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This month's On the Spot is a collaboration with Jaime Ponce, MD, outgoing president of the American Society for Metabolic and Bariatric Surgery (ASMBS). We hone in on two issues that have become debate fodder: the current role of the laparoscopic adjustable gastric band and the current role of centers of excellence (COEs).
Justin B. Dimick, MD, MPH is the Henry King Ransom Professor of Surgery, Chief of the Division of Minimally Invasive Surgery, and Associate Chair for Faculty Development at the University of Michigan.
Michel Gagner, MD is senior consultant at the Hopital du Sacre Coeur, University of Montreal, Quebec, and Clinical Professor of Surgery at the Herbert Wertheim College of Medicine, Florida International University, Miami.
John Morton, MD is Director of Bariatric Surgery and Surgical Quality at Stanford Hospital and Chief of Minimally Invasive Surgery at Stanford University, Calif.
Ninh Nguyen, MD is vice-chair of the department of surgery at University of California Irvine School of Medicine, Orange, Calif.
Paul O'Brien, MD is Director of the Centre for Obesity Research and Education (CORE) at Monash University in Melbourne.
Jaime Ponce, MD is the Medical Director for the Bariatric Surgery program at Hamilton Medical Center, in Dalton, Georgia, and Memorial Hospital in Chattanooga, Tennessee. He is the current president of the ASMBS.
Christine Ren-Fielding, MD is Professor of Surgery at NYU School of Medicine, Division Chief of Bariatric and Minimally Invasive Surgery, and the Director of the NYU Langone Weight Management Program, New York City.
Raul Rosenthal, MD is Professor and Chairman, Department of General Surgery, Director of Minimally Invasive Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic, Weston, Fla.
Matthew Weiner, MD is a solo, private practice surgeon in Commerce Township, Mich., and the president of the Michigan State Chapter of the ASMBS.
Colleen Hutchinson: Last year when we did this column, you stated that your goals as ASMBS president were to: 1) finalize and implement our new quality improvement—to improve quality, access and insurance acceptance, and offer quality process to international colleagues; 2) consolidate the new annual "Obesity Week" meeting; and 3) establish guidelines for new procedures to be recognized/approved by ASMBS. How would you say the year turned out, based on those goals?
Jaime Ponce, MD: It has been a busy, challenging and satisfactory year of accomplishments. The MBSAQIP [Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program] joint program between ACS [American College of Surgeons] and ASMBS went through a process of careful analysis, detailed discussions and evaluation of what we can and can't do based on both organizations' structures and governance policies, and now the standards are finalized and ready to be implemented at the beginning of 2014. We are working on the resources for verification now, including training of more than 100 surgeons to become site inspectors. The data points for the MBSAQIP programs database have been carefully analyzed to eliminate unnecessary data points, ensuring centers and surgeons will not waste time collecting and entering unneeded data. The first national QIP is being released at Obesity Week and will be named DROP [Decreased Readmissions through Opportunities Provided], with the goal of decreasing readmissions by 50%.
Obesity Week is shaping up to be the best ASMBS meeting in history, with a superb program; and in conjunction with The Obesity Society and multiple level 2 and 3 society groups participating, it will be the largest and most comprehensive obesity meeting in the world. The program committee and ASMBS staff have done a tremendous job in accomplishing this milestone. We also will be celebrating the 30th anniversary of the ASMBS, so please visit www.asmbs30.org for details.
In addition to a new meeting and new accreditation standards, we have released a newsmagazine called "Connect." We have established new interaction with all our ASMBS state chapters (providing web, administrative, CME and other support), developed a new ASMBS website, and next year will release a new ASMBS textbook.
This year, we worked hard to improve access, establish a process through the research committee to study and recognize new procedures, develop revisional surgery guidelines, build collaboration with other societies, and increase political advocacy and communication with all private payors to align them with our accreditation process, and more.
It has been an honor to serve as president of ASMBS.
CH: What would you say incoming president Ninh Nguyen's biggest challenge(s) will be over the next year, and what advice would you give to him?
Dr. Ponce: I think Ninh will have big opportunities to continue to improve and expand the goals and mission of the ASMBS. Our educational offerings will continue to be the best; implementation of new standards and quality improvement will be better understood; and insurance companies' alignment with the MBSAQIP will increase. My advice is to continue with a strong collaboration among all parties to gain consensus to improve patient safety and outcomes. And as always, try to be open and transparent with the process to allow everybody to participate!
Ninh will represent us very well as president of ASMBS.
CH: What are your thoughts on the two issues in this installment of On the Spot, namely the role of the gastric band and the state of COEs?
Dr. Ponce: I agree that the number of LAGB [laparoscopic adjustable gastric band] procedures has decreased; I believe that it's still a viable option for some patients, specifically patients with a better understanding, who don't have geographic or financial limitations for access to care, who are not experiencing severe diabetes, and who have lower body mass index (BMI). Also, it is important that these patients get band adjustments and care at centers that are willing to dedicate the necessary efforts to care for band patients. It is not a procedure for every patient and every center. For many potential patients who are afraid of stapling procedures, the band still is a better option than continuation of failed medical weight loss management.
In regard to accreditation/COE, there's no question that we have seen tremendous benefits since the concept was established—from hospitals dedicating resources and staff, to establishing a safer patient environment, to now having the ability to gather data at a national level. Bariatric surgery is a complex procedure that is performed in a higher-risk patient who requires more long-term care than with many other surgical procedures. Accreditation is a venue through which to develop and implement the appropriate infrastructure, dedicated staff, specific process of care, and data collection, and is the pathway to establishing quality improvement. I personally think the surgeons from Michigan have created a very good quality collaborative with financial support that, by itself, is their "state accreditation."
The argument about accreditation decreasing access should be addressed in relation to patient safety. Access will increase as centers become better and safer, as they have via accreditation. The argument about accreditation being an administrative burden is well known, but it exists with private payors' accreditation requirements as well. The goal will be to work with insurance companies to decrease the burden to programs. Finally, the volume argument will diminish as the new standards require less volume, according to the evidence we have gathered from the data. We have made big improvements in patient safety over the past decade, and we don't want to see the examples we had in the past with higher mortality among Medicare patients (as described by Flum et al), that showed mortality in the range of 2% [data on Medicare patients having bariatric surgery from 1997 to 2002] (JAMA 2005;294:1903-1908).
Statement:The number of laparoscopic adjustable gastric band cases has decreased significantly in the past couple of years, and the band is no longer accepted as a viable option by many.
Michel Gagner, MD: Agree! After peaking in 2008 at 42.3% of worldwide procedures, banding has plummeted to 17.8% in 2011 (Obes Surg 2013;23:427-436). This trend will continue, while sleeve gastrectomy has increased exponentially to fill this gap, from 5.3% to 27.8% in the past three years of that survey. It also took more than 20 years for the Angelchik prosthesis (a silicone ring around the esophagus to treat gastroesophageal reflux disease) to be withdrawn from the market. Any foreign body around the gastrointestinal tract is not a good long-term solution; it is a violation of the basic principles of tissue healing.
We hear a defective ethical and moral discourse, with statements that the procedure has the lowest morbidity and mortality initially, and because we have so many to treat, we should allow it. Really? Why? It is faulty reasoning, because the frequent failures, conversions and reoperations have greater risks and mortality, jeopardizing the success of the next procedures. Although some teams have been successful with their patients, that success is not due to the surgical procedure itself, but rather an intensive follow-up with positive psychological reinforcement, which is not applicable or realistic within most practices around the world. Resources are limited, and the treatment of obesity requires more than just simple adjustable restriction (an attractive concept).
But what is killing the gastric band is that surgeons are tired of observing failures and dealing with "not enough" or "too much" restriction constantly; patients want to have their devices removed and be replaced with something else; and the public sees this shift. An FDA trial permitted a relatively safer introduction of the band in the United States (2001), later than the rest of the world, creating a lag phase of 10 years in the United States. Worldwide, more bands are removed than inserted, and the first country that used it (Sweden) has seen its use disappear. Insurance plans should stop covering it, in favor of more stapling procedures.
Raul Rosenthal, MD: Disagree. We are experiencing a decrease in banding and bypass cases due to the growing demand for and excellent outcomes of sleeve gastrectomy. Sleeve gastrectomy most likely will become, by the end of this year, the most popular bariatric procedure worldwide. Gastric banding will remain a valid treatment modality, but the number of cases most likely will stay low for years to come and increase again once we have safe and effective anorectic drugs that we can combine with it.
Christine Ren-Fielding, MD: I agree. The number of these operations being performed has decreased significantly around the world and the band is no longer accepted by many; however, this does not mean the adjustable gastric band is not or should not be a viable option for the treatment of morbid obesity.
Just like all other bariatric operations, the excitement of the band as a new treatment option was embraced and the number of operations peaked. In addition, many surgeons who performed gastric banding due to financial gain rather than medical care realized that the aftercare is just as important, if not more important, than the operation itself. The time and financial resources necessary to provide this aftercare is consuming and has become unpalatable for many; but without it, the weight loss outcomes are poor and reoperations are high.
Just as the band is not a "quick fix" for the patient, it is not a "quick buck" for the surgeon. Instead, the success of the adjustable gastric band relies on dedicated long-term management by both the surgeon and the patient. This realization over the past decade has clarified the importance of patient selection and surgeon selection, in order to maximize the advantages this operation offers and decreases the disadvantages, thus resulting in an appropriate decrease in the number of cases being performed. This has happened with the gastric bypass and surely will occur with the sleeve gastrectomy.
Paul O'Brien, MD: Yes, gastric band numbers are decreasing across several continents. So too, is gastric bypass. And the rise in the sleeve does not come close to equaling the losses. Bariatric surgery, in general. is not doing well. We are not winning the hearts and minds of the 80 million obese people in the United States or the 300 million-plus people worldwide. We now have better data than ever proving safety, substantial and durable weight loss, clear health benefits, improved quality of life and cost-effectiveness. All current bariatric procedures are effective, yet we are losing ground. Why could this be so?
Perhaps we are expending too much effort trying to prove one approach is better than another and not enough convincing physicians and their patients that bariatric surgery does work. It is, arguably, the most powerful treatment we have in medicine today because it achieves weight loss. The gastric band is a safe, simple outpatient procedure, but it does require significant effort in aftercare to get the best results. It is your call. You can either say "No, the aftercare is just a bit too hard" and walk away, or like us, you can do it properly and enthusiastically. We are able to do this, both at my clinic in Australia and at the American Institute of Gastric Banding in Texas, where I'm the national medical director. If you want to try the second option and you would like some help, please let me know. I am happy to share our methods with you. And please do not blame the patients and say it is their decision. They still want it. At both sites, we are treating more people than ever.
Statement:The Bariatric Surgery Center of Excellence accreditation process has been proven to improve safety and outcomes. However, the Centers for Medicare & Medicaid Services (CMS) has just removed its requirement that Medicare patients undergo bariatric surgery procedures at accredited facilities. This decision reflects an incomplete review and analysis of overwhelming scientific evidence and medical opinion that bariatric accreditation programs save lives, improve patient outcomes and enhance patient quality of care, and the proven assertion that accreditation is a critical venue for improving quality measures in bariatric surgery. In addition, this decision will place the higher-risk Medicare population at risk.
Matthew Weiner, MD: Disagree! The very checkered past of the bariatric surgery community's experience with accreditation programs has come to an end, thankfully, with the recent CMS decision. Accreditation programs permit surgery at some centers, while forbidding it at others. The exclusionary nature of these programs forces surgeons and hospitals to jump through hoops to get a seat within the inner circle. Accreditation programs are not in our best interest, nor the interest of our patients.
Our experience in Michigan with a quality improvement program that is open to all surgeons and hospitals and that fosters collegiality between competing centers serves as a model for the entire country. Although many may look at the CMS decision as a crushing blow to the yet to-be-finalized MBSAQIP standards, I predict that it will be viewed historically in a much more favorable light. CMS's decision to remove the COE requirement will allow the MBSAQIP standards to focus on accurately tracking outcomes and providing feedback to surgeons and hospitals, rather than performing site visits and reviewing meeting minutes and call schedules. It will force the MBSAQIP to become a true quality improvement program, not another accreditation program enforcing meaningless processes that discourage the creation of new programs in a time when we need to ensure better access to care for all patients suffering from obesity.
Ninh Nguyen, MD: Agree. In a study comparing outcomes of accredited versus nonaccredited bariatric centers, published in the Journal of the American College of Surgeons in 2012 [215:467-474], our group reported more than a threefold lower mortality rate when bariatric surgery was performed at accredited centers (0.06% vs. 0.21% at nonaccredited centers). The improved outcome was particularly evident for patients who underwent complex procedures such as Roux-en-Y gastric bypass and for higher-risk patients (greater severity of illness). Medicare patients undergoing bariatric surgery are well known to be a higher-risk group of patients, and would benefit the most if their operations were performed at accredited centers.
Despite this and other scientific evidence, CMS decided to remove the requirement for facility certification that likely will place Medicare patients undergoing bariatric surgery at risk for a higher mortality rate. A decision to support accreditation should always err on the side of caution, putting patient safety first. In this case, the CMS decision errs on the side that removing the accreditation requirement will improve access to care for Medicare beneficiaries. However, data have shown that access to bariatric surgery for Medicare beneficiaries has actually improved since the 2006 National Coverage Determination.
Another important point to note is that part of the facility certification is the requirement for an annual threshold case volume. The relationship between volume and outcome in bariatric surgery has been well established. With CMS removing the need for facility accreditation, its decision also ignored the data on this volume–outcome relationship. The end point of the decision is that Medicare patients now may potentially receive their bariatric care at a center that is ill-equipped to care for the obese patient, a center without available multidisciplinary team members, and at a center that is inexperienced, where only a few cases annually are performed. I urge Medicare patients to do their homework in selecting where to receive their care, because CMS has eliminated an important mandate that would guide patients toward obtaining the optimal and safest bariatric care.
Justin Dimick, MD: Disagree. CMS recently conducted a very thorough review of the literature when it reopened the National Coverage Determination for bariatric surgery. The CMS evidence review process is widely accepted as the gold standard for making such coverage decisions. The agency's staff includes methodological experts who weigh the relative merit of existing studies with the utmost rigor. After completing this process for the CMS bariatric surgery COE program, they summarized the literature as demonstrating no benefit of the COE program for Medicare beneficiaries. I agree with their assessment and have great faith in the rigor of their evidence review.
Two of the key studies in this evidence review were papers published in the Journal of the American Medical Association by our research group [JAMA 2010;304:435-442 and 2013;309:792-799]. The first study used clinical registry data from the Michigan Bariatric Surgery Collaborative (MBSC), a regional quality improvement collaborative. This study found no significant differences in outcomes between COEs and non-COEs. Of all the studies on the topic, this was the only one conducted using clinical registry data, and therefore the only one to have the clinical details to provide state-of-the-art risk adjustment, that is, the only one that could claim to compare apples with apples.
The second study, published this past February, was a formal policy evaluation of the CMS COE program. The Achilles' heel of many studies evaluating the COE program is a failure to fully account for time trends. Bariatric surgery has become much safer over the past decade. A simple before-and-after comparison therefore will not yield an accurate answer—many of the existing studies use this type of study design. In our February study, we used a rigorous design to fully account for these changes in outcomes over time. Once these were subtracted out, we found no independent effect of the COE policy on outcomes. It was clear that bariatric surgery outcomes improved dramatically in the past decade, but the decline started well before the COE policy was implemented.
Perhaps most importantly, CMS already has made its decision and abandoned the COE accreditation requirement. Rather than debating the past, we need to work together to create a better future for our patients. That future should include moving beyond COE programs and focusing on improving outcomes at all centers performing bariatric surgery. The data that we collect in our registries need to be used better. The data should be used to generate risk-adjusted reports for hospitals and surgeons. This is a necessary first step, but we also should do more than just measure outcomes. We should develop regional networks of providers, like the MBSC, who can share data, learn from one another, and implement best practices to continue to improve bariatric surgery outcomes at a population level. I think this is a future we can all agree on and work together to achieve.
John Morton, MD: Agree! It is disappointing to have CMS decide to remove the bariatric surgery facility accreditation. I believe that close review of the evidence shows support in abundance for bariatric surgery facility accreditation. I have a clear and present concern for current and future Medicare beneficiaries. Evidence demonstrates that Medicare beneficiaries have higher risk than the general bariatric surgery population. A 2006 Archives of Surgery publication, by Livingston, found that Medicare status had an increased odds ratio for mortality of 4.31. It is very clear that accredited facilities will save lives in comparison to nonaccredited centers. In this current climate of patient safety and cost containment, I am dismayed that CMS would remove a quality measure like bariatric surgery facility accreditation, which improves patient safety and lowers cost.
David Flum, MD, in his 2011 Annals of Surgery article [141:1115-1120] clearly demonstrates the value of the accreditation process in Medicare beneficiaries. The 90-day mortality rate pre-accreditation was 1.5%, and post-accreditation was 0.7% (P<0.001). The 90-day readmission rate decreased 25% post-accreditation (from 19.9% to 15.4%; P<0.001). The reoperation rate declined by 33% (from 3.2% to 2.1%), and the cost fell 20% (from $24,363 to $19,746; P<0.001 for both). The 2010 JAMA study from the Michigan Bariatric Surgery Collaborative presumably found no significant differences in outcomes between COEs and non-COEs, but 19 of the 25 centers were COEs. The 2013 JAMA study asserting that nonaccredited centers had similar outcomes to accredited centers is flawed. That 2013 study found the same improvement for the Medicare population after the National Coverage Determination as did the Flum study with reductions in any complication (from 12.3% to 7.9%) and serious complications (from 7.5% to 3.4%). What is stunning is that the improvements in outcomes between Medicare and non-Medicare populations were not significantly different; this is noteworthy given the high comorbid condition of the Medicare population. The authors utilize a difference-in-differences analysis and make a flawed assumption that the control group of non-Medicare patients wasn't exposed to the policy change. By 2006, non-Medicare patients already were exposed to the accreditation process given the requirement by private payors for hospital accreditation, and that accreditation by ACS and ASMBS preceded the CMS coverage decision.
In a recent study in Surgical Endoscopy (2013 Aug 13. [Epub ahead of print]), Jafari et al address both the utility of facility accreditation and the volume threshold. They used 2006 to 2010 laparoscopic, stapled bariatric surgery data from the Nationwide Inpatient Sample database, and found that inpatient hospital mortality was 0.17% at low-volume centers and 0.07% at high-volume centers. Within the high-volume population alone, the in-hospital mortality at high-volume nonaccredited centers was 0.22% and at high-volume accredited centers was 0.06%. When corrected for confounders with multivariate analysis, nonaccredited centers had significantly higher mortality (odds ratio, 3.6). Hallmarks of accreditation include culture of commitment, proven experience, ancillary staff and bariatric-specific resources, which are critical for the rescue of these patients if they encounter complications.
The bariatric surgery accreditation process has a rich legacy of patient safety success and a bright future of quality improvement. With more than 725 accredited centers, there is broad access to quality care and absolutely no sense of exclusion. While I applaud the Michigan Collaborative efforts at quality improvement, I would like to emphasize that inclusion into the Michigan Collaborative requires significant payor support and has the same components as accreditation, including a volume standard, site visits and a data registry.
The MBSAQIP embraces new centers and quality improvement. In 2014, MBSAQIP will launch a national program to decrease readmissions called DROP. We believe there is no deadline for quality improvement; it is an enduring effort. While robust improvements for bariatric surgery may be due to greater utilization of laparoscopy, increasing surgeon experience and fellowship training, all of these drivers for improvement were accelerated by facility accreditation, which provides a vehicle for hospital resource prioritization.
While we hope that CMS will join all other major insurers in supporting bariatric surgery facility accreditation, we will continue our mission of safeguarding patient safety as we did in 2004, when we established bariatric surgery accreditation two years prior to CMS's initial and appropriate decision to require accreditation.
Colleen Hutchinson is a communications consultant who specializes in the areas of general surgery and bariatrics. She can be reached at email@example.com.


