat and cheer and toil as Australians, I always feel that the Great Southern Land has shaped us all in an almost inexpressible way.
The simple pleasures – sharing a meal or a beer and spinning a yarn to reflect on what we have done as people as part of a nation – that's what it means to be Australian, to me.


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Ethnicity | White/ Caucasian |
Nationality | Russian |
Date of Birth / Age | March 24, 1986 |
Citizenship | U.S. |
Imigrational Status in the U.S. | Citizen |
Hair Color | Brown |
Hair Length | Short |
Eye Color | |
Height | 6' 0" |
Languages | English Russian |
City | |
State | NJ |
Valentin Chmerkovskiy
Valentin Chmerkovskiy is the brother of Dancing with the Stars pro Maksim Chmerkovskiy. Val has appeared on Dancing With the Stars as a guest dancer and is now taking center stage as a pro just like Maks. Oh brother!
Val was seven years old when he started dancing. At the age of 12, he went to his first overseas competition, the German Open, as one of only two U.S. couples there (his brother being the second). At 15, Val won his first IDSF World Championship and became the first and last American to ever do it.
Val has been a US champion an incredible 14 times over his 15 year dance career. His accomplishments include winning the German Open, Asian-Pacific Chamiponships, US Open, Blackpool and the World Championships 2-times (Junior and Youth). Val is currently the United States Amateur Latin Champion with his partner Daria Chesnokova.
Without a doubt, Val is one of the most accomplished Amateur Latin dancers in the history of Dancing with the Stars!
• IDSF World Champion
• 14-time US Champion
• German Open Champion
• Asian-Pacific Chamipon
• United States Amateur Latin Champion


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Demonstrations and protests in countries in North Africa and the Middle East in 2011 have led to this term being widely used. As a metaphor for change through popular uprisings, it has also been applied to countries not part of the Arab world.
It was used first for the uprisings that led to changes of regime in Tunisia and Egypt, as a term of hope that a domino process might lead to similar changes elsewhere. Armed retaliation by the governments of Libya, Bahrain and Syria against their own populations has since tarnished that hope.
The term was coined early in 2005 in reference to unrest in Egypt, Syria and Lebanon, probably as a play on Prague spring, the 1968 democratic uprising in Communist Czechoslovakia. In turn, that echoes springtime of the peoples and spring of nations (German Völkerfrühling and French printemps des peuples) that historians use as shorthand for the revolutions of 1848 in Europe. Many commentators have noticed parallels between the events of 2011 and those of 1848.
The Arab Spring, the great awakening, 2011's equivalent of the fall of communism in 1989, is spreading across North Africa and the Middle East like water pouring from a broken dam.
The Times, 19 Feb. 2011.
The frightening spiral of violence in Syria and the determination of its ruler, Bashar Assad, to crush peaceful opposition are a bleak reminder of how far the Arab spring still has to go before summer arrives — and how easily the region's hopeful mood could turn wintry again.
The Economist, 30 Apr. 2011.
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1. "Beer Bread" - just add beer and butter!
Larry The Cable Guy is ALWAYS a trustworthy food endorsement.
2. Entire breakfasts
What better way to start your day than with $1 scrambled eggs with hash browns and pork sausage links? Major DEAL.
3. Chunk Ham
4. Fish and cheese sandwich
Would definitely try the controversial fish 'n' cheese pairing in frozen sandwich form.
5. Cocktail Smoked Oysters
Solid seafood is hard to come by in suburban Utah, where this dollar store is located. Would try this in times of seafood need.
6. Lobster spread with cognac
Recession special fine dining. Would try this in times of major self-loathing.
7. …and shrimp spread, from the same illustrious folks
8. Wyler's Authentic Italian Ices
Wyler: definitely an authentic Italian name. Would try because Otter Pops are awesome.
9. Nacho cheese
Big tub of bright orange, questionable cheese - I'm actually pretty sure I'd enjoy this.
10. Potted Meat
I actually did try this one. Didn't get through the entire can without feeling violently ill, but willing to give it another shot.
11. Chicken-flavored snack crackers
Try with nacho cheese or lobster cognac spread.
12. All natural french fried onions
I don't know what this means. This product confuses me.
14. Sugar free parfaits
15. Luncheon Loaf
For a 'fitting lifestyle,' of course. Would try because BACON GRILL.
16. Beef flavored rice/vermicelli mix
Vermicelli does not appear to be pictured. Would try this to figure out where the vermicelli is.
17. Frozen packs of chicken drumsticks
18. Frozen pork filets, right next door
19. Vienna Sausage, from the people who brought you "Potted Meat"
20. Brown gravy mix, by "Chef Swagger's Kitchen"
This looks very promising - who could resist the charms of Chef Swagger?
21. Canned German potato salad
23. Pre-packaged cheeseburgers
Seems like a better bet than cheeseburger in a can, which also exists. Would try.
And conveniently right next to the food aisles, you can pick up industrial cleaners for your engine!
All photos taken in an Orem, UT Dollar Tree.


