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A glimpse of my budget...what's yours look like?
This is my upcoming July budget---I'll highlight bills as they're paid. If a number is written in the box, it's set up in my online bill pay, so I have almost every July & August bill scheduled to be paid. At the bottom, I've budgeted gas, groceries, savings, and extra money toward bills with balances. On the next page, I have a list off all the bills we have a balance on, so I can work on paying them off. I also have a list of bills I've already paid off.
What does your budget look like?
I've tried to get him to but he's stubborn :-/
Quoting nellyb118:
We don't have one...dh handles the money & doesn't use a formal system like that.
I've tried to get him to but he's stubborn :-/
We use Quicken to track our expenses and bills. We preview the next month before it hits and make sure unusual expenses (that don't occur monthly) are accounted for and that we cut where necessary to make it work. We also reviist our current month to check for overages in case we need to cut further the next month to make up for defecits.
Quoting RyansMommie07:wow... we dont have anything that impressive. we use usaa bank, and all our major bills are listed in online bill pay, so we use that pretty much. i wish we had one all fancy like that, i bet dh would love it!
120 grandpa (he co-signed for a loan awhile back so we can build credit, only 3 months left)
701 rent
117 elec
105 gas
150 cable
70 phones
33 netflix
20 xbox live
140 car insurance
30 lawn guy (teenage kid 2x a month mows and weedwacks)
60 household needs
150 cigs
150 gas for car
75 fast food
300 food
235 shopping
140 babysitter (3 kids x 10hr x 2doc obgyn appts monthly (that SO has to drive me to), plus travel time and monthly date night/the kids are driving us nuts night= close to this)
I pad a lot of our budget though because SO is horrible w/ money. The cable and gas are both about $50 less then listed each. By all accounts we should have money left over, but like I said SO is horrible w/ money HORRIBLE. He took back over the budget a few months ago and both times w/in 10days of payday we were broke for the month. But before I had all this, although did need to trim some of it because of unexpected large expenses.and we were never in the hole for the following month. But w/ him having control we are. I really hope he gets his raise next month, that'll help and should cover his overspending.


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Free Pussy Riot - Unregistered August 31, 2012 11:12 AM While Putin loots the Kremlin coffers, builds palaces, Russia is rotting, Vitaly took the money from these people, but in doing so he lost our sympathy.... 1 agree 9 disagree
Nas - Unregistered August 31, 2012 11:17 AM It's back to racing tractors in Russia for Vitali. 0 agree 0 disagree
mrfill August 31, 2012 12:15 PM 'There's never been interest from private sponsors. I've always said that its impossible to find sponsors in Russia for a project like F1. When there was support at the top level of government, this project worked commendably.'Doesn't auger well for a Socha GP in 2014. Reply Report abuse 0 agree 0 disagree
Pole Position - Unregistered August 31, 2012 1:26 PM Is this really a surprise? Results is the name of the game. Petrov is just an average driver. 2 agree 0 disagree
jose - Unregistered August 31, 2012 1:48 PM Looks like no money no seat for the Russian next season. Notsure the new sponsors want petrov as a driver.He arrived in F1 because of money. He will leave because of the same reason...$$ Adios baby!Jose 3 agree 0 disagree
richard August 31, 2012 2:17 PM i mentioned on the other petrov thread, that money was provided under two names....russian helicopters , and lada. Reply Report abuse 0 agree 2 disagree

