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Terrace Rectangular Planters
Give your plants a modern place to call home, inside or out. Our stainless steel planters are made to weather the elements with ease, in sizes and shapes that look great when grouped together.See the full Terrace collection
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Details of Terrace 16w 8d 22h Rectangle Planter
- Dimensions: 16"w 8"d 22"h
- Considerations: no drainage opening
- Product Origin: made in Minnesota
- Item Number: 066319
- Material: stainless steel See material details
- Finish: powder-coat
- Color: white
Product Care
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Reviewed by 4 customers
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Customer comments about Terrace Large Rectangle Planter:
We purchased these to use on our rooftop deck to hide the air conditioning units. It's positioned between the AC units and our outdoor sofa. The planters are a nice clean design and the depth is perfect for what we need it for. The only thing is there are no drainage holes in the planters. You would think that it would be taken care of considering the price. Regardless we really like the design of the planters.
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I bought two of these after seeing them on the balcony of the condo community that my mother lives in. I wanted to buy something for her balcony that wasn't very deep due to the limited space. This was a great solution. I haven't found anything around that is as well made. Clean and simply lines that with stainless steel that looks like it will weather the elements.
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Customer comments about Terrace Large Rectangle Planter:
Using these planters inside a building lobby, very chic and clean looking, great size and works well for indoor plants
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How a Stay-Home-Mom Became a Writer
I remember the day I began this journey with perfect clarity. Sitting in my office, there was a cup of coffee on the desk, a laptop open to a blank screen. From the window I could see my son with the sitter walking to the swing. Even now, I can feel the all-consuming guilt that held me captive as I watched him toddle hand-in-hand with someone else. A mother's guilt is a powerful thing. What was wrong with me that after only a year on the job as a stay-home-mom I was trying to forge a new one as a writer?I had hardly noticed the desire when it crept in. Driving in the car to my child's activities, I found myself constructing characters and dialogue. At night while I waited for the baby to call, I put together story lines and plots. The part of me I left behind when I opted-out to raise my kids kept calling me until, finally, there was nothing left to do but admit to myself that this was something I wanted, and needed.
When I finally turned away from the window that day, I began to write. I wrote one page. I wrote again two days later, then two days after that. When I was overcome with morning sickness, I stopped writing. When it passed, I started again. Then came the second baby, more stops and starts. I took my laptop with me everywhere. I wrote in the back of my car in the pre-school parking lot. I wrote during naps and drop-off swim class. I wrote when my husband watched the kids, when the sitter came. I wrote and wrote through years that were filled with self-doubt, with moments of clarity then confusion as to why I was so intent on pursuing something so inherently evasive – and, most alarming, something that had nothing to do with the life I had chosen as a stay-home-mom.
For the next year, I searched for an agent, finally finding one a few weeks after giving birth to the last of my three sons. She encouraged me to write women's fiction, but I was once again overwhelmed with the demands of a newborn. At thirty-seven years old with three children under six, I was officially embarking on a new career – a career I had come to desperately need. And yet, what was I thinking? How was I going to write an entire novel in the midst of the sleepless nights and frenetic days that constituted my life? It was, ironically, from this core-shaking doubt that the four characters in my first novel were born.
Four Wives was written in six months, pouring out of me and into these characters, filling page after page. As I await its publication this coming February, I am frequently asked how it came to be. I have to stop and think because my life doesn't feel that different. Still, it is within this same life that the answer emerges.
Here is what I have learned about pursuing a new dream in the midst of stay-home-parenting. First, say no to your house. No to redecorating, antiquing, and gardening. Your house can be your worst enemy. Second, micro-manage your time and resources. Every hour your kids are at school, with another parent or a sitter can be spent working. Third, work from your car. The vast majority of Four Wives was written from the back seat of my minivan in the school parking lot. Your house won't find you there. Fourth, say no to daytime socializing that does not include your kids. No to lunches, coffees and shopping sprees. Skip TV and see your friends for a night out. And last, say yes to your kids – school plays, field trips, baseball games. It is possible to stop working after they get home.
I came to be a writer one page at a time, starting with the first one I managed to write that day in my study. Through the guilt and doubt, it was built like a house, brick upon brick. It was built around everything that was in its way. It was built because beneath it laid a profound need to be seen and heard and valued in the world beyond my front door that so many stay-home-parents come to feel. And it can be done.
15 Responses to "How a Stay-Home-Mom Became a Writer"
# Mary Ickerton 25 Feb 2009 at 6:25 pm
Great post Wendy. Thanks for sending me the link to this. I will be looking forward to reading the Power Mom's book.
As for being a stay at home Mom and a writer, I am in the same boat. Although it never occured to me to write in the car, I actaully find that idea brillant. I have alwasy wanted to be a writer and write every day (or at least try to). Thanks for all the tips and suggestions about working on writing a book. Ignoring the house is by far my favorite.
# Marjonon 16 Mar 2009 at 7:45 am
i looked at your website and your video. That new book of you sounds great!
Can you buy it in Europe? I would like to reed it.
Well i am not really in Europe but in Bahrain, i guess you can't buy it here.
Your website looks really good.
Your under my favorites now.
Yes! In fact, Four Wives has just been published in the Netherlands. Also, Amazon.com has all my books.
# Heather Kepharton 18 Oct 2009 at 6:19 pm
Hello Wendy, and thank you for the great advice.
I am a stay at home Mom of a two year old son and one year old daughter. I've been blogging for about a year, and just recently acknowledged my burning inner desire to be a writer.
I've been struggling with the frustration that comes from the lack of alone time to flush out my thoughts. I don't know how to balance blogging with reading for pleasure, reading books on how to write, and actually writing. What to write? How to begin? If you're a blogger, how do you know what writings to include in your blog vs. what to submit for publication?
So many questions. Nice to know I am not alone.
Congratulations on your success. You are an inspiration!
It is so hard! Someone just asked me what I'm reading lately and I had to admit that reading has gotten jumbled up as work for me lately as I am in the midst of a new novel. Anything I read becomes research. It's very hard to separate our lives. For me, what works best is to focus on one thing (other than my kids) at a time. For the next three weeks, all I am doing is PR for Social Lives and sorting out my 2 new Chicken Soup books. Then I will spend 3 days writing my new novel, and 2 days editing Chicken Soup stories. If my deadline gets scary, I will adjust. It's a constant source of anxiety! I wish I had an answer. Let me know how your writing comes along! Wendy
# Jill Eisnaugleon 08 Dec 2009 at 12:12 am
Hi Wendy,
Great article! I feel your pain. While I don't have kids underfoot, I wrote my first two books while managing the needs of my ailing father and his disabilities. I would literally write a line or two and then run to the refrigerator and grab Dad's sandwich, write two more lines and grab him a Pepsi. It was a challenge but one well worth it.
I noticed that the Thanks, Dad deadline has been extended. I'll be sitting here patiently waiting to see if my story is included or if I'll be putting it on hold until the next submission for which it is a fit.
Happy writing!
# Dallason 31 Mar 2010 at 1:22 am
I am a lawyer, fast approaching 30, waiting desperately to be both a stay at home mom and a writer. Hubby and I are approaching our 10th anniversary, and I am really feeling the biological clock ticking… Thanks for writing this post, it really encourages me.
I'm so glad. Exciting times ahead for you and your husband. Stay in touch and let me know if I can help as you begin the journey as a writer!
# Nicky Ganton 08 Jul 2010 at 7:12 am
Wow … thank you for writing this. I am a SAHM of two boys (3 and 1) and can relate on every level to the difficulties you describe of wrestling the dream of being a writer with day to day tasks of raising the children. At 31 and knowing I'll want another child, while already busy with two, knowing you are publishing your first novel at 37 is absolutely the most inspiring thing I have ever heard. I find myself starting and stopping various writing projects, and a part of me 'believes' they are crystalizing inside of me and will birth when the time is right. Your novel born of your deep inner life being "born" in 6 months is absolutely wonderful. Congratulations, and thanks again for the inspiration.
# In Transitionon 18 Jul 2010 at 9:43 pm
Dear Wendy,
Wow, I am so glad I came across your website and this article. I'm in between careers right now. I've just recently come full circle in my life to finally accept that writing is what I want to do professionally. I've started writing about anything and everything, and trying to read as much as I can whenever and wherever I am. I have three children 12,9, and 17months. I have to say that I am enjoying it very much, but it definitely is a challenge. Your story is an inspiration to me.