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Sense of direction
No they don't give their surnames. The two explain that the idea of the site came because they were 'never able to find the right addresses of the most recent Modern Architecture when you set out to choose and prepare a city-trip.' Strikes a chord, that.
And, although the site is much more than this, it has around 10 such guides. They include London, Basel and Amsterdam. And there are several generic guides, one on photography, another to European landscapes.
What's really nice is that the blogsters encourage people to contribute guides, to put up their own pet buildings, and to comment. The latter is, of course, the hardest.
But already there are a thousand projects and hundreds and hundreds of design teams, contributors and photographers. And, it's so obvious that nobody seems to have done it on the architectural Web, there's a linked Google map pinpointing every building on the site.
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We are Kaleton Media, a leading digital marketing and web development / web design agency providing a range of online services to businesses throughout the UK. We are conveniently located between Leeds and York, and we work with both local businesses and clients as far away as London and Manchester.
From developing and hosting your web site, to handling your Google Adwords campaigns, social media strategy, SEO and email marketing, we do it all. When we work with you we become an integral part of your team that you can rely on to get the job done. Our goal is to help your business make more money using the Internet.
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A look at the Cowboys kicking competition
Shayne Graham was signed earlier today, giving the Cowboys four kickers in this camp. What does it all mean?
Let's look at where everyone stands in this compeittion at the moment.
Graham _ Far and away the most proven of the group and looked very good in his tryout Monday. Given his health and experience, could be considered the leading candidate at the moment.
David Buehler _ He won't kick this week, meaning he will miss at least two pre-season games. The dilemma: if he's going to be this team's kicker entering the season, the club can't rush him back from his hip injury. But if he doesn't come back and impress, has he really done enough to earn the job?
Dan Bailey _ Looked good early but has hit a plateau in recent weeks. The dilemma: he hasn't attempted a field goal in two pre-season games. Because that makes him an unknown quantity, the club felt it had to bring in a more experienced kicker in Graham. Of course, bringing in Graham diminishes the opportunties Bailey receives to prove he can win the job.
Kai Forbath _ He had a quad injury when he signed with the Cowboys and hasn't kicked in this camp. It's unlikely he will kick before the start of the regular season. That makes it hard to win a job.


