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Author Affiliations: Office of Education Research, Mayo Medical School (Dr Cook), and Division of General Internal Medicine (Drs Cook, Szostek, and Wang), Department of Surgery (Dr Zendejas), and Mayo Libraries (Ms Erwin), Mayo Clinic College of Medicine, Rochester, Minnesota; Department of Medicine, University of British Columbia, Vancouver, Canada (Dr Hatala); Department of Medicine, University of Toronto, Toronto, Ontario, Canada (Dr Brydges); and Academy for Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (Dr Hamstra).
Context Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education.
Objective To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention.
Data Source Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011.
Study Selection Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals.
Data Extraction Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors.
Data Synthesis From a pool of 10 903 articles, we identified 609 eligible studies enrolling 35 226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I2>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality.
Conclusion In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.
Responding to changing practice environments requires new models for training health care professionals. Technology-enhanced simulation is one possible solution. We define technology broadly as materials and devices created or adapted to solve practical problems. Simulation technologies encompass diverse products including computer-based virtual reality simulators, high-fidelity and static mannequins, plastic models, live animals, inert animal products, and human cadavers.
Although technology-enhanced simulation has widespread appeal and many assert its educational utility,1 such beliefs presently lack empirical support. Despite the large volume of research on simulation, its effectiveness remains uncertain in part because of the difficulty in interpreting research results one study at a time. Several systematic reviews2- 5 and at least 2 meta-analyses6,7 have attempted to provide such syntheses, but each had limitations, including narrow inclusion criteria, incomplete accounting of existing studies, limited assessment of study quality, or no quantitative pooling to derive best estimates of the effect of these interventions on educational and patient outcomes. We therefore sought to identify and quantitatively summarize all studies of technology-enhanced simulation involving health professions learners.
This review was planned, conducted, and reported in adherence to PRISMA standards of quality for reporting meta-analyses.8
We sought to answer 2 questions: (1) To what extent are simulation technologies for training health care professionals associated with improved outcomes in comparison with no intervention? and (2) How do outcomes vary for different simulation instructional designs? Based on the strength of the theoretical foundations and currency in the field, we selected 5 instructional design features2,9 (curricular integration, distributed practice, feedback, mastery learning, and range of difficulty) for subgroup analyses (see eBox for definitions).
Broad inclusion criteria were used to present a comprehensive overview of technology-enhanced simulation in health professions education. Studies published in any language were included if they investigated use of technology-enhanced simulation to teach health professions learners at any stage in training or practice, in comparison with no intervention (ie, a control group or preintervention assessment), using outcomes10 of learning (knowledge or skills in a test setting), behaviors (in practice), or effects on patients (eBox). We included single-group pretest-posttest, 2-group nonrandomized, and randomized studies; parallel-group and crossover designs; and studies of "adjuvant" instruction in which simulation was added to other instruction common to all learners.
Studies that evaluated computer-based virtual patients requiring only standard computer equipment were excluded because these have been the subject of a recent systematic review.11 Studies that involved human patient actors (standardized patients) or simulation for noneducation purposes such as procedural planning, disease modeling, or evaluating the outcomes of clinical interventions were also excluded.
An experienced research librarian (P.J.E.) designed a strategy (eAppendix) to search MEDLINE, EMBASE, CINAHL, PsychINFO, ERIC, Web of Science, and Scopus using search terms for the intervention (eg, simulator, simulation, manikin, cadaver, MIST, Harvey), topic (eg, surgery, endoscopy, anesthesia, trauma, colonoscopy), and learners (eg, education medical, education nursing, education professional, students health occupations, internship and residency). No beginning date cutoff was used, and the last date of search was May 11, 2011. This search was supplemented by adding the entire reference lists from several published reviews of health professions simulation and all articles published in 2 journals devoted to health professions simulation (Simulation in Healthcare and Clinical Simulation in Nursing) since their inception. Additional studies were sought from authors' files. We searched for additional studies in the reference lists of all included articles published before 1990 and a random sample of 160 included articles published in or after 1990.
The authors worked independently and in duplicate to screen all titles and abstracts for inclusion. In the event of disagreement or insufficient information in the abstract, the full text of potential articles was reviewed independently and in duplicate. Conflicts were resolved by consensus. Chance-adjusted interrater agreement for study inclusion, determined using the intraclass correlation coefficient12 (ICC), was 0.69.
A data abstraction form was developed through iterative testing and revision. Data were extracted independently and in duplicate for all variables when reviewer judgment was required, using the ICC to determine interrater agreement and resolving conflicts by consensus.
We abstracted information on the training level of learners, clinical topic, training location (simulation center or clinical environment), study design, method of group assignment, outcomes, and methodological quality. Methodological quality was graded using the Medical Education Research Study Quality Instrument (MERSQI)13 and an adaptation of the Newcastle-Ottawa Scale (NOS) for cohort studies14,15 that evaluates representativeness of the intervention group (ICC, 0.86), selection of the comparison group (ICC, 0.29, with 86% raw agreement), comparability of cohorts (statistical adjustment for baseline characteristics in nonrandomized studies [ICC, 0.86] or randomization [ICC, 0.89] and allocation concealment for randomized studies [ICC, 0.65]), blinding of outcome assessment (ICC, 0.58), and completeness of follow-up (ICC, 0.36, with 78% raw agreement). We further coded the presence of simulation features identified in a review of simulation2: feedback (ICC, 0.47), repetitive practice (ICC, 0.42), curriculum integration (ICC, 0.53), range of task difficulty (ICC, 0.37), multiple learning strategies (ICC, 0.45), clinical variation (ICC, 0.49), and individualized learning (ICC, 0.31). We also coded the presence of mastery learning (ICC, 0.65), distributed practice (whether learners trained on 1 or >1 day; ICC, 0.73), and cognitive interactivity (ICC, 0.28), the duration of training (ICC, 0.68), and the number of task repetitions (ICC, 0.69). We initially planned to abstract information on simulation fidelity but were unable to operationalize this construct with high reliability.
Outcomes were distinguished using the Kirkpatrick classification10 and information was abstracted separately for learning (knowledge and skills, with skill measures further classified as time, process, and product), behaviors with patients (time and process measures), and results (patient effects). When authors reported multiple measures of a single outcome (eg, multiple measures of efficiency), we selected in decreasing order of priority (1) the author-defined primary outcome; (2) a global or summary measure of effect; (3) the most clinically relevant measure; or (4) the mean of the measures reported. We also prioritized skill outcomes assessed in a different setting (eg, different simulator or clinical setting) over those assessed via the simulator used for training. When abstracting data from learning curves, the first time point was used as the pretest and the last reported time point as the postintervention assessment.
Each mean and standard deviation or odds ratio was converted to a standardized mean difference (the Hedges g effect size).16- 18 When this information was unavailable, the effect size was estimated using statistical test results (eg, P values).16 For 2-group pretest-posttest studies, we used posttest means adjusted for pretest or adjusted statistical test results; if these were not available, we standardized the difference in change scores using the pretest variance.17 For crossover studies, we used means or exact statistical test results adjusted for repeated measures; if these were not available, we used means pooled across each intervention.19,20 For studies reporting neither P values nor any measure of variance, we used the average standard deviation from all other studies reporting that outcome. If articles contained insufficient information to calculate an effect size, we requested this information from authors via e-mail.
The I2 statistic21 was used to quantify inconsistency (heterogeneity) across studies, with values greater than 50% indicating high inconsistency. Because there was high inconsistency in most analyses, random-effects models were used to pool weighted effect sizes. Planned subgroup analyses were conducted based on study design (randomized vs nonrandomized), total quality score, and selected instructional design features (presence of curricular integration, distributed practice over >1 day, feedback, mastery learning, and range of task difficulty) using the z test22 to evaluate the statistical significance of interactions. As thresholds for high or low quality scores, we used an NOS score of 4 (as described previously15) and the median of the MERSQI scores (12). Sensitivity analyses were performed excluding studies that used P value upper limits or imputed standard deviations to estimate the effect size. Although funnel plots can be misleading in the presence of inconsistency,23 we used these along with the Egger asymmetry test24 to explore possible publication bias. In cases of asymmetry, trim and fill was used to estimate revised pooled effect size estimates, although this method also has limitations when inconsistency is present.25 SAS software, version 9.1 (SAS Institute Inc, Cary, North Carolina) was used for analyses. Statistical significance was defined by a 2-sided α = .05, and interpretations of clinical significance emphasized confidence intervals in relation to Cohen effect size classifications (>0.8 = large; 0.5-0.8 = moderate).26
We identified 10 903 potentially relevant articles, 10 297 using the search strategy and 606 from the review of reference lists and journal indexes. From these, we identified 635 studies comparing simulation training with no intervention (Figure 1), of which 628 reported an eligible outcome. We identified 9 reports of previously reported data and 6 articles reporting different outcomes for previously described interventions; for these, we selected the most detailed report for full review. Nine articles contained insufficient data to calculate an effect size. We received additional information from 5 authors; the remaining 4 were excluded. Ultimately, we analyzed 609 studies enrolling 35 226 trainees. Table 1 summarizes key study features and eTable 1 lists all references with additional information.
Since the earliest study we identified, published in 1969,27 investigators have evaluated the use of technology-enhanced simulations in teaching laparoscopic surgery, gastrointestinal endoscopy, suturing skills, emergency resuscitation, team leadership, examination of the heart, breast, and pelvis, and many other topics. Nearly half the articles (n = 282) were published in or after 2008, and 24 were published in a language other than English. Learners in these studies encompass a broad range of health care professionals, including physicians, nurses, emergency medicine technicians, military medics, dentists, chiropractors, veterinarians, and other allied health staff, and range from novice to expert.