Thank you,
In Transition
# Joannaon 26 Mar 2012 at 7:51 am
Hi Wendy!
I left a small town in north America to move to a capital city in Europe for love. I risked a lot and have a story inside that is burning to come out. I am 33, run my own language consulting firm. We have a 3 year old daughter and are expecting our second child. I have decided to be a SAHM now and focus on my family, but this desire to write and publish is urging me to release the story! I start writing get really excited about the journey then…. doubt creeps in and I let it go. So this morning I just wanted to find inspiration from a mom and successful writer to gain strength and momentum and thanks to you, I found it.
Thanks again,
Releasing the voice from captivity,
I Am Going To have to visit again whenever my course load lets up – nonetheless I am taking your Rss feed so i can read your web blog offline. Thanks.
Wendy, I've stumbled upon your post at the best time. Thank you for this. I'm a SAHM mom of 2 children–and expecting a third at the end of the year. I keep a blog and am editing my first novel for a potential (Oh, I hope!) agent who is interested in seeing a revision and expecting it by mid-fall. I'm in a constant state of panic–I'm ignoring my kids! The house is falling apart! How will I ever get this finished! Am I wasting my time??–because I feel like I'm not doing anything very well. It's hard–especially when all you want to do is write, especially when your kids are young and don't understand Mom's "work."
Thanks for making us feel like we're not the only ones struggling with doubt and time. And congratulations on your success–I don't know what's more inspirational, your post or your growing resume.
Your info is incredibly helpful.

subset: commoncrawl


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Does Microsoft make allowances on exams for people with learning disabilities?
I have ADHD and I am planning on taking some of my certification exams towards my MCSE. The problem is I can do...
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the hands-on, but when it comes to written tests, I am not very good. I cannot comprehend/remember what I have read or explain properly how to do the job. My question is: Do you know if there are any special provisions or exceptions for taking the certification exams if you have this disability? Microsoft does make allowances for individuals with disabilities, but you need to work through the testing organization when you sign up for a test at Prometric or VUE. As you register for an exam, you must explain your special needs to them in terms of time, hardware, and/or software and work with them to see that those needs are met. If you can't get the help and consideration you need from the testing center of your choice, you'll need to work with the national offices for VUE or Prometric. Unfortunately, this means you won't be able to sign up for exams over the Web, but will have to call the testing companies by phone.
For VUE, this means going through the Web site to identify individual testing centers in your area. There, you'll find phone numbers that will allow you to call each center individually, to make the necessary arrangements. For Prometric, call 800-755-EXAM to get the same process rolling.
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Massachusetts Local Secrets 2010
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Best Ocean Stroll
'SCONSET BLUFF WALK, Siasconset
This public path provides a front-row view of the Atlantic's ceaseless undermining of the island's sandy foundations. Dawn to dusk, you'll stroll like an accidental gate crasher through the hedgerows and wind-sculpted arboreal bowers of neighboring seaside mansions. Begins at north end of Front St. 508-228-3643; nantucketchamber.org
Best Pressed Panini
ZONIN'S GOURMET MARKET, Springfield
Tucked off a side street, this small shop might elude the casual passerby, but almost any local can provide directions in a heartbeat. Pressed tuna panini ($6.50), made from oil-packed fish and fresh ciabatta baked next door, are so good they deserve their own aria. 18 Winthrop St. 413-732-1055; zonins.com
Best Slice of Tranquility
NEW ENGLAND PEACE PAGODA, Leverett
The serenity on this hilltop is inspired by Japanese landscaping, complete with koi pond, a fitting complement to the surrounding pastoral beauty. 100 Cave Hill Road. 413-367-2202
Best Trappist Preserves
ST. JOSEPH'S ABBEY, Spencer
For 50-plus years, the monks here have been creating jams, jellies, marmalades, and conserves. The gift shop carries all 30-some varieties. 167 North Spencer Road. 508-885-8720; spencerabbey.org
Best Panoramic Ocean View
RAFE'S CHASM PARK, Magnolia
A 10-acre public park protects a sharp cleft in the granite bluff, rising some 40 feet above Massachusetts Bay. Trail begins at the small fenced roadside parking area, 400 feet east of Old Salem Path. Grounds open dawn to dusk. Free. Hesperus Ave. 978-283-1601, capeannvacations.com; 978-281-8865, gloucesterma.com
Best Ice Cream
MELETHARB ICE CREAM, Wakefield
Dozens of flavors, made on the premises in small batches, attract a steady stream of ice-cream lovers, in weather both fair and foul. The shop's creativity is best displayed in the honey-accented flavor with chunks of baked baklava blended in. Delicious! 393 Lowell St. 781-245-4946; meletharb.com
Best Hot Dogs
CASEY'S DINER, Natick
Among historic diners, few have the pedigree of this 10-stool 1922 Worcester model, with its stained glass, oak interior, and original hot-dog steamer. That copper vat never rests: Order a couple of dogs "all around" (mustard, onions, relish), and you, too, will appreciate why there's rarely an empty seat. 36 South Ave. 508-655-3761
Best Excuse to Go Local
HINGHAM FARMERS' MARKET, Hingham
Gathering weekly at the bathing beach parking lot, locals appreciate regional foods, including smoked fish, organic granola, artisanal cheeses, and live shellfish. Open late May to mid-November, Wed. and Sat. 10-2. Jct. Otis St. & Route 3A; hinghamfarmersmarket.org
Please Note: This information was accurate at the time of publication. When planning a trip, please confirm details by directly contacting any company or establishment you intend to visit.


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Read more: Click here to see a longer version of this story
TALK about quick off the mark. Just days after the first protons were smashed together by the Large Hadron Collider, the first paper on the results has been written, signed off, and accepted by a journal.
The first collisions took place on Monday 23 November. By Saturday, a paper had been uploaded to the pre-print physics archive, where physicists often publish their results prior to formal publication (arxiv.org/abs/0911.5430). Three days later, it was accepted by European Physical Journal C.
The paper came from researchers working on ALICE, one of six experiments at the world's most muscular particle smasher, located at CERN, near Geneva, Switzerland. "It's probably a record," says David Evans at the University of Birmingham, leader of the UK contingent at ALICE. "Of course, it had a lot to do with the ...
To continue reading this article, subscribe to receive access to all of newscientist.com, including 20 years of archive content.


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Latanya Aprons are an Idakoos specialtiy! Idakoos has many things to offer. Whether you want to get a Latanya Apron for a special occasion, give a Latanya Canvas Apron as a present or need to represent with a funny Latanya Apron during Holidays or Family and Friends get-togethers, Idakoos is sure to have the right Latanya Apron for you! Even if it turns out you can't find the right Latanya Canvas Apron with the perfect design for your mother, father or children (or friends!); Idakoos offers all of its Latanya Aprons as Custom Latanya Aprons. Personalize any Latanya Apron the way you want to ensure the perfect gift.
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Connie Booth
|Connie Booth
|Constance Booth
January 31, 1944
Indianapolis, Indiana, U.S.
|Actress, author, psychotherapist
|Years active
|John Cleese (1968–1978)
John Lahr (2000–present)
|Cynthia Cleese (b. 1971)
Constance "Connie" Booth (born 31 January 1944)[1][2] is an American-born writer, actress, comedian and psychotherapist based in England, best known for appearances on British television and particularly for her portrayal of Polly Sherman in the popular 1970s television show Fawlty Towers, which she co-wrote with her then-husband John Cleese.
Early life[edit]
Booth's father was a Wall Street stock broker and her mother was an actress who had moved to the state of New York after Connie Booth's birth in Indianapolis, Indiana.[1][3] Booth entered acting and worked as a Broadway understudy and waitress, meeting John Cleese while he was working in New York City.[3] She married Cleese in New York on February 20, 1968.[4]
Booth secured parts in episodes of Monty Python's Flying Circus and in the Python film And Now for Something Completely Different. She also appeared in Monty Python and the Holy Grail as a woman accused of being a witch; in How to Irritate People, a pre-Monty Python film starring Cleese and other future Monty Python members; and in The Strange Case of the End of Civilization as We Know It (Cleese's Sherlock Holmes spoof, as Mrs. Hudson).
Booth and Cleese went on to write and co-star in Fawlty Towers (1975, 1979). She also appeared in a short film titled Romance with a Double Bass, adapted by Cleese from a short story by Anton Chekhov.
