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McGillis Hall, Linda PhD, RN, FAAN, FCAHS; Wodchis, Walter P. PhD; Ma, Xiaomu MSc; Johnson, Stacey MN, RN
Lawrence S. Bloomberg Faculty of Nursing (Dr Hall and Ms Johnson); Institute for Clinical Evaluative Sciences (Drs Hall and Wodchis and Ms Ma); and Department of Health Policy, Management and Evaluation (Dr Wodchis), University of Toronto; and Toronto Rehabilitation Institute (Dr Wodchis), Toronto, Ontario, Canada.
Correspondence: Linda McGillis Hall, RN, PhD, FAAN, FCAHS, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario M5T 1P8, Canada (firstname.lastname@example.com).
This study was funded by the Ontario Ministry of Health and Long-Term Care.
The authors declare no conflict of interest.
Accepted for publication: June 25, 2012
Published online before print: July 20, 2012
Clinical databases comprising data that are available at a national level provide the opportunity to explore the relationships between nursing interventions and patient health outcomes. This research examined baseline and changes in patient health outcomes between admission and discharge using data from 59 157 acute-care hospital-based patient records at 44 hospitals in Canada. Statistically significant improvements in all of the health outcomes were noted, with the exception of pressure ulcers. The standardized indicators offer a mechanism for evaluating the effectiveness and quality of nursing care interventions.
EFFORTS TO SUPPORT evidence-based management in the health care system have resulted in the development of clinical databases to enhance managerial decision making. The need for governments, policy makers, health care executives, and leaders to have data that provide a clearer understanding of patient health outcomes has long been identified as a need for the planning, measurement, and effective allocation of health care resources. Across North America, a number of initiatives have emerged to create databases that assist in determining the contribution that nurses make to patient health outcomes.1–3 This research provides evidence from a large health outcomes database developed in Canada that includes measures of patient clinical health status on admission and discharge in acute care hospitals.
The contribution of research-based nursing care interventions to improved patient health outcomes was established in a meta-analysis conducted more than 2 decades ago demonstrating that they led to improved patient outcomes.4 This research gave rise to increased efforts to measure patient health outcomes at the point of care to further evaluate nurse staffing and nursing care interventions. The establishment of standardized databases that include indicators to assess nurse-sensitive outcomes emerged in the early 1990s when the American Nurses Association developed the National Database of Nursing Quality Indicators (NDNQI).5
On the basis of preliminary work conducted by the American Nurses Association in a nursing report card aimed at identifying empirical links between nurse staffing and patient outcomes, 21 indicators were proposed for inclusion in the NDNQI.6,7 Pilot studies conducted in various settings across the United States evaluated the effectiveness of these initial indicators and resulted in a final set of 10 indicators that are currently in use.6–9 This database was designed to create a mechanism for monitoring the impact of nurse staffing on patient care quality and safety while providing individual hospitals with a quality improvement tool that allowed staffing and outcome comparisons across sites.10 Hospital participation in the NDNQI is voluntary. From a research perspective, the NDNQI produces national data comparisons that relate nurse staffing to the clinical patient outcomes of falls, pressure ulcers, pain assessment in pediatrics, intravenous infiltration in pediatrics, psychiatric patient assaults, restraint use, and health care–associated infections (ventilator-associated pneumonia, central line–associated bloodstream infections, catheter-associated urinary tract infections).11 In addition, the national database provides the individual participating sites with quarterly unit-level reports that can be used to compare performance in relation to patient outcomes. Data collection for the NDNQI began in 1998 with 1834 US hospitals currently participating.12
Further work in the United States led to the development of a national set of standardized performance indicators aimed at assessing nursing's contribution to the quality of health care, patient safety, and safe, professional work environments in acute care settings.13 The National Quality Forum (NQF) was developed in 1999 to promote patient and health care quality through publicly reported performance measurement. Fifteen indicators form the basis for measurement categorized into 3 areas: patient, nursing intervention, and system centered. There are 8 patient-centered indicators including death among surgical inpatients with treatable serious complications (failure to rescue), pressure ulcer prevalence, falls prevalence, falls with injury, restraint prevalence, urinary catheter–associated urinary tract infections in intensive care patients, central line catheter–associated bloodstream infection rate for intensive care and high-risk neonatal patients, and ventilator-associated pneumonia for these same patient groups. In addition, 3 nursing-centered intervention indicators are measured including smoking cessation counseling for acute myocardial infarction, heart failure, and pneumonia patients. The 4 system-oriented indicators are skill mix, nursing care hours per patient day, voluntary turnover, and an index of the nursing practice environment.13
