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Fulk, George D. PT, PhD; Ludwig, Miriam OT, MS; Dunning, Kari PT, PhD; Golden, Sue PT, BS; Boyne, Pierce BS; West, Trent PT, BS
Physical Therapy Department, Clarkson University, Potsdam, New York (G.D.F.); Good Shepherd Rehabilitation Hospital, Allentown, Pennsylvania (M.L., S.G.); and Drake Center (K.D., T.W.) and Physical Therapy Department, University of Cincinnati (K.D., P.B.), Cincinnati, Ohio.
Correspondence: George D. Fulk, PT, PhD, Physical Therapy Department, Clarkson University, Potsdam, NY 13668 (firstname.lastname@example.com).
Background and Purpose: Gait speed is commonly used to assess walking ability in people with stroke. It is not clear how much change in gait speed reflects an important change in walking ability. The purpose of this study was to estimate clinically important changes in gait speed by using 2 different anchors for what is considered "important": stroke survivors and physical therapists perceptions of change in walking ability.
Methods: Participants underwent outpatient physical therapy (mean 56 days post-stroke) after a first-time stroke. Self-selected gait speed was measured at admission and discharge. At discharge, participants and their physical therapists rated their perceived change in walking ability on a 15-point ordinal Global Rating of Change (GROC) scale. Estimated important change values for gait speed were calculated by using receiver operating characteristics curves, with the participants and physical therapists GROC as the anchors.
Results: The mean (SD) initial gait speed of all participants was 0.56 (0.22) m/s. The estimated important change in gait speed ranged from 0.175 m/s (participants perceived change in walking ability) to 0.190 m/s (physical therapists perceived change in walking ability), depending on the anchor.
Discussion and Conclusions: During the subacute stage of recovery, individuals poststroke who experience improvements in gait speed of 0.175 m/s or greater are likely to exhibit a meaningful improvement in walking ability. The estimated clinically important change value of 0.175 m/s can be used by clinicians to set goals and interpret change in individual patients and by researchers to compare important change between groups.
Gait speed is a measure that is commonly used to assess walking ability in people with stroke, both in the clinic with individual patients and in clinical trials to compare outcomes between groups. It has robust psychometric properties. Excellent test-retest reliability coefficients have been reported.1–4 Gait speed has strong construct validity. In people with stroke, gait speed is related to lower extremity (LE) strength,5,6 LE motor control,7 balance,8,9 functional mobility,7,9 gait endurance,10 energy expenditure,11,12 and disability.11 Gait speed can predict discharge destination13–15 and falls.16 Gait speed can be used to classify individuals poststroke into different functional walking categories,17 and transitions from between categories corresponds to improvements in social participation.18 Gait speed has been referred to as the gold standard19for measuring walking ability and as a "sixth vital sign."20(pg2)
An important property of any outcome measure is its ability to measure change. If a patient's gait speed improves from 0.50 m/s to 0.61 m/s, is this an important amount of change? A reference value is needed to aid the clinician in determining whether this 0.11 m/s change is important. The ability of an outcome measure to evaluate change is termed its responsiveness.21 There are a variety of methods to determine the responsiveness of an outcome measure. Two methods have particular clinical value, the minimal detectable change (MDC) and the minimal clinically important difference (MCID).22 The MDC is the minimal amount of change in the outcome measure that is necessary to exceed error and variability in that measure.22,23 It is considered to be the smallest amount of change in an outcome measure that is necessary for the change to be considered a true change.
The MDC of gait speed has been reported by various authors.1–4,24,25 The reported MDC of gait speed for people with stroke ranges from 0.07 m/s to 0.36 m/s, depending on the time since stroke onset, need for physical assistance when walking, need for an assistive device when walking, and the walking surface. An important limitation of the MDC is that it estimates only the threshold for true change. This change may not be an important amount of change. Anchor-based methods are required to estimate important change in an outcome measure.22,26
The MCID is an estimate of the minimum change in an outcome measure that is considered to be clinically important.27–29 The MCID uses an anchor-based approach to determine important change; it examines the relationship between the outcome measure of interest and some independent criterion to determine clinically important change.22,26,30 Different external criteria can serve as the anchor, such as mortality, level of function on a commonly used measure, or discharge destination.22,30 A Global Rating of Change (GROC) scale27 is often used as the independent external anchor. The GROC asks patients or clinicians to rate on an ordinal scale the degree of change (worse, no change, or better) they have experienced over a certain time.27 The article by Beninato and Portney31 in this special issue provides more information related to the responsiveness of outcome measures.
There is only 1 study of which we are aware that reported estimates of the MCID of gait speed in people with stroke. Tilson and colleagues32 estimated the MCID of gait speed in people with stroke who were between 20 and 60 days poststroke. These authors used the Modified Rankin Scale32 (MRS) as the anchor for important change in disability. Participants who demonstrated a change on the MRS of 1 or greater were considered to have an important amount of change. By using receiver operating characteristics (ROC) curve and Classification and Regression Tree analysis, they estimated an MCID for gait speed of 0.16 m/s.32 A limitation of this finding is that a change on the MRS may not directly relate to a change in walking ability.33,34
The MCID of gait speed for estimating change in overall disability has been reported, but further research is needed to determine important change in gait speed that reflects improvement in walking ability, as perceived by patients and physical therapists. The purpose of this study was to estimate clinically important change in gait speed by using 2 different anchors for what is considered "important": stroke survivors' perception of change and physical therapists' perception of change in walking ability measured with a GROC scale.
Participants were recruited from 2 outpatient physical therapy (PT) clinics: 1 in the Northeast and 1 in the Midwest United States. Inclusion criteria were undergoing outpatient PT after a first-time stroke; enrollment within 6 months poststroke; score of 2 or greater on the Functional Ambulation Categories35 (indicating the ability to walk atmost with the assistance of 1 person); and successful completion of the screening portions of the orientation, language, memory, and reasoning/judgment subscales of the Cognistat.36 Participants were excluded if they could not walk independently before the stroke. The institutional review boards at Clarkson University, Good Shepherd Rehabilitation Hospital, and the University of Cincinnati approved the study, and all participants provided informed consent.
Since the primary purpose of this study was to estimate important changes in gait speed, the intervention was not controlled. Physical therapy interventions were individualized by the participants' primary physical therapists on the basis of the body structure/function impairments, activity and social participation limitations, and goals of the participants.
During the first and last week of outpatient PT, the participants' self-selected gait speed was measured by using a GAITRite (CIR Systems, Inc, Havertown, Pennsylvania). The GAITRite is an electronic walkway with embedded pressure sensors, which captures the geometry of footfalls as a person walks along the walkway. Computer software applications convert the raw footfall pattern data into temporal and spatial aspects of gait such as speed, cadence, step length, and percentage of gait cycle in single limb stance. The GAITRite is a valid and reliable method for assessing gait.38 Participants were instructed to walk across the 17′ × 3′ electronic walkway at their self-selected, comfortable pace by using whatever assistive device and/or orthotic that was prescribed by their physical therapist and, if necessary, with whatever amount of assistance/supervision that was required to ambulate safely. The use of assistive device and/or orthotic was not controlled from admission to discharge. One walking trail was recorded.
During the last week of outpatient PT, the participants also completed a GROC scale questionnaire.27 The GROC asked participants to rate their change in walking ability since they started outpatient PT on a 15 point ordinal scale with −7 indicating "a very great deal worse," 0 indicating "no change," and +7 indicating "a very great deal better" (Figure 1). During the last week of outpatient PT, the participant's primary physical therapists were also asked to rate the participant's change in walking ability since they started outpatient PT on the GROC scale. The participants and physical therapists were neither aware of the gait speed results when they completed the GROC nor of each other's GROC score. Fourteen physical therapists participated and rated their patient's walking performance. The median experience of the physical therapists was 5.5 years, with a range from 1 to 30 years.
Participants were dichotomized into 2 groups on the basis of GROC scores: those who answered between −4 and +4 were considered to have minimal to no change (stable/not improved) and those who answered +5 or more were considered to have important change (improved).39–44 This was done for both the participant GROC scores and the physical therapist GROC scores. Traditionally, a cutoff of +3 is used to determine minimal change, where participants who answer +4 or more are considered to have experienced minimally important change.27 A the cutoff of + 5 was chosen for 2 reasons: all people who were undergoing PT during this relatively early time frame after stroke were likely to experience some change in walking ability, and we were interested in estimating how much change in gait speed was considered important, not just minimally important. A score of +5, "a good deal better" may be reflective of more important improvement than "somewhat" or "moderately" better, which have been used to indicate "minimally important" improvement.22,39,40 Other researchers have indicated a need to identify changes in outcome measures that are more than just "minimally" important.29,45,46
An independent t test (continuous data) and χ2 test of independence (categorical data) were used to determine whether participants baseline characteristics (gait speed; age; gender; side of paresis; time from stroke to beginning outpatient PT; time from stroke to discharge from outpatient PT; number of PT visits; use of assistive device; amount of physical assistance required to ambulate; and temporal/spatial aspects of gait, eg, cadence, unaffected LE step length, affected LE step length, and percentage of gait cycle in stance on the affected LE) were different between groups (improved and stable/not improved).