Booth played various roles on British television, including Sophie in Dickens of London, Mrs Errol in a BBC adaptation of Little Lord Fauntleroy, and Miss March in a dramatisation of Edith Wharton's The Buccaneers. She also starred in the lead role of a drama called The Story of Ruth (1981), in which she played the role of the schizophrenic daughter of an abusive father, for which she received critical acclaim. In 1994, she played a supporting role in "The Culex Experiment", an episode of the children's science fiction TV series The Tomorrow People.
Booth ended her acting career in 1995.[3] After studying five years at London University,[1] she began a career as a London psychotherapist, registered with the British Psychoanalytic Council.[1][3][5] For 30 years Booth had declined to talk about Fawlty Towers until she agreed to participate in a documentary about the series for the digital channel Gold in 2009.[6]
Personal life[edit]
In 1971, Booth and Cleese had a daughter, Cynthia,[1] who appeared alongside her father in the films A Fish Called Wanda and Fierce Creatures. Booth and Cleese divorced in 1978,[7] but have remained close friends.[8]
Booth married John Lahr, author and senior drama critic of The New Yorker, in 2000. They live in north London.[3]
Selected filmography[edit]
- And Now For Something Completely Different (1971) - Various characters
- Romance with a Double Bass (1974) - Princess Costanza
- Monty Python and the Holy Grail (1975) - The Witch
- Dickens of London (1976) - Sophie
- The Strange Case of the End of Civilization as We Know It (1977) - Mrs Hudson / Francine Moriarty
- Little Lord Fauntleroy (1980) - Mrs Errol
- The Story of Ruth (1981) - Ruth
- The Hound of the Baskervilles (1983) - Laura Lyons
- 84 Charing Cross Road (1987) - The Lady from Delaware
- High Spirits (1988) - Marge
- Hawks (1988) - Nurse Jarvis
- American Friends (1991) - Caroline Hartley
- Leon the Pig Farmer (1993) - Yvonne Chadwick
- The Buccaneers (1995) - Miss March
- ^ a b c d e Smith, Sean. "Don't mention the classic comedy series". Camden New Journal. London Borough of Camden. Archived from the original on January 20, 2004.
- ^ http://www.imdb.com/name/nm0095665/
- ^ a b c d e Milmo, Cahal (25 May 2007). "Life after Polly: Connie Booth (a case of Fawlty memory syndrome)". The Independent (London). Archived from the original on May 2, 2008. Retrieved 8 September 2011.
- ^ "John Cleese Biography (1939-)". FilmReference.com. Retrieved 2013-11-21.
- ^ "Fawlty Towers: Where are they now?". UKTV Gold. Archived from the original on November 21, 2013.
- ^ Parker, Robin (23 March 2009). "Gold to reopen Fawlty Towers". Broadcastnow. Retrieved 23 March 2009.
- ^ "Divorce for Cleese". The Glasgow Herald. September 9, 1978. p. 5. Retrieved 16 November 2010.
- ^ Hoyle, Antonia (21 July 2008). "Our divorceymoon! What happened when Cleese and Winner invaded Switzerland on a six-day road trip". London: Daily Mail. Retrieved 2008-08-03.
External links[edit]
|Wikimedia Commons has media related to Connie Booth.
- 1944 births
- Living people
- Alumni of the Open University
- American expatriates in the United Kingdom
- American television actresses
- American television writers
- Actresses from Indianapolis, Indiana
- People from New Rochelle, New York
- Women television writers
- American women comedians
- People from London
- Monty Python
- American psychotherapists


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Fire district weighs risks of old bridges
VALLEY CENTER Consider this combination: Rickety old bridges and the increasingly heavy firetrucks that must cross them during an emergency.
The Valley Center Fire Protection District — which owns engines as heavy as 55,000 pounds — has weighed the risks, and decided it's time private property owners get their bridges and culverts checked. This district launched a campaign last week requiring residents to verify the load capacity of their crossings and post signs showing those limits, or risk a slower response when emergencies strike.
The district mailed letters to owners of 360 crossings in the rural town northeast of Escondido, advising them of the new requirement.
Verifying a bridge's capacity could be as simple as showing a copy of a county permit from the time the bridge was built. Or, for bridges with no permit, it could be a long, expensive journey. A county spokesman said it would cost $1,774 and at least three to four weeks to permit a new bridge and said he believed the permitting cost was about the same for an existing bridge.
While Valley Center residents reached by a reporter said they were worried about the burden of the bridge checks, and any possible delayed response, district officials stressed that safety remains the district's top priority and is driving this campaign.
"We want to ensure the safety of the equipment and the safety of the people involved, so we don't lose a firetruck or injure a firefighter," said Weaver Simonsen, chairman of the fire district's board of directors. "We will still respond, but there may be a delay" without verification of the crossing.
"We cannot guarantee our fire apparatus will cross your bridge or culvert until such time as we receive verification that your elevated structure will support a capacity of 75,000 pounds," the district's letter states. "Rest assured we will continue to provide prompt service to your property; however, service will likely be delayed if the capacity of your structure remains unanswered."
Officials, including the district's Fire Marshal George Lucia, said they are not creating a new rule, but rather enforcing an existing one that appears in the 2010 edition of the California Fire Code, section 503.2.6., and the district adopted as an ordinance.
Officials added that the district does not have the authority to require improvements to the crossings, only the verifications and sign postings.
Fire officials said the effort is a response to finding "substandard, non-permitted" bridges throughout the district. A separate district's firetruck smashed through a culvert in the San Pasqual Valley in 2007, officials said. Fire departments in Vista and Fallbrook have issued similar crossing requirements, Valley Center officials said.
During a recent survey of about two-thirds of the Valley Center district, which stretches across 87 square miles of farms, ranches and rural estates, officials mapped 360 bridges and culverts plus another 300 small crossings, known as Arizona crossings, said John Byrne, the district's administrator.
The district has not decided whether the smaller crossings should be subject to the requirements.
Once the full survey is complete, Byrne said he expects the district will have mapped as many as 1,000 private crossings.


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|Hobby & Recreation Group
The Lamar Speedway had been leased by a motorcycle club that converted the old speedway into a motocross track.
The motorcycle club disbanded after a couple of years and the old Speedway lay dormant for another five years. The
following frames are of the condition the Speedway was in before the Racing Club went to work in January 2010. You
can watch the complete Reclaiming Of The Lamar Speedway in a slide show by clicking on the Slide show link.
Kelley Morris
|Vice-President Don
|Sectary / Treasurer
Daina Morris
|2010 Club Officers
|Don Woller
|Jerry Woolley


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Various Artists (add compilations to this artist)
~ Other
Various Artists, often abbreviated as VA or V/A, is a term used by the music industry for releases (singles or albums) that contain collaborations. Rather than listing the many individual singers or artists being credited individually, the name Various Artists is used instead.
Aggregated compilation albums containing tracks from a number of artists can also be credited to Various Artists. Various Artists compilation albums are often compiled from a particular musical style or period to another.
Another use for Various Artists is a specific artist "and Various Artists" or "featuring Various Artists". This is most common in remixes where there are many releases using the formula, such as "Rihanna featuring Various Artists" for remixes of "What's My Name?".
Showing official release groups by this artist. Show all release groups instead, or show various artists release groups.


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Twitter Journal Club is (as the name may suggest) a Twitter-based journal club. We meet fortnightly on Sunday nights at 8pm UK time (7pm GMT) to discuss & critique a variety of medical papers.
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Week 12 – ROCKET-AF study
Atrial fibrillation (AF) is an incredibly common condition – not a day goes by that I don't meet a patient with AF. As soon as it is diagnosed doctors and patients have to discuss the issue of anticoagulation, weighing up the risks and benefits for each individual patient due to the increased risk of stroke with AF. At the moment warfarin is the anticoagulant agent used, but it isn't without its problems.
Warfarin is an effective drug but not a particularly nice drug. Patients face numerous blood tests and dose adjustments, alterations to their diet, the potential of life threatening bleeds and concerns about interactions with other medications. For some patients the potential side effects and effect on their lives leads them to decide to not be anticoagulated. For years the search has been on for a medication with a similar level of efficacy but reduced interactions and risk of bleeding. Several studies of novel anticoagulants have been published comparing their efficacy to that of warfarin in patients with atrial fibrillation.