Of the 609 studies, 274 spread training across more than 1 day, 108 provided high feedback, and 59 used a mastery learning model. Table 2 lists other simulation key features. Of 910 outcomes reported in these studies, 785 (86%) were objectively determined (eg, by faculty ratings or computer scoring). The majority (n = 690) assessed skills in a training setting, including time to complete the task, process measures (eg, global ratings of performance, economy of movements in surgery, or minor errors), and task products (eg, quality of a dental preparation, procedural success, failure to detect key abnormalities, or major procedural complication). Skills were usually assessed with the simulator that was used for training. However, 36 of 210 time outcome measures (17%), 58 of 426 process measures (14%), and 15 of 54 product measures (28%) assessed skills using another simulation mode (ie, skill transfer). Knowledge outcomes (usually multiple-choice test scores) were reported in 118 studies; time and process behaviors with real patients in 20 and 50 studies, respectively; and direct patient effects in 32 studies. Behavior process measures included instructor ratings of competence, completion of key procedural elements, and procedural errors, while patient effects included procedural success, patient discomfort, complication rate, and patient survival; eTable 2 lists all behavior and patient outcomes.
Table 3 summarizes the methodological quality of included studies. The number of participants providing outcomes ranged from 2 to 1333, with a median of 24 (interquartile range, 15-47). One hundred thirty-seven of 204 2-group studies (67%) were randomized. Three 2-group studies (1.5%) determined groups by self-selection or completion/noncompletion of training. Although such groupings are susceptible to bias, sensitivity analyses excluding these studies showed similar results. Twenty-four of 118 studies (20%) assessing knowledge, 73 of 210 (35%) assessing time skills, 133 of 426 (31%) assessing process skills, 18 of 54 (33%) assessing product skills, 10 of 20 (50%) assessing time behaviors, 12 of 50 (24%) assessing process behaviors, and 12 of 32 (38%) assessing patient effects lost more than 25% of participants from time of enrollment or failed to report follow-up. Again, sensitivity analyses excluding these studies showed no substantial difference. Assessors were blinded to the study intervention for 503 outcome measures (55%), but only for knowledge outcomes did blinding show a significant association with effect size. Mean quality scores were relatively low, averaging 2.1 (SD, 1.5) for the NOS (maximum, 6 points) and 11.6 (SD, 1.9) for the MERSQI (maximum, 18 points).
Figure 2, Figure 3, Figure 4, and Figure 5 (also eFigures 1-7) summarize the meta-analysis results. In general, simulation training was associated with moderate to large, statistically significant positive results but with high inconsistency. Subgroup analyses demonstrated no consistent interactions. Sensitivity analyses did not alter study conclusions, and where funnel plots were asymmetric, trim-and-fill analyses yielded results similar to the original.
Simulation compared with no intervention; positive numbers favor the simulation intervention. P values reflect statistical tests exploring the differential effect of simulation training (ie, interaction) for study subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made and the number of trainees is not reported. Some features could not be discerned for all studies; hence, some subgroups do not sum to the total number of studies. NOS indicates Newcastle-Ottawa Scale; MERSQI, Medical Education Research Study Quality Instrument. See also eFigure 1 and eFigure 2.
Simulation compared with no intervention; positive numbers favor the simulation intervention. P values reflect statistical tests exploring the differential effect of simulation training (ie, interaction) for study subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made and the number of trainees is not reported. Some features could not be discerned for all studies; hence, some subgroups do not sum to the total number of studies. NOS indicates Newcastle-Ottawa Scale; MERSQI, Medical Education Research Study Quality Instrument. See also eFigure 3 and eFigure 4.
Simulation compared with no intervention; positive numbers favor the simulation intervention. P values reflect statistical tests exploring the differential effect of simulation training (ie, interaction) for study subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made and the number of trainees is not reported. Some features could not be discerned for all studies; hence, some subgroups do not sum to the total number of studies. NOS indicates Newcastle-Ottawa Scale; MERSQI, Medical Education Research Study Quality Instrument. See also eFigure 5 and eFigure 6.
Simulation compared with no intervention; positive numbers favor the simulation intervention. P values reflect statistical tests exploring the differential effect of simulation training (ie, interaction) for study subgroups. Participant groups are not mutually exclusive; thus, no statistical comparison is made and the number of trainees is not reported. Some features could not be discerned for all studies; hence, some subgroups do not sum to the total number of studies. NOS indicates Newcastle-Ottawa Scale; MERSQI, Medical Education Research Study Quality Instrument. See also eFigure 7.
Knowledge. One hundred eighteen studies (with 8595 participants providing data) reported comparison with a preintervention assessment or a no-intervention control group using knowledge as the outcome (Figure 2a and eFigure 1). The pooled effect size for these interventions was 1.20 (95% CI, 1.04-1.35; P < .001), consistent with large26 gains. However, there was high inconsistency among studies, with individual effect sizes ranging from −0.42 to 9.45 and I2 = 96%. Three studies (studies 70, 365, and 416 in eTable 1) reported a negative effect size (ie, outcomes were worse for simulation), although in the study with the largest negative effect size (study 70), the skills outcomes showed substantial benefit. The funnel plot was asymmetric and the Egger asymmetry test result was significant. Assuming this asymmetry reflects publication bias, trim-and-fill analyses provided a smaller but still large pooled effect size of 0.86 (95% CI, 0.68-1.04). Among the 16 studies with randomized group assignment, the pooled effect size was 0.63.
Tests for interactions in subgroups indicated that interventions distributed over more than 1 day (vs a single day) and those that were optional (vs integrated or required activities) were associated with significantly larger effect sizes. Studies scoring low on the modified NOS were associated with larger effect sizes than high-quality studies, and blinded outcomes were associated with higher effect sizes than unblinded assessments.
Time Skills. Two hundred ten studies (5651 participants) reported the time required to complete the task in a simulation setting (Figure 2b and eFigure 2). The pooled effect size of 1.14 (95% CI, 1.03-1.25; P < .001) reflects a large favorable association. There was high inconsistency across studies (I2 = 84%), and effect sizes ranged from −1.55 to 21.0. In each of the 10 studies (studies 171, 176, 215, 269, 270, 292, 354, 367, 407, and 525 in eTable 1) with negative effect sizes for time skills, other skill outcomes showed substantial improvements (ie, learners took longer but performed better). Funnel plot analysis suggested possible publication bias, but trim-and-fill analysis decreased the effect size only slightly to 1.10 (95% CI, 0.98-1.21). The 47 randomized trials had a pooled effect size of 0.75.
Interventions providing low (vs high) feedback and those with curricular integration were associated with larger improvements in time outcomes. Lower study quality, as measured by both the NOS and MERSQI, was associated with significantly larger effect sizes.
Process Skills. Four hundred twenty-six studies (20 926 participants) reported skill measures of process (eg, global ratings or efficiency) (Figure 3a and eFigure 3). The pooled effect size of 1.09 (95% CI, 1.03-1.16; P < .001) reflects a large favorable association but large inconsistency (I2 = 89%). Effect sizes ranged from −0.50 to 8.55. Possible explanations for the 7 studies with negative effect sizes (studies 95, 126, 185, 193, 319, 496, and 566 in eTable 1) include misalignment between the intervention and the assessment (2 cases [studies 95 and 185] of training for one procedure [eg, cholecystectomy] and assessing performance on a different procedure [eg, appendectomy]) and delayed testing with continued clinical training during the interim (a 3-month [study 566] or 2-year [study 126] delay). In 2 other cases (studies 319 and 496), all other outcomes assessed showed improvements. Funnel plot analysis suggested possible publication bias; trim-and-fill analysis provided a smaller but still large pooled effect size of 0.94 (95% CI, 0.87-1.01). The 87 randomized trials had a pooled effect size of 0.98.
Interventions using a mastery learning model, in which learners must achieve a rigorously defined benchmark before proceeding, were associated with significantly higher outcomes than nonmastery interventions.
Product Skills. Fifty-four studies (2158 participants) evaluated the products of the learners' performance, such as procedural success or the quality of a finished product (Figure 3b and eFigure 4). There was a large pooled effect size of 1.18 (95% CI, 0.98-1.37; P < .001) and high inconsistency (I2 = 87%). Effect sizes ranged from −0.09 to 6.24. For the single study (study 58 in eTable 1) showing a negative product skills effect size, other skill outcomes showed a positive association. Trim-and-fill analysis in response to an asymmetric funnel plot yielded a pooled effect size of 1.0 (95% CI, 0.77-1.23). The 15 randomized trials had a pooled effect size of 0.76.
Interventions using a mastery learning model were associated with lower learning outcomes, and lower study quality was once again associated with significantly higher learning outcomes.
Behavior. Twenty studies (384 participants) used a measure of time to evaluate behaviors while caring for patients (Figure 4a and eFigure 5). The association approached a large effect size (0.79; 95% CI, 0.47-1.10; P < .001), with I2 = 66%. Effect sizes ranged from −0.24 to 5.6, and for each of 3 studies with negative effect sizes (studies 151, 504, and 530 in eTable 1), the other behavior outcomes showed large positive associations. The funnel plot was reasonably symmetric. In contrast with other outcomes, higher study quality was associated with larger effect sizes. The 13 randomized trials had a pooled effect size of 1.01.
Fifty studies (1975 participants) reported other learner behaviors while caring for patients (Figure 4b and eFigure 6), with a large pooled effect size of 0.81 (95% CI, 0.66-0.96; P < .001) and I2 = 70%. Effect sizes ranged from −0.46 to 2.25. Three studies (studies 312, 547, and 583) found negative results. In one (study 312), the authors questioned the accuracy with which their simulator mimicked reality. Another (study 547) found slightly smaller behavior and patient effect outcomes when adding a 30-minute refresher course to routine intubation training. The 30 randomized trials had a pooled effect size of 0.85. There were no statistically significant associations in any of the planned subgroup analyses. The funnel plot was symmetric.
Effects on Patient Care. Thirty-two studies (1648 participants) reported effects on patient care (see aforementioned examples and Figure 5, eFigure 7, and eTable 2). For these outcomes, simulation training was associated with a moderate pooled effect size of 0.50 (95% CI, 0.34-0.66; P < .001). Inconsistency was high (I2 = 67%) and effect sizes ranged from −0.28 to 1.68, with 2 studies reporting a negative effect size. One of these studies (study 547) is described above; the other (study 387) found slightly worse patient outcomes but a substantial improvement in behaviors. The 14 randomized trials had a slightly smaller effect size of 0.37. The funnel plot was symmetric. Distributed training was associated with larger effect size.