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ODT Online
ODT /directory
It delivered 232,909oz for the 2012 calendar year, surpassing its downgraded full year guide.
Crucial cash costs to produce each ounce were cut from expectations of more than $US1000 an ounce to an average unaudited $US940 for the year, with fourth quarter cash costs down to $US638 an ounce.
Oceana shares traded at $3.50 following the quarterly result, but plunged to $3.41 at the close.
Its newly commissioned northern Philippines gold and copper mine, Didipio, initially returned gold recoveries at 80% and copper at 85%, with concentrate sent for export.
However, the plant is ''temporarily off-line'' for the ''next few weeks'' as modifications are made to ''deficiencies'' in its tailings delivery system.
Oceana chief executive Mick Wilkes said both its Macraes operations, in East Otago, and Reefton, on the West Coast, delivered higher grades of gold-bearing ore to the mill, with production up 55% on the quarter to September.
''The decrease in cash costs from the third quarter 2012 was mainly attributable to higher ounces of gold sold,'' Mr Wilkes said.
Earlier guidance for Oceana's full-year production were downgraded from 230,000oz250,000oz to 225,000oz-230,000oz during the year - with 232,909oz produced, and 230,119oz sold during the year. Mr Wilkes reiterated guidance given last month for production of 285,000oz-325,000oz this year, having said in August that by 2016 Oceana wanted to produce 600,000oz of gold from the New Zealand and Philippines operations.
For the fourth quarter, revenue was $US119 million from the sale of 69,761oz at an average global spot price of $US1705oz.
Craigs Investment Partners broker Peter McIntyre said the fourth quarter result was ''strong'' for Oceana, from a combination of mining higher grade ore, and taking more gold to market.
''Oceana can probably maintain that cash cost [around $US600], with Didipio yet to come on stream,'' he said.
Forsyth Barr broker Peter Young said ''the biggest positive surprise'' was the cash costs, at $US638 oz, ahead of his firm's $US887 forecast.
The cash costs were $US17 million below forecast and $10 million-$15 million below typical quarterly costs.
''We will need to speak to Oceana to understand why there has been such a large drop in cash costs,'' Mr Young said.
Mr Wilkes said Didipio throughput rates had approached the equivalent of 2.5 million tonnes a year, and once plant modifications were completed, the project was expected to increase to 3.5 million tonnes a year.
There are an estimated 44 million tonnes of ore to be mined at Didipio over 16 years, with eventual annual gold production targets of 300,000oz-350,000 oz Oceana's full-year report is due to be released in mid-February.
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Now things get tough for the State Fair Community College men�s basketball team.
The Roadrunners� schedule to start the second half of their season could provide a rude awakening.
�When you look at our schedule in January and February, it�s going to be quite a challenge, but I think one that I hope our players are excited about,� State Fair coach Dale Ribble said.
With 15 games left on their schedule, the Roadrunners will face eight teams that are ranked or receiving votes in the latest National Junior College Athletic Association Division-I or Division-II polls.
State Fair (9-6) is enjoying its best start in recent years, having already surpassed its win total from the past two years combined.
The play of Sanijay Watts has been one of the keys for State Fair. The 6-foot-4 sophomore forward is averaging more than 20 points per game.
�We knew he could score,� Ribble said. �When he decided to come to State Fair, we knew he was a good scorer. ... I think the thing that I really like about Sanijay is not only can he score, he�s very efficient.�
The first-year coach said the Roadrunners have been the most successful when they have others � like Norrel Holder and Shasta Scott � scoring in double figures to complement Watts.
Ribble points to the Roadrunners� defensive play as another key to their wins and a major point of focus for the second half of the season.
�I think for our team to be really good, we�ve got to be very good defensively and we�ve got to limit teams to one shot,� he said.
Even with the improvements, State Fair heads into the second half of the season ranked last in Region 16 in scoring and points allowed.
The Roadrunners face the unenviable task of facing three nationally recognized teams within the first week of retaking the floor after a month-long break.
�It�s almost like we�re starting over,� Ribble said of the break. �With the guys being off for Christmas break, and then coming back, we�ve got to get in really good shape and do the best we can because we�ve got a lot of games in a short amount of time.�
State Fair opens its second half at 7 p.m. Monday in Ottumwa, Iowa, against Indian Hills, which is receiving votes in the latest Division-I poll. The Roadrunners return home Wednesday for a 7:30 p.m. showdown against Penn Valley, the 10th-ranked team in Division II.
The brutal week wraps up Saturday when the Roadrunners open Region 16 play against Three Rivers. Three Rivers (11-3) is ranked sixth in the latest Division-I poll.
�I think we�ll find out very quickly where we stand up with those people,� Ribble said. �No matter what the result is there, I hope our guys learn and I hope the coaching staff learns that it�s going to help us improve, no matter what the result is.�
The schedule never really lets up, with two games being the longest stretch the Roadrunners will go without facing a ranked opponent.
All five teams in the region head into the second half with winning records. Missouri State-West Plains, ranked 16th in the latest poll, has the best overall record at 15-1.
Mineral Area (12-4) is likely sitting just outside of the polls and Moberly held a 10-5 record heading into a home game against Kirkwood on Saturday night.