The ROCKET-AF study was published in the NEJM in September and was a multi-centre, double blind RCT that compare rivaroxaban (an oral factor Xa inhibitor) with warfarin in over 14,000 patients who were at moderate or high risk of thromboembolic stroke. Patients were divided into two treatment arms:
- Rivaroxaban group – received a fixed once daily dose of 20mg once daily with normal renal function or 15mg if the creatinine clearance was 30-49ml/min
- Dose adjusted warfarin aiming for an INR of 2.0 – 3.0
Patients in each group also had a placebo tablet in order to maintain blinding to their treatment arm.
The primary efficacy end point was for stroke (ischaemic or haemorrhagic) and systemic embolism with the principal safety end point being major and nonmajor clinically relevant bleeding events.
Rivaroxaban was found to be non-inferior to warfarin in the prevention of stroke or systemic embolism (1.7% per year comparied to 2.2% in the warfarin group – hazard ratio in the rivaroxaban group was 0.79, p<0.001 for non-inferiority – this is the per-protocol analysis).
For the primary safety endpoint major and clinically relevant nonmajor bleeding occurred in 1475 patients in the rivaroxaban group and 1449 patients in the warfarin group (14.9% and 14.5% per year respectively).
The bottom line:
In conclusion, in this trial comparing a once-daily, fixed dose of rivaroxaban with adjusted-dose warfarin in patients with nonvalvular atrial fibrillation who were at moderate-to-high risk for stroke, rivaroxaban was noninferior to warfarin in the prevention of subsequent stroke or systemic embolism. There were no significant differences in rates of major and clinically relevant nonmajor bleeding between the two study groups, although intracranial and fatal bleeding occurred less frequently in the rivaroxaban group.
This week's journal club focuses on the ROCKET-AF study but also the wider question – is this the beginning of the end of warfarin as the agent of choice for anticoagulation?
The discussion points will be posted tomorrow and the discussion will start at 19.30 BST (half an hour earlier than normal).
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Week 11 – Introduction: Role of Media Reports in Suicide
This study by Niederkrotenthaler at al., published in the British Journal of Psychiatry, examines the role media content on suicide has in suicidal behaviour in the public, both increase and decrease in suicide rates, and the effect of different types of article.
The current evidence suggests that the media does play a role, with an increase in suicides reported following reports in the media, showing a dose-response relationship between the quantity of reporting and subsequent suicides. Furthermore, the increase in suicide rate is greatest in areas where a higher proportion of the population is exposed to such media reports. This copy-cat behaviour is referred to as the Werther effect, and while not as large as other psychosocial risk factors, does play a role in an individual's likelihood of taking their own life.
The study looked at 497 suicide reports in the Austrian media in the first half of 2005, and looked for associations between specific characteristics of reports, and subsequent short-term changes in suicide rates. (In addition to the Werther effect, the team refer to any post-reporting reduction in suicide rates as the "Papageno" effect, in reference to Mozart's The Magic Flute.)
I won't go into great detail here about the different characteristics of reports that were used, since these can all be found in the methods section of the paper. Briefly, however, they assessed the content of the articles, the extent of the reporting, and the article's prominence, and coded these semi-quantitatively by noting the absence or presence of a number of attributes. The characteristics of the article's content (such as "describing the suicide method in the headline") were generated using guidelines for media reporting of suicide produced by the WHO and a number of other national agencies.
The authors found that suicide rates increased with quantity of reporting, though prominence of the articles was not associated with more suicides. Where the reported method of suicide was jumping, this correlated with an increase in suicide rates (r=0.15, P=0.001), but there was no significant relationship for other methods (NB: suicides by jumping are more likely to be reported by the print media than any other method). Furthermore, dichotomous thinking in the report, reference to multiple suicides and/or a suicide 'epidemic', and reporting on myths that surround suicide, were all associated with an increase in suicides in the population. Articles which discussed increasing societal problems as a cause of suicide were also more likely to result in increased suicide rates.
The only characteristic to be associated with reduced suicide rates was that of articles focusing on suicidal ideation (e.g. an aborted suicide; considering suicide but not going through with it). Yet articles which focused on suicide research, reported on expert opinion, or gave contact details for support services (e.g. Samaritans) seemed to cause an increase in suicides, although the authors found that these attributes were likely to be found in media reports that contained unfavourable, sensationalist comments.
The idea that certain types of reporting raise suicide rates does not seem surprising to me. The concept of triggering is well known, and as I understand it, is a bit like the straw that broke the camels back. People who are vulnerable, show suicidal ideation and suicidal urges, may read an article about suicide and be strongly influenced by it. In some instances, it may trigger an individual to attempt suicide. Another example of this is self-help forums on the internet that discuss either suicide or self-harm (by which I mean self-destructive behaviours without suicidal intent). These are full of posts with "**trigger**" in the title, to alert users to potentially upsetting, or "triggering", content. (Just Google "suicide triggering" to see what I mean.)
But why does reporting instances of suicidal ideation reduce suicide rates? The authors suggest that such articles highlight the reported outcome as "going on living". I would add that such articles perhaps point out to individuals with suicidal ideation that they are not alone, and that the subsequent reduction in feelings of isolation may play a role. Articles that raise awareness of mental illness can also be beneficial, as discussed in the middle paragraphs of this article (yes, I like cricket and I am biased!).
The key limitations of the study that I could identify (and most of which the authors also identlfied) are as follows:
- Only print media was analysed. Although a large proportion of the population is exposed to the print media, this research fails to take into account influences from e.g. film / television and the Internet.
- Limited geographic area.
- I'm not an expert on stats, but some of their methods seem very complicated to me. Can anyone who knows a bit more explain whether the methods used are solid and reliable or not? There do seem to be a fair few attempts at validation, and the authors report "high intersubjective analytic consensus".
- No causality, only correlation, and consequently large potential for confounding factors.
- Study only looked at 6 months of print media, while suicide rates are known to differ seasonally.
The role of the media in all things medical is important, but this example of suicide rates is, I feel, particularly worthy of discussion, since the outcomes are so evident and tragic. I look forward to this week's #TwitJC on Sunday evening (8pm UK time; 7pm GMT) and hope it will be both interesting and thought provoking.
Other links:
Samaritans UK guidelines on reporting suicide.
Media Wise link to an extensive selection of articles and reports on suicide reporting.
This Wired blog looks at copycat suicides, and how the increased prevalence of a new method put first responders at risk.
Press Complaints Commission – Editors' Code of Practice (See section 5.ii) for mention of suicide)
Mind guidelines on reporting on mental health and suicide.
Finally, if you, or someone you know, is feeling suicidal, do talk to someone; either someone you know and trust, your GP, or Samaritans on 08457 909090. (Although strictly speaking, based on what I've just written, I probably shouldn't have included that sentence.)
EDIT: Added link to PCC Code of Practice and Mind guidelines.
Posted in Introductions, Week 11 1 Comment
Week 10 – Introduction: Early Palliative Care in Patients with Metastatic NSCLC
I should first admit a small conflict of interest in writing this post: mummy Silvey is a lung cancer nurse specialist and I am very passionate about the care of lung cancer patients as a result. Lung cancer is the most common cancer in the world. According to Cancer Research UK, 1.61 million new cases are diagnosed worldwide each year. Lung cancer has a poor prognosis – patients with non-small cell lung cancer have approximately a 50% 2 year survival rate if the cancer hasn't metastatised; for patients where the cancer has spread, this falls to 10%. These figures are devastating.
My mum has been a lung cancer nurse specialist for over 10 years now and has previously sat on the NICE guideline committee for lung cancer. When she started her post a senior community nurse told her the importance of referring patients early to the community palliative care team. Most lung cancers are not curable and therefore she felt that the involvement of specialists in palliative care early was vital. Furthermore, she felt these patients needed early pallaitve care input for good symptom control and that this had helped the patients she had looked after. This evidence is ancedotal, but it was her experience. However, there is now evidence to support her views: evidence now exists that shows early palliative care, at time of diagnosis, is both appropriate and beneficial for patients with non-small-cell lung cancer.
The paper #TwitJC will look at this week is "Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer" by Temel et al., published in the New England Journal of Medicine last year. It is a randomised trial in which 151 newly diagnosed metastatic non-small cell lung cancer patients were ransomised to received either early pallative care in conjunction with standard oncologic care, or to standard oncologic care alone. This trial measured quality of life and mood at baseline and at 12 weeks using the Functional Assessment of Cancer Therapy – Lung and the Hospital Anxiety and Depression Scale, respectively. The primary outcome of the trial was the change in quality of life at 12 weeks.