Nine of the NDNQI indicators are endorsed for use in the NQF initiative, which uses a consensus approach that includes standard development and review before voting and approval of use of the measure.3 Endorsement of these NDNQI indicators by the NQF demonstrates that standardized measures for evaluating nursing care are being employed.3 The concordance of the nursing indicators between NDNQI and NQF has been reported in a comparative analysis of the types, content, and intended purpose of nursing indicators available in the United States,14 potentially making them a preferred data source for researchers and quality managers. A number of research initiatives are currently funded that support study of these indicators in exploring the relationships between nursing care and patient outcomes.2,15
In Canada, the Health Outcomes for Better Information and Care (HOBIC) database emerged following research initiated in 1999 aimed at identifying nurse-sensitive outcomes that could be abstracted from patient records and retained in an administrative database.16,17 An expert panel conducted consultations with stakeholders to determine which outcomes were considered relevant before commissioning an analysis of outcomes that related to nurses' contributions to patient care.16–19 A subsequent feasibility study provided evidence that the outcomes of functional status (activities of daily living [ADL]); symptom control (fatigue, nausea, dyspnea, and pain); therapeutic self-care (TSC); falls; and pressure ulcers could be collected reliably and were relevant to nursing practice.20,21 As a result, the expert panel identified these 8 nurse-sensitive outcomes for ongoing data collection, using existing reliable and valid measures.19,22
Provincial government support was received in 2006 to implement collection of data on this standardized set of indicators across the health sectors including 62 acute, 123 long-term, and 16 community home care settings17,19 to address the need for data to inform government and health care leaders in decision making related to patient outcomes across the spectrum of health care delivery. The HOBIC data are collected by nursing staff using outcome measures that have been embedded in existing online clinical documentation systems.19 The HOBIC data collection takes place on admission and discharge in all sectors with the exception of long-term care, where assessments are completed quarterly or when there is a significant change in the resident's condition.18 An implementation team worked with the health care settings to provide needed support with the process of data collection.19
The development of large clinical databases provides the opportunity to identify the contribution of nurses and nursing care interventions to patient and health outcomes that can be attributed to nursing care. To examine these relationships, it is important to assess the sensitivity of these clinical data to the concepts being measured. This research describes the results of a study aimed at determining whether there are changes in health outcome scores from admission to discharge for medical and surgical patients in acute care settings that could be related to nursing interventions. The specific research question was: Are there changes in HOBIC outcome mean scores, specifically ADL, pain, fatigue, bladder continence, dypsnea, nausea, falls, pressure ulcers, and TSC, in acute care settings between admission and discharge?
This retrospective study included 59 157 adult acute-care hospital-based patient records from 44 hospitals in Ontario, Canada, between December 9, 2006, and March 31, 2010, who had assessment records in the HOBIC database. The HOBIC data are collected electronically on a set of standardized measures of patient status during the admission and discharge assessments conducted by nurses as part of their day-to-day care. Admission assessments are made within 48 hours of patient admission to capture the patient's status at the time of entry into the facility, whereas the final assessment is made at discharge. The HOBIC data are housed at the Institute for Clinical and Evaluative Sciences, a secure data warehouse that holds health information used solely for evaluation and research purposes. Data are available and anonymized with a unique identifier to protect individual privacy while enabling linkage across clinical administrative databases. The project received ethics approval from the Sunnybrook Health Sciences Research Ethics Board affiliated with the University of Toronto.
To avoid replication, the data and measures used to capture the health outcomes data for HOBIC come from existing clinical documentation instruments employed within health care facilities in Canada.19 Thus, for many of the acute care outcomes, interRAI Acute Care (AC) instrument systems form the basis for measurement in the HOBIC database. InterRAI instruments are derived from the Minimum Data Set Resident Assessment Instrument (RAI) originally used in nursing homes. InterRAI AC is a suite of data collection instruments that was developed through an international collaborative of researchers and clinicians aimed at providing standardized assessment and care planning for older patients admitted to acute hospitals (including medical and surgical wards) with conditions that may benefit from comprehensive assessment.23 Patient care assessment data are collected by care providers within 48 hours of admission, to capture the individual's pre–hospital admission status or status early in the hospital stay, and again shortly before discharge.23 InterRAI AC domains of care with an evidence base linked to nursing interventions formed the basis of the HOBIC measures including ADL, pain frequency, fatigue, bladder continence, dyspnea, falls, and pressure ulcers.