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Blogger Eric Rosenberg shares analysis about the decline of automobiles in the United States as well as why and how people are living a car-free life.
The 2000s have brought enormous changes to the way we live. One of those changes is the desire for large, suburban homes among younger Americans. As people across all generations are giving up suburban life and are moving into dense, urban areas, it changes how we think about our cars.
Urban Trends
New York City has always been a special case in the United States when it comes to cars. With the incredibly density of Manhattan and the excellent public transportation around the surrounding boroughs, many New Yorkers don't need cars to get around.
However, recent studies have shown other cities following suit. According to a University of Michigan study, 56% of New Yorkers are no car homes. Also on the top of the list are dense cities like Washington, D.C, Boston, Philadelphia, and San Francisco.
What has surprised some people is the overall trend. Since 2007, a full half percent of American households have gotten rid of their cars. While a half percent might not seem like much, that is still nearly 2 million people.
Of the 30 biggest cities in the United States, 21 have seen an increase in no-car
One Car Homes
In addition to people living in urban areas with more reliance on biking, walking, and public transportation, many more families are becoming one-car families than in the past, also primarily in urban areas.
Where one family member can go to work without driving, owning two cars is not as practical as it once was for many Americans. The cost of car ownership can be much higher in urban areas, and parking is more difficult, so many families opt for one car.
In my own building in Portland, Oregon, about half of all families only have one car.
On-Demand Rentals
If you are considering living in a one-car or no-car families, that doesn't mean you will never have a car to use. There are several companies offering on-demand car rental service.
Some companies, such as Lyft, Uber and Sidecar offer on-demand ride sharing at competitive rates, which is great for people that need to do a large trip to the grocery store, hardware store, or even IKEA to grab furniture.
If you need a car for a full day, Relay Rides may have cars listed in your neighborhood at a great rate. Within a short bike ride from my home, RelayRides has seven cars listed and available right now starting at $25 per day.
Can You Live Without a Car?
Having spent three years in urban living, walking or biking to work, the supermarket, and for an evening out on the town has been a popular option for many neighbors and friends. According to AAA, the average cost of car ownership in the United States is more than $9,000 per year.
Imagine the savings if you didn't own a car and just rented one when you need it. Imagine what you can do with an extra $9,000 in your pocket each year. Many Americans are doing just that, will you be part of the trend?


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Bruce Sass, Ph.D.
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Ph.D., Physical Chemistry, University of Pennsylvania
M.S., Geochemistry, Washington State University
B.S., Geology, State University of New York, Binghamton University,
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Hydrogeology, Earth Sciences, Environmental Sciences,
Dr. Bruce Sass, a senior environmental scientist and geochemist based in Ohio, has more than 20 years of experience in the development and implementation of chemical process improvements and environmental remediation technologies. His practice focuses on developing a deep understanding of chemical processes in engineered systems and in geological settings. He provides analysis, design, and forensic investigation services to clients in the electric power, manufacturing, and oil and gas industries.
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Dr. Sass is nationally recognized for his expertise in geochemical site characterization, chemical and geochemical modeling at ambient and extreme conditions, and laboratory experimentation. He has extensive experience in the assessment of chromium in the environment resulting from past manufacturing and processing operations. Working U.S. Department of Defense research programs, Dr. Sass contributed to new approaches for the assessment of contaminant mobility in sediments. In a study for NASA, Dr. Sass combined groundwater chemistry data with stable isotope analyses to improve the understanding of groundwater flow conditions associated with source delineation of perchlorate contamination. Additionally, he has worked extensively on gas and liquid separations, air pollution control systems, and developing environmental controls for recalcitrant compounds and metals. He recently applied his expertise to developing a carbon management services business, with emphasis on CO
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Dr. Sass continues to advance the state of the practice as the author or co-author of more than 60 professional scientific publications and reports. He is widely recognized for his expertise in the remediation of recalcitrant compounds and metals-impacted sites as well as the areas of carbon footprint analysis and sustainability. He chaired Battelle's International Conference on Remediation of Chlorinated and Recalcitrant Compounds (Monterey, California) in 2006 and 2008. He was a pioneer in the development, demonstration, and application of permeable reactive barriers for degrading chlorinated organic compounds. Dr. Sass developed carbon sequestration strategies for oxy-combustion retrofitting for coal-fired boilers. He evaluated manufacturing practices of large, integrated steel mills to identify potential opportunities for economically capturing carbon dioxide (CO
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The United Hook and Ladder fire company responded to a garage fire on Sutton Road in Abbottstown around 6:20 p.m. Tuesday.
A four-car garage was engulfed in flames when Hook and Ladder arrived. It took roughly 15 minutes to subdue the flames due to a busted fire hose and difficulty connecting to the fire hydrant, said Captain Steve Rabine.
While damage to the building is repairable, three custom cars and a boat were destroyed in the fire, Rabine said.
The cost of the loss is possibly too great to estimate, he said.
No one was injured in the fire.


text:
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Results for (603)-689-7680
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Phone Number: 6036897680
Due to number portability, some numbers may have been transferred to a new service provider and nearby city.
Premium Information is up to date and includes owner name, most recent address, and much more.
About NASHUA, NH
Location Type: City
Complaints about 603-689-7680
Caller Type: Unknown (4 Reports)
File a Complaint About 603-689-7680
calls everyday and i have no reason why?
Keeps calling me on my cell phone: 10282013 12:14pm 10262013 8:58am 10252013 11:32am 10242013 10:29am 10212013 8:42am 10142013 10:14am On 1021 I actually got a message, but I couldnt understand what they said their name or company was, only that they had some incredible news for me!. It apparently wasnt incredible enough to tell me what it was or leave a message any of the other times.
Claimed I won a trip somewhere. I had gone to a convention in my state recently and they said I entered to win this prize there but I definitely did not.
Calls everyday and never leaves a voicemail
They call my phone at least once a day and never leave a message. I googled the number and a lot of other people are getting calls by them and reporting it as spam. I have never called them back and just had my phone company block their number.