subset: commoncrawl


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In 1981, clusters of cases of unusual pneumonia and cancer in otherwise healthy gay men led to the identification and first reports in the United States of what we now know as Acquired Immune Deficiency Syndrome (AIDS) (CDC, 1981). Epidemiologic studies showed that the virus was transmitted by sexual contact with an infected person, exposure to infected blood and blood products, sharing of contaminated syringes and needles, and from infected mothers to infants during pregnancy, at the time of delivery or via breastfeeding (IOM/NAS, 1988). Three years later, the cause of AIDS, a newly recognized retrovirus now known as Human Immunodeficiency Virus or HIV, was identified (Barre-Sinoussi et al., 1983; Gallo et al., 1984).
HIV infection causes progressive damage to the immune system by destroying white blood cells called CD4+ T-lymphocytes. Initial infection with HIV causes a flu-like illness in some individuals. Others have no symptoms at all until 10 or more years later when they experience symptoms of infections or other diseases that take hold due to their lowered immunocompetence. These conditions can range all the way from dementia, to cancer, to chronic diarrhea (Pantaleo et al., 1993; Fauci et al., 1996).
Testing the blood for antibodies against HIV infection indicates whether the individual is infected with the virus, but does not allow one to determine the stage of the infection. This is done by measuring viral replication, or the amount of virus in the blood (HIV RNA), and the state of the immune system (CD4+ cell count). AIDS is a term used to define those persons with HIV infection that have a CD4+ count < 200 cells/µL
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Executive Summary
In 1981, clusters of cases of unusual pneumonia and cancer in otherwise healthy gay men led to the identification and first reports in the United States of what we now know as Acquired Immune Deficiency Syndrome (AIDS) (CDC, 1981). Epidemiologic studies showed that the virus was transmitted by sexual contact with an infected person, exposure to infected blood and blood products, sharing of contaminated syringes and needles, and from infected mothers to infants during pregnancy, at the time of delivery or via breastfeeding (IOM/NAS, 1988). Three years later, the cause of AIDS, a newly recognized retrovirus now known as Human Immunodeficiency Virus or HIV, was identified (Barre-Sinoussi et al., 1983; Gallo et al., 1984).
HIV infection causes progressive damage to the immune system by destroying white blood cells called CD4+ T-lymphocytes. Initial infection with HIV causes a flu-like illness in some individuals. Others have no symptoms at all until 10 or more years later when they experience symptoms of infections or other diseases that take hold due to their lowered immunocompetence. These conditions can range all the way from dementia, to cancer, to chronic diarrhea (Pantaleo et al., 1993; Fauci et al., 1996).
Testing the blood for antibodies against HIV infection indicates whether the individual is infected with the virus, but does not allow one to determine the stage of the infection. This is done by measuring viral replication, or the amount of virus in the blood (HIV RNA), and the state of the immune system (CD4+ cell count). AIDS is a term used to define those persons with HIV infection that have a CD4+ count < 200 cells/µL
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or a specific opportunistic infection and represents the advanced stage of HIV disease (CDC, 1992; Pantaleo et al., 1993; Fauci et al., 1996).
Recent advances in treatment of HIV disease have resulted in slowing the progression of the disease, and often temporary restoration of immune functioning, in infected individuals. Early detection of HIV infection, before the infected person develops AIDS, can allow the individual to enter care and thus receive treatment and preventive services that could limit the spread of infection and prevent the morbidity and mortality of AIDS.
The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, enacted in 1990 and reauthorized and amended in 1996 and 2000, provides funding to cities, states, and other public and private entities to provide care and support services to individuals with HIV and AIDS who have low incomes and little or no insurance (Ryan White CARE Act. 42 U.S.C. § 300ff [2003]). The CARE Act was named after Ryan White, a teenager from Indiana whose struggle with HIV/AIDS and AIDS-related discrimination helped raise awareness of the disease. The CARE Act is a discretionary program that relies on annual appropriations from Congress. Since its original authorization, CARE Act funding has increased from $220 million in fiscal year (FY) 1991 to $2.0 billion in FY2003 (HRSA, 2003). The Health Resources and Services Administration's HIV/AIDS Bureau (HRSA/HAB) has lead responsibility for implementation of the CARE Act.
The CARE Act is composed of four major program titles and several other components. Title I provides grants to Eligible Metropolitan Areas (EMAs—currently 51) that have been disproportionately affected by the HIV/AIDS epidemic (HRSA, 2002a). Title II provides grants to U.S. states and territories to improve the quality, availability, and delivery of health care and support services for individuals with HIV disease, and provides access to medications through the AIDS Drug Assistance Program (ADAP) (HRSA, 2002b). Title III provides direct grants to nonprofit entities for primary care and early intervention services, and capacity building and planning grants (HRSA, 2002c). Title IV provides grants for family-centered care for infants, children, youth, and women living with HIV disease and their families (HRSA, 2002d). Other components of the CARE Act include the AIDS Education Training Centers, the Dental Reimbursement Program, and the Special Projects of National Significance.
The CARE Act operates against a backdrop of significant inequalities in access to health care in the United States. More than 43 million Americans are uninsured (Mills and Bandhari, 2003), and millions more hold insurance policies that do not cover basic medications or treatments (IOM,
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2001a). Congress enacted the CARE Act in 1990 at least in part to address this challenge regarding people with HIV infection.
Uninsured and underinsured HIV-infected individuals rely on a variety of safety-net programs, including CARE Act–funded providers, community and migrant health centers, private free clinics, and public hospitals (Kaiser Family Foundation, 2000). Some individuals with private or other sources of insurance also rely on programs funded under the CARE Act because other sources of coverage are poorly coordinated and gaps often remain (Kaiser Family Foundation, 2000). Congress established the CARE Act, also referred to as RWCA, as the "payer of last resort"; the RWCA funds care for low-income, uninsured, or underinsured individuals who have no other resources to pay for care (Ryan White CARE Act. 42 U.S.C. § 300ff-11 [2003]). Funding for the CARE Act, however, has been insufficient to redress all of the inequalities and gaps in coverage for people with HIV.
In response to a congressional mandate in the Ryan White CARE Act Amendments of 2000, HRSA and the Centers for Disease Control and Prevention (CDC) commissioned the Institute of Medicine (IOM) to conduct this study. The Committee's charge has three components (Box ES-1):
To assess whether reported HIV cases are adequate, reliable, and sufficiently accurate for inclusion in formula grants under Titles I and II of RWCA and to make recommendations for the improvement of HIV reporting systems (discussed in Chapter 4).
To identify data and tools for assessing a community's severity of need and how that information can be used in allocation decisions (discussed in Chapter 5).
To identify available health outcome and other data that can be used to measure the quality of and access to RWCA-funded services (discussed in Chapter 6).
Each of the three components of the Committee's charge is discussed below.
Formulas are used to allocate 70 percent of RWCA funds through Title I and II ($1.3 billion in FY2002) (HRSA, 2003). These formula alloca-
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Charge to the Committee
In the Ryan White CARE Amendments of 2000, Congress directed the IOM to examine the following issues (Ryan White CARE Act. 42 U.S.C. § 300ff-11 [2003]):
Use of HIV Data in the Title I and II Allocation Formulas
"whether the surveillance system of each of the States regarding [HIV] provides for the reporting of cases of infection with the virus in a manner that is sufficient to provide adequate and reliable information on the number of such cases and the demographic characteristics of such cases, both for the State in general and for specific geographic areas in the State."
"whether such information is sufficiently accurate for purposes of formula grants under parts A and B of title XXVI of the Public Health Service Act" [i.e., Title I and II of the RWCA].
"With respect to any State whose surveillance system does not provide adequate and reliable information on cases of infection with the virus, [provide] recommendations regarding the manner in which the State can improve the system."
Information for Estimating Severity of Need for Resources
"Existing and needed epidemiological data and other analytic tools for resource planning and allocation decisions, specifically for estimating severity of need of a community and the relationship to the allocations process."
Quality-of-Care Measures
"The availability and utility of health outcome measures and data for HIV primary care and support services and the extent to which those measures and data could be used to measure the quality of such funded services"; and
"other factors determined to be relevant to assessing an individual's or community's ability to gain and sustain access to quality HIV services."
NOTE: The Ryan White CARE Act Amendments of 2000 also directed the IOM to study the public financing and delivery of HIV care. HRSA commissioned a separate IOM study to address those issues.
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tions are based on estimated living AIDS cases (ELCs),1 using data from the AIDS case reporting system2 (HRSA, 2001). Many have raised concerns that such allocations are not equitable because the epidemic is not adequately reflected by AIDS cases alone, and that areas with emerging HIV epidemics are underfunded because all cases of HIV disease are not included (U.S. Congress, 2000a,b). A related concern with basing allocations on AIDS cases is that jurisdictions are not compensated for providing early access to care and treatment (U.S. Congress, 2000b). There is a widely held perception that incorporating HIV data in the formulas would increase the equity of RWCA allocations by targeting funds according to need (U.S. Congress, 2000a,b).
Prompted by these concerns, Congress specified in the 2000 reauthorization of the CARE Act that reported cases of HIV disease should be incorporated into RWCA Title I and II formulas as early as FY2005—provided that the Secretary of Health and Human Services determines that such data are available from all eligible areas, and that they are "sufficiently accurate and reliable" (Ryan White CARE Act. 42 U.S.C. § 300ff-13 [2003]). Cases of HIV disease are to be incorporated in the formulas no later than the beginning of FY2007 (Ryan White CARE Act. 42 U.S.C. § 300ff-13 [2003]). The legislation authorized the IOM to assist the Secretary in assessing the readiness of states to produce adequate and reliable HIV case-reporting data, determine the accuracy of using HIV cases within the existing allocation formulas, and establish recommendations regarding how states could improve their HIV case-reporting systems (Ryan White CARE Act. 42 U.S.C. § 300ff-11 [2003]).
At the outset, the Committee recognized the difficulty of defining such terms as "sufficiently accurate," "adequate," and "reliable" to char-
ELCs are calculated by applying annual survival weights to the most recent 10 years of reported AIDS cases and summing the totals. CDC updates the survival weights every two years. CDC provides both the survival weights and the most recent 10 years of reported AIDS cases to HRSA, which performs the award calculations (HRSA, 2001).
Legal authority to require reporting of diseases resides primarily at the state level (Thacker, 2000). All U.S. states and territories have laws requiring health care providers and laboratories to report cases of AIDS using a standardized name-based reporting system. As a result of changes in the natural history of the disease due primarily to improvements in therapy, data from the AIDS case-reporting system have become less informative about current trends in the HIV epidemic. Many states also have passed laws, some as early as the mid-1980s, requiring the reporting of cases of HIV (non-AIDS) disease in an effort to obtain more recent information about trends in HIV epidemic and to assist in program planning, evaluation, and targeting of prevention resources. Unlike AIDS case reporting, which relies on a standardized name-based reporting system, HIV reporting practices vary substantially by state (see Chapters 3 and 4).
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acterize the quality of HIV surveillance data. No absolute standards of accuracy, adequacy, or reliability exist for assessing HIV reporting data; these standards vary according to the purposes and tasks for which the data are used. Evaluating HIV reporting systems for use in resource allocation formulas requires a different set of performance criteria than evaluating these data for public health purposes (e.g., epidemic surveillance, contact tracing, and partner notification). While CDC (1999) has established performance criteria3 for evaluating the latter function, it was not the purpose of this Committee to assess these standards. Rather, the Committee defined criteria for "sufficiency," "adequacy," and "reliability" in terms of over- and underfunding errors to RWCA grantees.
Congress specified that allocation formulas should incorporate information about HIV cases based on the belief that such information would better characterize the HIV/AIDS epidemic and areas' needs for resources than AIDS cases alone (U.S. Congress, 2000b,d). Thus, the Committee focused on whether incorporating HIV reporting into the RWCA formulas would provide a better representation of HIV disease-related resource needs across jurisdictions and more fairly channel scarce RWCA resources.
The Committee concluded that four conditions need to be met for this to occur:
Every state would need to be capable of providing data on HIV cases for the formulas.
The quality of HIV data across states and EMAs would have to be comparable. This means that if there are biases in HIV reporting, those biases should be of similar direction and magnitude across areas.
Incorporating HIV case-reporting data into the formula would need to produce different and more accurate assessments of the "relative disease burden" among states and jurisdictions and their resource needs than AIDS data alone.
CDC issued surveillance guidelines in December 1999 (CDC, 1999) outlining the performance criteria for states' HIV/AIDS surveillance systems. Several of the performance measurements had specific quantitative measurements. The criteria outlined in the document stated that the system had to be timely (66 percent of HIV/AIDS cases reported to the health department within 6 months of diagnoses), provide accurate case counts (≤5 percent mis-matched reports and ≤5 percent duplicate cases in the database), have complete ascertainment of mode of exposure to HIV (≥85 percent of reported cases, or representative sample, must have reported transmission mode after complete epidemiologic follow-up), and have complete case reporting (≥85 percent of diagnosed cases reported to the health department). In addition, states must show that they can match to other databases of public health importance, follow up on cases of public health importance, collect valid and reliable data for key data elements, and use data for public health planning (CDC, 2003).
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Including HIV data in the RWCA allocation formulas would result in significant variation in the relative size of awards to states and EMAs and more equitable allocations. If, in contrast, HIV data dampen variations in awards among jurisdictions, then the formulas may not result in more equitable allocations.
Capability of States to Provide Data for the Formula
To evaluate the capability of states to provide data for the formulas the Committee asked three questions: (1) Does each state have an HIV reporting system? (coverage); (2) Has the HIV reporting system of each state had sufficient time for full implementation? (maturity); (3) Are the data from every state with a system of HIV reporting reliable enough to be used in the formulas? (full use of reported data).
The Committee found that (as of October 2003) all U.S. states, territories, and cities, except Georgia and Philadelphia,4 had implemented HIV reporting systems, but that states are not equally capable of providing high-quality data. Some have only recently implemented such systems and need time to fully implement or refine them. Furthermore, CDC does not accept data from states that use codes rather than names to report their cases, owing to a lack of methods for unduplicating those coded cases.
Comparability of HIV Reporting Data
Even if all states were capable of providing data on HIV cases, data should be of comparable quality across jurisdictions before they are used in the RWCA formulas, or the differential errors should be such that incorporating the data increases—rather than decreases—the equity of the resulting RWCA allocations. Differential rates of completeness and timeliness of HIV reporting, and the migration of people living with HIV across jurisdictions, have the potential to create significant biases in allocations. Methodological inconsistencies in the finding or reporting of HIV cases across jurisdictions, such as variations in policies on laboratory reporting and the aggressiveness of case finding, can also lead to differential biases in underlying HIV data. Due to lack of data, the Committee could not fully investigate the potential influence of possible patterns of underreporting, reporting delays, migration of people with HIV disease, or variation in laboratory reporting policies and the aggressiveness of