Sensitivity Analyses. We used P value upper limits (eg, P <.01) to estimate 150 of 910 effect sizes (16%) and we imputed standard deviations to estimate 83 effect sizes (9%). Sensitivity analyses excluding these 233 effect sizes yielded pooled estimates similar to those of the full sample (approximately 5%-7% higher than those reported above for knowledge, process skills, and product skills outcomes; no change for patient effects; and 2%-7% lower for time skills, time behaviors, and other behaviors outcomes). Because most studies involved few participants, the possible dominance of very large studies was assessed by excluding the 22 studies with more than 200 participants; this analysis showed nearly identical results.
Technology-enhanced simulations, in comparison with no intervention or when added to traditional practice, were with only rare exceptions associated with better learning outcomes. Pooled effect sizes were large26 for knowledge, skills, and behaviors, and confidence intervals excluded small associations. Effect sizes for patient-related outcomes were smaller but still moderate.
Yet in nearly all cases, the magnitude of association varied substantially for individual studies (high inconsistency), and subgroup analyses exploring simulation design differences largely failed to explain this variation. Although distributing learning activities over more than 1 day was consistently associated with larger effect sizes and mastery learning was associated with larger effect sizes for most outcomes, these differences were rarely statistically significant and inconsistency usually remained high.
In contrast, with rare exceptions there was lower inconsistency for 2-group posttest-only studies, randomized trials, and studies with high modified NOS scores. Also, 2-group studies and studies with high quality scores had a consistent (and often statistically significant) association with smaller effect sizes. These findings could be due to chance, other between-study differences such as variation in simulation design, or the sensitivity of the outcome measure. Still, it makes sense that studies with a comparison group, which helps control for maturation and learning outside of the intervention, would show smaller effect sizes than single-group studies, and this has also been found in studies of Internet-based instruction.28
Because of this review's comprehensive scope, pooling outcomes across diverse simulation modes and educational contexts, we necessarily deferred exploring many topic- and design-specific interactions. The high inconsistency among studies was not surprising, reflecting variation not only in modes and clinical topics but also in learner groups, instructional designs, research methods, and outcome measures. Because the overwhelming majority of training interventions were associated with benefit, this heterogeneity could be interpreted as supporting the effectiveness of technology-enhanced simulation across a broad range of learners and topics.
Inferences are limited by the quality of available studies. Many reports failed to clearly describe the context, instructional design, or outcomes; poor reporting may have contributed to modest interrater agreement for some variables. Most studies had important methodological limitations. Two-thirds were single-group pretest-posttest comparisons and small samples were the norm. Most studies reported multiple measures of the same outcome, and although the results were usually congruent in direction, the magnitude varied slightly; however, we used a consistent approach in selecting measures to minimize bias. Because technology-enhanced simulations are designed for health professions training, we did not include studies from nonhealth fields. We could not blind reviewers to article origins.
The subgroup analyses should be interpreted with caution because of the number of comparisons made, the absence of a priori hypotheses for many analyses, the limitations associated with between-study (rather than within-study) comparisons, and inconsistent findings across outcomes. For example, we found (contrary to expectation) that interventions with high feedback were often associated with smaller effect sizes. These and other counterintuitive results could be due to confounding (eg, simulation features unrelated to feedback that consistently affect the design or outcome), variation in outcome responsiveness, chance, or bias as well as true effect.
Strengths of the review include the exhaustive search; inclusion of multiple non-English articles; reproducible inclusion criteria encompassing a broad range of learners, outcomes, and study designs; duplicate, independent, and reproducible data abstraction; and rigorous coding of methodological quality. Funnel plots and trim-and-fill analyses suggested that publication bias is unlikely to affect our conclusions.
The 2005 review of high-fidelity simulation by Issenberg et al2 identified 109 studies evaluating high-fidelity simulation in the health professions. Our meta-analysis contributes to the field by adding and synthesizing 500 additional studies. Previous meta-analyses of simulation training for health care professionals have found that laparoscopic surgery simulation (23 studies6) and training with deliberate practice (14 studies7) are associated with improved outcomes compared with no training. Systematic reviews of surgical simulation in general4,5 have likewise concluded that simulation is beneficial. The finding of large associations when comparing technology-enhanced education with no intervention is consistent with recent meta-analyses of Internet-based instruction15 and computer-based virtual patient simulations.11
Technology-enhanced simulation training is associated with improved outcomes in comparison with no intervention for health care professionals across a range of clinical topics and outcomes, including large effects on clinician behaviors and moderate effects on patient care. In light of such large associations, and with only 4% of the outcomes failing to show a benefit, we question the need for further studies comparing simulation with no intervention (ie, single-group pretest-posttest studies and comparisons with no-intervention controls).
The important questions for this field are those that clarify29 when and how to use simulation most effectively and cost-efficiently.30,31 Unfortunately, the evidence synthesized herein largely fails to inform the design of future simulation activities. Subgroup analyses weakly suggested a benefit to extending training beyond 1 day and using a mastery model but otherwise did not identify consistent associations involving instructional designs. However, between-study (rather than within-study) comparisons are an inefficient research method.32 Thus, theory-based comparisons between different technology-enhanced simulation designs (simulation vs simulation studies) that minimize bias, achieve appropriate power, and avoid confounding,30 as well as rigorous qualitative studies, are necessary to clarify how and when to effectively use technology-enhanced simulations for training health care professionals.
Corresponding Author: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, Baldwin 4-A, 200 First St SW, Rochester, MN 55905 (firstname.lastname@example.com).
Author Contributions: Dr Cook had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Cook, Hatala, Hamstra.
Acquisition of data: Cook, Hatala, Brydges, Zendejas, Szostek, Wang, Erwin.
Analysis and interpretation of data: Cook.
Drafting of the manuscript: Cook.
Critical revision of the manuscript for important intellectual content: Cook, Hatala, Brydges, Zendejas, Szostek, Wang, Erwin, Hamstra.
Statistical analysis: Cook.
Administrative, technical, or material support: Cook, Zendejas, Wang, Erwin.
Study supervision: Cook.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: This work was supported by intramural funds, including an award from the Division of General Internal Medicine, Mayo Clinic.
Role of the Sponsor: The funding sources for this study played no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation of the manuscript. The funding sources did not review the manuscript.
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- Now with this the best curing irons, you can show other people your potential skill of a barber
Ceramic Hair Waver Curling Iron Effect:
How to Use a Ceramic Curling Iron on Long Hair?
Using a ceramic curling iron on long hair is an easy way to add soft waves and sexy style. While the idea of a curling iron makes many women a little nervous, practice definitely makes perfect in this case. Grab your ceramic curling iron and curl away.
Things You'll Need:
- Shine serum
- Curling iron
- Oven glove
- Hairspray
- Use a shine serum specifically for protecting hair from hot styling tools. Use the product sparingly, as it will weigh hair down, shorten the life of your curls and make your hair look dirty. Start with a pea-sized amount, rub it between your palms and work your way from the ends towards the scalp. Stay about an inch or two away from the roots to keep the hair from looking greasy
- Separate dry hair into one- to two-inch sections, depending on how big and loose you want the curls to be. The larger the curling iron, the bigger and softer your curls will be. Use an oven glove (you'll need the kind that separates all of your fingers, a mitten won't work) and wrap the hair around the iron. Make sure that the tip of the iron is consistently angled down. If you turn the iron in different directions, your curls will all point in different directions. Wrap the hair that is closest to your scalp around the base of the iron and work your way toward the tip of the ironThough your curling iron probably has a clip to hold hair in place while it sets, holding it with the oven glove and keeping the clip off of it will create much more natural-looking curls
- Separate the curls gently with your fingers. If you want them to be softer, brush through your hair using your finger tips. Once you have achieved the exact look you want, spray lightly hairspray
- How much hairspray you use is completely dependent on how much hair you have, how well it holds a style naturally and how natural you want you hair to feel. The more spray you use, the better your curls will hold, but beware as a lot of hairspray can create an obvious coat of product on the hair, which can make it look and feel unnatural
- If you're doing this for the first time, give yourself plenty of time to finish. Rushing this process the first time around can result in burning yourself or curls that look very unnatural. Be realistic with the curls you are trying to achieve. If your hair is not long (i.e. past your shoulders) you won't have enough hair to wrap around a large curling iron
- Use your hair products sparingly, you can always add more if you need it later. If you add too much, however, you'll have to wash your hair and start again. The oven glove is not necessary, but it's a great way to avoid getting burned, especially if you're an amateur hair curler
Package Included:
- 1 x Curling Iron
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It's a footrest, a legrest, a headrest and a back support with a center opening to keep your remote control handy! Contoured memory foam pillow is flat on one side, curved on the other, with a zip-off, machine-washable cover of plush microsuede. Keep one on the couch, another on the bed! 14 1/2"W x 11"D x 5"H.
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The Office of Faculty Affairs is responsible for all aspects of administration pertaining to faculty, research scientist, and annual appointments, as well as faculty searches and standing committees of the faculty.
- Here is: The 2014 – 2015 schedule of faculty meetings and selected faculty committees, and committee charges and membership
Title IX & Gender Equity
NEW UNIVERSITY TITLE IX POLICY AND PROCEDURE: Harvard will implement for the coming academic year a new, University-wide Title IX policy and procedures to prevent sexual harassment – including sexual violence – related to sex, sexual orientation or gender identity.
Download the new University-wide policy and procedures for faculty and non-faculty academic appointees.
- Harvard Chan School specific policies and procedures for either (a) faculty, (b) research scientists or for (c) annual appointments are found in each guidance area in purple menu on left or through the appropriate Harvard Chan School Title IX Coordinator
- Diversity, Harassment and Miscellaneous Policies as are applicable to all schools/unit are found at the University level here: http://diversity.harvard.edu/pages/policies
- Grievance Procedures begin at the school/unit for the affiliation of the individual for whom the complaint is against and by selecting the school/unit shield here first: http://diversity.harvard.edu/other-policies-procedures-school
90 Smith Street, 1st Floor / Boston, MA 02120
617-432-1047 / 617-432-4711 (fax)