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Favorite Latin SelectionsItem #: HL.00504601
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by Hal Leonard
As performed by Mike Garson.
Pianosoft. Yamaha software for the Disklavier. With Disk. 5x5.5 inches. 4 pages. Published by Hal Leonard. (HL.00504601)
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Found in: Latin Piano Software Performances
1. The Girl From Ipanema 2. Black Orpheus 3. Wave 4. Once I Loved 5. Quiet Nights of Quiet Stars 6. How Insensitive 7. Searching 8. One Note Samba 9. Desafinado 10. Meditation
Songs Include:


text:
"Johnny" from Massachusetts was your typical 10 year old. The oldest of four, his
mother "Susan" had carefully followed his program of study. She attended conferences,
read magazines and blogs about upcoming curriculum ideas, and spent a small
fortune on books and games that would give Johnny the skills he would need to lead a
successful life as he got older.
Early on, Susan recognized the importance of the computer to her son's education.
She realized that computing is a way of life today. The key to success when living
in such a computer-centric world is to develop keyboarding skills. There was only
one problem. Johnny didn't know how to type. So, Susan went out and bought a
popular learn-to-type software program. It was filled with fun exercises, flashing
lights, sound effects, and typing games, and Johnny was able to advance at his own
pace, "completing" the course in less than a week. He still didn't know how to type.
Think of an athlete. Hitting a baseball, throwing a football, or kicking a soccer ball is
effortless... a result of repeated practice. They perform basic skills naturally, without
thinking. It's the same with any skill, even typing.
Along with educators at the renowned Ben Bronz Academy in Connecticut, we've
studied students in various learning environments for over two decades, watching
and developing methods to improve the learning process. We concluded that young
people with and without learning issues, can succeed more effectively through the use
of computers. And when they learn to touch type, they are able to channel their focus
on what they're learning. Their fingers actually become an unwitting extension of their
It's all about muscle memory. Great typists, like great athletes, need to learn the
fundamentals by practicing them day after day, building new skills only after they master
something less difficult. An effective keyboarding program should be systematically
designed so a student must truly master a skill, before advancing to a more challenging
one. To make this program more productive we have developed a unique product
called Finger Guides.
Finger Guides attach to a standard computer keyboard with
velcro pads and guide a student's fingers to the correct keys, allowing them to learn
touch-typing without incorrect, error-prone moves.
In a lot of ways, we've just gone back to basics, creating a structured but simple way for
students to learn how to type… a skill they'll use nearly every day for the rest of their
By the way, Johnny has been using his new typing program for six months, practicing
his keyboarding skills for just 15 minutes every day. Susan wrote us a note last
week telling us he's now fluent at 35 words per minute and she's noticed a marked
improvement in his other work as well. Now she says, "Johnny knows how to type."
Carrie Shaw is an educator and the President of Keyboard Classroom, one of the fastest growing learn-
to-type software programs in America. Her website is www.keyboardclassroom.com and she can be
reached via email at firstname.lastname@example.com.


text:
Narrow your search
At the Los Angeles auto show, Cadillac heralded its next big model line change-up with the XT5 medium-sized SUV, replacing the SRX and the first of four new SUV models.
Pricing not available
Cadillac's performance V-Series grows with the addition of the very capable compact ATS-V. We hit the track at the Circuit of the Americas in Texas.
Cadillac defies conventional wisdom for its new flagship luxury sedan, offering not eight, but six cylinders under the hood.
Pricing not available
The new 2015 Escalade still isn't for everyone, but it is better than ever.
Although lacking well-integrated connected features, the 2015 Cadillac ATS Coupe makes a worthy rival to its European competition, and should be a top consideration for anyone interested in a sport-luxury coupe.
With a top speed of 200 mph, the high-performance sedan is also Caddy's fastest.
Pricing not available
While the beautifully-designed 2014 Cadillac ELR offers refined electronics and comfort worthy of the brand, Its lack of sporting performance and high price tag limit its appeal.
The twin-turbocharged Cadillac ATS-V debuts at the LA Auto Show... and it looks angry.
Pricing not available
The 2013 Cadillac ATS is a fun, nimble little luxury car that offers an easy all-around driving experience, and while its cabin electronics features are solid, the touch-screen performance proves frustrating.
The wagon format of this powerful 2013 Cadillac CTS-V gives it an undeniable cool factor, while the handling is surprisingly excellent. But outdated cabin tech gives incentive to wait for an updated 2014 model.


text:
Titans Rookie Joseph Hills Taped to Goal Post in Rookie Hazing
The Titans ended their practice Monday with some of your garden variety rookie hazing. According to John Glennon of The Tennessean, they did dizzy bat races with a twist. "Players paired off in twos – facing one another – and were told to run about 30 yards with a football wedged between their chests. The…Read More


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Zoning Minutes 11-6-2007
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Holland Zoning Board of Appeals
Meeting Minutes
Date: November 6, 2007
Present: Sarto Caron, Chairperson
Don Beal, Scribe
Ray Korny, Member
Todd Mayo, Associate
Ron Seaburg, Secretary
7:00 PM The minutes of October 16, 2007 were read and accepted.
The Board discussed their visits to the Soper property.
7:30 PM Special Permit Continuance
Clarence Soper
90 Stafford Road
18-A-05 Book 2538 Page 484
Mr. Soper, engineer Mark Farrell, and abutter Ronald Paquette were present. Mr. Soper presented his house plans. The attached garage will face Hisgen Road. Mr. Paquette stated he does not want an increase of water flow into his house or water to sit or pool on his property line after Mr. Soper finishes building his house and grading is completed. Mr. Farrell stated that the front driveway area would be cut down to improve water run-off. Mr. Paquette admitted that water has entered his basement three to four times a year. Mr. Paquette said that he attended a HCC meeting as the Board suggested. He said that since there were no HCC issues involved they did not have to make any comments regarding building on the site. Voting in favor of the project to be built as presented were Sarto Caron, Don Beal, Ray Korny, Ron Seaburg and Todd Mayo.
8:00 PM Special Permit Request
Gerald Joyal and Donna Possardt
13 Massaconnic Trail
Mr. Joyal and Ms. Possardt want to tear down the present house and re-build a two-bedroom house on the existing house footprint. Mark Farrell said the house would use a "flow through" foundation. The house will be 28'8'' wide and 42' long. The attached shed will be 14'5'' x 6'5''. House overhang distances were a Board concern and would be examined. A site review was scheduled for Wednesday, November 7, at 9AM. A continuance was scheduled for November 20, at 7:30 PM.
The meeting was adjourned at 8:40 PM.
CC: Building Inspector, Executive Secretary, Town Clerk, HCC, ZBA Files
Submitted by:
Ronald Seaburg, Secretary
Town of Holland 27 Sturbridge Road, Holland, MA 01521
Phone: 413-245-7108 Fax: 413-245-7037
Hours Vary by Department
Virtual Towns & Schools Website