Since the release of this report, Georgia implemented name-based reporting and Philadelphia adopted code-based reporting. All areas of the United States now have HIV reporting.
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case finding on resulting formula allocations. CDC is currently conducting an evaluation that would provide information about several of these issues in selected regions, but additional studies are needed to examine the comparability of data from the HIV case-reporting system across jurisdictions for the purpose of allocating resources.
Relative Disease Burden and Ranking of Need Across Jurisdictions
Including data on HIV cases in allocation formulas would not increase the overall amount of RWCA allocations, but it could potentially shift the amounts provided to different jurisdictions. One premise underlying this possibility is that the HIV epidemic is in different stages of maturity in different areas of the country. Here maturity refers to the length of time that the epidemic of HIV infection has been established in at-risk populations. Because the risk of AIDS is low in the first years after infection and then rises over time, one would expect the ratio of reported HIV to AIDS cases to be higher in more recently infected populations than in populations where the epidemic had been established for a longer period of time, and most infected individuals acquired the HIV virus many years ago. Thus, assuming very different stages of maturity of the epidemic would lead one to expect significant variation in this ratio across jurisdictions. States that believe that their HIV epidemic was established relatively recently suspect that the current measure (based on AIDS cases alone) places them at a disadvantage in RWCA formula allocations. If, however, the epidemic is at similar levels of maturity across jurisdictions, and therefore the ratio of reported AIDS cases to reported HIV cases is relatively constant, including data on HIV cases in the formula will, in fact, have little influence on the relative measure of disease burden, and hence little influence on the resulting awards.
Although it seems reasonable to assume that the epidemic is in various stages of maturity in different jurisdictions, it is difficult to confirm this belief. Some data do suggest the possibility of regional variation—specifically that the epidemic may be growing more quickly in the southern region of the United States than elsewhere. Between 1994 and 2001, the number of reported AIDS cases appeared to increase faster in southeastern states than in other parts of the country (Kates and Ruiz, 2002). Inspection of the cumulative distribution of AIDS cases suggests that the AIDS incidence curves have fairly similar—though not identical—shape across states over time (Chapter 4, Figures 4-1 and 4-2); similarity in shape implies roughly similar epidemic dynamics. These figures also illustrate shifts over time in these curves, implying that the stage of epidemic maturity differs somewhat from state to state (and from EMA to EMA). The conclusion is that while we might expect a higher ratio of HIV to AIDS
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cases in some jurisdictions than others, this effect is not likely to be particularly large. The assumptions regarding regional variability in epidemic maturity need further assessment.
Sensitivity of Formula Allocations to Changes in the Underlying Input Data
For HIV reporting data to more fairly channel resources, allocation formulas need to be sensitive to changes in the underlying data. The Committee could not examine the impact of including HIV data in the formula because data on HIV cases were not available from all states, including several key states with a high disease burden. Since data from those states could have a large influence on results, any analyses based on partial data could be very misleading. Instead, using a combination of data from states for which reported HIV cases are available and estimated HIV cases in others, the Committee examined what the current allocation is using the ELCs (the measure now used for RWCA resource allocation) and combined estimates of HIV prevalence and AIDS prevalence (see Appendix C).5
In its analyses, the Committee examined allocations per case (using Title I and II funds) across states and EMAs as a point of departure. The Committee acknowledges that there are many reasons why an equitable system would depart from this standard, including unequal costs of care, unequal need, differences in the efficiency with which jurisdictions apply funds, differences in the quality and comprehensiveness of the existing resource base from one jurisdiction to another, and differences in economies of scale.
Similar to the findings from a previous General Accounting Office (GAO) study (2000), the Committee found substantial variations in the amount of Title I and II funds received per ELC across states and EMAs. This appeared to stem primarily from the Title II formulas, which give an advantage to states with EMAs. Such variations persist regardless of the measure of disease burden used.
The Committee also found that except for San Francisco, Title I formula allocations per ELC are uniform across EMAs. The large allocation to San Francisco reflects the influence of the hold-harmless provision; removal of this provision would reduce San Francisco's allocation to within the reported range for other EMAs, but would have a small impact
The Committee also examined current allocations using AIDS prevalence alone. The differences in allocations using estimated AIDS prevalence and ELCs were not informative, suggesting that any methodological differences between the calculation of ELCs and the calculation of AIDS prevalence is not important for the purposes of identifying allocation variations.
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on other EMAs, which would observe a 2.6 percent increase in their allocation if San Francisco's dropped. As noted by the GAO (2000), the hold-harmless provision has a small overall effect on allocations to EMAs, except for San Francisco.
The Committee identified a number of structural features of the Title I and Title II funding formulas (including hold-harmless provisions, set-asides, minimum funding thresholds, and the eligibility criteria for EMAs) that have a large influence on resulting allocations. These features may dampen the influence of and obviate the potential benefits of adding HIV data to the RWCA formulas.
The Committee also used multiple regression analysis to examine cross-state variations in Title I and Title II RWCA funding allocations. Similar to previous GAO findings (GAO, 2000), these analyses indicated that the presence of an EMA was a significant factor in determining funding allocations. States whose reported AIDS cases were concentrated within EMAs received greater combined RWCA funding per case than did other jurisdictions. Appendix C provides further details.
The Committee notes with concern that southeastern states appear to receive the smallest allocations, per estimated living AIDS case, under the current formulas. While southeastern states might benefit more than other states from a measure that includes reported HIV cases, the structure of RWCA formulas, which favors states with EMAs, is more important in explaining the relative disadvantage of southeastern states.
RWCA funds are intended for individuals who are low income and uninsured or underinsured. Insofar as the current RWCA case reporting–based formula counts patients that have other sources of insurance or funding, it overestimates the number of cases that qualify for RWCA services, just as it may underestimate the needs of a particular jurisdiction with greater proportions of patients with HIV. In addition, the current formulas do not account for variations in costs of care or fiscal capacity across Title I and II jurisdictions (GAO, 1995).
The Committee makes several recommendations for improving the quality and completeness of HIV case-reporting systems for the purposes of allocating RWCA resources. Greater use of electronic laboratory reporting, and potentially the use of data from pharmacies, could enhance the comparability of HIV reporting data across states in terms of completeness and timeliness.
Name-based reporting is cited as one way to facilitate elimination of duplicate reports (CDC, 1999). However, it is unclear if name-based reporting is intrinsically superior to code-based reporting for eliminating duplicate reports. Due to name variations, even name-based systems do not permit complete unduplication. In addition, code-based reporting systems were developed by some states after substantial political debate,
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and altering those systems would require significant legislative changes, time, and effort. For this reason, and because name-based reporting is not clearly superior to code-based reporting for the specific goal of accurately estimating the number of known cases for determining RWCA allocations, better methods for unduplicating reports for both code- and name-based reporting states need to be developed and implemented so allocation formulas can include data from all states. At the same time, the Committee recognizes that there are strong feelings, both pro and con, about the use of name-based reporting for other surveillance functions (Colfax and Bindman, 1998; Osmond et al., 1999; Hecht et al., 2000). The Committee did not take a position on these issues because its charge limits its scope of activity to reporting for allocation purposes.
Other techniques for estimating the prevalence of HIV infection and the differential disease burden among states and EMAs, such as modeling and survey-based approaches, should also be explored. Such approaches have the potential of providing estimates that are more accurate, more timely, and more consistent across jurisdictions than complete enumeration. The Committee further emphasizes knowing the size and distribution of the undiagnosed HIV-infected population is an important marker of our success in providing care for all patients with HIV.
The Committee makes the following recommendations to address these issues.6 The Committee targets these and subsequent recommendations to several different entities including Congress, the Secretary of Health and Human Services (HHS), HRSA and CDC, and independent bodies. The Committee directs several recommendations (4.5, 5.2, 6.2c) to Congress that are related to the intent of the Ryan White CARE Act program. Many of the recommendations (4.2a, 4.2c, 4.4, 5.4, 6.2, and 6.3) are targeted to the Secretary of HHS, who has broad oversight responsibilities for the implementation of the CARE Act. The Committee also targeted recommendations to the Secretary of HHS when the recommendations involved coordination among multiple agencies. Several recommendations involving specific technical issues are targeted to HRSA (4.1, 5.1, 5.3, 6.1, 6.2a, 6.2b) and CDC (4.2a, 4.2b, 4.2c, 4.3, 6.2b). In a few instances, the Committee makes recommendations that assessments be undertaken, or reviewed, by an independent body (4.3, 4.4). An independent body was specified when the recommendations required a broad assessment of the science base or when the Committee thought that an independent entity could protect the federal entities from any appearance of vested or conflict of interest, since those agencies would be applying
All recommendations (4-1 through 6-3) found in the Executive Summary are identified by chapter number and recommendation number within that chapter.
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awards, the effort required for grantees to complete the application seems unjustified. Accordingly, the Committee recommends the following:
Recommendation 5-1 HRSA should modify the Title I supplemental application process. The severity-of-need component of the Title I supplemental award should be based on two components:
Quantitatively defined need, based on a small number of measures that can be calculated by HRSA/HAB.
Locally defined need described in a short narrative by the applicant.
Recommendation 5-2 A predominance of the weight for determining Title I awards should be given to the quantitative measure of resource needs that reflect variations in costs of care and fiscal capacity across EMAs.
Proposed New Approach
The Committee notes that either direct or indirect measures of resource needs could be developed. The Committee also describes a way to develop indirect indicators. This approach—sometimes referred to as social-area analysis—attempts to relate the characteristics of geographically defined populations to variations in disease or the use of services (Shevky and Bell, 1955; Pittman et al., 1986; Kessler, 1998).
The first step in the latter approach would be to identify direct measures or predictors of resource needs that meet acceptable standards of scientific importance, soundness, and feasibility. The second step is to develop a more explicit definition of the factors that are considered when defining resource needs. Once useful predictors of need have been identified, it will be necessary to assess the extent to which that information predicts variations in resource needs among areas. (Details of this analysis are presented in Chapter 5 and Appendix D.) Accordingly, the Committee recommends the following:
Recommendation 5-3 HRSA/HAB should evaluate the feasibility and usefulness of using social-area indicator models that are based on publicly available data that are collected in standardized ways across jurisdictions, to estimate EMA-level resource needs for the Title I supplemental award. This approach also might be useful in assessing resource needs for other RWCA discretionary grant programs.
Recommendation 5-4 The Secretary of HHS should evaluate the cost and utility of redesigning and coordinating studies conducted by HRSA/HAB and CDC to assess the specific needs and circumstances
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of people living with HIV. These data can be used to estimate resource needs and as part of quality assessment activities. The Secretary of HHS should also assess the cost and utility of the indirect modeling approach described in Recommendation 5-3 for assessing regional variations in resource requirements.
HRSA/HAB and RWCA grantees have undertaken a variety of quality-improvement initiatives. The 2000 reauthorization placed more emphasis on quality by requiring that all RWCA grantees establish a quality-management program. Although Titles III and IV grantees already had such programs in place, the new provision required Titles I and II grantees to implement them. The focus on quality in the most recent reauthorization reflects two national trends in quality improvement and accountability. First, the health sector has seen growing interest in measuring and improving quality (IOM, 2000, 2001b). Second, federal policy and funding decisions are increasingly being based on demonstrable performance indicators.
Progress on this broad agenda cannot be adequately measured by outcomes alone. Considering this context, the Committee interpreted this charge as a request to examine and make recommendations regarding the availability and usefulness of not only outcomes, but a broad continuum of measures for assessing and improving the quality of both primary care and support services funded through the CARE Act. Knowledge about what constitutes the best possible HIV/AIDS care is constantly changing, and the applicability of specific measures is limited by the evolving nature of the epidemic, including changes in the affected populations, the course and outcomes of infection, treatment standards, and policies and programs for financing and delivering care. Accordingly, while the Committee makes recommendations regarding measures that HRSA and grantees can use to monitor quality of care (see Recommendation 6-1), the Committee felt it could best contribute by providing a framework, criteria, and process for selecting measures that can evolve with the epidemic.
Conceptual Framework
HIV quality assessment can be thought of as having four key dimensions: the population of interest, the level assessed, the type of measures employed, and the spectrum of services to be evaluated.
Population: The HIV-infected population consists of three groups: (1) those who are not yet diagnosed (and thus are not in care), (2) those who
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are diagnosed but are not currently in care,7 and (3) those who are diagnosed and are receiving care. The CARE Act traditionally has focused on individuals who are diagnosed and currently in care. The Committee believes that quality assessment in HIV disease should extend to the entire HIV-infected population. Although quality assessment typically evaluates the care provided to those already receiving services, the number of persons not in treatment in an area can be an important indicator of access to care.
Level of Assessment: Quality can be assessed at the individual patient level, at the clinic/provider level, or at the population level. When assessing the quality of a clinic or provider, analysts aggregate individual levels of quality to the program level. For example, a measure of the quality of care provided by clinics is the proportion of patients with indications for treatment who are receiving appropriate highly active antiretroviral therapy (HAART). Provider organizations, including HRSA and its grantees, now commonly employ a variety of such provider-level measures. Little attention has been paid to assessing quality for whole communities, metropolitan areas, or states.8
Type of Measure: The Committee adopted the widely accepted taxonomy that classifies measures into three domains: structure, process, and outcome (Donabedian, 1966). Structure measures assess the characteristics and resources of an organization, such as staffing, supplies, equipment, and training. Process measures usually focus on the actions of a provider or organization to improve care, such as promoting self-care, conducting diagnostic tests, and offering appropriate therapies. Outcome measures assess the changes in a patient's health status. The three elements are interrelated and theoretically causally linked; that is, structure affects the probability of good processes of care, which can in turn affect outcomes such as health status and quality of life.
Despite compelling arguments for analyzing outcomes as ultimate indicators of quality, such measures are often only weakly related to the quality of care provided by specific clinics. For this reason, process measures are often used in lieu of outcome measures at the program or clinic level, while the monitoring of outcomes is both a simpler and more compelling way of assessing the impact of all care provided in an area.