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The Global Volcanism Program has no activity reports for Pululagua.
The Global Volcanism Program has no Weekly Reports available for Pululagua.
The Global Volcanism Program has no Bulletin Reports available for Pululagua.
Pululagua is a relatively low, forested volcano immediately north of the equator, about 15 km north of Quito. The volcano contains a 5-km-wide summit caldera narrowly breached to the west and partially filled by a group of dacitic lava domes. Older pre-caldera lava domes are found on the eastern, SE, and southern sides of the caldera, with a group of younger pre-caldera lava domes primarily on the eastern side. Four post-caldera domes rises up to 480 m above the caldera floor. Large explosive eruptions producing pyroclastic flows took place during the late Pleistocene and Holocene. Caldera formation took place during a series of eruptions lasting 150-200 years beginning about 2650 radiocarbon years ago. The latest dated eruption occurred from post-caldera lava domes about 1670 years ago and produced lava flows and pyroclastic flows.
Summary of Holocene eruption dates and Volcanic Explosivity Indices (VEI).
Start Date | Stop Date | Eruption Certainty | VEI | Evidence | Activity Area or Unit |
0290 (?) | Unknown | Confirmed | Radiocarbon (uncorrected) | ||
0450 BCE ± 150 years | Unknown | Confirmed | 4 | Radiocarbon (uncorrected) | |
0690 BCE ± 150 years | Unknown | Confirmed | 5 | Radiocarbon (uncorrected) | |
4800 BCE (?) | Unknown | Confirmed | Radiocarbon (uncorrected) |
This compilation of synonyms and subsidiary features may not be comprehensive. Features are organized into four major categories: Cones, Craters, Domes, and Thermal Features. Synonyms of features appear indented below the primary name. In some cases additional feature type, elevation, or location details are provided.
Synonyms |
Pululahua | ||||
Domes |
Feature Name | Feature Type | Elevation | Latitude | Longitude |
Chivo, Loma el | Dome | 2698 m | 0° 2' 28" N | 78° 29' 31" W |
Marca, Loma la | Dome | 3083 m | 0° 1' 34" N | 78° 27' 14" W |
Pondona, Loma | Dome | 2975 m | 0° 3' 0" N | 78° 29' 38" W |
The following references have all been used during the compilation of data for this volcano, it is not a comprehensive bibliography. Discussion of another volcano or eruption (sometimes far from the one that is the subject of the manuscript) may produce a citation that is not at all apparent from the title.
Andrade D, Molina I, 2006. Pululahua caldera. Fourth Conf Cities on Volcanoes, IAVCEI, Quito, Ecuador, 2006, Excursion A3: 1-11.
Barberi F, Ghigliotti M, Macedonio G, Orellana H, Pareschi M T, Rosi M, 1992. Volcanic hazard assessment of Guagua Pichincha (Ecuador) based on past behavior and numerical models. J Volc Geotherm Res, 49: 53-68.
Hall M L, 1977. El Volcanismo en El Ecuador. Quito: Biblioteca Ecuador, 120 p.
Hall M L, 1992. . (pers. comm.).
Padron E, Hernandez P A, Toulkeridis T, Perez N M, Marrero R, Melian G, Virgili G, Notsu K, 2008. Diffuse CO2 emission rate from Pululahua and the lake-filled Cuicocha calderas, Ecuador. J Volc Geotherm Res, 176: 163-169.
Papale P, Rosi M, 1993. A case of no-wind plinian fallout at Pululagua caldera (Ecuador): implications for models of clast dispersal. Bull Volc, 55: 523-535.
Volentik A C M, Bonadonna C, Connor C B, Connor L J, Rosi M, 2010. Modeling tephra dispersal in absence of wind: Insights from the climactic phase of the 2450 BP Plinian eruption of Pululagua volcano (Ecuador). J Volc Geotherm Res, 193: 117-136.