text:
|Alcohol use and mismatch negativity in young patients with psychotic disorder.
MedLine Citation:
|PMID: 22009194 Owner: NLM Status: Publisher
|Mismatch negativity (MMN) is a neurophysiological indicator of the brain's ability to extract relevant information from an irrelevant background. MMN has been described as a reliable biomarker of schizophrenia and more recently it has found to be impaired in the early stages of psychosis. In addition, drugs (including alcohol) that block glutamate's N-methyl-D-aspartate receptor have been shown to reduce MMN. This study aims to determine whether risky alcohol consumption in young patients with psychotic disorder further impacts or changes their MMN response. Patients with high-alcohol use were found to show reduced temporal MMN amplitudes compared with patients with low-alcohol use and controls. In contrast, early psychosis patients with low-alcohol use showed reduced fronto-central MMN amplitudes compared with controls; whereas patients with high-alcohol use showed an intermediate response at these sites. Correlational analysis revealed distinct patterns of association between MMN and alcohol use in patients with early psychosis compared with controls. This study shows that early psychosis outpatients who engaged in risky drinking have decreased temporal MMN amplitudes, compared with their peers. This may reflect an additive effect of N-methyl-D-aspartate receptor hypofunction and high-alcohol consumption.
|Kate M Chitty; Manreena Kaur; Jim Lagopoulos; Ian B Hickie; Daniel F Hermens
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Publication Detail:
|Type: JOURNAL ARTICLE Date: 2011-10-15
Journal Detail:
|Title: Neuroreport Volume: - ISSN: 1473-558X ISO Abbreviation: - Publication Date: 2011 Oct
Date Detail:
|Created Date: 2011-10-19 Completed Date: - Revised Date: -
Medline Journal Info:
|Nlm Unique ID: 9100935 Medline TA: Neuroreport Country: -
Other Details:
|Languages: ENG Pagination: - Citation Subset: -
|Clinical Research Unit, Brain and Mind Research Institute, University of Sydney, Sydney, Australia.
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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To register
Complete Form P.47 (iSeek Forms) and send it to IT Learning Programmes, DC2-627 or fax (212) 963-1456Please Note: If you are interested on attending the course, you can send the form even if the class is not yet scheduled in the calendar. You will be invited once a class is scheduled. It is valid for 6 months from the date submitted.
For more information
Call extension 3-0770 or e-mail email@example.com
Windows XP Support and Troubleshooting
Four days
Target audience
Departmental technical focal points and their assistants who serve as the first line of user support and need to escalate support requests to OICT Help Desk services
Windows XP, MS Office applications, and Internet Explorer. Basic understanding of core operating system technologies, including installation and configuration; hardware component and their functions; major desktop components and interfaces; basic experience of command-line utilities; and basic understanding of technologies that are available for establishing Internet connectivity. Participants must also know how to create a shortcut on their desktop; be aware of the network logon process and be familiar with control panel applet features. Any knowledge of TCP/IP protocol is helpful but not mandatory.
Topics covered
- Introduction to the Desktop Support Tech Role & Environment
- Resolving User Account and Logon Issues
- Resolving System Configuration and Security Issues
- Resolving Network Connectivity Issues
- Resolving Hardware Issues
- Resolving File and Folder Issues
- Resolving Printer Issues
- Resolving Startup Issues
- UN User Manager (UUM)
- Introduction to Supporting Users Running Applications on Windows XP
- Troubleshooting Desktop Application Support Issues
ITIL Foundations
Participants will learn the principles and core elements of the service lifecycle approach to IT Service Management according to ITIL 2011 Edition. An interactive approach is used combining lecture, discussion and case study experience to prepare participants for the ITIL 2011 Edition certification exam as well as providing valuable practical knowledge that can be rapidly applied in the workplace. Quint Wellington Redwood's integrated case study deepens the participant's appreciation of how ITIL best practices can be applied in order to improve IT performance.
This course covers the latest version of core ITIL best practices presented from a lifecycle perspective. The course introduces the principles and core elements of IT service management (ITSM) based on ITIL 2011 Edition
3 Days
Target Audience:
IT Professionals, IT Support Staff, Application, Project and Business Managers, Any member of an IT team involved in the delivery of IT Services.
At the end of this course, you will be able to:
- Identify the principles and concepts of IT Service Management based on ITIL 2011 Edition.
- Identify the best practices of implementing ITIL 2011 Edition in an organization.
- Define the terminology used in ITIL 2011 Edition
- Identify the concepts and definitions used in the Service Lifecycle.
- Define Service Strategy concepts
- Define Service Design concepts
- Define Service Operations concepts
- Define Service Transition concepts
- Define Continual Service Improvement concepts
- Define the roles, processes, and components within key areas of IT Service Management based on ITIL 2011 Edition
- Prepare the student to take the ITIL 2011 Edition Certification exam
Topics Covered
Lesson 1:
Introduction to key ITIL concepts
IT as a Service
Introduction to processes and process management
The Service Lifecycle approach
Lesson 2:
Service Strategy
Purpose, goal, objectives & Scope
Value Creation through Services
Assets – Resources and Capabilities
Service Strategy – Main activities
Service Strategy processes
Service Portfolio management
Demand management
Financial management
Lesson 3:
Service Design
Purpose, goal, objectives & Scope
Service Design processes
The 4 P's
Service Design aspects
Service Catalog Management
Service Level Management
Capacity Management
Availability Management
IT Service Continuity Management
Service Portfolio
Information Security Management
Supplier management
Lesson 4:
Service Transition
Purpose, goal, objectives & Scope
Service Transition value to the business
Technology and architecture in Service Transition
Service Transition Processes
Change Management
The 7 R's of Change Management
Service Asset and Configuration Management
Release and Deployment Management
Knowledge Management
Lesson 5:
Service Operation
Purpose, goal, objectives & scope
Service Operation definitions
The Service Desk
Technical Management
Application Management
IT Operations Management
Service Operations Processes
Event Management
Request Fulfillment
Problem Management
Access Management
Lesson 6:
Continual Service Improvement
Purpose, goal, objectives & scope
Models and Processes
The Deming Cycle
Measurement and metrics
Continual Service Improvement activities
Risk management
Continual Service Improvement interfaces
Interface with Service Level Management
Lesson 7:
Exam Preparation
Sample Exams


text:
I'd love to blog about this fully as this is such a HUGE change in my view, but time is short. See in the meantime please read Search Engine Land's report of the recent change to Google results pages for local queries.
LINK Major changes in organic listings for Local
This Brain wave was posted in Local Search, SEO on 29 October 2010 13:08
Author: Attacat Tim


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Chris Mathews
Ranch Hand
Joined: Jan 08, 2001
Posts: 46
Aug 06, 2002 13:42:00
I am writing a
program which, in nut shell, reads from a file and write to a file.
The input file is like this :
Bush is the President of USA.
then the output file will have
Bush is the President of USA.
Bush is the President of USA.
Bush is the President of USA.
Bush is the President of USA.
Bush is the President of USA.
Basically it will repeat the first line the number of times defined in the second line of the input file.(like 5 in the above example)
The program is working just fine.But I now I have noticed a problem.The problem is when the number of iteration is a very high number -- like let's say
1000,000,000 (=1 billion).
It gives an error which says
Exception in thread "main"
How should I handle this outofmemory error.
Your input will be quite appreciated.
Jessica Sant
Joined: Oct 17, 2001
Posts: 4313
I like...
Aug 06, 2002 13:47:00
1- What does your code look like? Maybe you're creating lots of objects unnecessarily and not removing the reference so they're taking up all your memory.
2- You can adjust the heap size of your memory (but normally this will only delay the problem if you have a memory leak somewhere).
To adjust your heap size, use the -Xmx and -Xms parameters when starting your JVM (call java -X for specific info on the -X options)
ex: java -Xmx 256M com.jess.MyClass (this starts the JVM with a 256 Megabyte heap)
Jim Yingst
Joined: Jan 30, 2000
Posts: 18671
Aug 06, 2002 14:02:00
From the description of what you're trying to do, there is no reason you need to be using enough memory to require changing the JVM memory settings. You're doing something which is saving things in memory - adding to a
perhaps? Putting strings in a Vector or other object? No need. Just write your message directly to whatever Writer /
you're using for output, however many times you need to. The message should not be building up in RAM - it should be getting written to a file. If you still have problems, please show the code you're using to write the file. Good luck...
"I'm not back." - Bill Harding,
Chris Mathews
Ranch Hand
Joined: Jan 08, 2001
Posts: 46
Aug 07, 2002 09:26:00
I realized that problem is in some other method.
Here is what this method is supposed to do :
Input File(input.txt) is like this :
The output will contain the following :
1. The total Number of records in the input file -- in the above example it will be 10.
2.The number of unique values in the first column -- in this case 6.
3. The number of unique values in the second column -- In this case it will be 3 (CNN,FOX and USA).
This is what my code look like :
import java.io.*; import java.util.*; public class Test { public static void main(String[] args) throws Exception { BufferedReader br = new BufferedReader ( new InputStreamReader( new FileInputStream("input.txt"))); HashSet hs1 = new HashSet(); HashSet hs2 = new HashSet(); String sLine; int i, j; for (j = 0; br.ready(); j++) { sLine = br.readLine(); i = sLine.indexOf(','); hs1.add(sLine.substring(0,i)); hs2.add(sLine.substring(i+1,sLine.indexOf(',',i+1))); } System.out.print(j + " " + hs1.size() + " " + hs2.size()); } }
This is working just fine as I said in my previous post but when input file has large number of records (say 1 Billion or so) then it crashes saying 'OutofMemoryError'.
So where is the memory leak ? what is the better option to handle such a large file ?
Your input is appreciated.
[ edited to correct code formatting -ds ]
[ August 07, 2002: Message edited by: Dirk Schreckmann ]
Jim Yingst
Joined: Jan 30, 2000
Posts: 18671
Aug 07, 2002 12:01:00
Well, if you keep putting values into a
, it gets bigger.
I wouldn't call that a "leak"; it's the expected behavior here. You just need to find a more efficient way to do it.
First, do as Jessica suggested and increase the memory allocated to your JVM. This will be simplest, if you have the memory to spare.
Try separating your loop into two loops - one for hs1; another for hs2. Sure, you'll spend twice as much time reading lines, but this way you won't have to keep both in memory at the same time. (Set hs1 = null once you're done with it, before the second loop.) This will only have a significant effect if the two HashSets are of roughly comparable size. If hs2 only has a few hundred entries at most, it's not worthwhile putting it in a separate loop.
Next, try replacing
hs1.add(new String(sLine.substring(0,i)));
(Likewise for hs2.) This may seem strange, but the
created by substring() uses the same character array as the original String you got from readLine(). This means that even though you're only interested in, say, the first 7 characters of it, you're actually keeping the whole line in memory when you save a reference to the substring. By using the new String() constructor, you create a new String that uses only enough memory for the substring - not for the extra chars of the full original line.
It looks like the first field is always a number. If so, you can probably get additional space savings by storing it as an Integer rather than a String. (An int would be even more efficient, but collections don't work with primitives.
Going a step further, if you're going to have a
of different integer values, it may well be more efficient to use a
rather than a
. If the first column is always an integer less than 10,000,000, you can allocate a
with 10,000,000 bits (~1.2 MB) which will keep track of each number individually. This may seem like a lot, but the advantage is that it will never have to grow in size (unless you try to store a number greater than 10 million). If you have 100 unique values to save, the
will be smaller - but if you have 1,000,000, the
will certainly be smaller. You can optimize further if you can restrict the range of possible values. E.g. if the number will always be between 5 and 6 million, you can subtract 5 million, and store numbers 0 to one million - taking a tenth as much memory as 0 to ten million did.
I'm guessing these techniques (particularly the
) will take care of the problem for you. If not, you'll probably need to look into alternate techniques which do not require you to represent all values read in memory, but instead rely on writing some things to intermediate files instead. Proably the easiest way to do this is to use a database, which will have already coded this functionality for you. Good luck...
[ August 07, 2002: Message edited by: Jim Yingst ]
Chris Mathews
Ranch Hand
Joined: Jan 08, 2001
Posts: 46
Aug 07, 2002 12:26:00
Could not understand the messages :
When I used -Xmx option like :
java -Xmx 256M
I got the following message :
Incompatible initial and maximum heap sizes specified:
initial size: 1048576 bytes, maximum size: 0 bytes
The initial heap size must be less than or equal to the maximum heap size.
The default initial and maximum heap sizes are 1048576 and 67108864 bytes.
Could not create the Java virtual machine.
When I used -Xms option like
java -Xms 256M Test
I got the following message :
The specified initial heap size is too small. (262144 bytes required.)
Could not create the Java virtual machine.
I don't know how to increase the size of VM . Any link to get more info on these ?
Am I doing something wrong here ?
Jim Yingst
Joined: Jan 30, 2000
Posts: 18671
Aug 07, 2002 12:33:00
java -Xmx 256M Test
should be
java -Xmx256M Test
Dave Landers
Ranch Hand
Joined: Jul 24, 2002
Posts: 401
Aug 07, 2002 12:36:00
java -Xmx256m ...
no space between the -Xmx and the size.
I agree. Here's the link:
subject: OutOfMemoryError
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I moved here from eastern North Carolina over 30 years ago and at that time Macon County was growing and there were plenty of jobs, as was the rest of the country. Look what our elected officials have done for us. Because of all the government regulations we have just about stopped developments and building in Macon County, which means jobs gone. Without jobs we cannot pay the taxes it takes to pay the salaries for the people necessary to enforce these regulations.
On the federal level it is no secret why our companies are going to other countries.
The so called free trade agreement was only free to the other countries that were involved in this agreement. These countries are not burdened with workman's comp., O.S.H.A, Environmental Protection, ACLU, and matching Social Security, along with many other government regulations. Because they go out of this country they also get many other tax breaks as well as not having to deal with unions.
Our government leads us to believe that it is the cost of labor that makes these companies leave when in fact our labor force is the most efficient in the world. It is Government regulations from the counties to Washington that stifles our growth and sends our jobs abroad. We do not need government to regulate everything we do.
A hundred years ago we did not have all these government regulations and we were the most prosperous nation in the world.
People need to get involved first on our local level and then on the state and federal levels. Start by going to our town and county meetings and voice your opinions. Only you can make things change.
Larry Turlington — Franklin, N.C.