Spectrum of Services: Both primary care and support services are essential components of high-quality care. Quality measurement to date has focused almost exclusively on clinical care.
The category of those who are "not in care" also includes those who are not in regular care.
HRSA, however, has recently initiated some work focused on developing quality measures at the EMA level.
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Review of Existing Measures
The Committee reviewed the quality measures used by key organizations and frequently cited studies (see Table 6-2 for a list), and the measures used in RWCA programs. While there is some consistency in the measures used across sources, there is also a great deal of variation in how the measures are defined and implemented. This review also shows that many sources use numerous process measures and, to a lesser extent, outcomes measures. Process measures, almost all of which were closely related to well-accepted clinical guidelines,9 were over 10 times more frequent than outcome measures.
Comparable attention has not been devoted to measures of structure, such as the availability of clinicians with the appropriate expertise and experience, despite studies linking increased provider expertise, capacity, and number of HIV-specific services to longer patient survival and prevention of opportunistic conditions (Bennett et al., 1989; Ball and Turner, 1991; Kitahata et al., 1996; Turner et al., 1998). The Committee identified relatively few measures of support services, and no systematic efforts to assess patient experiences with care. Finally, the Committee found that all measures focused on the provider level, and that no population-level process or outcome measures of quality were in routine use, despite their importance as an indicator of the overall impact of an area's epidemic and prevention/treatment/support programs.
Based on its review of selected quality-of-care measure sets, the Committee recommends a standardized set of structure, process, and outcome quality measures for assessing and facilitating quality improvement at the clinic level and at the EMA/state levels (See Recommendation 6-1). For the well-developed process of clinical care measures, measures were selected if at least four of the nine groups included them. Other measures were identified using expert judgment. A detailed review of measures used by these sources is included in Appendix E.
The Committee also recommends several population-level measures be included in RWCA quality assessments at the EMA and state level. The Committee notes that RWCA grantees do not bear the entire responsibility for outcomes among their patients; private and public insurers and others do as well. However, population-based measures are essential in monitoring HIV care in a region and identifying areas for improvement. Rather than being interpreted as direct measures of the quality of care
See Department of HHS guidelines (http://www.aidsinfo.nih.gov/guidelines/) and International AIDS Society-USA guidelines (Yeni et al., 2002; http://www.iasusa.org/).
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provided by specific clinics, they could be interpreted as reflecting the cumulative effects of many influences on case quality and outcomes.
Overall, HRSA and RWCA-funded clinics and programs are doing an admirable job of defining, assessing, and attempting to improve the quality of care received by HIV-infected individuals. In many ways, RWCA-funded programs have a more advanced approach to measuring and improving quality of care than most general medical facilities. However, HRSA, RWCA grantees, and providers could still do much more to measure and improve quality of care by adopting a common framework and starting to standardize the assessment of quality.
A critical step in moving from the current situation of uncoordinated data collection to a more standardized approach would entail reaching a consensus on how different indicators should be defined and implemented, and then putting into place a mechanism for ensuring the quality of the ensuing data. Although there are many ways of doing this, the National Committee on Quality Assurance (NCQA) and the National Quality Forum have developed procedures and policies that could be emulated or modified. For example, NCQA has technical advisory groups that provide advice on the importance, scientific soundness, and feasibility of different measures, and maintains a standing Committee on Performance Measurement that evaluates recommendations from technical experts and staff. A comparable set of procedures should be established by HRSA. The Committee summarizes these recommendations below.
Recommendation 6-1 Quality measures: HRSA should adopt quality measures that are comprehensive with respect to populations (diagnosed in care; diagnosed but not in care; not diagnosed, not in care), level of assessment (provider and population levels), types of measures (structure, process, and outcome), and spectrum of services (clinical and supportive services). At a minimum, HRSA and grantees should strongly consider inclusion of the following standard set of measures to assess the quality of care provided by RWCA-funded providers and EMA and state-level programs. Standard definitions and detailed criteria for these measures need to be developed by HRSA in collaboration with grantees, affected communities, and other stakeholders after a rigorous examination of the importance, scientific soundness, and feasibility of potential measures.
A. Structure
1. Proportion of providers with appropriate expertise and experience in treating patients with HIV*
2. Availability of case management services
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B. Process
Screening for:
3. Cervical cancer*
4. Hepatitis B
a. And administration of hepatitis B vaccine if negative
5. Hepatitis C*
6. Syphilis*
7. Toxoplasmosis
8. Tuberculosis*
Performance of the following clinical monitoring tests:
9. CD4+ cell count and HIV viral load (process)*
Antiretroviral treatment:
10. Provision of indicated antiretroviral treatment*
11. Provision of adherence counseling and monitoring
Vaccinations and prophylaxis for opportunistic infections:
12. Influenza vaccination
13. Pneumoccocal pneumonia vaccination
14. Hepatitis B vaccination if patient not immune
15. If indicated, Mycobacterium avium complex (MAC)
16. If indicated, Pneumocystis carinii pneumonia (PCP)*
C. Outcomes
17. Monitoring of CD4+ and viral load values*
18. Proportion of patients with a history of an AIDS-defining opportunistic condition*
19. Proportion of patients who have >2 missed scheduled clinic appointments per year
20. Hospitalizations and emergency room visits without hospital admission*
21. Proportion of patients with unmet need for support services (e.g., assistance with obtaining housing)^
Outcome measures related to access and care:
22. Proportion of HIV-infected persons in an area who are not diagnosed^
23. Proportion of diagnosed persons in area who are receiving regular care^
24. Proportion of people with HIV who died within 12 months of an HIV diagnosis*
25. Proportion of people with HIV who progressed to AIDS within 12 months of initial HIV diagnosis*
Key: * indicates high priority; ^ indicates high priority, but may require further development. Other measures are important, but of lower priority.
Recommendation 6-2 Infrastructure development: The Secretary of HHS should provide additional resources to HRSA and CDC to develop infrastructure for monitoring quality at the patient, clinic, and population levels. This infrastructure development strategy has three major components:
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HRSA should enhance support for information technology and personnel to enable clinics to collect, aggregate, and report a focused set of clinical and patient-reported data.
HRSA should collaborate with CDC and other agencies to develop innovative population-based measures that can be captured using existing data sources or other community-based information gathering activities, such as surveys of unmet needs.
Congress should enhance flexibility in the administrative caps at the grantee level to promote infrastructure development.
Recommendation 6-3 Collaborative quality activities: The Secretary of HHS should convene a working group, not restricted to, but including the NCQA; state insurance commissioners; state Medicaid officials; and representatives from HRSA, CDC, the Centers for Medicare & Medicaid Services; providers of community, outpatient, and inpatient care; and members of the relevant research communities to consider strategies for promoting greater collaboration between public health departments and public- and private-sector providers in order to establish tools and methods to assess systems of care and quality, building on the successful collaborative models developed by the CDC for immunization (e.g., Clinic Assessment Software Application and Assessment Feedback Incentives Exchange).
RWCA is a program that has provided lifesaving care to millions of persons who otherwise would not have access to adequate services, and that has helped develop an infrastructure for providing high-quality care that would not exist in its absence. Despite this success, it is critical to periodically reevaluate whether allocation strategies are an equitable and efficient way of distributing resources to jurisdictions with the greatest needs. Furthermore, it is important that activities for assessing and improving the quality of care be refined and expanded.
With the advent of HAART and the availability of a wide array of other support services and prevention efforts for HIV-infected individuals, it is essential to promote efforts to make individuals aware of their status and to facilitate their entry into care. Significant and continued improvements in long-term morbidity and mortality related to HIV will not occur unless these individuals are under appropriate care. The Committee recognizes that the last frontier to eliminate morbidity and mortality from HIV disease will be primary prevention.
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The Committee proposes that overarching principles of equity be used to guide the development of a refined and more explicit framework for evaluating the distribution of RWCA resources. It proposes several specific types of analyses that could be used to guide the evaluation and improvement of allocation formulas. Similarly, it proposes a framework for assessing quality of care provided to HIV-infected persons, and several specific steps that could be taken to build on existing work and develop a national, standardized approach to quality assessment. Such refinements in the approach to distributing and evaluating the impact of RWCA resources could help the CARE Act remain a pathbreaking approach to providing care to some of the nation's most vulnerable citizens.
Ball JK, Turner BJ. 1991. AIDS in U.S. Hospitals in 1986–1987: A National Perspective. Rockville, MD: Agency for Health Care Policy and Research. DHHS publication (PH) 91–0015.
Barre-Sinoussi F, Chermann JC, Rey F, Nugeyre MT, Chamaret S, Gruest J, Dauguet C, Axler-Blin C, Vezinet-Brun F, Rouzioux C, Rozenbaum W, Montagnier L. 1983. Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS). Science 220:868–71.
Bennett CL, Garfinkle JB, Greenfield S, Draper D, Rogers W, Mathews C, Kanouse DE. 1989. The relation between hospital experience and in-hospital mortality for patients with AIDS-related PCP. Journal of the American Medical Association 261:2975–9.
CDC (Centers for Disease Control and Prevention). 1981. Pneumocycstis Pneumonia–Los Angeles. Morbidity and Mortality Weekly Report 30:250–2. Atlanta, GA: CDC.
CDC. 1992. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report 41(RR–17):1–19. Atlanta, GA: CDC.
CDC. 1999. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report 48(13):1–28. Atlanta, GA: CDC.
CDC. 2003. Update on the Evaluation of the Performance of Integrated Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) Surveillance Systems. (Email communication, Patricia Sweeney, CDC, March 4, 2003).
Colfax GN, Bindman AB. 1998. Health benefits and risks of reporting HIV-infected individuals by name. American Journal of Public Health 88(6):876–9.
Donabedian A. 1966. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 44(3 (Supp)):166–206.
Fauci AS, Pantaleo G, Stanley S, Weissman D. 1996. Immunopathogenic mechanisms of HIV infection. Annals of Internal Medicine 124(7):654–63.
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Gallo RC, Salahuddin SZ, Popovic M, Shearer GM, Kaplan M, Haynes BF, Palker TJ, Redfield R, Oleske J, Safai B, et al. 1984. Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 224:500–3.
Georgia Division of Public Health, Epidemiology Branch, HIV/STD Epidemiology Section. 2003. Proposal for HIV Infection Reporting in Georgia. [Online]. Available: http://www.ph.dhr.state.ga.us/epi/hivreporting.shtml [accessed September 25, 2003].
GAO (General Accounting Office). 1995. Ryan White CARE Act of 1990: Opportunities Are Available to Improve Funding Equity. GAO/T-HEHS-95-91. Washington, DC: GAO.
GAO. 2000. Ryan White CARE Act: Opportunities to Enhance Funding Equity. GAO/ T-HEHS-00-150 . Washington, DC: GAO.
Hecht FM, Chesney MA, Lehman JS, Osmond D, Vranizan K, Colman S, Keane D, Reingold A, Bindman AB. 2000. Does HIV reporting by name deter testing? MESH Study Group. AIDS 14(12):1801–8.
HRSA (Health Resources and Services Administration). 2001. A Primer on Title I and Title II Formula Allocation Calculations. Unpublished document. (Email communication, Steven Young, HRSA, November 21, 2001).
HRSA. 2002a. Title I: Grants to Eligible Metropolitan Areas. [Online]. Available: http://ftp.hrsa.gov/hab/titleifact.pdf [accessed May 22, 2003].
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HRSA. 2002d. Title IV: Services for Women, Infants, Children, Youth, and Their Families. [Online]. Available: ftp://ftp.hrsa.gov/hab/titleiv.htm [accessed May 22, 2003].
HRSA. 2003. CARE Act Overview and Funding History. [Online]. Available: ftp://ftp.hrsa.gov/hab/fundinghis03.xls [accessed October 9, 2003].
IOM (Institute of Medicine). 2000. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press.
IOM. 2001a. Coverage Matters: Insurance and Health Care. Washington, DC: National Academy Press.
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Kaiser Family Foundation. 2000. Financing HIV/AIDS Care: A Quilt with Many Holes. Capital Hill Briefing Series on HIV/AIDS.
Kates J, Ruiz S. 2002. Sources of Coverage and Care for People with HIV/AIDS in the United States: Assessing Coverage in Southern States. Southern States Summit on HIV/AIDS and STDs. Menlo Park, CA: Kaiser Family Foundation.
Kessler RC. 1998. A methodology for estimating 12-month prevalence of serious mental illness. Mental Health, United States 1998. DHHS Pub. No. (SMA) 99-3285 ed. Washington, DC: Government Printing Office.
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Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. 1996. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. New England Journal of Medicine 334(11):701–6.
Mills R, Bhandari S. 2003. Health insurance coverage, 2002. Current Population Reports. Washington, DC: U.S. Census Bureau. Pp. 60–223.
Osmond DH, Bindman AB, Vranizan K, Lehman JS, Hecht FM, Keane D, Reingold A. 1999. Name-based surveillance and public health interventions for persons with HIV infection. Multistate Evaluation of Surveillance for HIV Study Group. Annals of Internal Medicine 131(10):775–9.
Pantaleo G, Graziosi C, Fauci AS. 1993. New concepts in the immunopathogenesis of human immunodeficiency virus infection. New England Journal of Medicine 328(5):327–35.
Pittman J, Andrews H, Struening E. 1986. The use of zip-coded population data in social area studies of service utilization. Evaluation and Program Planning 9(4):309–17.
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Thacker SB. 2000. Historical development. Principles and Practice of Public Health Surveillance . 2nd ed. Teutsch SM, Churchill RE, eds. New York: Oxford University Press.
Turner B, Markson L, Cocroft J, Cosler L, Hauck WW. 1998. Clinic HIV-focused features and prevention of Pneumocystis carinii pneumonia. Journal of General Internal Medicine 13(1):16–23.
U.S. Congress, House of Representatives. Committee on Commerce. 2000a. Report on Ryan White CARE Act Amendments of 2000 (106-788). 106th Cong., 2d Sess. July 25, 2000. Pp. 24–6.
U.S. Congress, House of Representatives. Committee on Commerce. 2000b. Report on Ryan White CARE Act Amendments of 2000 (106-788). 106th Cong., 2d Sess. July 25, 2000. P. 30.
U.S. Congress. 2000c. Congressional Record. 146(123): S10032.
U.S. Congress, Senate. 2000d. Ryan White CARE Act Amendments of 2000—Managers' Statement of Explanation. October 5, 2000.
Yeni P, Hammer SM, Carpenter CC, Cooper DA, Fischl MA, Gatell JM, Gazzard BG, Hirsch MS, Jacobsen DM, Katzenstein DA, Montaner JS, Richman DD, Saag MS, Schechter M, Schooley RT, Thompson MA, Vella S, Volberding PA. 2002. Antiretroviral treatment for adult HIV infection in 2002: Updated recommendations of the International AIDS Society-USA Panel. The Journal of the American Medical Association 288(2):222–35.
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(For Printable Size Chart (pdf), Click Here)Camera-ready ads should be submitted as correctly sized press-optimized pdf files, version 1.3 (PDF/x-1a) preferred. Ads may also be submitted in "native" layout format accompanied by all supporting image and font files. In preparing all ad layouts, please refer to image specifications listed below and ad sizes chart. Please be aware that because of the limitations and variations inherent in the printing process, we do not guarantee an exact color match. Images
If M.A.D. produces your ad for you: Send us your copy, images (high resolution digital images, photographic prints, slides, or color transparencies—no negatives, please), and a rough sketch of the proposed layout. We will create the ad and send you a color proof prior to publication. There is no additional charge for layout services. All color advertisers will receive a free standard listing in the 2015 Trade Directory as well. Payment - Color advertising invoices will
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Now Playing
Daddy Scrubs Part 2 Post Delivery |
Daddy Brad and Daddy Clay talk to Daddy Danny about the delivery of his son. Danny recounts the 30 hours of labor and their busted birthing plan. In the end, everything comes out fine and Danny and Miranda are the proud parents of a whopping 10 pound baby boy. Congratulations you two! |