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Big Air is for kids 46" and over and all adults. It's an open area of wall-to-wall trampolines where you can get some serious air! Gallery
Small Air is a fun corner of the Get Air Trampoline Park reserved for kids under 46"! Gallery
Plan your next BIRTHDAY party at Get Air! Enjoy our private party rooms for cake and presents. Reserve today! Gallery
Play a game of dodgeball on the trampolines! Form your own team or take part in a pick-up game! Gallery
Jump into Get Air's Ultimate Foam Pits! The pits give you a soft place to land and you can watch your jump on our live monitors! Gallery
Dunking just got a whole lot easier with Get Air's basketball trampoline court. Get some lift to your game! Gallery
We have accommodations for children and adults with special needs. Talk to our helpful Get Air staff! Gallery
Relax in one of our leather massage chairs! Why not get a little pampering on the job? Gallery


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Explore the Property
Luxury Apartment Homes
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Our state-of-the-art fitness center is available to you 24 hours a day and is equipped with ellipticals, stair climbers, treadmills, weight machines, free weights and more.
Refresh your mind, body and spirit! Our sparkling aquamarine lap pool is open and heated year-round for 365 days of rejuvenation!


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This article was written in 2012, however many of the places do an annual Thanksgiving feast. Check the websites of the venues to see what they are offering. -david
It's that time of the year, when Americans gather around the Thanksgiving table. Because of the number of requests from travelers, and some locals, here is a round-up of places serving Thanksgiving meals. Since the holiday is celebrated on Thursday, which is a regular working day in Paris, many places offer the meal on other nights of the week as well.
I've linked to the venue, and the event, so folks can check out what each place is offering. I can't make specific recommendations since I usually stay at home so this list is for informational purposes. Listed are two places that sell Thanksgiving supplies and foods, and most outdoor markets and butchers in Paris also sell turkeys (and turkey melons!) There are excellent farm-raised turkeys in France, although they're not as common to find as other poultry.


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Dentures Center - Levittown, NY
WebMD Physician Directory
Levittown, New York
What are dentures?
When a person is missing teeth, he or she may experience a variety of problems. The person may become less confident in their smile and have difficulty speaking and eating certain foods. Dentures are appliances that ar...
Other Related Dentures Articles
Emergency Contact for Levittown
Nearby Levittown Hospitals *
Saint Joseph Hospital
Nassau University Medical Ctr
Plainview Hospital
South Oaks Hospital
Brunswick Hall
Syosset Hospital
Mercy Medical Center
Winthrop University Hospital
Sagamore Children's Psych Ctr
South Nassau Communities Hosp
Franklin Hospital
Saint Francis Hospital
Long Island Jewish Medical Ctr
Cohen Children's Medical Center
Zucker Hillside Hospital
North Shore University Hospital
Queens Children's Psychiatric
Glen Cove Hospital
Good Samaritan Hospital Med Ctr
Creedmoor Psychiatric Center
Huntington Hospital
Long Beach Medical Center
Pilgrim Psychiatric Center
Holliswood Hospital
St Mary's Healthcare Children
Southside Hospital
Queens Hospital Center
St John's Episcopal Hospital
VA Medical Center-Northport
Cornerstone Medical Arts Center
Flushing Hosp Med Ctr
Jamaica Hospital Medical Center
New York Hospital Medical Ctr
Forest Hills Hospital
St Catherine Of Siena Med Ctr
Bronx Psychiatric Center
Calvary Hospital
New York City Children's Center
Montefiore Medical Center
Sound Shore Medical Center
Elmhurst Hospital Center
Jacobi Medical Center
St Vincent's Hosp Westchester
Wyckoff Heights Medical Center
Mount Vernon Hospital
Brookdale University Hospital
Montefiore Wakefield Campus
Bronx Lebanon Hospital Center
St Barnabas Hospital
Montefiore Medical Center
Mount Sinai Queens
North Central Bronx Hospital
Greenwich Hospital
Bronx Lebanon Hospital Center
Interfaith Medical Center
Woodhull Mdcl & Mntl Hlth
Kings Brook Jewish Medical Ctr
Lawrence Hospital Center
Lincoln Med/Mntl Hlth Ctr
Kingsboro Psychiatric Center
James J Peters VA Medical Ctr
Stamford Hospital
Kirby Forensic Psychiatric Ctr
Manhattan Psychiatric Center
Metropolitan Hospital Center
University Hospital Of Brooklyn
Harlem Hospital Center
Gracie Square Hospital
Hospital For Special Surgery
Kings County Hospital Center
Allen Hospital
Memorial Sloan-Kettering Cancer
New York Weill Cornell Med Ctr
Rockefeller University Hospital
Burke Rehabilitation Hospital
*Provider Directory Terms of Use:
The WebMD 'Provider Directory' is provided by WebMD for use by the general public as a quick reference of information about Providers. The Provider Directory is not intended as a tool for verifying the credentials, qualifications, or abilities of any Provider contained therein. Inclusion in the Provider Directory does not imply recommendation or endorsement nor does omission in the Provider Directory imply WebMD disapproval.