An independent t test was used to examine the differences between change in gait speed and change in other temporal/distance measures of gait (cadence, unaffected LE step length, affected LE step length, and percentage of gait cycle in stance on the affected LE) between participants categorized into the improved group and those categorized into the stable/not-improved group. This was done to determine whether participants' and physical therapists perception of change in walking ability, as measured by the GROC scale, accurately reflected objective changes in gait characteristics. The relationship between the participant and physical therapist GROC and change in gait speed was explored by using a Spearman correlation coefficient to determine the relationship between the anchor (GROC) and the change score (change in gait speed from admission to discharge).
Receiver operating characteristic curves were constructed by plotting sensitivity values (true positive rate) on the y axis and1-specificity values (false positive rate) on the x axis for different changes in gait speed for distinguishing improved from stable/not-improved participants. Separate ROC curves were constructed for each of the 2 anchors: participant GROC and physical therapist GROC. The area under the curve (AUC) and 95% confidence intervals were obtained as a method for describing the ability of each measure to distinguish participants who improved from those who were stable/not improved.21,38–43 An AUC of 0.50 or less indicates that change in gait speed has no ability beyond chance to distinguish between participants who improved and those who were stable/not improved (as defined by the score on the GROC), while a value of 1.0 would indicate perfect ability to distinguish between improved and stable participants.
Clinically important changes in gait speed were estimated by identifying the point on the ROC curve nearest the upper left-hand corner, which is considered to be the best cutoff score for distinguishing improved from stable/not-improved participants.47 Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated for the estimated important change values. This was done for both the anchors (participant GROC and physical therapist GROC). Previous research has indicated that the use of an assistive device and the amount of assistance required to walk may have an impact on the MDC of gait speed in people with stroke.1 Because of this, the clinically important change in gait speed for participants who initially used an assistive device to ambulate and who could not walk independently was estimated by using the same methods described previously.
Forty-four individuals with stroke participated in the study. On the basis of the participants' GROC scale, 11 participants (26.8%) were categorized as stable/not improved (GROC score ≤ +4) and 30 (73.2%) were categorized as improved (GROC score ≥ +5). The lowest GROC score reported by a participant was +2 (Table 1). In 3 participants, the participant GROC data were missing; data from these participants were not used for the analysis pertaining to the participants GROC but were used in the analysis pertaining to the physical therapists GROC as the anchor. On the basis of physical therapists GROC scale, 22 participants (51.2%) were categorized as stable/not improved (GROC score ≤ +4) and 21 (48.8%) were categorized as improved (GROC score ≥ +5). The lowest GROC score reported by a physical therapist was +1 (Table 1). The physical therapists GROC data for 1 participant were missing; data from this participant were not used for the analysis pertaining to the physical therapists' GROC but were used in the analysis pertaining to the participants' GROC as the anchor.
There were no significant differences in baseline characteristics (Table 2) and gait characteristics (Table 3) between the improved group and the stable/not-improved group (P > 0.05).
There was a significant difference in change in gait speed and other gait characteristics between participants who were categorized as stable/not improved versus improved on the basis of stroke survivors' GROC scores (Table 4). The mean change in gait speed for participants who were categorized as improved was 0.31 m/s, while mean change in gait speed for participants who were categorized as stable/not improved was 0.11 m/s; P < 0.05. There was also a significant difference in change in affected and unaffected step length and change in the percentage of gait cycle in single limb stance on the affected LE between improved and stable/not-improved participants. There were no significant differences in changes in gait speed (0.28 m/s vs. 0.22 m/s) or gait characteristics between participants that were categorized as stable/not improved vs. improved based on physical therapists GORC scores, p > 0.05 (Table 4).
As shown in Table 5, by using the participantsGROC score as the anchor, the AUC of the ROC curve was 0.80 (Figure 2). This resulted in an estimated clinically important change in gait speed of 0.175 m/s. Using the physical therapists GROC score as the anchor, the AUC of the ROC curve was 0.58 (Figure 3). This resulted in an estimated clinically important change in gait speed of 0.190 m/s.
The ROC curve results were similar for data obtained from participants who initially used an assistive device to walk and for data obtained from participants who could not walk independently (Table 6). Using the participants GROC score as the anchor for participants who used an assistive device to walk at baseline, the AUC of the ROC curve was 0.80. This resulted in an estimated clinically important change in gait speed of 0.175 m/s. Using the physical therapists' GROC score as the anchor for participants who used an assistive device to walk at baseline, the AUC of the ROC curve was 0.64. This resulted in an estimated clinically important change in gait speed of 0.190 m/s. Using the participants' GROC score as the anchor for participants who could not walk independently at baseline, the AUC of the ROC curve was 0.85. This resulted in an estimated clinically important change in gait speed of 0.130 m/s. Using the physical therapists' GROC score as the anchor for participants who could not walk independently at baseline, the AUC of the ROC curve was 0.71. This resulted in an estimated clinically important change in gait speed of 0.185 m/s.
The results of this study estimate that a change of 0.175 to 0.190 m/s in gait speed is clinically important in people with stroke who are undergoing outpatient PT during the subacute stage of recovery after stroke. The estimated clinically important change in gait speed is similar using either stroke survivor's perception of change or a physical therapist's perception of change in the walking ability. However, the AUC of the ROC curve, sensitivity, specificity, positive LR, and negative LR are all stronger based on stroke survivors' perception of change compared with physical therapists' perception of change. In addition, there was not a significant relationship between the physical therapists' GROC scores and change in gait speed, while there was a significant relationship for participants perception of change and change in gait speed. Using the important change value of 0.175 m/s in gait speed estimated from the participants' may be a more valid estimate of important change in gait speed.
These results can be used to help clinicians determine how much change in gait speed is necessary during the subacute stage of recovery after stroke to reflect a clinically meaningful improvement in walking ability. For example, if a patient's gait speed was 0.45 m/s at the initial examination, and on discharge from outpatient PT, it improved to 0.67 m/s, the treating physical therapist could conclude that this 0.22 m/s improvement was clinically meaningful. This amount of improvement exceeds the estimated clinically important change in gait speed of 0.175 m/s of this study.
In addition to reporting the statistical significance of differences in gait speed between 2 groups, researchers can use this criterion value for important change in gait speed to examine differences between intervention groups by comparing the proportion of subjects in the experimental group with that in the comparison group whose change in gait speed exceeded 0.175 m/s. These proportions can be used to determine the number needed to treat (NNT). The NNT is the number of patients who need to be treated with the experimental intervention before you can be sure that 1 patient improved, who would not have improved with the comparison intervention.48 Presenting results of research studies by using the NNT in addition to statistically comparing the differences between the groups in this manner has greater clinical utility than presenting only the statistical difference between groups.48 The lower the NNT, the greater the clinical impact of the experimental intervention compared with the comparison intervention.
Our results are similar to the MDC findings for gait speed reported by other authors for subjects with a similar time since stroke onset. In a sample of people 2.8 months poststroke, Hill and colleagues2 reported a 95% confidence interval for true change in gait speed of 0.08 to 0.16 m/s. In people 3.7 months poststroke, Stephens and Goldie4 reported a 95% confidence interval related to the error of measuring change of −0.10 to 0.12 m/s on a tiled walking surface and −0.13 to 0.17 m/s on a carpeted walking surface. The estimated clinically important change in gait speed of 0.175 m/s found in this study is slightly greater. This is encouraging, as an important change in an outcome measure should exceed the amount of error and variability in a measure.29,30
Our finding of an estimated clinically important change in gait speed of 0.175 to 0.190 m/s is also similar to the MCID of gait speed of 0.16 m/s, reported by Tilson and colleagues.32 This slight difference in values is likely due to the difference in the anchor defining important change; stroke survivor and physical therapist report of important change in walking ability versus improvement in overall disability, as measured by the MRS. It is encouraging that despite these differences, the estimated important change in gait speed was very close between the 2 studies; a difference of only 0.015 m/s was noted.
It appears that people with stroke were better able than physical therapists to judge change in their walking ability as it related to gait speed. There were differences in change in some gait characteristics between the improved and stable groups based on participants' GROC scores, but there were not differences in change in gait characteristics between the improved and stable groups based on physical therapists' GROC scores. This could be a result of physical therapists having preconceived criteria for important change in gait based on experience and due to the fact that they see the patient in a relatively closed environment for a relatively short period of time. People with stroke are basing their criteria for important change on how changes in walking ability are impacting their daily lives. The physical therapist may not realize these changes as he/she sees the patient for only a limited amount of time in the environment of the clinic. Physical therapists may be basing their criteria for important change on other components of gait such as quality of movement, and this may not be reflected in the change in gait speed.