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Healthy Agua Fresca Recipe
The Debloating Refresher You'll Want to Sip All Summer Long
One of my favorite drinks is the strawberry agua fresca sold every Wednesday at my neighborhood taqueria. A simple but oh-so-smart blend of fresh strawberries, water, and sugar, the traditional Mexican drink makes hot days bearable. I love buying mine right before closing after the strawberries have been soaking in the water for hours and I get bits of the fruit in my glass from getting one of the last servings.
Depending on where you go, aguas frescas can be filled with more sugar than a can of soda, but this recipe from NYC-based juicery Love Grace allows for the natural sweetness of the fruit to take precedent. It's everything you love about a great Summer farmers market in one glass, but with a secret weapon: the chia seed. Aside from giving the recipe a fun texture — almost like mini tapioca balls — it adds omega-3s and fiber to the drink.
From Love Grace
Berry Chia Fresca
2 cups water
2 teaspoons chia seeds
1/2 cup strawberries
1/2 cup raspberries
1 tablespoon fresh lime juice
1 tablespoon raw honey or agave
- Mix the chia and water together in a bowl and set in the fridge to plump for 15 minutes. Remove, mix again, and combine all ingredients in a blender. Puree until well combined and adjust the sweetness if needed.
- Category
- Smoothies, Drinks
- Yield
- 1 serving
- Cook Time
- 20 minutes