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- Filed Under
The Fairport Merchants Association (FPMA) has announced that the winner of the 36th Anniversary Fairport Canal Days Festival poster contest is artist Susan Prener.
The poster will be available for viewing at the Fairport Farmer's Market at 10 a.m. in Fairport Village Landing.
Prener, a resident of Perinton, and is a graduate of Wittenberg University in Springfield, Ohio. The original work, in watercolor, is a highly graphic representation of a scene Fairport residents and Canal Days attendees will recognize. In it, Prener tries to "capture the spirit of the moment," and the tradition of ...


text:
Terry Brooks' career in health care began in 1968 as the legislative director for the American Osteopathic Association. With more than 35 years of experience in health and hospital law, she now represents clients across the full spectrum of health care, including health care systems and institutions, physicians, specialty providers, pharmaceutical companies, managed care entities, health-related companies, financial institutions, units of government and trade associations, and public equity firms.
Before entering private practice, Terry served as director of legal affairs and policy development for the Michigan Hospital Association. She also served as the director of the Washington office of the American Osteopathic Hospital Association and was the associate director for federal agency liaison of the Washington Office of the American Hospital Association.
Her practice focuses on the legislative, regulatory, and policy issues in the health industry, as well as transactions and operational issues affecting clients. She also has experience as director of EBG Advisers (a health care consultancy), as well as in leadership positions within law firms.
Terry is a frequent lecturer and author on health and hospital law and policy, including Medicare and Medicaid reform and payment policy, HITECH, and health care policy and regulation.


text:
Judy Davis
Dubbed "one of the most exciting actresses in the world" by Woody himself, this Aussie actress has appeared in six of the director's films, including this summer's "To Rome With Love" and 1992's "Husbands and Wives," for which she received a Best Supporting Actress Oscar nomination. But Judy says she and Woody barely spoke when the cameras stopped rolling. "Around Woody Allen, I was unbelievably shy, because he never said anything," she told Australia's "Sunday" in 2001. "So even though I've made a few films with him, we never really said anything. And he seemed to be happy with that, and it suited me fine."
© 2015 Whalerock Industries


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Manufacturing Dissent
By George Shadroui
September 12, 2003
Dissent is a quarterly socialist magazine of politics and culture edited by Mitchell Cohen, a professor of political theory at Baruch College and the City University of New York, and Michael Walzer, who writes on political theory and moral philosophy.
Dissent was founded in 1954 by the literary critic Irving Howe, whose objective was to salvage socialism from Stalin's legacy. While many on the left continued to defend Stalin's repression and murder, Howe and his cohorts denounced those atrocities without repudiating the socialist cause. In addition, they rejected the Marxist idea that culture should always be the servant of ideology. This introduced a pragmatic dimension to Dissent, considered heresy on the Stalinist left.
During the 1940s and 1950s, Howe was at war with the Stalinist vanguard. By the 1960s and early 1970s, he also found himself in conflict with the "New Left," which had embraced passionate anti-Americanism as its hallmark. Though he eventually did oppose America's involvement in the Vietnam War, Howe showed early support for U.S. efforts to find a "third way" and never romanticized Ho Chi Minh and the Vietnamese communists the way many on the left did. He rejected leftist infatuation with Fidel Castro and Che Guevara and had little patience for leftist-inspired street violence. In several public debates, Howe challenged new radicals such as Tom Hayden to explain their silence regarding Soviet aggression in Eastern Europe, and he openly disputed the hate-America stance of Noam Chomsky.
In short, while not surrendering its socialist agenda, Dissent tried to preserve its intellectual integrity. Its writers sought to keep the focus on the working class, and not on the trendy cultural elitism of the 1960s left. Howe was no fan of the social mores pushed by the New Left, and could even be a tad conservative on issues of traditional family, education and literary criticism, as he sought to preserve the human element that Marxism, with its ideological baggage, often destroyed.
This independence of thought can be found in Dissent even now, under Michael Walzer's guiding hand. With respect to the war in Iraq, Walzer has allowed a variety of views to be expressed -- from those of Iraqi dissident Kanan Makiya, who supported military action, to those of Marshall Berman, who opposed it. In the essay, "So, Is This a Just War?" Walzer found a middle ground in which he tried to balance the criticism aimed at President Bush without embracing the war per se. He suggested that Saddam Hussein might have been contained and destroyed without full-scale military action, but also questioned the sincerity of opponents of the war, including the French, who, he implied, would have postponed action indefinitely.
Another recent essay also sets Dissent apart from the reflexive anti-Americanism of The Nation, The Progressive, and others on the left: Joann Barkan, in the Winter 2003 issue of Dissent, probed the thinking of the "hate-America first" left. In the aftermath of 9/11, she wrote, "some of us saw the desire to fly American flags everywhere as a sign of solidarity and grief. … they saw only jingoism and vulgar sentimentality." Barkan went on to accuse leftists of being "obsessive and undiscriminating in their anti-Americanism," and suggested that 9/11 did represent a threat to the U.S., whether one agreed or disagreed with the decision to take down Saddam Hussein's regime.
In the area of economics, Dissent has remained steadfastly committed to the idea of a centralized, socialized economy.
On matters of race, the editors of Dissent have often showed glaring inconsistencies. Despite Howe's stated objections to street violence and ideological extremism of the sort embraced by the Black Panthers during the 1960s and early 1970s, his periodical published Norman Mailer's essay "The White Negro," which endorsed violence as a natural expression of discontent and was rife with sexual stereotypes. Howe later admitted that running the article was a mistake, but Dissent's editors nonetheless included it as a featured essay in their 40th anniversary collection of Dissent's best. In another critical essay aimed at Ralph Ellison and James Baldwin, Howe impugned both writers for not accepting "the clenched militancy" of author Richard Wright, who was ferocious in his depiction of racial problems in the United States. Ellison responded that Howe was trying to lock black writers in a genre he called the "protest novel."
This profile is adapted from the article "Manufacturing Dissent," written by George Shadroui and published by FrontPageMagazine on September 12, 2003.
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From auto tailpipes to stoves to lightbulbs, every day we use more power than we need and waste the excess heat that's generated. And you can imagine how much extra heat is lost from industrial-strength facilities and large offices. But analytics and computers are coming to the rescue. One federal estimate says as much as two-thirds of the energy we produce is actually wasted. For instance, more than half the energy it takes to run a car engine just blows out of exhaust pipes and heats the engine compartment.
Power plants emit more waste heat than actual produced electricity. And the same thing happens at home when heat leaks out or cold air blows in. But even at the family house level, analytics and tools such as Blue Line Innovations and Power House Dynamics are creating opportunities to know more about your energy use. Monitoring and computer analytics that run on your home PC can identify and analyze power use room by room, even device by device. Using a sensor that is attached to your electric meter, the gear records how much power is used by always-on items such as refrigerators or water heaters. It can also spot "phantom power" – even if you think your house isn't haunted. Up to 8 percent of a home's electric bill can be the result of standby power – "zombie-like" devices still drawing current even though they're turned off. Some call this "phantom power." Examples abound in the LEDs that show your electric toothbrush is charged. Or how about constant-use in clocks on stoves, wireless phone chargers left in the plug, microwave ovens, VCRs, cable boxes, computers or peripherals in standby mode.
Check out this report by the Federal Energy Management Program on power used by idle electronics – it is great food for thought.
David Wallace
Spotfire Blogging Team
Image Credit: Microsoft Office Clip Art