There are limitations of using a GROC scale to determine the threshold for important change in outcome measures. Participants may have difficulty recalling their initial status when reporting on change in ability on the GROC scale.29,30 They may instead report on their current status. However, in this sample of people with stroke, it appeared that they were able to accurately report on change in walking ability on the GROC to some degree. There were significant differences in change in some of the gait characteristics between stroke survivors who were categorized as improved compared with those who were categorized as stable/not improved based on their GROC scores. In addition, the GROC is a global scale. It asked participants to rate their overall improvement in walking ability; however, gait speed is just one aspect of walking ability. Some participants with stroke and therapists perceived that their walking ability improved, but this was not reflected in a change in gait speed. Other aspects of gait may have improved such as requiring less assistance or a more normal walking pattern.
Another limitation of this study is the relatively small sample size used to estimate the important change in gait speed, although other studies that have used a GROC scale for the anchor of important change have used similar sample sizes.38,49 The estimated important change values reported here should be used only with individuals with similar characteristics. Most of the participants in this study had a mild to moderate stroke, as evidenced by the fact that most subjects would be classified as limited community ambulators on the basis of their gait speed.17 We did not control for the type of assistive device used when measuring gait speed. At both the initial and discharge gait speed measurement participants walked with the assistive device they were using at that time. Any potential change in assistive device to one that was less-supportive may have impacted their gait speed. However, in clinical practice, physical therapists often prescribe less-supportive assistive devices as patients improve. Of the 19 participants in this study who changed from an assistive device to either no assistive device or a less-supportive one, only 3 had a decrease in gait speed at discharge.
Estimated clinically important change values are likely to vary depending on the baseline scores of the outcome measure.29,30,50 Individuals with an initial low score on an outcome measure may need only a relatively small amount of change for it to be important. If we considera patient who has an initial gait speed of 0.15 m/s and improves to 0.30 m/s, this change represents a doubling of the patient's gait speed and may be important, but it does not exceed the estimated important change threshold of 0.175 m/s. This criterion score for important change in gait speed should only be used with patients that have characteristics that are similar to the participants of this study.
A change of 0.175 m/s is estimated to be a clinically important change in walking ability in people undergoing outpatient PT after a stroke. This criterion score can be used with individual patients to interpret changes in gait speed or by clinical researchers to compare the effectiveness of different interventions designed to improve walking ability in individuals with stroke. The estimated important change exceeded error/variability in the measurement of gait speed2,4 and is similar to a reported value of the MCID32 that used improvement in disability as the anchor for important change in gait speed.
Stroke; Gait; Walking; Outcome Measures; Responsiveness
© 2011 Neurology Section, APTA
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Top 25 Italy Moments – #14 Siena Language Barrier
In 2002 my good friend and talented chef Keith was studying cooking in Siena. I happened to be on vacation in Tuscany and made my way back to Siena a 2nd time (the first time is in the Top 5) on this journey to meet Keith.
I returned to Siena on a foggy evening in September. Keith had given me his address and we had arranged to meet that day; however, the time had not been pre-selected and I roughly knew Keith's class schedule so I figured I would find him.
This is pretty much how things work for me in Italy and especially before cell phones became an affordable option. I would tell someone or someone would tell me where to meet them and then the dance would begin.
On this occasion I had a map of the city and Keith's address. My Italian was serviceable at best so I had to ask things slowly and use lots of gestures. That is another funny thing about Italy, their gestures are a language unto themselves and so misuse of gesture is the equivalent of a non-verbal Malaprop. My ignorance of the language and gestures would really come to bite me in the ass the next day.
After 2 conversations with a pair of smartly dressed women and one with a merchant I finally reached what I believed to be Keith's place. The street was completely sepia and wet. There were rows of single-story units much like duplexes lining the street. The road itself was flat which is a rarity for Siena. After receiving no answer when I knocked on Keith's door I quickly found myself pacing. I happened to have a few smokes left from the previous night and wound up smoking alone in the misty evening. A curious pair of children continued to pop in and out of their home to see what the tall foreigner was doing.
I wish it was like this in America. Where I come from if we saw a foreigner, weapons got loaded and comments like "can I help you Mr?" and "you sure are far from home ain't ya?" were the norm. I am certain this is why it has always been a nervous endeavor for me to wander aimlessly into a store in a foreign country because I assume someone will be suspicious of me. As was and is often the case in Italy, people are mostly curious without being overt. Kids tend to like people in general and especially if they seem like something new.
I began to make silly faces for the kids and they laughed and giggled running in and out of their front door. It was only around 7pm, however, the lights and the mist made it seem like a medieval midnight. I was growing weary of my own pacing and the cigarettes were clearly a bit stale. There was a bus stop about 150 meters from Keith's door and each time it made a stop I assumed Keith would emerge.
After the kids went inside for good and I couldn't possibly smoke another cigarette I decided I would leave Keith a note and make my way to a nearby bar for a sandwich and a beer. I went to the bus stop and when the next bus arrived out popped Keith just as casual as you could be as if I had been living with him forever and this meeting along a Tuscan road was nothing out of the ordinary.
I attempted to regale him with stories of my journey and within minutes Keith was at the stove cooking porcinis and making a tempura batter for vegetables. I was so jazzed to be getting a home cooked meal I soon forgot the ordeal of my last 2 hours and Keith and I drank beer, smoked his much fresher cigarettes, and discussed our next day.
I had not slept much in the previous days so Keith offered me a mother's little helper and thus began my awareness of such miracles. 13 hours later I awoke as Keith was leaving for school. I walked with him to class and met his teacher before I disappeared into Siena for a foggy day. I was not really supposed to stay at his house without paying and of course the typical nosy Italian landlord knew I was there because he had spotted me wandering aimlessly up and down the street the night before. Che palle!
On our way to school Keith informed me that the old geezer had requested the honor of our presence that afternoon to settle my lodging debt. I was not looking forward to the formality of meeting with this guy.
I spent most of the day in an internet cafe and when Keith and I met just outside the cafe when he finished class we stopped by the pharmacy where I used my bad Italian to score an entire box of little helpers. We then moved on to a local bar for coffees and some smokes.
In Italy, the Bar is the central hub of each street area. Each neighborhood has its streets and on each is usually a Bar. Some bars are filled with jocks, gamblers, and douche-bags. A few bars are mixed-sex venues with high quality coffee and snacks. There are those for the blue-collar denim crowd, and these are usually a bit rough and tumble. Lottery tickets, freezer-burned ice creams, strong coffee, thick local accents and dialects are all ingredients in an Italian blue-collar bar. This is the kind of bar Keith chose for our coffee. Of course you can always buy cigarettes in a Tobacco shop but since we had just had a coffee we ordered smokes as well.
The proprietor was drawn and tanned like a raisin with a grey edge. He wore a denim jacket even though it must have been 80 degrees in the shop. He smelled of strong cigarette smoke and the Italian equivalent of Old Spice. I wanted to call him Vecchia Spezia. There were the usual cronies on both sides of the cash register. These guys were standing directly…actually they were leaning on the cashier's part of the bar when we arrived. The reluctantly moved as we placed our orders but only to the two sides on our left and right. In essence we were surrounded by cronies.
Keith gave the guy a 20 euro bill for our 6 euro 10 tab. The guy gave him back 3 euro 90. It was apparent to us that the guy shorted Keith and he told Old Spice in English, "hey I gave you a 20." The guy did not grasp the exact words Keith used but it seemed apparent he knew the gist. Keith went back and forth with no success so I interceded with my way-too-direct Italian. In Italy if you simply come right out and say something it is assumed you are angry and that you do not respect the person you are addressing. This was not my intention, but boy was it ill -received.
At this point Old Spice reaches in the register and shows us a 10 euro bill he claims to have gotten from Keith. I look at Keith in hopes that he was in error, but Keith persisted with "that's not what I gave you man." I knew this was not going to go well as now the cronies were involved and each of them professing the proprietors virtue and pleading his case. Time seemed to slow as I assessed which one of these guys I would hit across the head first when it all started getting ugly.
It was at that point that Old Spice said something in Italian that I understood to mean,"this is not Naples sir, we are not thieves here!" I began to chuckle and the cronies began to gesture with two fingers in affirmation of this little-known fact and a certain didn't you know that you stupid foreigner gesture. Keith still seemed unwilling to acquiesce so I told him I would give him the 10 euro, as once this kind of statement is invoked there was no hope of our proving the point.
I will never know 100% whether or not Old Spice stole 10 Euro from Keith. I do know that Mother's little helpers did their job moments after we escaped the Bar with our lives.
I was quite stoned and very relaxed when we met the landlord. My Italian, failing and miserable in the bar an hour before, was now fluid and dulcet. I told the landlord I had come unannounced and that because of a train strike I was stuck in Siena. I explained that I would happily pay my way which of course the landlord very graciously refused. Keith was impressed I had swayed the crotchety old bastard, and I simply was happy to deal with a man that didn't smell of Old Spice.
In the end, Keith and I quit our corporate jobs to chase the dreams only these kinds of experiences can illuminate. I continue to frequent blue-collar bars in all Italian regions and it never fails that someone is wearing denim.
Such a great story..it must be a bit scary to get into an argument in a foreign country where there are so many known and unknown barriers…
Great post. I stray from arguments in Italian, I dont have the hand gestures down pat yet with the exception of the middle finger, but that can only take me so far.
There's something about speaking a language badly, I love it. ;p
An interesting, well-written story, Michael. I enjoyed it. The photographs are special too. I'm still smiling about "Old Spice"!
i think I may need some mlh! 🙂