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Basement of the undead /
When Lew, Gary, and Lugnut are trapped in their middle school basement, they discover that at night it becomes the domain of zombie teachers and students--will they survive or be forced to join the undead? Full description
Main Author: | Strange, Jason. |
Other Authors: | Parks, Phil,, Dal Lago, Alberto, |
Format: | Book |
Language: | English |
Published: |
Mankato, Minn. : Stone Arch Books, 2012 |
Subjects: |


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Monthly Traffic Report – December 2012
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Dukeo being a live case study, it's important to keep track of traffic stats to follow the growth of this blog. I share the REAL stats of this website copied directly from Google Analytics.
Use these traffic reports to keep an idea of the kind of traffic you can generate over time when starting a blog from scratch, without leveraging any other web property.
Unique Visitors and Pageviews
Let's start with some general data about this month traffic: unique visitors and pageviews. These two indicators are the most commonly used in web statistics. Every webmaster know how many unique visitors he is receiving monthly as well as the number of page impressions. Here is Dukeo's data for this month:
Traffic Sources
Here is a general overview of the sources where dukeo's traffic has been coming from during the past month.
Top 5 Traffic Sources
Wondering what are the top 5 traffic sources of dukeo.com? Here comes the answer.
Top 10 Keywords
Following comes the list of the top 10 keywords which brought some traffic from search engines to dukeo.
- thousands for surveys reviews (44)
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- dukeo (29)
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- thousands for surveys (18)
- adding a new gmail address to my gmail account (17)
- dukeo income report (13)
Let's add some interesting information about the number of keywords which are bringing traffic to dukeo.
Top 10 Posts/Pages
And finally, here is the list of the top 10 most viewed posts/pages during last month. This may include some posts which have been published during previous months but are still very popular or highly ranked in SERPs.
- Homepage (10899)
- How To Start A Blog: Complete Guide (7189 Words) (5384)
- WordPress SEO: Get Insane Traffic From Google (7985 Words) (2363)
- DON'T Check Your Email First Thing in The Morning (1421)
- Bounce Rate: Everything You Need To Know (6051 Words) (1095)
- You Can Make Money Online Doing Anything You Want (943)
- 10 Reasons Why Your Blog Sucks (770)
- 9 Things to Consider Before You Send the Next Email (660)
- 6 Mistakes to Avoid on Email Subject Lines (656)
- Top 5 Blogging Misconceptions (607)
- 20 Blog Tips to Help You Succeed (570)
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Hi great to see that you are getting so much traffic. You didn't build any back links also right. What about the income


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Update: Iraq war 'was about oil'05/06/2003 14:12 - (SA)
Although The Guardian earlier reported that US deputy defence secretary, Paul Wolfowitz had said that the Iraq war was all about oil, the newspaper has now removed the article from its web site, and will print a full correction in Friday's edition. According to the Guardian's ombudsman, the quote, "Let's look at it simply. The most important difference between North Korea and Iraq is that economically, we just had no choice in Iraq. The country swims on a sea of oil," was taken out of context, and misconstrued.
Below is a copy of the original story as it appeared on News24:
Cape Town - Oil was the main reason for military action against Iraq, a leading White House hawk has claimed, confirming the worst fears of those opposed to the US-led war.
The Guardian reports that the US deputy defence secretary, Paul Wolfowitz - who has already undermined Tony Blair's position over weapons of mass destruction (WMD) by describing them as a "bureaucratic" excuse for war - has now gone further by claiming the real motive was that Iraq is "swimming" in oil.
The latest comments were made by Mr Wolfowitz in an address to delegates at an Asian security summit in Singapore at the weekend, and reported on Wednesday by German newspapers Der Tagesspiegel and Die Welt.
Asked why a nuclear power such as North Korea was being treated differently from Iraq, where hardly any weapons of mass destruction had been found, the deputy defence minister said: "Let's look at it simply. The most important difference between North Korea and Iraq is that economically, we just had no choice in Iraq. The country swims on a sea of oil."
Mr Wolfowitz went on to tell journalists at the conference that the US was set on a path of negotiation to help defuse tensions between North Korea and its neighbours - in contrast to the more belligerent attitude the Bush administration displayed in its dealings with Iraq.
His latest comments follow his widely reported statement from an interview in Vanity Fair last month, in which he said that "for reasons that have a lot to do with the US government bureaucracy, we settled on the one issue that everyone could agree on: weapons of mass destruction."
Prior to that, his boss, Defence Secretary Donald Rumsfeld, had already undermined the British government's position by saying Saddam Hussein may have destroyed his banned weapons before the war.
The Guardian says that Wolfowitz's frank assessment of the importance of oil could not come at a worse time for the US and UK governments, which are both facing fierce criticism at home and abroad over allegations that they exaggerated the threat posed by Saddam Hussein in order to justify the war.
Wolfowitz is viewed as one of the most hawkish members of the Bush administration. The 57-year old expert in international relations was a strong advocate of military action against Afghanistan and Iraq.
Following the September 11 terror attacks on the World Trade Centre and Pentagon, Wolfowitz pledged that the US would pursue terrorists and "end" states' harbouring or sponsoring of militants.
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Galactic Black Hole with Optical Jet
May 26, 2011
The energy source needed to create and maintain the galactic let in galaxy PKS 0521-36 is generated deep within the core of the galaxy, and is far too small to resolved. The favored mechanism behind these cosmic fireworks is a spinning, massive black hole. The hole is fueled by a continual in-fall of nearby gas and stars. This gravitational accretion process is far more efficient at converting mass to energy than thermonuclear fusion processes which power individual stars. The extraordinary high pressure and temperature generated near the hole would cause some of the in-falling gas to be ejected along the direction of the black hole's spinning axis to create the galactic let.
Relativity, Dark matter, Galaxy, Supermassive black holes, Stellar evolution, Black holes, Galaxy formation and evolution


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Thereʻs so much to say about a stuffed Teddy Bear; they are warm, cozy, best friends and put a smile on your face. A childʻs room wouldnʻt be complete without a stuffed Teddy Bear on the bed to hold onto during the dark night and play with during the light of day. As an adult, getting a Teddy Bear brings back those wonderful memories that will make their day special and let them know you care about them. (Just pay Shipping and Handling) Adorable Teddy Bear sent to your special someone Your own personalized message A custom gift box to make sure your Teddy Bear is delivered safe and happy. Make Someoneʻs Day Special Today! We believe everyone should feel special and let them know you are thinking about them without having to spend upwards of $50 or more. Flowers are wonderful but when those companies add all of their service fees, handling, special care fees, taxes and other charges it usually costs nearly $50. Thatʻs a lot of money. We want everyone to be able to give everyone a special day so we make it very affordable, the Teddy Bear is free. We just ask you to pay the shipping and handling charge of just $8.98. Thatʻs it. No hidden fees to surprise you. So make someoneʻs day special today by sending them a wonderful teddy bear sure to brighten their day and let them know you were thinking of them. We will carefully hand select one of our adorable Teddy Bears to send to that special someone for you. They range from 5 1/2 inches to 7 inches tall. We believe they are the perfect size..not too big or small…just right for giving smiles and hugs. They come in various colors from white, beige, brown and pink and sure to brighten any ones day. Adorable Teddy Bear FREE
Each Teddy Bear FREE + $8.98 S&H
Why Free?
Just Pay Shipping & Handling


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Anthony Edwards |
Dr. Mark Greene |
Eriq La Salle |
Dr. Peter Benton |
George Clooney |
Dr. Doug Ross |
Julianna Margulies |
Nurse Carol Hathaway |
Noah Wyle |
John Carter |
Sherry Stringfield |
Dr. Susan Lewis |
Pierre Epstein |
Dr. Bradley |
Guest Star |
Alexis Cruz |
Terry |
Guest Star |
Alanna Ubach |
Unknown |
Guest Star |
Abraham Benrubi |
Jerry |
Recurring Role |
Rick Rossovich |
Dr. John Taglieri |
Recurring Role |
Sam Anderson |
Dr. Jack Kayson |
Recurring Role |
In this episode, Susan tells Jerry she doesn't smoke, yet in an earlier episode ("Another Perfect Day"), when Carter meets her on the roof she's putting out a cigarette.
Diane: Dr. Ross...
Doug: Doug.
Diane: Before you try any harder, Cindy Sadwick is a very good friend of mine.
Doug: Mm-hmm. How is Cindy?
Diane: Well, she can't say your name without adding a few words I don't want my son to hear.
Doug: Tell her I said "hello."
Susan: Jerry, I really need a cigarette. Do you know where Lydia keeps her stash?
Jerry: I didn't know you smoked.
Susan: I don't.
In this episode, Gloria Reuben makes her first appearance as Jeanie Boulet. She would be a recurring guest star throughout the rest of the season and into the next, before joining the main cast as a regular in the Season 2 episode "Days Like This."
Previous title: "Missing Persons"
Title: "Long Day's Journey"
The title of this episode is a reference to Eugene O'Neill's autobiographical play Long Day's Journey into Night. Written in 1940 but published posthumously in 1956, it concerns a family that finds it difficult to live in the present, and whose existence is mired in the dark recesses of a bitter and troubled past.
S 15 : Ep 22
Aired 4/2/09 (1:24:58)
S 15 : Ep 21
Aired 3/26/09 (43:37)
S 15 : Ep 20
Aired 3/19/09 (43:44)
S 15 : Ep 19
Aired 3/12/09 (43:40)
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User Score: 95