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Christian Velazquez, a family member and a tow-truck driver assess how to remove a 2005 Ford Escape from the Ruidoso River Friday.
Velazquez, who lives in Ruidoso, said he was driving the car about 11 p.m. Thursday, when it hit a patch of ice on Country Club Drive, flipped multiple times and landed in the river. He was not injured.


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IT firms often service a range of industries, as companies of all types need some level of IT support. But concentrating on a certain vertical market—a group of similar clients doing business in a specialized field—can mean higher revenues, better margins, lower cost of sales, and more and larger orders. Moreover, getting into a vertical market gets better and better; selling accounts will take progressively less time as you build references in the market and become better at communicating what sets your services apart.
Here are 10 steps that can simplify the complicated process of getting started in a new vertical market:
Step 1 Select a target vertical market: Look at your existing clients and note similarities in the markets they're in, their size and how they do business. From there, look at your current capacity and what it'd take to specialize in that market, as well as the overall trajectory of the market itself.
Step 2 Create a profile for clients within the vertical market: Identify those clients providing the majority of your revenue, then look at their common characteristics and determine how many clients of this type are in the vertical market you're considering.
Step 3 Estimate the localized market value for your chosen vertical: By determining the number of prospects you can identify and how many fit your client profile, how many buying decisions they make per year and how many of these you can expect to secure for your firm, and what your margins will be on these deals, you can estimate the value of this vertical and decide whether or not to get into it.
Step 4 Commit to the vertical: Once you've decided to get into a vertical, commit. Immerse yourself in it, not just financially but philosophically. Learn about how it operates, what its culture is, what technology it's using and who are the key vendors in the space, as well as what regulations affect it directly.
Step 5 Identify key industry groups, websites and publications: Identify and get involved in any associations relevant to the industry and carefully study what they offer. Subscribe to and read any publications covering this industry and get directly involved with them on an editorial level if possible.
Step 6 Develop training programs: Ensure that your employees know as much about this vertical market as possible. Encourage and support their attendance at relevant trade shows.
Step 7 Identify key industry influencers: Identify thought leaders servicing this vertical market; such as top consultants, lawyers, accountants, etc. You may even seek to organize an advisory council built around these individuals to regularly draw from their subject matter expertise.
Step 8 Create a positioning statement: Craft a statement of how you're positioned toward your industry vertical, what makes you unique in the space, related practices your firm provides that support the main thrust of your work, and questions for potential clients to determine fit.
Step 9 Identify initial sales targets: Start with a list of roughly 150 prospects and break it down by geographic area and your client profile. From there, build out a database of contacts at these firms.
Step 10 Learn to partner: Look for potential partners; those firms selling non-competitive, related products in your vertical market. Define metrics and goals around these partnerships.
To learn more about entering new vertical markets and to access a variety of business tools and resources, visit www.comptia.org where CompTIA members can download the full CompTIA Quick Start Guide to Entering a Vertical Market.


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Learn to Handle Your Joint Disease Today
Learn To Handle Your Joint disease Today.
Joint disease comes frequently nowadays and is renowned for getting a huge effect on huge numbers of people around the world. It may stop the earliest and most powerful of players right where they are or disable your legs of youthful mother in her own 20's. It is primarily the wide selection that causes it to be so desperately to battle or prevent, but it is possible.
Find time for yourself. Putting aside around 30 minutes each day to behave strictly for you shouldn't cause you to feel guilty. Carrying this out will make you more lucrative and relaxed, that will consequently prevent outbreaks or painful swelling. Learn how to relax, and you'll end up in better health.
You can't plan whenever your joint disease will flare, so plan your activities accordingly. Should you prepare and arrange for joint disease issues before they happen, you won't be disappointed if signs and symptoms show and you've got to take a rest. Should you start a task, attempt to make certain you are able to finish at any time to ensure that for those who have an joint disease break out, you are able to return into it later.
Don't stop a medicine simply because you are feeling it's not working. Most joint disease medications originate from days to several weeks to really make an effect in your signs and symptoms. Never stop a brand new medicine without speaking together with your physician first because there might be unwanted effects from a rapid withdrawal.
Take time to have your loved ones educated regarding your rheumatoid arthritis symptoms and also the different challenges which will occur when you accept this problem. You will find classes available with the Joint disease Foundation, and you will find many books available you can use to train your loved ones concerning the condition.
Scientific studies reveal that putting on high heel shoes can increase the risk of joint disease in females. It is applicable elevated pressure around the heels and also the joints within the ft. This isn't good over a long time period. While high heel shoes are something which women decide to put on for style along with other reasons, you might want to reconsider putting a set of high heel shoes on.
Schedule amount of time in your entire day to relaxation and relax. Getting just a little down time can help to eliminate the discomfort inside your joints and assist you to feel more vitalized. You need to do wish to take care not to get an excessive amount of relaxation, however you should stay active to assist using the signs and symptoms connected together with your joint disease.
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Fixed Gear Tank - Men's Graphic T-Shirt
Item: 1410411-060
We're gearing up for summer with our favorite mode of transportation. Printed on our super soft, knit tank.
Fabric Content: 70% Cotton, 30% Polyester
Care Instructions: Machine wash cold with like colors, do not bleach, tumble dry low, and warm iron if needed.
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BQE - Men's Graphic Tank$12.99
Thomcat - Men's Graphic T-Shirt$36.00Made in the USA! Organic & Eco-Friendly!


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Photo credit: Oddur Thorisson Growing up between Hong Kong and France, author Mimi Thorisson has always been deeply passionate about food. When she and her husband, Icelandic … read more
Holiday Gift Guide
The 5 Rules of Great Gift Wrapping
Everything gets hectic around the holidays but, aside from the North Pole itself, there's possibly no busier place than the Williams-Sonoma gift wrap room. In … read more
Gifts with Taste: Matt Armendariz, Blogger at Matt Bites
With the holidays just around the corner, we asked some top tastemakers in the food community to curate their own gift guides from our collection. … read more
Holiday Gift Guide: Pantry Upgrades
Today's gift guide features all of our sure-to-please gifts for your favorite cook — pantry items to take any dish to the next level. Enjoy! … read more


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A man prosecutors say has three prior domestic assault convictions appeared in court Tuesday on a felony partner or family member assault charge, alleging he beat his wife on Monday.
Cleve Michael Riggins, 49, appeared by video from the county jail in Yellowstone County Justice Court, where Judge David A. Carter set the man's bond at $20,000.
Police arrested Riggins on Monday after responding to an assault reported on the 300 block of South 33rd Street, according to charging documents.
When an officer responded, the alleged victim said Riggins, her husband of three years, had been drinking and assaulted her.
The woman told police that Riggins hit her in the face, called her stupid and yelled at her, grabbed her head and shook it and then knocked over a coffee table when she said she was calling police.
The woman said she had thought Riggins would kill her and that he threatens or assaults her about once a month.
According to prosecutors, Riggins has three prior domestic assault convictions.
He is scheduled to enter a plea to the charge June 23 in District Court.