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Nestled in the Central Valley, our hotel is located between Sacramento, Oakland, San Francisco, San Mateo, San Jose, Stockton, Modesto and Tracy. Our opportune location places you minutes from Big League Dreams, Stockton Ports Baseball, Haggin Museum, Old Town Sacramento, University of the Pacific and a variety of local restaurants, shopping and entertainment. Popular area attractions include Del'Osso Family Farm, Micke Grove Park and Zoo, Manteca Golf Course and Mossdale Crossing Regional Park.
Business travelers appreciate that we proudly offer a well-equipped business center and complimentary WiFi. We're located near Ghirardeli Chocolate Company, Ford, Daimler Chrysler, Monier Lifetile, Pilkington North America, Honda, Doctors Hospital of Manteca, San Joaquin General Hospital in the Central Valley.
Hotels in the Stockton, CA area can't compete with our extensive list of amenities that make your stay unforgettable, like a complimentary, hot Express Start breakfast bar and on-site convenience store. Enjoy a dip in the indoor, heated pool and whirlpool after you burn off those extra calories in the fitness center.
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He and his wife, Bonnie, contacted Animal Control and were given the number for a Wildlife Damage Control Agent.
Tripp Bowling, Cleveland County Animal Control Shelter Supervisor, said the Walkers' description of the animal's behavior didn't match that of a sick or rabid fox.
"If the fox is acting strange we will go out and first make sure all of the pets have been vaccinated," Bowling said. "They will act very aggressive. This fox seemed like it was afraid of the person."
Protecting her pups
The Walkers also contacted Danny Ray, District 8 Wildlife Biologist, who listened to their description and explained the fox's behavior as a mother protecting their young.
"He told us how she was acting and that she was trying to lead everybody away from the den," Bonnie said. "The fox was doing exactly as he said."
Ray told the Walkers to inform their neighbors to keep their children away and to stay away from the area.
"Leave them alone and they will leave you alone," Ray said. "When she finishes raising the pups, they will move on."
Animals seen more often in the spring
Ray said foxes raise their pups in the spring and it is not unusual to see them.
"I've gotten several calls this spring," he said. "I seem to get them with foxes. You might get the occasional coyote."
He said all wildlife will act in a similar way to protect their young, and he has also gotten calls about birds swooping down on people to protect their nests.
Daytime sightings on the rise
He said people shouldn't jump to the conclusion that seeing a wild animal in the daytime means it is sick. Because cities have built up in the last 20 years, and people have invaded their territory, animals are no longer afraid to be seen by people.
"Raccoons, skunks, foxes, coyotes - all these animals are in the community and have been all along," Ray said. "Wildlife are quickly learning to adjust to living around people. The fox thinks, 'I've been around 100 people and they haven't threatened me, so I'm going to run across this guy's back yard."
A sick animal, he said, will appear emaciated and dehydrated. The animal could be suffering from distemper or some other sickness, not necessarily rabies.
"Any kind of sick animal will act differently," he said. "They will hold their head down and be in more of a daze. Rabies will make an animal more aggressive, but once it gets to that stage the animal is in the latter stages of the disease and will not last too much longer after that."
Reach Jackie Bridges at 704-669-3337.
- Cleveland County Animal Control: 704-481-9884
- Danny Ray, District 8 Wildlife Biologist, N.C. Wildlife Resources Commission, 828-391-1161, email@example.com
10 a.m. Friday May 10
A resident in a west Shelby neighborhood told The Star that a fox growled at hime in the neighborhood this morning. We're looking into getting more information about what's being done. Now that it's getting warmer, have you noticed any new visitors to your neighborhood? Any acting aggressive?
Check back for updates on the story as they develop.


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I dropped everything I was watching, but I'll probably pick it back up at some point. In any case, a few days ago I started on Gintama and currently am up to Ep. 5. (****ing college schedules slowing my *** down...)
I guess I'll add a listing when I add new series.


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Installing solar power at their Shelter Island, N.Y., Ace Hardware store seemed like the right thing to do for the planet, say owners David Gurney and Meredith Page. But now that the brother-and-sister ownership team have the system, they're finding that it's also good for their wallets.
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SEIA is the solar energy industry's go-to source for the latest coverage on solar power, including U.S. and international policy, research and polls, business and financing trends, and more. Our staff strives to support the media covering solar energy issues and guide our members on effective media outreach with clear statements, background materials, news and multimedia resources.
SEIA is committed to informing policymakers, the media, and the American public about the benefits of solar energy for today's communities, our economy, and our country.
Learn more from our statements and industry news below.
Renewables Want Level Playing Field
Growth in renewables manufacturing is about to slow, and thousands of jobs will be lost, if Congress doesn't level the playing field between renewables and traditional fossil energy sources, renewables advocates told the National Hydropower Association conference April 18 in Washington DC.
Austin City Council to Form Solar Committee
Under pressure from solar-power advocates who fear Austin may short-circuit a budding local industry, the Austin City Council is rethinking the city's strategy for expanding solar power.
LIPA Celebrates Earth Day with Host of Solar Accomplishments, Initiatives
Long Island has become a leader in renewable energy in New York State, the Eastern region and the nation with initiatives and milestones including the installation of Long Island's 5,000th solar roof and Long Island Power Authority's CLEAN Solar Initiative (CSI).
NYSEIA Praises Gov. Cuomo's NY-Sun Initiative
New York Solar Energy Industries Association (NYSEIA) today praised Gov. Andrew M. Cuomo's NY-Sun Initiative to double the amount of customer-sited solar power installed annually in New York and quadruple that amount by 2013.


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Is Giovanna Plowman the ultimate embodiment of tween fame perception? [The Girl Who Sucked Her Tampon]By Carles on 24 Jan 2013
One of the disorienting aspects about 'growing up' is how your perception of 'fame' evolves. If you are relatively smart/self-aware, you begin to deconstruct the contextual mechanisms that create and sustain 'fame.' Eventually, you find yourself feeling a little bit silly for worshipping athletes, singers, and humans with notoriety. You understand that the majority of 'famous' people aren't always living great lives', and aren't as rich as 'really, really rich people' anyways. The idea of being 'famous' as a means to have your entire life 'taken care of' seems to be absurd. Every one has problems, and 'having people know who you are' doesn't necessarily mean anything. In fact, it can eventually just add another complex layer to personal and financial problems.
Then the internet came and created hyper-microfame, where a single meme can propel one human to 'human meme status.' It is clear that these people will 'go viral', be processed by the mainstream newscycle which 'uses' the internet to poach for 'oddly enough' stories, and eventually become a 'well known' talking point of the day, usually illustrating some sort of generic 'lapse in morals' in the current iteration of our 'failed society.'
God Bless Giovanna Plowman.
In a way, she perfectly embodies the perception of how tweens perceive 'social media fame' as 'fame.' Judging influence, relevance, and reach by perpetual engagement on Twitter. I feel like as a child, you saw a television or newspaper and thought that if some one was 'in that', they had become successful [via 'fame']. Since many of us have grown up alongside the internet's media evolution, it doesn't feel like the internet is an absolute space. The single pages of HTML don't really 'mean anything' besides knowing that a content farming monkey was ordered to write a post about it. We've seen internet trend cycles come and go for years now.
But next comes the Giovanna Plowman generation. Those who do not know what life 'without the internet' was like. #Trending 'means' something to them, it's not just an added feature to Twitter to improve real-time value. Tween-fame-perception has an increased valuation of the perpetual need for that realtime engagement. 'Being in Google' means that they are in an exclusive, relevant database. Follower counts 'mean' something to them, whether or not they are actually have a monetizable skill or gateway into an emerging industry.
Giovanna Plowman's conceptual art masterpiece provides relevant commentary on the physical maturation of the evolving female because her 'tampon sucking experiment' was used as a means to achieve 'fame.' This teen female forfeited the privacy that most of us want as we are sexually maturing. Experiencing our first menstruations, erections, ejaculations, and orgasms. Plowman's sexual exploration by way of sucking on her own tampon could be processed by some as hyper-sexual fetish porn, but in reality was motivated by a rather naive desire for 'fame.'
She perfectly uses technology to create a meaningful viewing experience, complete with the use of a 'smart phone', and her decision to play a buzz rap song, "212" by Azealia Banks.
Giovanna Plowman seems to be self-obsessed, a stereotypical 'overweight teen' who is 'fortunate' enough to have big enough breasts to give her a heightened sense of self-confidence. The simplification of her sexual identity is not entirely her fault, nor is her simple perception of 'the fame acquisition process.'
Does this look yummie 2 u?
How far would u go 2 achieve 'fame'?
Do u think she will be able 2 get a relevant career?
Will she be able 2 get in2 a top tier college or University?
Will she be eternally #bullied?
Is she 'the new Honey Boo Boo'?
Do u think Honey Boo Boo will eat her tampons for 'the love of the game', not 4 fame?
In the wake of the Plowman Tampon controversy, she has taken to Twitter (@ItsGiovannaP), actively using the social network to scold all of her 'haters' and bask in the praise of all of her fans, who have celebrated her. It is interesting to think about the Bieberfication of the tween fame perception. One must first upload video(s) to Youtube. The video will be viewed by many people. Convert them to Twitter Followers and Facebook Likes. Then 'fame' will work itself out. You will be 'covered.' You will go on a Press Tour. People will love you. There will be haters. You say that the haters pay ur bills. You will be remembered forever.
Will Giovanna Plowman be 'remembered forever'?
Do __% of girls do their own 'off camera' tampon tasting at least once in their lives'?
Do all tweens just think 'getting on Ellen' will make them rich & famous?
At the end of the day, do we all want the same things?
Don't we all want 1 last oportunity 2 shine bright like a _______ [via a tampon]?
Was this video 'real'?
How do u feel about 'fame'?
Is the idea of 'being famous' appealing 2 u?
Do tweens 'get' fame?
Who is 'truly famous'?
Can ppl 'be famous' in the internet era, or is the idea of 'niche fame' more clear than evr?
On a per capita basis, are people who are 'famous' in 2013 actually 'less famous' than some1 who was 'famous' in 1983?
Is Giovanna Plowman 'effing hot'?
R u on #TeamGiovanna?
Did she get everything that she ever wanted?
Does 'internet fame' mean more or less than evr?
Do u miss the days of innocent memes Chris Crocker/Tay Zonday?
Have tweens and AZNs taken over the internet? [via PSY]
[via knowyourmeme.com]