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June 8, 2012 Israel builds huge underground hospital for protection against attacks |
The Rambam Medical Center in Haifa has unveiled the world's largest fortified hospital, intended to protect more than 2000 patients from missile and rocket attacks. Construction of the Sammy Ofer Northern Regional Underground Emergency Hospital was spurred by missile attacks by Hezbollah and Hamas, particularly during the Second Lebanon War in 2006. The patients will be housed dozens of meters below ground and will also be protected from chemical and biological weapons. During peaceful times, the underground structure will be used as a parking facility for up to 1,400 vehicles, the Times of Israel reported. |
JewishJournal.com is produced by TRIBE Media Corp., a non-profit media company whose mission is to inform, connect and enlighten community © Copyright 2015 Tribe Media Corp. |


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International Journal of Alzheimer's Disease
Volume 2012 (2012), Article ID 493670, 8 pages
Tau and Caspase 3 as Targets for Neuroprotection
The Adams Super Center for Brain Studies, The Lily and Avraham Gildor Chair for The Investigation of Growth Factors, The Elton Laboratory for Molecular Neuroendocrinology, and Department of Human Molecular Genetics and Biochemistry, Sagol School of Neuroscience, Sackler Faculty of Medicine, Tel Aviv University, 69978 Tel Aviv, Israel
Received 27 February 2012; Accepted 1 April 2012
Academic Editor: Hanna Rosenmann
Copyright © 2012 Anat Idan-Feldman et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The peptide drug candidate NAP (davunetide) has demonstrated protective effects in various in vivo and in vitro models of neurodegeneration. NAP was shown to reduce tau hyperphosphorylation as well as to prevent caspase-3 activation and cytochrome-3 release from mitochondria, both characteristic of apoptotic cell death. Recent studies suggest that caspases may play a role in tau pathology. The purpose of this study was to evaluate the effect of NAP on tau hyperphosphorylation and caspase activity in the same biological system. Our experimental setup used primary neuronal cultures subjected to oxygen-glucose deprivation (OGD), with and without NAP or caspase inhibitor. Cell viability was assessed by measuring mitochondrial activity (MTS assay), and immunoblots were used for analyzing protein level. It was shown that apoptosis was responsible for all cell death occurring following ischemia, and NAP treatment showed a concentration-dependent protection from cell death. Ischemia caused an increase in the levels of active caspase-3 and hyperphosphorylated tau, both of which were prevented by either NAP or caspase-inhibitor treatment. Our data suggest that, in this model system, caspase activation may be an upstream event to tau hyperphosphorylation, although additional studies will be required to fully elucidate the cascade of events.


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Iran-United States Claims Tribunal Precedent in Investor-State ArbitrationChristopher S. GibsonSuffolk University Law School Christopher R. DrahozalUniversity of Kansas School of Law Journal of International Arbitration, Vol. 23, p. 521, 2006 Suffolk University Law School Research Paper No. 07-15 Abstract: The article examines the jurisprudential value of Tribunal decisions and awards from both theoretical and empirical perspectives. The article considers four factors for assessing the precedential value of awards and decisions of international tribunals: (i) the integrity and authoritative standing of the court or tribunal issuing the earlier decision; (ii) the similarity of the relevant facts in the two cases, (iii) the similarity of the law relied on as necessary to making the decision (the decisional law); and (iv) the merits or instructive value of the prior tribunal's reasoning in reaching its decision - hence, its exposition of the law. Applying these factors to the jurisprudence of the Iran-U.S. Claims Tribunal demonstrates the importance of that jurisprudence as persuasive authority in investor-State arbitration. Part I of the article examines the extent to which Tribunal precedent has been cited by parties and tribunals in investor-State arbitrations. The citation analysis finds significant citation of Tribunal precedent in awards and decisions in arbitrations administered by the International Centre for Investment Disputes (ICSID), and in party submissions in arbitrations under Chapter 11 of the North American Free Trade Agreement. Thus, the awards and decisions of the Iran-U.S. Claims Tribunal have been and likely will continue to be an important source of authority in investor-State arbitration. Number of Pages in PDF File: 27 Date posted: April 3, 2007Suggested CitationContact Information
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Wednesday, April 18, 2012
inspiration -- neon.
ATTAINABLE: Banana Republic Heritage Ikat Skirt
www.bananarepublic.com; $98
I'm a little obsessed with this chic little pencil skirt. The crisp cotton is so pretty, and the pleats are perfection. But best of all is the lovely ikat print. In shades of chocolate and cream, it would be so pretty with brights or neutrals, and is incredibly versatile: it would wear as nicely for lunch with friends as it would as a fantastic work piece for the season.
It's been said that everything old becomes new again -- and when it comes to style, this is certainly true. Rompers. Aviator sunglasses. Platform pumps. Of course, each of these trends cycles in and out with a new spin each time, and I like to hope that they get less tacky as the years wear on. Enter: neon hues. Bold and bright, these colors swept the world of fashion in the 1980s and early 90s... And it's done so again now. Of course, I prefer it with neutrals and rich textures rather than teased hair and legwarmers -- but I leave that entirely up to you.
What's inspiring YOU today?
xo Josie
Thanks to Banana Republic and A Little Sparkle on the Side for the photos.
37 comments:
- LoveT. said...
Nice Post ,love the Skirt too :)
xoxo - April 18, 2012 at 8:30 AM
- BonBon Rose Girls Kristin said...
I want that neon lace top!
- April 18, 2012 at 9:24 AM
- C said...
I love that skirt!!! Big sigh!
Oh banana republic, how I love you, let me count the ways.... - April 18, 2012 at 10:31 AM
- Cate said...
Oh, neon is so fun in small doses - love it for accessories:)
cate @ wildruffle.com - April 18, 2012 at 10:32 AM
- Linds said...
i LOVE that picture of the sequin shorts and mini cambridge satchel - these colors are making me anxious for a summer vacay, and it's only April!
- April 18, 2012 at 11:25 AM
- TheChambrayCountess said...
I love the neon trend but I am not brace enough to make a monochromatic outfit, so I will be sticking to pops of color in my outfits! I love the lace top, the purse and those earrings you picked :)
- April 18, 2012 at 11:34 AM
- A BRIT GREEK said...
I'm loving pops of neon, always brightens up my day... I hit Zara yesterday and was blown away by the gorgeous collections. I picked up some gorgeous cobalt shorts with gold zips, so cute!
x.o.x.o - April 18, 2012 at 11:50 AM
- PinaR said...
I love the Neon Trend
Pinar - April 18, 2012 at 12:23 PM
- Katie said...
I just order a neon Rebecca Minkoff mac mini from Shopbop. It's the 3rd neon pink item I've bought lately. I think it's becoming a problem...
- April 18, 2012 at 1:06 PM
- Beautygirl24 said...
I'm completely beyond obsessed with the neon trend. I think I like it now because it just screams happiness! And paired with neutrals, it looks really chic. Not at all like the neons of yesteryear!
- April 18, 2012 at 2:13 PM
- meg said...
Love the neon look. Oh..always inspired what Zooey wears on THE NEW GIRL..now if I could only write the show..and they'd follow my script...I might enjoy the show more.
- April 18, 2012 at 2:34 PM
- Nnenna said...
I love outfits with a touch of neon- like that amazing RM bag above! :)
- April 18, 2012 at 3:01 PM
- Honey said...
oooh, i love the neon picks, especially the minkoff bag. and those silver shorts are so hot.
- April 18, 2012 at 4:09 PM
- this free bird said...
I can't get onboard the neon wagon. I just can't. Well maybe if it's a stripe on a bracelet. Caving?
- April 18, 2012 at 6:11 PM
- Style, She Wrote said...
Neons are great, but I'm drooling over that Banana Republic ikat skirt! xo style, she wrote
- April 18, 2012 at 7:34 PM
- beancakes said...
great selection here josie! and i too am obsessed with neons, especially chartreuse!!
xoxo - April 18, 2012 at 7:53 PM
- joannewchoi said...
I love the rebecca minkoff purse :)
I'm personally also loving the neon yellow cambridge satchel. I included it in my polyvore post and featured it on my blog too!
<3joanne - April 18, 2012 at 8:53 PM
- Haylee Mae said...
Love! Neons are so pretty and really make me feel like I stand out when I wear them.
http://www.dolledupdaily.com - April 18, 2012 at 11:17 PM
- Alessandra Mazzini said...
i'm liking that trend a lot!
http://www.fashionindahat.com - April 19, 2012 at 12:38 AM
- beckspick.com said...
i love everything neon. oh my the cross body is a must have! x
www.beckspick.com - April 19, 2012 at 1:20 AM
- Rachel - Notes from my closet said...
I really love it when trends re emerge like this :) It's always handy to have a 'what not to do' reference :)
Love, Rachel - April 19, 2012 at 2:02 AM
- isa said...
great post , i love neons ;D
xoxo - April 19, 2012 at 5:02 AM
- Kultur und Stil said...
I'm wearing something neon today, a neon pink sweater from zara. I love the things you showed above, only neon yellow isn't perhaps a good color for me...
And I like your blog and your style, I follow you ;-) perhaps you've some time to visit my blog too - and if you like it, I'd be happy to have you as a follower too!
xxx Anita - April 19, 2012 at 5:35 AM
- Audrey Leighton said...
LOVE the neon and love all of the neon pieces you've picked out!
Be Frassy - April 19, 2012 at 7:33 AM
- Erika said...
I am OBSESSED with neon accessories right now - especially handbags. They pair so well with cuffed denim! :)
- April 19, 2012 at 8:31 AM
- Geneva Garcia said...
OMG I love the set you did abour neon! :)
Please do visit my blog if you have time.
xx Geneva
http://fromgenevawithlove.tumblr.com - April 19, 2012 at 8:54 AM
- yiqin; said...
omg love neon <3
- April 19, 2012 at 10:54 AM
- Jessica said...
love the inspiration :)
http://runninginsideus.blogspot.com/ - April 19, 2012 at 10:57 AM
- STYLE'N said...
Loving the bright colors and neons right now and how cute is that BR skirt? I am hitting the mall today so maybe I will see if I can find that skirt
- April 19, 2012 at 11:11 AM
- S said...
Love that neon/grey/sequins combination, so stylish and feminine!
Great finds!
http://s-fashion-avenue.blogspot.com - April 19, 2012 at 2:15 PM
- Erin said...
that Banana Republic skirt is amazing! & I love the neon thing-it makes even the palest look a little bit tan!
Erin @ http://www.trufflesnruffles.com/ - April 19, 2012 at 2:47 PM
- Leeann @ Join the Gossip said...
I'm def all about neons right now! My nails are highlighter orange hehe :)
- April 19, 2012 at 5:58 PM
- Elle Sees said...
i'm loving mint and also neon!!
- April 19, 2012 at 8:48 PM
- Elle said...
I loveeee neon too!! Cant wait to get my first neon item!! That neon bag is super cute!
Www.melelle.com.au - April 20, 2012 at 9:03 PM
- Fashion Tales.... said...
I am addicted to neon items, especially handbags love that Ikat skirt! -xo
- April 21, 2012 at 10:51 PM
- LifestyleBohemia said...
I must pick up a yellow bag asap. Love your selections!
Joanna - April 22, 2012 at 2:17 PM
- Rachel Jensen {Da Paura ♥} said...
Neon is inspiring me lately too!! Loving ALL your neon pics here!
- April 22, 2012 at 5:18 PM