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Halle Berry's Storm Is The Next DAYS OF FUTURE PAST Character Portrait In The Series
Add Halle Berry to the line-up of X-Men: Days of Future Past character portraits. Ms. Berry joins the previously released Michael Fassbender, Ian McKellen, James McAvoy, Patrick Stewart, and Daniel Cudmore pics. Storm is wearing the basic black costume all of the future X-Men seem to be sporting. The trend shows no signs of stopping, so check back tomorrow for another new pic of one of the character's in Bryan Singer's X-Men inbetweequel. We could probably make a Xavier School For Gifted Youngsters year book when it's all said and done. What do you think about Storm's photo? Days of Future Past hits theaters May 23rd.
The ultimate X-Men ensemble fights a war for the survival of the species across two time periods in X-MEN: DAYS OF FUTURE PAST. The beloved characters from the original "X-Men" film trilogy join forces with their younger selves from "X-Men: First Class," in an epic battle that must change the past — to save our future.
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Source : X-Men Movies UK


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Download this free, 140-page Flexible Packaging Playbook jam-packed with strategies for success, best practices, and pitfalls to avoid. Learn more »
Article | January 10, 2007
Ampac : Stand-up beverage pouch
Ampac Flexibles has launched PureFlex™, a clear, stand-up pouch structure for water and other taste- and odor-sensitive beverages.
The 7- to 9-layer proprietary coextrusion features an organoleptic sealant layer, nylon, and an optional EVOH layer for additional oxygen barrier. The nylon helps provide structural strength while also acting as a barrier to odor ingress. Pouches are available in a range of shapes and sizes from 175 to 1,000 mL. Companies may choose from more than a dozen stock pouch designs, or have a custom shape created. Spouted fitment options (with or without 1-way valves) are also available.
Phone: 513/671-1777
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Harford County Children's Photographer | Wild8Designs
Just when I'd thought I'd seen it all, my friends started producing these awesome ribbon sculpture hairbows and started selling them. Since I have the girliest of daughters, I was thrilled when they asked me to do a shoot for them in exchange for a hair-drobe. The little models were so cute and suprisingly tolerant of the multiple outfit and hairdo changes.
I think this is my favorite from the shoot. The looks say it all.
I'm telling you. Ribbon geniuses.
I'm totally bummed that the holidays are over and my daughter isn't this little anymore. Not necessarily in that order.
Hooked? Check out their Etsy store here.


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It's The Wienermobile!
November 3, 2009
Share ideas for Newport Way upgrades
November 3, 2009
City officials want to know how nearly a mile of Newport Way near Issaquah Valley Elementary School should be improved. Bring ideas to a city open house at 7 p.m. Nov. 12 at the school, 555 N.W. Holly St. Read more
Klahanie Park closer to transfer of ownership
November 3, 2009
The King County Parks Department has taken a major step toward ceding Klahanie Park to the city of Sammamish. Read more
City reviews last flood, prepares for future crises
November 3, 2009
Floodwaters caused about $1 million worth of damage and left behind piles of debris and muck when Issaquah and Tibbetts creeks overflowed in January, but the disaster also readied emergency planners for the next flood.
The next time flood waters rise, volunteers will fan out across flood-prone neighborhoods and city officials will unleash a deluge of information about water levels, road closures and recovery efforts. Many of the procedures were tested during what officials characterized as a successful response to the major flood in mid-January.
But the next flood could occur as early as the next several weeks, and officials said work remains to be done to prepare Issaquah for another natural disaster. On Oct. 27, City Council members received a briefing about the response to the January flood and preparation efforts for the upcoming flood season.
City Emergency Management Coordinator Steve Campbell said readings from a pair of flood gauges did not correlate with the damage caused by floodwaters. A U.S. Geological Survey gauge downstream on Issaquah Creek appeared inaccurate, Campbell said. The gauge indicated about 2,500 cubic feet per second, Campbell said, but flood damage was similar to the 3,500 cubic feet per second estimate from the last major flood to hit Issaquah, in 1996. Read more
Former police officer faces official misconduct charges
November 3, 2009
A former Medina police officer and Issaquah resident was charged with official misconduct after authorities said he forced a woman he had ticketed to have sex with him. Read more
Honor veterans at VFW ceremony on Nov. 11
November 3, 2009
At 11 a.m. Nov. 11, the VFW Albert Larson Post No. 3436 will hold its annual Veterans Day Service at Veterans Memorial Field, at the monument between City Hall and the Issaquah Valley Senior Center. In case of inclement weather, the ceremony will be moved indoors to the Eagle Room at City Hall, 130 E. Sunset Way. Read more
Weather causes phone problems at district schools
November 3, 2009
Due to stormy weather, telephone lines were out at Challenger and Briarwood elementary schools and Liberty High School Oct. 26 and Oct. 27. But the problems were fixed by Oct. 28. Read more
Senior center seeks new leader
November 3, 2009
Issaquah Valley Senior Center leaders will pick a new executive director in the next several weeks. Read more
Issaquah salon owner faces jail for injecting phony Botox
November 3, 2009
Issaquah resident Xin "Faith" He is guilty of injecting customers with counterfeit cosmetic products at her Bellevue salon, a federal judge ruled Oct. 30. Read more
Issaquah Blockbuster will end run in January
November 3, 2009
Make it a Blockbuster night — but hurry: The Issaquah outpost of the movie-rental giant will close in early January. Read more


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Writing Effective Resumes & Cover Letters
Looking for your first job after college can be stressful, especially if students are not prepared. Institutions of higher education need to help their students prepare now to job search later. This workshop will show students how to create a more effective cover letter and resume that will stand out to potential employers. Students will learn how to organize the information, be concise, utilize effective action verbs and express themselves in a professional and effective manner.
Objectives: Students will learn:
- Use the cover letter and resume to relate their education, experiences and achievements in a professional and effective manner
- Tailor their resume to different types of jobs
- Organize the essential information
- Utilize effective action verbs
- Prepare a powerful resume that will distinguish themselves from other candidates
Go to the workshop login page!


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- Filed Under
I remember, a few years ago, banners hanging in a community as a way to point out school district emphasis on character education. One of the words to be emphasized was "trust."
When I began teaching more than 30 years ago, teachers were trusted. Teachers were considered to be professionals responsible for the education of their students. It was up to a teacher's judgment, from years of experience in the classroom, to decide how to teach and adapt a curriculum to fit their students' needs.
If students needed more time to grasp a concept, teachers felt no pressure to race to complete a mandated ...


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We are pleased to announce Management Reporter 2012 for Microsoft Dynamics NAV. Management Reporter provides real time financial reporting along with powerful collaboration and distribution capabilities. Management Reporter 2012 fully integrates to Microsoft Dynamics NAV's general ledger out of the box, making it very easy to create reports.
Existing Microsoft Dynamics NAV customers, who are on an active Business Ready Enhancement Plan running Microsoft FRx today, will be offered an upgrade to Microsoft Dynamics Management Reporter 2012 with integration to Microsoft Dynamics NAV 2009.
What about organisations not using FRX?
Or new customers?
More details on how to get Management Reporter for Dynamics NAV are here: blogs.msdn.com/.../how-can-you-get-management-reporter-2012.aspx
"Microsoft Management Reporter is supported for NAV 2009 but will not be supported for NAV 2013.


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San Francisco, CA 94133
Get Directions:
- Hours
Monday: 11:00 AM - 10:00 PMTuesday: 11:00 AM - 10:00 PMWednesday: 11:00 AM - 10:00 PMThursday: 11:00 AM - 10:00 PMFriday: 11:00 AM - 10:00 PMSaturday: 11:00 AM - 10:00 PMSunday: 11:00 AM - 10:00 PMLunch Mon-Sun 11am-4pm Dinner Mon-Sun 4pm-10pm
- Attire Casual
- Atmosphere Romantic, Live Music, Scenic View, Family / Children, Bar Scene
- Amenities TV, Private Party Room
- Special Needs Non Smoking Area, Booster/High Chairs, Wheelchair Access, Child Menu
- Bar Full Bar, Beer, Wines, Micro Brews
- Banquet Facilities Over 100 People
- Meal Times Served Lunch, Dinner, Happy Hour
- Parking Availability Street
- Payment Methods
Tony & Tina's Wedding - "Broadway" comes to Fisherman's Wharf every Friday and Saturday at 7 PM. Please contact us to make reservations. Castagnola's is a world class destination in the heart of San Francisco's Fisherman's Wharf. Known since 1916 for fine Italian Cuisine and locally caught seafood. Our specialties include Dungeness crab, lobster, prime rib, steaks and a full menu of other sophisticated dining choices. From the bar, order your favorite cocktail or choose from a large selection of wines. Our lounge is a favorite wharf hangout for after work and during happy hour. We have live music daily. Private Party Facilities: Enjoy private dining overlooking the wharf and fishing fleet with the city skyline in the background. Seating for groups of 40 up to 200 with private bar and a surrounding deck area.
- Chef's Bio
- Castagnola's is the oldest family owned and operated restaurant on Fisherman's Wharf.
- Best Known For
- Thomaso Castagnola invented the now famous crab cocktail in 1916. Come visit Castagnola's and try our famous crab cocktail and other delicious fresh seafood and steaks.
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