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Hello everyone!
I am here teaming up with Tamrac to give a little insight on the shoots I did for Canon. Over the next eight weeks we will be posting a new image with the story behind the lens and I hope everyone enjoys them.
– Ted Craig
ted craig tuesdays | week 1
Right from the pulmonary stages of this shoot I was very excited to execute it. Canon wanted the message to be "one with nature" with a straight down perspective. At first we were going to use dirt to show a part of nature but I have always loved the look of grass from a birds eye view so I received the go to use my backyard carpet. This image is a seven image composite. I used a large soft box and balanced it out with the ambient light in the shade.
ted craig tuesdays | week 2
This was a fun shoot where I had the chance to enjoy the great outdoors of Mammoth Lakes, CA. There was a concern on the way up that there would not be enough snow due to the heatwave at the end of March. The goal of this image was to market that Tamrac bags will follow you through thick and thin. I thought it would be unique to have myself covered up to my ears in snow with the bag beside me. I wanted to convey that I don't need to worry about my equipment because I know it's going to be safe and dry. The first day consisted of scouting with snow shoes and warm coffee, unfortunately there wasn't much snow at first. Thankfully, a light snowfall happened that night and I was able to find the perfect secluded spot the following day. After I got myself situated on set, I waited for the right amount of backlight to illuminate the snowfall. The image itself consists of six separate frames and I would acquire a cold for the next three days.
ted craig tuesdays | week 3
This was on our way to the Sierra Nevada. More accurately, this was shot at a rest stop off the 395. The sky was beautiful and moving fast with the clouds which created holes of light. We waited and shot till a large cloud covered the mountain behind me, creating that natural spotlight. I wanted the image to be striking; from composition, to use of color, so that the viewer felt no confusion about what to look at first. I am not a huge fan of contrast photos but I ended up being really happy with this image. This is a three image composite. I used the natural sun and a reflector.
ted craig tuesdays | week 4
I had a blast with this shoot. This location was where I grew up; I can see this part of the meadow from my old childhood bedroom. Though, within the last year or so, someone planted a baby tree on top of this hill. For that year I have been wanting to take photos up there or around there, or somehow incorporate it from afar. My original thought for the shoot was much farther away with more minimalism. I had to come closer to make it more of a full length shot of the tree, still I think it has that simplistic feel. It was a windy day which is what was needed to come across in the image. I did receive a couple honks during the shoot, due to the fact I looked somewhat looney on the edge of this hill, hanging on to this tree as if she was the love of my life. This image is a five image composite. I used just the natural light.
ted craig tuesdays | week 5
For this shoot I got to create that unhygienic kid mud hole that everyone loved! Belly flop and all I jumped in and covered my self in soil and dirt. The message was I could go anywhere with my equipment even back to my childhood. It really was a blast to get filthy, but finding dirt in my hair a week later wasn't so sweet. This image is a six image composite. I used a 6′ octobox and natural light.
ted craig tuesdays | week 6
Call this shoot "Strength in hands." I remember climbing the baseball field's backstop fence as a kid, but what I didn't remember was the difficulty in doing it. Canon wanted an urban setting and a "getting that shot not matter what" message across. It was a beautiful day with just a minimal amount of clouds. I really wanted that element in the photo so I ended up doing a couple test shots to get my timing down climbing up that fence. Came to the, regretful, conclusion that my hands couldn't take that many climbs with the equipment; granted the top of the fence was 15′. I waited for the cloud to come in, climbed up, snapped three frames with my remote, and jumped off calling it a day. Don't have those ambition childhood hands anymore. This is a two image composite. I used just the natural light.
ted craig tuesdays | week 7
This was another urban shot Canon wanted. It was crazy windy and I bent two umbrellas that day; not fun. Since I wanted the subject to be looking into the sun, I had to have the umbrella facing right into the wind. To fix this problem I had my assistant bear hug the umbrella like the trooper she is. This is a two image composite. I used a 580exii just behind the bag and the natural light.
ted craig tuesdays | week 8
Hope everyone had a great Labor day weekend!
Going into this shoot I had a completely different shot in my head. I really wanted a lot of sand coming in at different directions and freezing right before hitting my camera. But white sand on white sky is pretty unseeable. I moved into the shade to get that flatter light and to have some bokeh in the background, hoping it would bring out the sand a little more. It still wasn't enough, and I didn't want to spend hours in post making it visible, so I looked around and found a little stream of water; a run off from a hose. I grabbed the mud, did a test shot, and we had dirt! It took many tries but we got mud + camera together nicely. This is a ten image composite. I used the natural light and a reflector on camera right..
Every Tuesday we'll roll out a new installment of our eight week series titled Ted Craig Tuesdays. This series highlights 8 images created by Ted Craig for Canon.
For more of Ted Craig check out his website and follow him on instagram.
Want More? Follow us on Facebook, and find us on Instagram to keep up with all things Tamrac!


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Economic Importance for Humans: Positive
Amphiprion percula and other anemonefishes are some of the most colorful fish species available for the aquarium trade. They also demonstrate interesting behaviors and are easily adaptable to captivity (Fautin and Allen, 1992). Consequently, these characteristics make them good reference fishes for scientific research, especially when conducting nutritional studies and determining egg and larval quality (Gordon et al., 2000). (Fautin and Allen, 1992; Gordon et al., 1998)
Positive Impacts: pet trade; ecotourism; research and education
- Fautin, D., G. Allen. 1992. Field Guide to Anemonefishes and their Host Sea Anemones. Perth: Western Australian Museum.
- Gordon, A., H. Kaiser, P. Britz, T. Hecht. 1998. Effect of feed type and age-at-weening on growth and survival of clownfish *Amphiprion percula* (Pomacentridae). Aquarium Sciences and Conservation, 2: 215-226.