The results demonstrate that of the 107 patients who completed the assessments, patients assigned to the early palliative care showed a better quality of life than those assigned to standard care (mean score on FACT-L 98 vs 91; P=0.03). Patients in the early palliative care group also had fewer depressive symptoms (using HADS 33% vs 54%; P=0.05).
However, the surprising result was that even though fewer patients in the early palliative care group received aggressive end of life care, the median survival was actually significantly longer in this patient group (11.6 months vs 8.9 months; P=0.02).
The conclusion:
Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.
A list of discussion points will be posted shortly and I look forward to another interesting discussion of a very interesting paper. I would recommend reading the NEJM editorial about this piece of research – it is an insightful read.
A plea: Lung cancer awareness month is in November. This never gets a high profile but I just want to make people aware of it and remind everyone how important it is to raise the profile of lung cancer. The less of a stigma we have about it and the more we talk about the symptoms of lung cancer hopefully more people will start to come forward earlier with symptoms. Remember that 1 in 9 people who develop lung cancer have NEVER smoked in their lives and many others gave it up years ago. The Roy Castle Foundation is a fantastic organisation helping to raise the profile of lung cancer and is a charity I am proud to support.
Also I would like to dedicate this week's journal club to my mum – I am constantly in awe of the amazing job she does for her patients everyday and I couldn't be more proud of her.
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Week 9 – Introduction: Prevention of HIV-1 Infection with Early Antiretroviral Therapy
HIV by numbers (2009 WHO Data):
- 33.3 million people with HIV
- 2.6 million new infections with HIV in 2009
- 1.8 million deaths in 2009
The sheer scale of the burden of HIV is beyond the scope of mere numbers alone but the numbers are staggering. I spent my elective inTanzania and saw first hand the devastating impact HIV has had. Every day the clinic by our house was filled with people coming to be tested, and treated, for HIV. I will never forget the stories that I heard from people affected by this awful virus. I have also witnessed first hand how antiretroviral treatment can transform lives and protect children from mother-to-child transmission of the virus. But transmission of this virus still occurs every second of every day and there have been a huge numbers of studies looking at how to prevent transmission.
Previous cohort studies have shown that antiretroviral treatment reduces the rate of transmission of HIV. In the August edition of the New England Journal of Medicine Cohen et al published the results of a multicontinent, randomised controlled trial to evaluate the effect of combination antiretroviral therapy on the prevention of HIV-1 transmission to uninfected partners.
A total of 1763 discordant couples were enrolled in this trial, the HIV-1 infected partner had a CD4 count between 350 and 550 cells per cubic millimetre. HIV-1 infected partners were then randomised into the two arms of the study:
- Early antiretroviral therapy – therapy commenced at enrolment
- Delayed antiretroviral therapy – therapy commenced when the CD4 count dropped below 250 cells per cubic millimetre or a HIV-1 related event occurred
The main question: would antiretroviral treatment of the HIV-1 positive partner reduce the rate of transmission to the non-infected partner as previously suggested by cohort studies?
The headline figure – there were 39 HIV-1 transmission events and 28 of those were genetically linked (i.e. the transmission was from the infected partner). Of these 28 infections only one occurred in the early therapy group, a 96% reduction in the rate of transmission, a staggering result. Of the 27 infections in the delayed-treatment group all occurred when the infected partner was not receiving antiretroviral therapy.
A second question was asked: would immediate therapy slow disease progression in the HIV-1 infected partner when compared to the delayed therapy? Again the study showed a positive result – a total of 105 participants had at least one clinical end point (see the paper for details). 40 of these were in the early-therapy group and 65 in the delayed therapy group – a reduction of nearly 40% in those treated immediately.
The conclusion:
In this trial, we found that early antiretroviral therapy had a clinical benefit for both HIV-1–infected persons and their uninfected sexual partners. These results support the use of antiretroviral treatment as a part of a public health strategy to reduce the spread of HIV-1 infection.
A list of discussion points for tomorrow's journal club will be posted in the morning and I look forward to another interesting discussion of a fascinating paper.
For anyone interested in HIV I can highly recommend the wonderful book by Elizabeth Pisani – The Wisdom of Whores. There aren't many books I would describe as a must-read but this is one.
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Week 8 – Introduction: FEAST
A huge number of studies are published in journals everyday. Most are read with interest by people involved in the area in which they are published but few every reach the attention of the world's media. The FEAST study is an exception to this; it attracted a huge amount of attention, the headline from the BBC news story – "Africa trial questions shock treatment for children" was typical of coverage of this trial.
The use of fluid boluses for shock is an international standard, the American College of Critical Care Medicine recommend the use of 60mls per kg of fluid for a child with a fever who has shock. However, in resource-poor countries these boluses are simply not available.
FEAST – Fluid Expansion as Supportive Therapy – was published in June 2011 in the New England Journal of Medicine with the aim of evaluating the effect of fluid boluses and early fluid resuscitation for shock in febrile children in Sub-Saharan Africa. This was a randomised controlled trial carried out in 6 hospitals inKenya,Tanzania and Uganda. The trial assessed the effects of giving a fluid bolus to children with a febrile illness and impaired perfusion (i.e. children with hypovolaemic shock). Children were randomised into two groups:
- Stratum A – children without severe hypotension – randomised to receive either a saline bolus (20mls per kg), an albumin bolus (20mls per kg) or no bolus (control group)
- Stratum B – children with severe hypotension – randomised to receive saline bolus (40mls per kg) or albumin bolus (40mls per kg)
The protocol was changed in June 2010 and initial boluses were increased to 40ml per kg in stratum A and 60mls per kg in stratum B. Children from the age of 60 days to 12 years were included and the exclusion criteria were children with severe malnutrition, diarrhoea, burns, surgery and trauma. All children received appropriate treatment for their condition as well as being involved in the trial.
The primary endpoint was mortality at 48 hours after randomisation.
The study was stopped in January 2011 after the independent data and safety monitoring committee reviewed the 5th interim analysis from the study and recommended stopping owing to safety concerns in both fluid bolus groups.
The headline finding – 48 hour mortality:
- 10.6% in the albumin bolus group
- 10.5% in the saline bolus group
- 7.3% in the control group
The relative risk for any bolus vs control was remarkable – 1.44 (P=0.003). The results were found to be consistent across the trial sites and across the subgroups even in respect to the underlying conditions (malaria, coma, sepsis, acidosis and severe anaemia).
The authors of the paper concluded:
The results of this study challenge the importance of fluid resuscitation as a lifesaving intervention in resource limited setting for children with shock who do not have hypotension and raise questions regarding fluid-resuscitation guidelines in other settings as well
This week I emailed Professor Kathryn Maitland for her thoughts ahead of our discussion and I thank her for taking the time to email me back. Her response:
The major take home message is that we were all surprised by the result. There was no 'signal' from the SAE's and the clinicians involved in the trial — said they all saw children 'improve' on boluses and believed that boluses were good. This is why trials are important.
Overall, mortality was lower than they had previously experienced– which was probably due to training of all staff involved in paediatric care.
Professor Maitland also highlights the FEAST study trial video which in her words "takes you to the bedside and puts the trial into context".
* * *
Tomorrow I will be posting the discussion points for Sunday evening's journal club meeting and I look forward to critiquing this fascinating paper.
Thank you to @welsh_gas_doctor for his help with this summary.
Posted in Introductions, Week 8 1 Comment
Week 7 – Introduction: Benefits of PCI in Stable Coronary Heart Disease
Percutaneous Coronary Intervention (PCI) is a surgery in which obstruction in a stenotic coronary artery is cleared either by balloon angioplasty or stenting. It is a very common procedure, with a 2006 American Heart Association report estimating 1.2 million procedures in 2003 in the US.
PCI is not generally effective in reducing numbers of myocardial infarctions (MI) or mortality in patients with chronic stable angina, but rather only improves quality of life. (This is according to a number of randomised trials and meta-analyses, most notably the highly-publicised COURAGE trial.) Conversely, PCI can be effective in reducing morbidity and mortality in unstable angina.
This study looked at 153 patients who were undergoing diagnostic cardiac catheterisation, but who had also signed consent form for PCI to be performed if it was deemed to be necessary by the interventional cardiologist. They were asked about demographic characteristics, history of angina, whether they felt they were adequately informed about the procedure, and what their expectations of its benefits were.