subset: commoncrawl


text:
WITHIN the Marxist-Leninist ideological armory high priority is assigned to principles governing the interrelationship between Party organs and individual Party members. Elaborated primarily by Lenin, this operational code seeks to reconcile the precepts of inner democracy with the paramount needs of iron discipline and autocratic leadership. Thus, unwittingly, Lenin built into the chosen Party a Jekyll- Hyde complex with the good Dr. Jekyll steadily losing ground to the evil Mr. Hyde. In due time the high-minded principles of "inner- Party democracy" shared the fate that has befallen so many other tenets of Marxism-Leninism. Their substance had been corroded by the destructive acid of totalitarianism.
The Czechoslovak Communists have been as imitative of the Soviet Party in the adoption of their operational code as in the arrangement of their Party's organizational structure. The time-honored Leninist precepts of "democratic centralism," "free and businesslike discussion," "criticism and self-criticism," and "the observance of Party and state discipline" were enthroned as supreme deities guiding the Party's behavior. The chapter of the KSČ Statutes dealing with the duties of Party members was taken bodily from the Soviet Party rules. When the post-Stalin condemnation of the "cult of the individual" elevated the "Leninist principle of collective leadership" in Soviet Russia, Czechoslovak Communists at their Tenth Party Congress in 1954 promptly inserted a like section in their Party Statutes. Also, the KSČ inherited from the Soviets the sharp contrast between theoretical concepts and their application in actual practice.
According to its Statutes, the foundation of the Party's internal life is "inner-Party democracy" and its cornerstone is "democratic centralism." " Lenin's and Stalin's bolshevik principle of democratic centralism," said Gottwald, "offers a reliable guidance on how to