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Birdland, 5.7+ | [ Sizes: Orig | Large | Med | Small | Thumb ] | |||
2nd Pitch- 110'- 5.7/ You have two options. The intent of the route is to follow the arête directly above the anchor hooking into a crack to the left, but right of a right facing chimney section. You could also move the belay to the left and start in the chimney. In any regard, follow the crack to a ledge below a corner and then take the corner straight up, moving right below a block to reach an anchor on a large treed ledge. This is where you can divert and do Big Horn to the left, yet rappel and return to finish Birdland from this large ledge. Birdland, 5.7+, 5 Pitches, Spectrum Wall, Bridge Mountain, Red Rocks, April, 2008 | Image Data
Image ID: 396527 Hits: 1036 Object Title: Birdland, 5.7+ Image Type(s): Rock Climbing |


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Cozy Beach Cottage: Far From The Maddeing Crowd
Bedrooms: | 1 |
Bathrooms: | 1 |
Sleeps | 4 |
Per night | $100 - $150 |
Per week | $750 - $875 |
Type: | Cottage |
This beach cottage would be an ideal home for a URI student, The monthly rate is $700.00 Includes cable and trash. Nightly rate is $125.
Laurie Bates
Property Rates
Begins | Ends | Week Night |
Weekend Night |
Weekly | Monthly | Min Stay |
Sep 07 2013 | May 31 2015 | - | - | - | $700 | Full Period |
Sep 07 2014 | May 31 2015 | $100 | $150 | - | $700 | - |
Jun 01 2015 | Jun 28 2015 | - | - | $750 | - | 1 Week |
Jun 28 2015 | Sep 07 2015 | - | - | $875 | - | 1 Week |
: 12 p.m. : 10 a.m. | ||||||
Deposits: Yes. | ||||||
Payment Options: Cashier's Check, Money Order | ||||||
Other Fees: Security Deposit |
Reviews for this vacation cottage rental in Narragansett, Rhode Island
Anne Lovett
August 27, 2012
This was a great find. I just came back from staying there. Place is not fancy but clean and has anytyhing that you would need to have a great week. The owner was very nice and helpful but gave me my privacy. The beach is just a couple of steps from the cottage. You cant see it from the cottage but you can hear the waves at night. Wow! I will be back next year.
Laurie Petroske
Long Island, New York
Cozy Cottage
May 30, 2012
Cozy cottage just steps from a gorgeous beach! Very comfortable and clean, Sandy (owner) is very hospitable and welcoming! Cottage is set behind the owners house. Small, beachy neighborhood but two great seafood restaurants within walking distance. Would highly recommend this cottage and location for a relaxing get-away!
Deb Estrella
W. Warwick, RI
Just what I needed
November 1, 2011
This cute cottage has more room than meets the eye and is stocked with everything you need for a week on the beach. I stayed there alone, and the location was far enough from home to make it feel like a true vacation, but close enough for family and friends to visit for the day. Sandy was generously accomodating and neighborly, while respecting my privacy. And the beach was beautiful. I will definitely be back.
gail parker
Port Chester, New York
Surviving Hurricane Irene on the coast of RI
September 18, 2011
Even though we had to evacuate for one night and had no power for 4 days we loved this spot. We were able to cook out breakfast and dinner and enjoy the beach and beautiful weather, with the breath taking sunsets. Sandy did all she could to offer us as much comfort as possible in the situation, and we like to go back when everything is working without the threat of a hurricane. She was a wonderful owner.
Julien Bouget
Albany, NY
lovely, modest getaway
September 7, 2011
Sandy was very kind, generous, and accommodating, making for a wonderful experience. This is a quaint, cheerful little cottage, with every square inch of space well utilized. Even with 5 of us (including three kids under 6), we didn't feel cramped. There was even enough room for a pack-n-play crib in the bedroom. There is a shallow kids' beach just around the corner that was perfect for our family. I highly recommend this for a low key getaway.
wm murphy
June 13, 2010
Enjoyed our stay and found Sandy friendly and accomidating. Just prior to all the tourist which is the way we like it. Nice area, close to most everything you need.
Nice Cottage
July 6, 2009
The cottage was very clean and the location was convenient. It was an enjoyable week.
Jaime A. Heidel
Wallingford, CT
A quiet, restful place.
June 15, 2009
I really enjoyed my stay at this cute and cozy little beach house. Sandy, the owner, was very friendly and accommodating. I had an entire week of sun, sand, peace and quiet. The house is conveniently close to shopping areas, restaurants and the Block Island ferry. I had a great time and would highly recommend this little house for a relaxing and fun vacation getaway!
Dominic Angelini
Poor Management
May 31, 2009
Never did go on vacation. Never recieved a reponse from the owner for the rental. I had to write 5 TIMES before I recieved a reponse. The week was open per your web site. But after 5 tries and three weeks. The owner, unprofessionally, wrote back NOT AVAILABLE !! When your web site said it was ????? So, Did Not Go On Vacation. Awful Experience with your company !!! POOR MANAGEMENT from the start!!
Jane Smith-Decker
Harrisburg, PA
Not quite what I expected
May 24, 2009
This was advertised as ocean front. It was but from the owner's deck in front of her large windows. No privacy. Otherwise, nice cottage, location, and cool breezes.


text:
Nuclear Energy Insider: Exelon, Progress Energy and TVA in crucial Power Uprate meeting
Huge challenges including time, cost, quality and procurement must be overcome when undergoing a power uprate project. With costs of uprating a unit at $250-500 million, creating a potential market of $25 billion, the US nuclear industry must have a clear understanding of the most effective methods to uprate nuclear power.
(PRWEB) April 02, 2012
To advance the latest industry developments and learn from the first-hand experience of others, key utilities such as Exelon, Progress Energy, TVA, E.On will be meeting major OEM & EPC firms including Westinghouse, GE Hitachi, Shaw Power Group and Bechtel.
The conference they´ll be attending is undoubtedly the best chance in 2012 for service providers to meet and network with the major US utilities and vendors that are actively seeking new, innovative and practical solutions to aid their uprate projects.
Delivering expert case studies and focusing on specific issues such as engineering specifications for procurement and installation of major components during an Extended Power Uprate, this meeting is not to be missed. Attendees will benefit from:
- An exclusive tour of the new Siemens Energy Turbine and Generator Manufacturing and Service Facility in Charlotte, North Carolina
- Insight into the extended power uprate project at E.On´s OKG Oskarshamn 3 plant — now the world´s largest BWR — so you can develop schedules that save you time and money
- An Operations & Engineering perspective of the Crystal River 3 uprate program from Progress Energy giving you the tools to improve your uprate strategy
- Update on the Browns Ferry uprating program from the TVA giving you the facts on the latest opportunities and progress
- Expert case studies from Bechtel's uprate work at Point Beach & St Lucie and analysis of the North Anna uprate project from ALSTOM
As well as comprehensive power uprate analysis from Exelon, Shaw Power Group, Westinghouse, GE Hitachi and more.
The 3rd Annual Nuclear Power Uprate Conference will supply your business with the critical intelligence and tools you need to understand effective uprating strategies. Delivered by the best in the industry — you´ll be able to take away key lessons and real world action points that you can implement to slash costs.
The conference will be bringing together 200 power uprate experts for two days of business critical intelligence, unrivalled networking and stimulating discussion. With senior level business leaders from across North America, leading contractors and equipment providers and specialist service companies — can you afford to miss out?
For more information follow: http://www.nuclearenergyinsider.com/uprate
For the original version on PRWeb visit: http://www.prweb.com/releases/prweb2012/4/prweb9352064.htm


text: What's the best way to survive the Monday drag? Keep the weekend going. The cats at the underground label Black Scale, known for their fresh clothing and hip-hop lifestyle continue to kill it…on a Monday night. If you're in the Bay Area, head over to Harlot tonight for Black Scale's Belvedere IX Launch SF Party.


text:
Clean out the closet. Do a thorough declutter of the space that you want to clear out. Make the donation pile so that you know what's ready to go.
Prepare the clothes. Remove hangers, check the pockets and wash if possible. Don't forget we need shoes, purses and accessories.
Donate bath towels, blankets, and sheets. Even towels and bedding that are threadbare can have a second life as they are used for cleaning up, and recycling.
Put the clothes, bedding, and other items into suitable containers. Containers that are suitable include plastic garbage bags, unwanted tote and other bags (they'll get resold too if in good condition), baskets,boxes, etc.
Click on the truck below and we'll come get your items and leave you a tax receipt!!