The study also looked at physicians' responses to a similar survey. Ten interventional cardiologists and 17 referring cardiologists were asked about their beliefs on the benefits of PCI, and expected outcomes for various hypothetical patients. With interventional cardiologists, the authors also asked about beliefs for study patients undergoing surgery. From my perspective, the numbers here are strikingly small, though since this is a single-centre survey, this probably placed limits on the number of cardiologists who could be asked. It does, however, mean that some of the n numbers in the results section are very small.
The key finding of the paper is that, among patients, 88% believed PCI would reduce their risk of MI, and 82% believed it would reduce their risk of fatal MI; however, among physicians, only 17% believed PCI would reduce the risk of MI and 15% believed it would reduce fatal MI. Furthermore, there was little agreement between individual patients' and their cardiologists' responses.
Despite this disparity, most patients reported their doctor spending at least 5 minutes explaining the procedure to them, and over half received some written information on the matter. Furthermore, 96% believed they knew why they might undergo PCI, and more than half felt they had been actively involved in decision making. With patients on whom PCI was carried out, physicians were more likely than patients to believe that the patient had been involved in decision making (78% v 94%). Also of note: patients felt they were at greater risk of MI than their cardiologists did (according to a 5 point Likert scale). Perhaps bizarrely, patients who thought they knew why there were getting PCI were more likely to hold the inaccurate belief that PCI prevented MI though this did not reach significance (Odds ratio = 5.3, CI 0.82-34.53).
The physician responses to hypothetical scenarios also generated some interesting results, perhaps most significantly:
In the first 2 scenarios, 70% of cardiologists did not identify any bnefit associated with PCI, yet 43% of these indicated that they would proceed to PCI anyway
I can't help but question why a doctor would go ahead with a procedure from which they could foresee no benefit. In addition, this recent study also showed that for non-acute indications, 12% of PCIs were classified as inappropriate. The majority of these procedures performed in patients with little to no angina or with low-risk ischemia on stress testing.
Patients overestimating the benefits of drugs is not limited to PCI and cardiology, but why is it that patients perceive benefit when there is none? Given that most patients in this study had a discussion with their cardiologist, why were they not better informed about the potential outcomes of PCI? Is it a failure to adequately distinguish between unstable and stable angina? It does follow logically that alleviating the symptoms of cardiovascular disease would alter some underlying mechanisms to reduce the risk of MI, but shouldn't cardiologists be making it clear to patients that this is not the case? What can doctors do differently to communicate effectively with their patients?
If you have any other comments on the paper, please do raise them this evening. As usual, a bit before 8 o'clock this evening (UK time, so 7pm GMT) I'll post the key points for discussion.
Posted in Introductions, Week 7 1 Comment
Week 6 – Introduction: Beta-Blockers and COPD
Beta blockers are widely prescribed for a range of conditions and are now widely used in the management of cardiovascular disease. Patients with chronic obstructive pulmonary disease (COPD) often have concurrent co-morbidities including cardiovascular disease. However there has been concerns regarding the prescription β-blockers in these patients due to worries about the effect it may have on their respiratory function:
- evidence that the use of β-blockers in patients with COPD may lead to a reduction in their lung function (by reducing their FEV1 - Forced expiratory volume in one second)
- β-blockers may increase airway hyperresponsiveness
One of the mainstays of treatment of COPD is the use of beta-agonists and there have been concerns that β-blockers may lead to inhibition of the bronchodilator response to these drugs.
As such there has been some reluctance to prescribe β-blockers in these patients. This paper published in the BMJ looked at the use of β-blockers in patients with COPD to assess the effect on mortality, hospital admissions and exacerbations when used in combination with established therapy for COPD.
This was a retrospective cohort study which identified cases from a disease-specific database in Tayside which is used by GPs and secondary care respiratory physicians. All patients fulfil the GOLD guidelines for diagnosis of COPD and data on these patients was collected by respiratory nurses at yearly visits. The authors then identified patients who had an admission to hospital due to COPD and also gathered data on the prescription of respiratory and cardiovascular drugs and on deaths from the general register.
The main outcome measures were hazard ratios from all cause mortality, emergency oral corticosteriod use (use to treat exacerbations of COPD) and respiratory related hospital admissions. In these patients 88% of the β-blockers used were cardioselective.
The results – this paper showed a 22% reduction in all cause mortality in patients prescribed β-blockers. There was a reduction in the adjusted hazard ratio for patients prescribed β-blockers with standard treatment for COPD compared to those who weren't (0.28 vs 0.43). The paper also showed a reduction in oral corticosteriod use and hospital admission. There was no adverse effect on lung function detected at all stages of the stepwise treatment approach to COPD.
The authors of this paper concluded that:
β blockers may reduce mortality and COPD exacerbations when added to established inhaled stepwise therapy for COPD, independently of overt cardiovascular disease and cardiac drugs, and without adverse effects on pulmonary function
A list of discussion points will be posted shortly. Thank you to @amcunningham for suggesting this paper.
Posted in Introductions, Week 6 1 Comment
Week 5 – Introduction: Safer Surgery Checklist
A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population – Haynes et al for the WHO Safe Surgery Saves Lives Study Group
The paper chosen for this week's journal club has had an impact on patient safety worldwide: As an F1 during my colorectal surgery job (on the rare occasions I went to theatre) I saw how this paper has changed practice with the implementation of the WHO safe surgery checklist.
In the surgical setting it has been estimated that almost half of all complications are unavoidable. This is a huge patient safety issue. In 2008, the WHO published guidelines to ensure the safety of surgical patients. From this, the authors of the NEJM paper designed a 19 item checklist with the with the aim of reducing surgical complications and its subsequent morbidity and mortality.
The surgical safety checklist is a simple intervention, a checklist that is followed at three key points with the whole surgical team present – before the induction of anaesthesia, before skin incision and before the patient leaves the operating theatre. The primary endpoint of the study was the occurrence of any major complication, including death, during a period of postoperative hospitalisation, up to 30 days (complications were defined as outlined in the American College of Surgeons' National Surgical Quality Improvement Program).
The trial was run at eight sites in a range of healthcare settings worldwide. Before the checklist was implemented at the trial sites, baseline data, including complication rates, were reported for 3,733 patients at all trial sites. The checklist was then implemented, consecutively enrolling patients over the age of 16 years undergoing non-cardiac surgery. During the pre-checklist period the rate of any complication at all sites was 11%. After the implementation of the checklist this fell to 7% (P<0.001). The total in-hospital rate of death fell from 1.5% to 0.8% (P=0.003). The authors of the paper concluded that:
Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications, although further study is needed to determine the precise mechanism and durability of the effect in specific settings.
According to the WHO over 3000 hospitals worldwide have now implemented the surgical safety checklist, an impressive figure that shows how research can translate into a world-wide change in practice. Tonight night at 8.00pm BST we will be discussing this paper – a list of discussion points will be posted shortly. I look forward to another interesting and lively debate.
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Week 4 – Introduction and Discussion points: Medical schools and Performance in MRCP
Thank you Fi for asking me to write an introduction and suggest some discussion points for tonight's Twitter journal club. Having a special interest in medical education I was very happy to see this paper by McManus et al. suggested for Week 4 of the journal club.
Discussion point 1: What factors do you think might explain variation in performance in MRCP between medical schools?
What did authors do? They looked at outcomes in MRCP (Member of the Royal College of Physicians) examination for entrants from all medical schools between 2003 and 2005. They found that in the Part 1 and 2 exams, Cambridge, Oxford, and Newcastle graduates did significantly better than average , and the performance of Liverpool, Aberdeen, Dundee and Belfast students was significantly worse. In the PACES section (a clinical examination based on a modified OSCE) Oxford students performed significantly and Liverpool, Dundee and London students significantly worse.
This first part of the analysis is quite easy to understand but the authors then go on to construct a multi-level model to see if they can explain variation between the medical schools.
Since it is known that ethnicity and gender are correlated with MRCP performance, and they had this as individual level data, they adjusted for this.
Discussion point 2: Is it surprising that the average offer to those applying to a medical school may predict performance of graduates in MRCP?
Two complex analyses were performed in this study: a multilevel model, and a structural equation model. Unfortunately the results of the multilevel model are not produced in an easy to understand format, although there is a figure in an additional file which is downloadable.
The authors looked for correlations between medical school performances in MRCP and a plethora of other factors. This information was pulled from other sources such as the Guardian tables, a survey of the cohort of medical students who started university in 1990/1, and the offers which each medical school made to students in the mid-1990s.