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From Wikipedia, the free encyclopedia
This article does not cite any references or sources. (December 2009) |
Olhuala is a type of yam grown on the island atoll of Fuvahmmulah, Maldives (olhuala is a word from the Dhivehi language).
This vegetable-related article is a stub. You can help Wikipedia by expanding it. |


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Don't have to keep Chrom away from all female candidates, just make sure there's more interation between him and Olivia compared to the others. For example, I had Sumia with a chance to get a C Support, but refused it until Chapter 14 (after he marries), had him paried up with Olivia the entire battle on Ch. 13, and let him basically go tank mode (reclassed him to Cavalier by that point for the Discipline skill). He ended up marrying Olivia as I had wanted.Personally, I like OliviaxChrom the best; not to mention that having her son with Royal Weapon, Galeforce (made Olivia reach Lv 15 as a Dark Flier before entering that chapter; not fun x.x), and going from Mercenary > Myrmidon > Assassin for Lethality... Let's just put it this way: he makes Volke look like Sothe in PoR that way XD
Just marry his options off before chapter 11, have her dance once, and BAM.Also he marries on 11 NOT 13.


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By Ken Guidry | The Playlist January 14, 2013 at 1:21PM
While its 135-minute running time may have made it too long for some viewers, once again Judd Apatow reminds us just how much longer "This Is 40" could've been. He's already graced us with four other deleted scenes, which range from topics like the Kardashians to Green Day's Billie Joe Armstrong's death metal side project. Here, we get to see a bit more from Megan Fox, Jason Segel and Chris O'Dowd's characters from the movie.
More of an extended scene than a deleted scene, this clip sheds a bit more light on the humorous relationship dynamics amongst the three characters. The scene takes place in the midst of all the chaos that is Pete's 40th birthday party. While Pete and Debbie's relationship reaches its breaking point, Desi, Ronnie, and Jason are just hanging out, getting to know each other, talking about zodiac signs. In typical Apatow fashion, there are many dirty jokes, including a funny reference to "The Kids Are All Right." The clip could be considered a consolation prize for those who thought Segel, Fox, or Chris O'Dowd didn't get enough screen time in the film. Still, you can see why most of this scene wound up on the cutting room floor.
"This is 40" is still out in theaters everywhere so if you're still itching to see it, you better hurry up. It's way too early to tell when the DVD/Blu-ray will come out, but if these deleted scenes are any indication, we could be getting a five hour director's cut. [Mashable]