text:
WHO Says Pandemic May Be Evolving
GENEVA -- The H1N1 flu virus is likely to keep spreading rapidly among people, within countries and across the globe, the head of the World Health Organization said on Monday.
Ministers and experts began a meeting in Geneva to discuss how to fight the virus with vaccines and drugs, as well as what would trigger the WHO to declare a full pandemic.
"For the first time in humanity, we are seeing, or we may be seeing, pandemic influenza evolving in front of our eyes," WHO Director-General Margaret Chan told her U.N. agency's World Health Assembly.
Japan confirmed Monday that 125 people have been infected with the new strain. Most of the new infections were among high school students in the western prefectures of Hyogo and Osaka who hadn't traveled abroad, the Health Ministry said.
Schools and kindergartens were closed across the two areas but local governments advised businesses to operate as usual. Kiosks at some stations in the region were closed, and a festival in the city of Kobe that usually attracts tens of thousands was canceled.
In New York, a school principal died from the new flu on Sunday, marking the city's first death from the virus.
WHO said it is watching the situation in Japan closely, but it wasn't clear yet whether the outbreak, the largest outside the Americas, would trigger a move to level 6, the highest on its global pandemic alert scale. WHO raised the alert to 5 last month.
Under WHO rules, signs that the disease is spreading in a sustained way in a second region of the world would prompt a declaration that a full pandemic is under way. Other large clusters have been seen in Spain and Britain.
Dr. Chan and U.N. Secretary-General Ban Ki-moon will meet top pharmaceutical executives on Tuesday to discuss their ability to make vaccines to fight the strain. Delegates will seek an agreement on how samples of the virus should be handled and shared with pharmaceutical companies.
Richard Besser, head of the U.S. Centers for Disease Control and Prevention, told a high-level meeting during the week-long assembly that the virus had spread to nearly all 50 U.S. states and showed no signs of abating.
New York has recorded its first death from the virus and Chile reported two new cases, adding to its first two cases reported on Sunday. Initial tests showed the first suspected case in Greece, a Greek man traveling from the U.S., the Health Ministry said.
Forty countries have confirmed cases of the strain, a mix of swine, human and avian viruses. Almost all of the 74 dead were in Mexico, but mostly, people have had relatively mild symptoms.


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Lambda Locator Bug
So i've been working on this one and have gone through the game twice using the guides. I have been to every single location this i know for a fact. So it would seem i have some kinda bug that is causing them not to register. Anyone else had this problem or know of a work around?
mm It's weird, it must be a problem with your game, I didn't know about this problem
Went ahead and deleted my save files. Went back through and got the last 2 i was missing. Which is weird because i know i had them unlocked before since i had never seen the entire area then were in before.
Same thing happened to me 44/45 I went through 3 different guides and the youtube videos Im 100% sure I did not miss any. So the only possibility is a glitch or bug. It really sucks, a lot of time wasted and no achievement lol:(
sometimes you have to get the items that are hidden with the lamba sign aswell. maybe that was a reason but if you went back another time it probably was a bug
Well...I went through every single location and I picked up every one of them according to the guide. There was one that never would register, so I went back after completing the game because I knew exactly where it was. I loaded up a save and went straight there...picked up the ammo, health that this particular Lambda was marking...and it still won't register. I have 44/45 now...I know exactly which one it is...I got there...and it still won't unlock!!! Please help!!!
this happened to me i had to pick up i certain item nd i couldnt find it for ages
I can't say that I have it figured out,...but I am going to try a few things. I just can't get how it can be screwed up when I know exactly which one it is,...and I go straight to the one it is...and it won't register!?!?!?!
Same thing for me. I'm on my third playthrough and I'm stuck at 44/45
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text: I want to separate planned work and duration from actual. I have a task which is scheduled for start 4/7 Finish 4/8 work hours of 16, i want to adjust the entry table in a way so that it reflects actual start 4/7 and actual finish 4/9 along with hours. I have tried doing so but for some reason the actual work is coinciding with w/ duration at 3 days and actual work at 24 hrs. Is there anything that i might be missing, any help for this will be appreciated.


text: I am planning to get myself an internet TV as the region in which we leave doesnt have a cable network. One which is available doesnt provide many channels. I am confused between Roku TV and Google TV as they both are fine and good for use. Since I havent used any of them and neither do I have any friend or relative who has any of them, I am having problem deciding which one to get. Can someone who has used these internet networks tell me which will be best among them?