They found correlations between:
- Offers made to students (A level or Scottish higher grades)- the higher the offer the better the performance
- The proportion of final year medical students reporting being interested in a career as a physician, and reporting interesting medical teaching, and better performance in MRCP.
- The higher the percentage of graduates taking MRCP, the better the performance.
However when these factors were analysed together, it was only admission grades that seemed significant.
They also looked at correlations with data from the Guardian tables. In a multiple regression, again only admission criteria were found to be significant.
In the multilevel model, the entrance qualifications of graduates were found to explain 62% of variance, which in this type of study is a large amount. 38% of variance remained unexplained but a commenter has suggested that the contribution of entrance qualifications may be under-estimated because of the 'ceiling effect'- many entrants may have been offered the highest grades of 3 As.
Discussion point 3: Are the authors correct to conclude that this analysis suggests that a national exit exam should be introduced?
What do the results of this study mean? To place the study in context it is perhaps useful to start with the last words of the authors in the paper. They believe that this analysis supports the case for the "introduction of a national licensing examination" in the UK.
We don't have a national exit exam in the UK. Instead the General Medical Council (GMC) regulates medical education through individual medical schools. Quality assurance of medical education and the final exams which must be passed to gain provisional entry to the medical register rests with the GMC and external examiners.
This analysis shows that different medical schools admit students with different school qualifications, and that the higher the entrance requirements, the greater the success may subsequently be in MRCP. McManus et al refer to a study which shows this is also true of performance in MRCGP exams, but I cannot find that publication.
Discussion point 4: How should we judge the performance of medical schools? Is performance of graduates in post-graduate examinations important?
When this study was published it contributed to discussion about whether a national exit exam should be introduced. Ian Noble, a Sheffield medical student, writing in the BMJ, suggested that medical schools should be judged on whether the graduates they produced performed as competent foundation doctors, not on how well graduates performed in subsequent examinations. Since it is rare for graduates to be pulled up for poor clinical performance this suggests that we have no problem for a national exit exam to solve.
Discussion point 5: How helpful is it to read reviewer's comments on a paper? Is this something that all journals should aim for?
This paper is published in BMC Medicine which also posts the comments of the peer-reviewers. One of the reviewers suggested that this paper should not be published as although it involved a commendable analysis of multiple datasets it did not "help me to understand the problems in medical education better, nor does it help me to improve medical education or to advance medical education as a science". The authors' response to this criticism is also published. The reviewers and the main author also had a dispute over another analysis published in BMC Medicine on gender and ethnicity and success in MRCP. But that discussion was pre-submission so is private correspondence between those involved.
Conflict of Interest: I'm a Belfast graduate!
Posted in Discussion Outlines, Introductions, Week 4 2 Comments
Week 3 – Introduction: CRASH-2
For the past two weeks Twitter journal club has looked at two fairly old but still very relevant papers. The paper chosen for this week is at the cutting edge of research and recently won the award for Research Paper of the Year at the 2011 BMJ Awards. This award recognises a paper that the judges believe will have an impact on doctors and patients over the next 5 to 10 years.
The results of CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) were published in The Lancet in June 2010. This was a randomised placebo controlled trial which recruited 20,211 trauma patients with, or at risk of significant haemorrhage in 274 hospitals in 40 countries. Patients were randomised into two arms of the study – either to receive placebo or the drug tranexamic acid. Tranexamic acid is an antifibrinolytic, this drug works by blocking sites on an enzyme that causes blood clot breakdown. The trial was designed to assess whether early administration of this treatment (within eight hours) would have an impact on patient deaths due to bleeding.
The headline finding – all-cause mortality was significantly reduced with tranexamic acid (14.5% in the treatment group vs 16.0% in the placebo group – relative risk 0·91, 95% CI 0·85—0·97; p=0·0035). Risk of death due to bleeding was also significantly reduced (4·9% in the treatment group vs 574 5·7% in placebo group ; relative risk 0·85, 95% CI 0·76—0·96; p=0·0077).
The number needed to treat in this trial – 67, an impressive result (from all-cause mortality figures). The findings of this large scale study have the potential to have a huge impact on the management of trauma patients – the authors of the study have called for this drug to be available to doctors treating trauma patients worldwide and that it should be considered for the WHO's List of Essential Medicines. As the CRASH 2 team said at the BMJ awards:
"Our research showed that giving tranexamic acid to bleeding trauma patients is both effective and cost effective. These findings are of global importance because every year, over 2 million people die from traumatic haemorrhage"
A very simple intervention with a relatively inexpensive drug that could have a global impact on the mortality of trauma victims worldwide – this is why we have chosen to discuss CRASH-2 in this week's journal club.
I will be posting a list of discussion points in advance of the journal club on Sunday at 8pm BST. I am very excited to have the opportunity to critique this paper and look forward to another interesting and informative discussion.
Posted in Introductions, Week 3 1 Comment


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- Product Consultation
- Foot conditions
- Lower Body pain
- Skin conditions
- Products & brands
- Savings & offers
Foot odor occurs when excess perspiration from your feet soaks the lining of your shoes and socks. Perspiration creates an optimal environment for bacteria which can grow and cause a bad odor.
Sweaty, smelly feet and/or shoes are the most common signs.
People who wear poorly ventilated shoes, synthetic or non-leather boots, or non-wicking socks made of polyester or nylon tend to have persistent foot odor.
Bacteria are the major source of foot odor. Bacteria consume dead skin cells on the feet, which then produce foot odor.


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- From Puck Rakers – Russell Out of Worlds: Update on defenseman Kris Russell, who according to Scott Howson has a spiral fracture of his tibia. He's been ruled out of the World Championships, but who isn't? Rick Nash (Canada), Fedor Tyutin (Russia), and Jakub Voracek (Czech Republic).
- From Carry the Flag – Methot Set to Wear Half Shield: With Marc Methot's decision to switch to a visor for 2011-12, Dan – a hockey player himself – gives us his $0.02 on the matter.
- From The Cannon – Game 80: Insult and Injury: As always, Matt conjures up a pretty in depth look at the last game, with a pretty interesting point – "Does anyone else feel a moment of bemusement that there was a disputed goal in yet another game against Dallas, and Derek Dorsett was involved each time?"
- From the Dark Blue Jacket – DBJ's crowdsourced ballot for the 2011 NHL Awards: In lieu of our beloved (protesting) NHL writers doing it, DBJ is running a fan vote for the NHL Awards. Check it out and weigh in on his Facebook page.
- From Fire the Cannon – Eric Smith's Weekly Podcast: This week featuring Tom Reed of the Columbus Dispatch and rookie Cam Atkinson.
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- DHS and Department of Justice (DOJ) announced the execution of seizure warrants against 10 domain names of websites engaged in the advertisement and distribution of child pornography as part of "Operation Protect Our Children"—a new joint operation between DOJ and U.S. Immigration and Customs Enforcement (ICE) to target sites that provide child pornography. This enforcement action was spearheaded by ICE's Cyber Crimes Center, under a nationwide ICE initiative to identify, investigate and arrest those who prey on children.
- As part of Operation Predator, an initiative to identify, investigate, and arrest child predators and sexual offenders, Secretary Napolitano and Attorney General Eric Holder announced charges against 72 individuals for their participation in an international criminal network dedicated to the sexual abuse of children and the creation and dissemination of graphic images and videos of child sexual abuse throughout the world.
- The U.S. Secret Service (USSS) led an interagency investigation which identified an individual who had breached a Federal Reserve Bank computer server as part of a fraud scheme. An analysis of the subject's computer disclosed credit card data with an estimated value of approximately $200 million.
- The ICE Cyber Crimes Center and the USSS's Electronic Crimes Task Forces continue to work with international law enforcement to share expertise and resources to combat electronic crimes such as identity theft, network intrusions and a range of financial crimes. This includes the opening of a new USSS office in Tallinn, Estonia to more efficiently counter cyber crime originating from Eastern Europe.