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Baseball Results
Dordt College Baseball vs. Mount Marty
April 16, 2010
Game Media
(Yankton, South Dakota) Mount Marty swept the Dordt Defenders in baseball action Friday night with a 13-9 decision in game two of their doubleheader. The Lancers grabbed the early lead with two runs, one in the first and one in the second but relinquished the lead when Dordt plated four runs in the top of the third. All the runs came with two outs when Travis Feekes walked and scored on a Josh Bowers double. Travis Dekkers singled in Bowers and Tony Asta doubled in Dekkers for the third run. A Kyle Davis single through the left side of the infield gave Dordt a 4-2 lead.
Mount Marty came back with five in the home half of the inning to take the lead for good on five hits and they stranded two.
Dordt cut the 7-4 lead down by a run with a Phillip Sears double followed by a Ben Fife single that scored Sears. Mount Marty erupted for one more big inning with six in the fourth and Dordt mustered four in the fifth when Trey Schneider connected for a grand slam with Dekkers, Asta and Davis aboard.
Neither team scored in their final two at-bats.
Dordt was out hit 16-9 in the loss and stranded three while Mount Marty left eight on the basepaths.
Dordt's Jensen Callaway took the loss after working two and two-thirds innings and gave up seven runs while striking out three and allowing eight hits. Jake Slings and Brad Trimm pitched in relief with Trimm allowing three runs on six hits, three walks and struck out three.
Asta and Bowers each had two hits for the Defenders, a double and single each. Asta and Dekkers each scored two runs and Schneider had four runs batted in with his bases clearing homerun.
Dordt falls to 8-20 overall and 4-10 in the league while Mount Marty, the conference leader, is 25-11 overall and 12-2 in the GPAC. Dordt will face Nebraska Wesleyan on Saturday at 1:00 in Lincoln, Nebraska in a doubleheader.
Dordt's Current Record: 8-20 (4-10)
Opponent's Current Record: 25-11 (12-2)
Team | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | R | H | E |
Dordt College | 0 | 0 | 4 | 1 | 4 | 0 | 0 | 9 | 9 | 1 | ||
Mount Marty | 1 | 1 | 5 | 6 | 0 | 0 | x | 13 | 16 | 2 |
Winning Pitcher: Hemeyer (Mount Marty)
Losing Pitcher: Jensen Callaway (Dordt College)
For more information, please contact Mike Byker, Sports Information Director, at email@example.com or (712) 722-6301.


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Entry from British & World English dictionary
Definition of no-mark in English:
British informal An unimportant, unsuccessful, or worthless person: a bunch of glue-sniffing no-marks with underfed dogs on strings
More example sentences
- You had to drag in this bunch of no-marks to make up the numbers!
- Sheridan was never going to do to him what he did to the Aussie no-mark the week before.
- Whole Wide World is one of the first songs a bunch of scruffy young teenage no-marks ever played in public, down in Lower Salthill.
1980s: perhaps from the idea of performing badly at school.
What do you find interesting about this word or phrase?
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When successful businessman Ryota Nonomiya learns his biological son was switched with another child at birth, he is forced to make a life-changing decision.
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This week's board spotlight is the Anime Board! Swing by and chat about your favorite series!
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Play show, get girl's number, get ride home from random sketchy lady.
Discussion in 'The Vestibule' started by Vesper_Returns, Dec 5, 2012.
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