text:
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Fantastic Game system
This review is from: iBUYPOWER Desktop PC Gamer Supreme NE780i Intel Core i7 3770 (3.40 GHz) 8 GB DDR3 1 TB HDD Windows 7 Home Premium 64-Bit
Pros: Fast, powerful, excellent case, nice KB and Mouse
Cons: Case is large, if that is a concern. No card reader built in that I can see...
Other Thoughts: Purchased this for my son who wanted to start doing some PC gaming. So far it has no troubles at all with any modern game we have tried on it.
Manufacturer Response:
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Don't Buy
This review is from: iBUYPOWER Desktop PC Gamer Supreme NE780i Intel Core i7 3770 (3.40 GHz) 8 GB DDR3 1 TB HDD Windows 7 Home Premium 64-Bit
Pros: Cool looking case
Cons: Everything. First off it took them forever to ship the computer it was sitting in the warehouse for 5 days before it moved an inch. When I finally got it I was running updates for graphics card and windows updates. 2 hours later the card blew out, it does NOT work anymore. And then I found out it was the wrong motherboard inside. They sent it with a very poor Gigabyte motherboard instead of the ASrock model they have in the details and specs of the computer. Also a 500W PSU for a i7 and 7850 card is WAAAAAAAAY to low.
Other Thoughts: I've bought a computer from IBUYPOWER before and it was smooth, but this one is another story. I do NOT recommend this computer to anyone unless they can fix the several issues posted above
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never again
This review is from: iBUYPOWER Desktop PC Gamer Supreme NE780i Intel Core i7 3770 (3.40 GHz) 8 GB DDR3 1 TB HDD Windows 7 Home Premium 64-Bit
Pros: over all decent PC
Cons: package was damaged upon arrival.
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Environmental Audits Companies in New Hampshire
Business type: Training provider ×
Category: Environmental Management ×
Subcategory: Environmental Audits ×
Location: USA ×
Location: New Hampshire ×
Perry Johnson, inc..
based in Troy, MICHIGAN (USA)
Perry Johnson, Incorporated (PJI) is one of the world's leading training organizations and is the largest ISO 9000 trainer in North America. Since 1983, the professionals at PJI have presented seminars to more than three million people - in seven languages and in more than 80 cities worldwide - with a client base in excess of 40,000 organizations. PJI has been involved ...
Aarcher Institute of Environmental Training LLC
based in Annapolis, MARYLAND (USA)
The Aarcher Institute of Environmental Training, LLC, was established in response to a need for reliable source of complete and practical environmental training presented by a team of instructors that are practicing experts in the field and dedicated to environmental training. Aarcher Institute courses address developing environmental management and regulatory challenges, ...
SAI Global
based in Independence, OHIO (USA)
SAI Global provides organizations around the world with information services and solutions for managing risk, achieving compliance and driving business improvement. We provide aggregated access services to Standards, Handbooks, Legislative and Property publications; we audit, certify and register your product, system or supply chain; we facilitate good governance and ...
The Compliance Center (ICC)
based in Niagara Falls, NEW YORK (USA)
ICC Compliance Center (ICC) is a provider of solutions for regulatory compliance in transportation and workplace safety, specializing in labeling, packaging, training and consulting. ICC`s onsite manufacturing capabilities and recognized regulatory expertise serves customers in chemical distribution and manufacturing, transportation and logistics, paint and coatings, ...
Kelmac I Group, Inc
based in Chicago, ILLINOIS (USA)
Kelmac I Group, Inc is a leading conformity and compliance audit, consulting, compliance software and certified training company in the U.S Kelmac Group is certifled by IRCA, RAB QSA International, the Safe Quality Food Institute and the International HACCP Alliance as a Training Provider. We were the first and are the oldest IRCA Accredited Training Provider in Ireland, ...
Environmental Resource Center
based in Cary, NORTH CAROLINA (USA)
Environmental Resource Center is a full-service environmental, health, safety, and transportation consulting firm. Since 1981, we have served the needs of industry, academia, and federal and state government agencies by providing high-quality safety and environmental consulting services. We offer a variety of seminars, including all required EPA hazardous waste management ...
based in Oklahoma City, OKLAHOMA (USA)
Online safety training for organizations of all shapes and sizes. We provide innovative e-learning solutions to meet your professional development, regulatory compliance, and risk management challenges. Our online safety training solution provides training for your organization 24 hours a day, 7 days a week.
14000 Store
based in Eden Prairie, MINNESOTA (USA)
The 14000 Store provides documentation, tools, and training to help organizations achieve and maintain ISO 14001 certification for their Environmental Management System (EMS) - on their own. We offer many free tutorials on our website to help you understand ISO 14001, the registration process, as well as other tips. Easy to use checklists can simplify environmental ...
Denby Energy
based in Scottsdale, ARIZONA (USA)
Our company provides home energy audit certification, commercial energy audit certification, BPI, and RESNET.
SEQM Ltd.
based in Newcastle Upon Tyne, UNITED KINGDOM
SEQM specialise in the design and implementation of Safety, Environment & Quality Management systems, auditing and provision of a wide-range of accredited and non-accredited training courses. We also offer franchising of training courses around the world Established in 1994 by industry experts, SEQM Ltd provides a leading edge in all areas of quality, environmental and ...
Need help finding the right suppliers?
Let the XPRTs do the work for you


text:
BEST ENTRANCE: Food Court
LOCATION IN MALL: Lower Level Food Court
(678) 835-7240 | Driving Directions | View Deals | Mall Map
More stores to consider
Little Tokyo
Bourbon St. Cafe
Farmer's Basket
#modifiedmonday: "Midnight Special" aka 14, add vito, avocado and sauce. Submitted by JJ Rockstar Sammy Smith from Fort Pierce, FL! #JimmyJohns
Read More
.@KevinHarvick 2nd place, hellavuh race! #CocaCola600 #NASCARsalutes/p>
Jimmy John's
?????? https://t.co/cJXRibyKCo/p>
RT @KHIManagement: Tonight, @KevinHarvick & the No. 4 @jimmyjohns team will be racing in honor of LCPL Elrod. #NASCARsalutes https://t.co/d…/p>
Boogity boogity boogity....let's go racing! #NASCARSalutes/p>
RT @espurr512: Great #MemorialDayWeekend on the lakefront. Now time to watch @KevinHarvick drive that @jimmyjohns hot rod to victory lane…/p>
Check out jimmyjohnssnaps to see who stopped in for a sandwich today! https://t.co/fGxsZ4kW0Q/p>
Waiting for my food like… https://t.co/EHeQTutGm3/p>
Kiddos of JJ team having some fun on this beautiful Thursday afternoon. JJ is the driver. Great fun thanks all!! https://t.co/A6NPPWIbhn/p>
Colorado Springs, CO! Stop by 5885 Stetson Hills Blvd. today from 4pm-8pm to grab a sub for a $1! (#1-6 & JJBLT, 1 per person, inshop only)/p>
There's going to be sandwiches? Ok, I'll come./p>
#modifiedmonday: "The Hot Pig"
Gotta fuel the fans ???? https://t.co/RrCwnmsaBQ/p>
That's why I need a one sub/p>
What should JJ's new sandwich stickers say? Check us out on Snapchat and submit your ideas to JimmyJohnsSnaps! https://t.co/ydCfawNJ2Y/p>
What should JJ's new sandwich stickers say? Check us out on Snapchat and submit your ideas to JimmyJohnsSnaps!
Shout out to the rock stars in Peachtree Corners. You guys rocked this guy's food in 19 seconds! JJ
Hard work can change your life
I sent Ultimate Fan Daniel to Dover to watch Kevin Harvick take on the Monster Mile, check it out!
?? https://t.co/7DUzhKYODb/p>
?? https://t.co/OzVo1pAFBO/p>
This is Kyle cranking it out at store #2504 Scottsdale. Loved being with you Kyle, Jimmy J! https://t.co/15SsCcwuc6/p>
He better call Jimmy with the good sub/p>
Making sure Pops' car is gonna be freaky fast
RT @FreakyFastRcng: Making sure Pops' car is gonna be freaky fast
xoxo https://t.co/dOGWGhAMBP/p>
JJ behind the line in Scottsdale!
Awesome story about my visit to Northwood High. You kids were fantastic, questions were cool, hope the food was yum! https://t.co/9WA3nmWY35/p>
I love being your study buddy #Finals ?? https://t.co/cnNFBgqwOQ/p>
???? https://t.co/eF2Fm1Kt7N/p>
#ModifiedMonday: "The Cruise"
Happy Mothers Day! #jimmyjohns #happymothersdaytoallthemothers
RT @NASCAR: Retweet if you're amped to go night racing in Kansas! #GB400 https://t.co/OV8st8t3dk/p>
A bad day with subs is better than a good day without them/p>
May the #4 be with you #starwarsday #turkeytom #jimmyjohns #maythe4thbewithyou #humpday
First time trying Jimmy John's ??
First NASCAR race on May 15th ??
First time as Jimmy John's #UltimateFan
DM me!???? https://t.co/OsriLLbAcL/p>
I don't want food. Food wants me./p>
#modifiedmonday: "The Conbomb" aka #10, TBO, add sauce, oregano, bacon, sprouts (where available, eat at your own risk) and extra lettuce. Submitted by JJ Rockstar Connor Yungman from North Kansas City, MO. #JimmyJohns #freshfasttasty
Totes my oats! #OatmealCookieDay #instayum #jimmyjohns #cookies #oatmealraisin #yummy
Turn your 6 pack into a 24 #jimmyjohns #catering #12pack #24pack #minijimmys #beach #party
When Jimmy John's had $1 subs but it was one per customer ??
Repost from @foxheadinc using @RepostRegramApp - Our friends @joy_bethany and @anthonynapo are hosting a Supercross viewing party today in Costa Mesa. Shout out to @jimmyjohns for hooking them up this weekend. #SX #sxfoxfan #foxracing
On his way to steal your sub #jimmyjohns #hedgehog #hedgehogsofinstagram
Watch Kevin Harvick in the Freaky Fast Racing #4 car at the Charlotte Motor Speedway tomorrow at 6PM ET on FOX! #CocaCola600
Thanks for the sticker ideas! Time to vote for your fave. Add JimmyJohnsSnaps on Snapchat & screenshot to vote! https://t.co/FKlbVtnBrR/p>
I bet Belle would have come around a bit sooner if this were the case #BeautyAndTheBeast
I bet Belle would have come around a lot sooner if this were the case #BeautyAndTheBeast https://t.co/671rmtanPg/p>
?????? https://t.co/42h2oeWmsY/p>
Freaky Fast Racing
#BiketoWorkDay2016 #MiniJimmys https://t.co/eYy5lATNU5/p>
What should JJ's new sandwich stickers say? Check us out on Snapchat and submit your ideas to JimmyJohnsSnaps! #jimmyjohns #snapchat
Eat your heart out #NationalSendANudeDay https://t.co/xmFElox6tP/p>
.@HunterHodgin4 Hey man, wanna be my Ultimate NASCAR fan in Charlotte? DM me!/p>
If you don't have anything nice to say, then order JJ's, you're probably just hangry./p>
???? https://t.co/Hijl7tOQRo/p>
???? https://t.co/NV4txufW0Q/p>
Here he comes! ?? #FreakyFast #MonsterMile https://t.co/lKTKGBZHTI/p>
.@KevinHarvick with a 4 second lead! ?? ?? #AAA400 #FreakyFast/p>
All that and a chocolate chip #jimmyjohns #chocolatechipday #chocolatechunkcookies #yummy
Catering. Any time. Any place. Anywhere. #minijimmys #12pack #24pack #catering #jimmyjohns