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Gallery: PICS: Property Damage From Irene Could Hit $7 Billion
Increased numbers of natural disasters (you can thank climate change for that) over the last year have already strained the insurance industry. According to the New York Times:
The A. M. Best Company, which rates the financial strength of insurers, called the level of natural disasters this year "unprecedented" in a report on the American insurance industry issued last week. The company, based in New Jersey, said disaster-related losses this year had already exceeded the total for all of 2010. It estimated the losses at $27 billion through June 30, compared with $11.9 billion in the first six months of last year and $19.6 billion for all of 2010. The company based its findings on a survey of roughly 150 insurers, which it said accounted for 80 percent of the industry.
Like we said before, make sure to take photos of any damage sustained to your property. State officials are urging people to do so in order to properly make insurance claims. Your first reaction may be to try to fix the damage, but take a photo first to document exactly what happened. You should also not attempt any permanent repairs until your insurance company can examine the situation. If you haven't already done so, you need to contact your insurer, as many companies have deadlines for filing after disasters.
As of 8 a.m. this morning, some 44,000 Con Ed customers were still without power across the five boroughs. There were several deaths by fast and furious rising waters, and the Fire Department rescued 63 people from flooded homes. Several ocean front homes in Coney Island and the Rockaways were severely damaged, with one summer home in Broad Channel completely collapsing into the ocean. Thankfully no one was inside, and no one was hurt.
New Jersey was hit a bit harder than NYC, with winds reach 75mph and the highest rainfall being recorded at 10.2 inches. This morning, 712,000 customers were still without power, and heavy flooding and extensive amounts of debris are hampering repairs, meaning that customers could be without power for several days. Long Island and Connecticut also had significant damage, with flooding and numerous downed trees and power lines. More than half a dozen homes are reported to have severe property damage, and two beach front homes in Connecticut collapsed.
If you live in New York and have any questions about filing your claims, you can call the state's Financial Services department from 8 a.m. to 8 p.m. at 800-339-1759.
Via The New York Times, NBC New York, and The Wall Street Journal
Lead image © Kevin D'Angelo
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I haven't had a lot of time to play over the last month. I'm in a relatively hardcore guild. As a result, I'm way behind everyone else. Pretty much everyone else in the guild has gotten to 70. In fact, I think that I have the lowest level main character in the guild.
This experience has made me really understand the desire to power-level characters. I really want to play with my guild, to see new content with them. I like levelling, and I don't really want to skip content, but I do want to play with my friends.
Levels and progression are both boon and bane to this genre. The idea of slowly improving your character is a major attraction, and just the process of levelling up is fun. But when levels are out of sync, they are annoying because they are preventing you from playing with your friends.
I have a couple of real life friends on the server as well. One just started a month ago, so all of our levels are out of whack. To be honest, there's probably no real way we are all going to be able to play together until we all hit 70. When levels no longer matter.
In many ways, this is the central paradox of the MMO genre. Levels are the carrot, the reason for playing. They represent effort and achievement. But levels also prevent you from playing with your friends. This Penny Arcade comic sums up the dilemma perfectly.
I know different games handle it differently. WoW has the level caps and the slow-down in level speed, as well as rested experience. EvE Online has skills based on real-time, rather than in-game time. I believe that City of Heroes has a 'side-kick' system to temporarily boost a lower level character up. But I don't think any of these solutions truely solve the problem.
I have no idea what the perfect solution is. It may well be that there isn't one, that this is just a total paradox, and the best you can do is make a reasonable trade-off.
Sunday, February 18, 2007
Left Behind
I haven't had a lot of time to play over the last month. I'm in a relatively hardcore guild. As a result, I'm way behind everyone else. Pretty much everyone else in the guild has gotten to 70. In fact, I think that I have the lowest level main character in the guild.
4 comments:
- Anaea said...
That is my favorite PA comic ever. It really captures the sometimes tense process of leveling up with my husband. :) We each got so jealous of the other being a bar or two ahead!
I think Blizzard has tried to address some of the leveling disparity. 70s still need to grind Underbog etc. for their Cenarion rep to get the Heroic dungeon, so that will keep them in the loop of the 5-mans as their guildies level up.
It won't solve every problem, and it's still a far cry from being on the "exploration team" and seeing all of this new content with the group. I hope things work out for you! :)
- 9:49 AM, February 19, 2007
- Happypappy said...
I know exactly how you feel, I'm hit 69 yesterday and am nearly the last person to hit 70. I don't think the leveling to 70 has much to do with player skill though, its more of a time factor, I feel that when I'm actually playing I'm leveling very quickly, but I don't get much time to play, and thus I'm not level 70 yet....
- 6:43 PM, February 19, 2007
- Anonymous said...
My thought on leveling vs playing with friends is that you need to ask what your priorities are.
Do you derive the most enjoyment from playing with friends? Experiencing new content with them? Moving up together? Wiping together? Laughing about it later?
Or do you prefer to be 'solo'? Does seeing something first, or getting the coolest loot, or something else appeal to you more?
The problem with friends trying to play together is that you have to make a choice: do you move at a slower pace in order to experience things together? Or do you move at your pace and see things as quickly as possible? Are you capable of delaying gratification? This is something we do with other media all the time.
For example, consider seeing a movie. Most people won't go to the theater alone, or even rent a movie to watch alone. Seeing a movie is a social event. If you want to see a movie, you'll call up a friend and try to convince the friend to come with you. If the friend can't come, you'll delay, or if the friend doesn't want to come, you'll find someone else.
Video games are traditionally something you play with / move through at your own pace though. And since games like WoW allow for that, its sorely tempting to just go play a bit even though someone you normally play with can't make it.
I don't think its a failing of WoW so much as it is a failing of us as people. Players jumping ahead of their friends because they couldn't resist playing is a comment on our inability to delay instant gratification for the betterment of the whole. Its a comment on the selfishness of humanity.
- 8:07 AM, February 21, 2007
- Anonymous said...
The above poster nailed it.
Not only in a simple game but in Life, selfishness is something that negates the betterment of the whole in favor of personal gratification.
Maybe this embodies the capitalistic, destructive ways of our modern day society and thus, to put it in an extremely simplistic way, the root of all "evil".
WoW, as any other MMORPG, can be a mirror of life with all it's issues concerning loot, raid attendance and whatnot.
We are already a bunch of bastards in the real world, couldn't we behave honourably and be nice to each other in a game with no real consequence in Real Life?
- 6:41 AM, February 26, 2007


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lymphocyte immune globulin, anti-thymocyte globulin (rabbit) - inj, Thymoglobulin (cont.)
OVERDOSE: If overdose is suspected, contact a poison control center or emergency room immediately. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.
NOTES: Laboratory and/or medical tests (such as complete blood counts) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.
MISSED DOSE: For the best possible benefit, it is important to receive each scheduled dose of this medication as directed. If you miss a dose, contact your doctor or pharmacist immediately to establish a new dosing schedule.
STORAGE: Not applicable. This medication is given in a hospital or clinic and will not be stored at home.MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).
Information last revised March 2013. Copyright(c) 2013 First Databank, Inc.
Medically Reviewed by a Doctor on 4/16/2014
Report Problems to the Food and Drug Administration
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.
Need help identifying pills and medications?
Back to Medications Index


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Male Breast Cancer Center - Prescott, AZ
Prescott Oncologist Doctors for Male Breast Cancer
Type of Physician: Oncologist
What is a Oncologist?
A subspecialty certification by the Board of Internal Medicine; the oncologist specializes in the diagnosis and treatment of all types of cancer and other benign and malignant tumors. These subspecialists decide on and administer chemotherapy as well as consult with surgeons and radiotherapists on other treatment for cancer.
Specialty: Oncology (Medical)
Common Name: Cancer Doctor
Oncologist Doctors in Prescott *
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*Provider Directory Terms of Use:
The WebMD 'Provider Directory' is provided by WebMD for use by the general public as a quick reference of information about Providers. The Provider Directory is not intended as a tool for verifying the credentials, qualifications, or abilities of any Provider contained therein. Inclusion in the Provider Directory does not imply recommendation or endorsement nor does omission in the Provider Directory imply WebMD disapproval.


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From the beginning I didn't really like this tire. Tires absolutely suck in any type of snow. But good tire for casual highway or city driving. 50% thread left at 27000km
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Women's Volleyball Swept by Queens' Balanced Attack on Wednesday Night
November 2, 2011
MISENHEIMER, N.C. Queens University of Charlotte used a balanced mix of offense and defense to claim a 3-0 (25-14, 25-23, 25-18) sweep over host Pfeiffer in Conference Carolinas womens volleyball action on Wednesday night. The win pushes the Royals to a division-best 19-8 overall, 13-2 in league play while the Lady Falcons dip to 9-13, 6-9.
Queens took early control in set one as kills from Lindsey Everhart (Cincinnati, OH) and Brittany Harvey (Matthews, NC) coupled with three Lady Falcon errors put the visitors up 5-0. A pair of kills by Milana Mervosh (Roebuck, SC) brought the Lady Falcons within three a few plays later until Queens ran away for good with a six-point spurt with another kill coming from Everhart. The Royals closed out the opening set with a 15-7 run capped off by a Keri Kemp (Lake Mary, FL) kill to end it.
The middle set saw Pfeiffer carry a five-point lead late at 22-17 after a Queens error and pair of kills by Jordan OBryant (Reidsville, NC). Following an Everhart ace, Pfeiffer error and kill by Harvey, the Royals were down just one forcing a Lady Falcon timeout at 22-21. Mervosh provided another kill after the break to make it 23-21 until four-straight kills by Harvey, Avery Moore (Arlington, TX), Brittany Barren (Ham Lake, MN) and Kemp completed the rally putting Queens up in the match 2-0.
In the final set, Pfeiffer again carried a lead midway through as OBryant and Mervosh put down back-to-back kills for a 17-15 lead. From there, Jocelyn Kellinger (Roanoke, VA) served up the next eight points with two more kills by Anna Gibbs (Hickory, NC) and four miscues by the Lady Falcons. Barren would post three block assists during that spurt including back-to-back blocks with Gibbs before putting down the matchs final kill for a 25-18 win.
Barren for Queens and Mervosh for Pfeiffer each shared honors for a match-high 10 kills. Barren posted a .353 hitting percentage while Gibbs hit at a .545 clip. Cate Glendenning (Holly Springs, NC) led al with a match-high 25 assists while Moore put up 22 for Queens. The Royals held a 10-5 advantage in team blocks on defense.
Pfeiffer will wrap up the 2011 regular season clinging to playoff hope as they travel to Coker on Friday before hosting St. Andrews on Saturday. Live video and live stats will be available through http://www.gofalconsports.com.