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Last Published Date: June 25, 2015


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The best fashion ranges by shabby chic
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1993 Toyota Camry Q&A
1993 Toyota Camry Question: Door panel Removal
How to remove door panel - stamp21
Answer 1
, here we go. first, open the rear door. then look at the window switch. ( if you have power windows ) put a small screw driver in from the front and it comes out. Disconnect the window switch. There should be a phillips screw under there, unscrew it. there are 2 small phillips screws on the bottom of the panel, unscrew them. now there are 2 small plastic clips on the rear of the panel. push the center of them and pull them out from the ends. to reinstall them, pull the center out again more than they were, put in the slot and push the small button till flush. now there are afew white clips inside the panel. you need a "crows foot" or a simple strong flathead screwdriver. put it between the panel and the metal of the door and start prying little by little going aroung from right under where the 2 plastic clips were. then once all the clips are disconnected, push the panel up. now you will need a 10mm socket and ratchet to remove the gold screws. good luck. You will most likely need to replace any plastic fasteners as these tend to break even when removing them carefully. These 'plastic clips' are not expensive and can be found at any Toyota dealership. - dandd
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Italy's Financing Costs Plunge at 6 Billion-Euro Bond Sale
Feb. 14 (Bloomberg) -- Italy sold 6 billion euros ($7.9 billion) of bonds, meeting its target, as borrowing costs on its benchmark debt fell to the lowest since March even after the nation was downgraded by Moody's Investors Service.
The Treasury sold 4 billion euros of benchmark securities due in November 2014 to yield 3.41 percent, down from 4.83 percent at the last auction of similar-maturity bonds on Jan. 13. Investors bid for 1.4 times the amount offered for the 2014 bonds, up from 1.22 times in January. The Rome-based Treasury also sold a total of 2 billion euros of bonds due in 2015 and 2017 to yield 3.77 percent and 4.26 percent respectively.
Italy's borrowing costs have been falling as Prime Minister Mario Monti takes steps to spur the economic growth needed to reduce the euro-region's second biggest debt and amid European Central Bank lending to the region's bank that is shoring up demand for government bonds. Monti's government passed 20 billion euros of budget cuts and tax increases in December to balance the budget in 2013. It followed last month with measures to spur competition and reduce bureaucracy.
Today's auction "is a sign that the government's efforts to make significant changes in the Italian economy are actually buying confidence amongst investors," Annalisa Piazza, a fixed-income analyst at Newedge Group in London, said in a note published after the auction. "All lines were well absorbed, despite last night's downgrade by Moody's that in our view was somehow expected."
Funding Needs
Italian bonds gained today, with the 10-year yield falling two basis points to 5.58 percent at 12:28 a.m. in Rome. The extra yield investors demand to hold the securities instead of benchmark German debt fell four basis points to 3.62 percentage points.
Italy, which needs to sell about 450 billion euros of debt this year, auctioned 12 billion euros in bills yesterday and rates on the one-year debt fell to the lowest since June.
Borrowing costs dropped even after Moody's lowered Italy's rating overnight to A3 from A2, citing a weak outlook and possible funding shocks for sovereigns and banks. Five other European nations were also downgraded.
Moody's action came after Fitch Ratings and Standard & Poor's lowered the country's credit rating last month. Italian bond yields have fallen since those downgrades as the European Central Bank offered banks unlimited three-year loans, propping up demand for government securities. The Frankfurt-based ECB has also been purchasing Italian bonds since August.
To contact the reporter on this story: Lorenzo Totaro in Rome at firstname.lastname@example.com
To contact the editor responsible for this story: Craig Stirling at firstname.lastname@example.com


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I've owned this TV for almost 3 years now, and have just finally figured out how to turn off the overscan that is set automatically from the factory. It's not in the normal On Screen Menu that you can access via your remote control, so there is a bit of technical work involved with making the change.
I had never noticed the overscan until I attached a mac computer to my TV to use Frontrow, Boxee, and some other entertainment based applications. It never really bothered me until then, and I searched through every bit of the on-screen menus to try and turn it off.
I found that there was no way to turn it off. If I turned on overscan in the display settings on my mac, it made the top menubar move off the top of the screen, and the dock was barely visible. If I turned off the overscan feature it made a black border about 3/4″ thick all the way around the screen. There was no way that I could find to get the screen to fit correctly.
I really started to notice this when watching movies through Netflix Streaming and Hulu+ TV shows on my new AppleTV and my RokuHD box. I finally got my girlfriend to look up the answer for me. There wasn't anything in the way of an answer except the information of how to get to the service menus on the TV.
So, without further ado:
- Turn off the TV.
- Unplug all devices from the back of the TV.
- Unplug the AC power to the TV.
- Press the Power button several times with the AC power unplugged, then hold the power button in for about 30 seconds with the AC power still unplugged. (This often took me several attempts to get the menu to come up).
- Hold down the Channel Down button on the side of the TV, while holding it down, plug in the AC power. Once you hear the TV turn on, release the Channel down button immediately. Within a few seconds you should see a two row menu come up on the screen.
- Use the Up/Down and Left/Right arrow keys on the remote (D-pad) to cycle through the options. This will be accomplished with the left-most number highlighted in a green block. You will want to use the Up/Down arrows to move to Item #25 (LetteerBoxOvSc).
- Now use the Left/Right arrow to move the green box to the column labeled "Value". Change the number to 0 using the Up/Down arrows, then use the Left/Right arrow to move back to the "Index" column.
- Now use the Up/Down arrows to go to item # 55 (LeftOvS), and again use the Left/Right arrow to move to the "Value" column and change the number to 0 using the Up/Down arrows.
- Move back to the "Index" column and repeat step 8 for items 56 – 58 (RightOvS, TopOvS, and BottomOvS).
- When all items are 0, press the "Menu" button on the remote to return to regular viewing mode.
- Turn off the TV. Re-connect a device that you know Overscans, and see if it looks proper now.
- If it does, then reconnect all devices and enjoy.
- If not, then you cn navigate back in and make the changes again.
- Hope this helps anyone else having this issue.


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UPDATE: Girl questioned in Har-Ber gun scare not at school Friday
Posted: February 28, 2014 at 5 a.m.
Updated: February 28, 2014 at 10:44 a.m.
SPRINGDALE -- Students at Har-Ber High School were locked in their classrooms for an hour Thursday after district and school administrators received a report of a gun on campus.
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Flat Tax or Fair Tax
House Republicans are quietly moving ahead with plans to dramatically reform the tax code through either a flat-rate income tax or a national tax on consumption. Those efforts are the topic of my column this week. Please check it out at Reason (here), the New York Sun (here), or Newsmax (here).
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Courses & Grades
Course Approval
Approve individual courses; approve individual courses for transfer credit; or merely acknowledge that the course of study the student has chosen is appropriate. We see our academic advisors as partners and as crucial to the application process. Academic departments have sole authority and responsibility for approving study abroad courses for Drexel credit. For any courses that they intend to take overseas, students will individually request course approval to their Academic Advisor using the Academic Pre-approval Form.
Sample Approval Form for Drexel Exchange Programs
Equivalencies vs. Transfer Credit
Equivalencies: When a Drexel student attends a foreign university through a Drexel sponsored study abroad program, their transcript reflects Drexel course numbers, titles and credit for the courses taken abroad. For some programs, the Study Abroad Office maintains an Equivalency sheet, which is a list of courses at the foreign university that have been approved for Drexel equivalencies. If the student would like to take courses that are not listed, they will need to have equivalencies approved by the appropriate department. For example, if the student intends to take a sociology course abroad for Drexel credit, the Sociology Department at Drexel must pre- approve the course and its Drexel equivalency. Academic advisors are important.
Transfer Credit: When a Drexel student participates in Independent Study Abroad (i.e. NOT sponsored by Drexel), the courses taken abroad will be listed as transfer credit on their Drexel transcript. In this situation, the academic advisor can pre-approve all courses and how the transfer credit will be distributed.
Grades and Transcripts
Students are taught and graded by faculty at the host university for all Drexel sponsored exchange programs. In this case, grades are noted as "CR/NCR" on their transcript and will NOT affect their GPA. In order to receive CR students must earn a "C" or above at the host institution. The goal is for the student to be a full-time student at the host institution while also taking the equivalent of a full-time load at Drexel. Therefore, students should obtain pre-approval for more courses than needed to leave some flexibility in their course registration abroad. Upon completion of the program, transcripts from the foreign institution are sent directly to the Study Abroad Office for posting the pre-approved courses and corresponding credits on their Drexel transcript.
If a student attends a Drexel sponsored "free standing" program (such as Drexel in London, Summer in Prague and IAS Abroad), grades will be noted on their transcript and WILL affect their GPA.
If the student participates in an Independent Study Abroad (i.e. NOT sponsored by Drexel) grades will NOT be reflected on their transcript. The students' Academic Advisor is responsible for entered the transfer credit disbursement into the students transcript.