text:
- 91Promote
Phone Cases
Undefined creatureby Süyümbike Güvenç
Protect your iPhone with a one-piece, impact resistant, flexible plastic hard case featuring an extremely slim profile. Simply snap the case onto your iPhone for solid protection and direct access to all device features.
wow this is so wonderful!
Thanks NikaQ! Glad that you like it ;)
Nice work!!!
Thank you Hugo ;)
Nice one!
Brilliant details! Really like the heart shaped composition! Nice work (again)! ;D
Thank you so much Seamless, gwenola. I really appreciate your comments.
Hey Balazs! Thank you (again) for your kind words. ;) Cheers!
Very cool!
Many thanks dear Andre! ;)
Thanks Tiago! Glad that you like it! ;)
This is awesome!
Thank you!
Very funky, love it!
Thank you dear Angelo :)
magical :)
Thank you for the magic catspaws ;)
This is fantastic!:)
Amazing works
A big thank you Chrisb.
Great color combo!!
Thanks @Barlena
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Admission: Free
Meeting Place: Withrow Spring
Bats are an important part of the ecosystem of Withrow Springs State Park. Join Park Interpreter Natalie to learn about these unique flying mammals and the threats to their existence. Bring a headlamp or flashlight if you have one.
Explore Withrow Springs State Park with our helpful maps and brochures! Just click on an icon to view, or right-click on your mouse to save a
copy to your computer.


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Katie Libecco | posted Jul 10th 2008
July 10, 2008 at the Trumbull County Fair.
From Story: PULLING THEIR WEIGHT Horses, teamsters and fans enjoy Trumbull fair showShare:
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My LO is 20 months old and I am due Jan 30 with our 2nd LO. I had a hard time breastfeeding with the first because the hospital told me to feed her every hour then I got her to go at least every 2 hours but she would only nurse off of one side at a time. So how do you get a baby to nurse off of both sides? I also had a supply issue around when LO was 8 months old and had to supplement and I do not want to do that this go around. I will be returing to work 6-8 weeks after delivery so I will have to start pumping.
how to get baby to nurse on both sides
Comments (6)
Are your nipples the same? This may be a reason why your little one is refusing. I have a slight inverted nipple so i have to help latch on one side.
Married to my loving DH
Angel Baby Oct 2011, Miracle Baby Nov 2012
CDing, BWing, BFing Gold First-Time-Mommie
My baby only nurses on one side at each feeding. She's a chunky, happy 10mo old and we're going strong on nursing still. She's able to get what she needs from one side at a time and it's faster, so I like it!
Katie (36) and DH (36), friends since 1991, married 2009, DD born 2/16/12, DS born 1/31/14
She didn't seem to have a problem other than eating every 2 hours.
Some don't need to eat from both at each feeding. They know when they are full, so will refuse the 2nd one if they are. As long as diaper counts are good, no worries:) It's best to nurse well on one side and get all the good hindmilk than switch to the 2nd and get too much foremilk. 8 months is a normal drop in supply, so just try to offer nursing more frequently when possible to counteract it and be sure to nurse before any solids as well.
Do any of you have to pump as well? If so, when you are away how often do you pump?


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Luxury Apartments at Huntersville in North Charlotte
Ideally located just off I-77 at Huntersville's Rosedale Commons with great shopping, dining, and entertainment just steps away, Bexley Commons at Rosedale is the perfect place to call home.
- NEW Cardio/Strength Fitness Center with LifeFitness Interactive Cardio Equipment—virtual trainer, smartphone connectivity, and more!
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- NEW Poolside Summerhouse with Fireplace, TV, and Grills
- NEW Poolside Fire Pit with Cozy Seating
- NEW Dog Park
- NEW Starbucks Coffee Bar


text: Installing and changing fonts in your plots comes now easy with the extrafonts-package. There is a excellent tutorial on the extrafonts github site, still I will shortly demonstrate how it worked for me. First, install the package and load it. You can now install the desired system fonts (at the moment only TrueType fonts): The


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Allegheny Co. & Santa Clara Co. Place Wager On Stanley Cup FinalGame on, San Jose Sharks.
Major Events May Make Downtown Chaos This WeekendThree major events this weekend may make the downtown area a bit messy.
Man Arrested In 2015 Oakland Crash That Claimed Life Of BicylistA man has been arrested in a fatal vehicle versus bicyclist crash that occurred last year.
Two Lanes Of Forbes Ave. To Reopen Following Water Main BreakTwo lanes of Forbes Avenue will reopen Saturday after being closed for more than a month due to a water main break.
Police: Thief Breaks Store's Glass, Steals 2 Bicycles From BusinessPittsburgh Police are looking for a man who they say was caught on surveillance video stealing two bicycles from a store in Squirrel Hill.
Forbes Ave. Water Main Break Repairs Plagued By Another SetbackThere's been another setback for crews repairing Forbes Avenue in Oakland.
Crews Rushing To Fix Damage From Forbes Avenue Water Main BreakThe view from South Neville tells the story, the gaping hole beneath the Forbes Avenue sidewalk and the road is a major issue.
Freeze-Thaw Cycle Being Blamed In Oakland Water Main BreakThe freeze-thaw cycle is being blamed for causing a large water main break in Oakland that's causing a lot of headaches for drivers.
Forbes Avenue Water Main Break DetoursFind out how to get around repairs on Forbes Avenue.
Man Arrested For Allegedly Firing Shots Near Carlow UniversityA man accused of firing shots near two universities in Pittsburgh is behind bars.
Person Arrested For Allegedly Firing Shots Near Carlow UniversityA man was arrested Saturday afternoon after firing a gun near Carlow University.
Police: Suspect Possibly Caught Bus After Robbing Downtown BankPittsburgh Bureau of Police are looking for a bank robbery suspect who may have hopped on the bus after stealing cash.