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Skagit River bridge on I-5 to reopen Wednesday
Scott Terrell / Skagit Valley Herald
The temporary span portion of the I-5 bridge over the Skagit River is shown Monday.
Scott Terrell / Skagit Valley Herald
A worker comes off his shift Monday on the temporary span on the Interstate 5 Skagit River bridge.
Frank Varga / Skagit Valley Herald
The final stretch of asphalt is laid down Tuesday on the north side of the southbound lane of the temporary span of the Skagit River Bridge in Mount Vernon.
A temporary four-lane span will open without fanfare just shy of a month after a semi-truck carrying an oversized load struck several of the bridge's overhead trusses, causing a 160-foot section to fall into the river.
Two vehicles went into the water but the three people traveling in them survived the harrowing May 23 incident.
Gov. Jay Inslee visited the site Tuesday as workers paved and prepared to stripe the roadway, a major artery for commuters and commerce that carries an average of 71,000 vehicles a day.
There will be some new rules when the bridge reopens.
The maximum speed will be 40 miles per hour, down from the 60 mph limit in effect before the collapse. That's because each of the four temporary lanes will be 11 feet wide, which is about a foot narrower than those on the section that fell into the water.
Nearly all cars, commercial vehicles and big rigs carrying legal loads allowed on the bridge before will be able to use it again, transportation officials said.
There will be a barrier between north and south traffic, but it will be made of steel trusses instead of the concrete that separates traffic on the rest of the bridge.
What won't be allowed are trucks that require a special permit to travel on state highways because they exceed legal rules for height, width, weight or length, said Travis Phelps, a Washington Department of Transportation spokesman.
"If you're getting a permit to drive on the highway, you won't be going over this bridge. You'll be using the detour routes," he said.
Time-lapse video by WSDOT.
All traffic has been detoured since May 23 when the truck struck the 58-year-old span.
The Washington State Patrol and National Transportation Safety Board are conducting investigations in the cause of the collapse.
Atkinson Construction of Renton received a $10 million contract to demolish the damaged portion, remove debris from the water and put in the temporary four-lane segment that Acrow Bridge of New Jersey built.
On Tuesday, the state awarded a $6.9 million contract to Max J. Kuney Co. of Spokane to construct the permanent replacement span.
Under the contract, work must be done by Oct. 1. It will require closing the bridge for up to two weeks in September to put the span in place, but the closure cannot occur until after Labor Day, according to contract documents.
When the bridge is restored to its pre-collapse capacity this fall, it will still be rated as "functionally obsolete" because it was not designed to handle today's traffic volume and big trucks. It's also considered "fracture critical," meaning that if a single, vital component is compromised, the bridge can crumple again.
Federal funds will cover 100 percent of the costs of the temporary fix and 90 percent of the permanent replacement.
Thus far the federal Department of Transportation has committed $16.6 million for the two projects from its Emergency Relief Fund. The federal agency provided $1 million in the days following the collapse and then last week pledged another $15.6 million.
With the announcement of the scheduled bridge reopening, Amtrak plans to cancel the extra round-trip train it added between Seattle and Bellingham following the span's May 23 collapse.
Two round-trip Amtrak Cascades trains per day still run between Seattle and Vancouver, B.C. Amtrak also operates five round-trip Thruway Motorcoach buses between the two destinations.
Reporter Bill Sheets contributed to this story.
Jerry Cornfield: 360-352-8623; firstname.lastname@example.com
- The Buzz: Let's play some bridge 6/19/13
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Synagis Vaccine
Synagis is a vaccination to help prevent Respiratory Syncytial Virus (RSV) in children with tracheostomies. RSV is a viral infection that is common among children who were born prematurely, during the winter season (when children get sick most often). The synagis vaccine is offered through your pediatrician's office. Please contact them for details.
Physicians from the Pediatric Airway, Voice and Swallowing Center have published articles in support of children with tracheostomies and other airway issues receiving Synagis. Download a pdf of an article to send to your insurance company.


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Hunter (Forums / Skills / Talent Calculator)
Improved Serpent Sting now deals the correct amount of damage.
Is this a buff or a nerf :/ ._.
Hunter (Forums / Skills / Talent Calculator)
Improved Serpent Sting now deals the correct amount of damage.
Is this a buff or a nerf :/ ._.
It's a fix of the buff hunters received a few hotfixes ago.
Yeah but now it will give us the correct amount of damage. Is that more or less damage? :P
Signature by Geekissexy Check out her Deviantart
I read a comment from Zeherah saying that Improved Serpent Sting was doing half the damage it should and that it was reported to Blizzard. Basically, ISS was doing 15% of the serpent sting damage as advertised (instead of the 30% before the hotfix), but it was not using the doubled serpent sting damage, and hence the damage done was actually half.
So, count it as a buff, I guess. Unless it was something else entirely.
The stated hotfix of ISS damage from 30% to 15% is neither a buff nor a nerf, because SrS damage in general doubled (15% of doubled is 30% of normal). What was happening though was that ISS was calculating 15% of normal, instead of double, causing it to do 7.5% instead of 15%. The hotfix to the hotfix brings it back up to 15% of a now doubled SrS, so.....
....ISS damage shouldn't be changed at all from 5.0.5 to 5.1. Lots of sound and fury, signifying nothing.
Considering the "wrong" version was in for 4 days, I felt it worthwhile to provide a larger picture.


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By Leah Ornstein
Radar Style & Beauty Editor
Stars were out and about all over the world this week dressed to rock and shock in the best, worst & wackiest fashions—and RadarOnline.com has all the photos in our weekly fashion feature!
PHOTOS: The Best, Worst & Wackiest Fashions Of The Week
Blake Lively was the queen of the style scene this week, promoting her summer blockbuster Green Lantern in smashing fashion. The Gossip Girl, who took a break from her new beau Leonardo DiCaprio to hang out with her family at the Los Angeles premiere of the DC Comics film, looked white hot in a gorgeously embroidered Chanel Couture gown, which showed off her legs-for-miles to perfection!
PHOTOS: Legs, Butts, Boobs & More! Bikini Babes Strip Down & Show Off Their Best Assets
Ice-T's curvy wife and recent reality star Coco Austin hit the Formula 1 Grand Prix in a racy ensemble—though her look was WAY more tacky than tasteful. The bootyful and boobilicious blonde left little to the imagination in her skintight turquoise jeans and colorful croptop.
PHOTOS: Booty Or Bust? Bikini Babes From Every Angle
And Ke$ha beat out Lady Gaga for the wackiest look of the week, hitting the swanky amfAR Inspiration Gala in NYC—totally exposing her bum!
PHOTOS: Riding High! Thongs, Brazilians And Other Bikini Booty Mishaps
Eva Longoria brightened up Washington DC in a color-blocked Victoria Beckham dress, while Cameron Diaz prowled around Moscow in a tiger-striped Emilio Pucci mini.
PHOTOS: Bikini Wars! Sexy Stars Who Have Posed For Playboy
What other stars were dressed to rock and shock this week? Click here to find out.


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Amelia Bedelia Chapter Book #1: Amelia Bedelia Means Business
Amelia Bedelia Chapter Book #1: Amelia Bedelia Means Business (Paperback)
With Amelia Bedelia, anything can happen!
Amelia Bedelia wants a new bike—a shiny, fast one just like Suzanne's. Amelia Bedelia's mom says that a bike like that is expensive and will cost an arm and a leg. Amelia Bedelia can't give away one of her arms and one of her legs! She needs both arms to steer, and both legs to pedal. What Amelia Bedelia needs is a job.
Look out! Here comes Amelia Bedelia, and she means business!
About the Author
Herman Parish was in the fourth grade when his aunt, Peggy Parish, wrote the first book about Amelia Bedelia. The author lives in Princeton, New Jersey.
Praise for Amelia Bedelia Chapter Book #1: Amelia Bedelia Means Business…
"No child can resist Amelia [Bedelia] and her literal trips through the minefield of the English language—and no adult can fail to notice that she's usually right when she's wrong."
-New York Times Book Review
Praise for the young Amelia Bedelia series:"Parish has turned the clock back, making Amelia Bedelia young again and giving a new generation of readers the opportunity to enjoy her humor and self-confidence."
-Kirkus Reviews
"Her ingenuous spirit will continue to capture hearts."
-Publishers Weekly
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