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Big Ten Football: Taking a super-early look at the West Division
Jonathan Dyer-USA TODAY Sports
How will the Big Ten West shape up in 2015? BTN.com senior writer Tom Dienhart has the answer in this post!
Use our handy, mobile-friendly TV schedule to see what shows and games air next on BTN & BTN2Go.
Jonathan Dyer-USA TODAY Sports
How will the Big Ten West shape up in 2015? BTN.com senior writer Tom Dienhart has the answer in this post!
Update: Penn State's football team is getting back 112 wins wiped out during the Jerry Sandusky child molestation scandal and the late Joe Paterno has been restored as the winningest coach in major college football history. The NCAA announced the new settlement with the school weeks before a scheduled trial on the legality of the 2012 consent decree it will replace.
In Friday's Big Ten links, we review the surprising news that Cardale Jones is staying at Ohio State. Plus, one writer looks at Kirk Ferentz's latest plan for Iowa while another looks at Mike Riley's desire to own the state of Nebraska in recruiting. BTN.com's Tom Dienhart looks at all of these stories and more.
Mary Langenfeld-USA TODAY Sports
Frank Kaminsky led Wisconsin to an impressive 70-55 win over Nebraska on Thursday night. Catch up on all the action here.
Mike Carter-USA TODAY Sports
Who is the toughest player in the Big Ten? BTN.com senior writer Tom Dienhart asked that question to five beat writers across the Big Ten. See their answers inside this post!
Tim Heitman-USA TODAY Sports
How will the Big Ten East race shape up in 2015? Find out BTN.com senior writer Tom Dienhart's answer inside this post!


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Editor and filmmaker Caleb Slain was inspired to make "P.S. Hoffman," a moving 20-minute tribute to the late, great Philip Seymour Hoffman. Watch below. Per Slain's description of the tribute, it took him 200 hours to condense Hoffman's 47 films into the piece.
The result is effective, with Hoffman's varied and often profound performances edited together to form a cohesive whole.
The Academy put Hoffman as the final name and face in their "In Memoriam" tribute at the 86th Oscars on Sunday, speaking to the devastating effect the actor's death has had on fans and the film community alike. Public memorials are set for this spring in both New York City and Hoffman's hometown of Rochester.


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ACE Fit Share
Add some diversity to your fitness program with these butt and hip exercises from the American Council on Exercise. We'll help you tone up those glutes and get that butt into shape. Choose from a wide variety of hip flexibility and strengthening exercises including glute bridges, BOSU lateral jumps and more. These exercises come with detailed instructions, step-by-step guidance and tutorials on proper equipment use. For full workout routines featuring butt and hip exercises, be sure to visit our Workouts section.
Fit Life Articles
Most snacking calories come from high salt, high fat and high calorie processed foods. These snack foods are cheap and convenient, yet they don't offer much in the way of nutrition. It's time to spring clean your kitchen and your diet by tossing these three food products...
Maintaining a healthy weight can be challenging and, for some people, even more difficult than losing weight. The good news is that achieving lasting weight maintenance is possible. Use these 13 tips to help you succeed at maintaining your weight-loss goals.
Wondering how you can turn sweet treats like cookies and brownies into something that offers a little more nutritional bang for your buck? Here are a few tricks you can use to transform your favorite desserts into healthier—yet still tasty—versions that are sure to satisfy...


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Washington outscored Elsberry 14-7 Tuesday night at the Elsberry Legion Field.
The Cardinals and White Sox close out their brief two-game Interleague series tonight at Busch Stadium. John Lackey starts for St. Louis. He's 6-and-4... more
Tyler Flowers' solo homer in the top of the 11th lifted the White Sox to a 2-1 win over the Cardinals in St. Louis.
Cardinals reliever Matt Belisle is on the 15-day disabled list with inflammation in his right elbow. The 35-year-old is 1-and-1 with a 3.00 ERA in 30 appearances this... more
Tomorrow is the last day to vote for this year's All-Star Game in Cincinnati.
With free agency set to begin, the Blues are talking to forward Vladimir Tarasenko about a new contract.
Former Blues defenseman Chris Pronger is headed to the Hockey Hall of Fame. He is part of the seven-member Class of 2015 that was elected this week.... more
Coming up tonight in senior legion baseball....
Washington travels to Elsberry. Game time is 6:00 and it will be broadcast live on KLPW-AM 1220.
After a day off, the Cardinals resume their homestand tonight with the first of a two-game Interleague series with the White Sox. Lance Lynn opposes Chicago's Chris Sale.
The KLPW Radio Athlete of the Week is Sophomore Lauren Gerlemann from New Haven High School.
Our nation's founders were well versed in the lessons of the history that preceded them. They knew of power's natural tendency to escalate into greater power.
So they included the Bill of Rights, based on the notion of individual self-determination.
Never talk about Sex, Religion or Politics.
Honey draws more flies than vinegar.
These adages seem to have gone by the wayside in today's world of the social-network connected.
Intolerance and groupthink are not the domain of a single party, candidate or ideology.


text:
White House Slashes Deficit Forecast for '09; Bank Bailouts Not So Costly
Byline: Patrice Hill, THE WASHINGTON TIMES
The White House is reducing its forecast of this year's budget deficit to $1.58 trillion as a result of significantly lower than expected spending on bank bailouts, congressional sources say.
A report due Tuesday from the White House Office of Management and Budget will show that the deficit is lower because of $262 billion less in spending on bank bailouts by the U.S. Treasury and Federal Deposit Insurance Corp. (FDIC) than the administration expected earlier this year, according to a memo written Monday by former Congressional Budget Office Director Douglas Holtz-Eakin that was obtained by The Washington Times.
The administration earlier this year in the midst of the banking crisis expected to spend more than $1 trillion closing some failed banks, bailing out others and helping many financial institutions get rid of toxic loan portfolios.
While the outlook for the deficit in the current fiscal year ending Sept. 30 has improved significantly thanks to reduced spending on banks, it is still on track to rise to a record and to drive unprecedented levels of borrowing by the Treasury in the months ahead.
Spending on bank bailouts slowed abruptly after the Treasury and Federal Reserve announced the results of stress tests on the 19 largest banks in March, providing reassurance to financial markets that the losses those banks were experiencing on mortgages and other loans were manageable. Since that time, major rallies have taken hold in the U.S. stock and credit markets, led by improving sentiment about the stocks and finances of big banks such as JPMorgan Chase & Co. and Bank of America Corp.
The number of bank failures has increased sharply in recent months, but most involve small community banks where the FDIC's exposure to losses is small compared with the cost of bailouts of big banks, totaling more than $50 billion apiece last winter. The White House now expects the FDIC's losses from bank closures to be $78 billion lower than previously estimated, said Mr. …