Activities of daily living self-performance assesses what the patient actually does within each activity category according to a performance-based scale. Self-performance is assessed from 0 to 6, with 0 indicating independence where little or no assistance is required and 6 referring to total dependence related for the activity. Individual assessments for each of 7 activities including bathing, personal hygiene, walking, toilet transfer, toilet use, bed mobility, and eating are collected in reference to a 24-hour period. Activities of daily living self-performance is calculated as a summary score ranging from 0 to 56, for the 7 individual ADL activities.
Pain frequency, an interRAI AC measure, captures the frequency with which the patient complained or showed evidence of pain in the past 24 hours on a 3-point scale ranging from 0 (no pain) to 2 (pain). In addition, a measure of pain intensity using an 11-point numeric visual analog scale was included.18 The scale ranges from 0 (no pain present) to 10 (the worst possible pain). Fatigue was assessed using the interRAI AC instrument, describing the gradations of fatigue or impaired stamina exhibited by the patient in the past 24 hours. The 4-point scale ranges from 0 (no fatigue present) to 4 (severe fatigue). Bladder continence assessed continence control over the previous 24 hours using the 5-point interRAI AC scale ranging from 0 (complete control) to 4 (incontinence). Dypsnea also was assessed using the 4-point interRAI AC instrument capturing data for the previous 24 hours, with 0 (absence of difficult breathing) and 3 (dyspnea while at rest).
As well, a measure of nausea was developed for use in HOBIC by the executive lead for the project. The nausea scale is scored similar to the ADL scales, with 0 (no nausea reported in the last 24 hours) and 4 (incapacitating nausea that causes the patient to remain in bed for part of the day interfering with eating and other ADL). Falls were assessed using the interRAI AC instrument, which is aimed at determining whether the person has a history of falling and thus is at risk of falling while in hospital. Falls data are captured on a scale ranging from 0 (no falls in the last 90 days) to 3 (2 or more falls in the last 30 days). Pressure ulcers are assessed using the interRAI AC measure that captures the most severe pressure ulcer that the patient has at admission and discharge, on a 5-point scale from 0 (no pressure ulcer) to 4 (breaks in the skin that expose muscle or bone).
Finally, a 13-item instrument (TSC) assessing aspects of self-care readiness at discharge was employed.21,24 The TSC scale assesses how much a patient is able to do for each care-related activity on a 5-point scale ranging from 0 (not at all) to 5 (very much). Self-care readiness activities capture information about patient knowledge and ability to manage their medications (3 items), changes in symptoms and health condition (4 items), general health knowledge (1 item), support and emergency contacts (2 items), and understanding of their ability to perform and/or adjust regular activities (2 items).
The reliability of the outcome assessment tools used in this study has been determined in previous research in 2 ways.25 First, interrater reliability was conducted to assess the extent to which results obtained by different raters using the same outcome assessment agree and tested using kappa statistics. The weighted kappa results assessing the interrater reliability demonstrated that there was good agreement between the different assessments for the items measuring the outcomes. The kappa scores ranged from 0.68 to 0.89 for the individual ADL, 0.83 for pain frequency, 0.93 for pain intensity, 0.80 for fatigue, 0.87 for bladder continence, 0.93 for dyspnea, 0.76 for nausea, 0.86 for falls, and 0.93 for pressure ulcers.25 Also, for the 2 psychometric scales used in the HOBIC outcomes assessment (ADL and TSC), internal consistency reliability was assessed. The Cronbach α coefficients of the ADL scale on admission was 0.88 and at discharge was 0.91; the TSC scale was 0.93 in previous research.25 Cronbach α for the ADL scale in this study was 0.94 and for the TSC scale was 0.97, indicating that the scales demonstrated excellent internal consistency reliability.
Admission and discharge scores for each patient were matched, means and standard deviations were summarized, and differences in mean scores were tested. Most scales contain more than 4 levels, and all were treated as continuous variables in the initial data analysis. Normal probability plots were used to test for normality with t tests, and Wilcoxon signed rank (nonparametric) tests were used to compare differences in admission and discharge scores for normal and nonnormally distributed outcomes, respectively. The admission and discharge scores for ADL, pain intensity, and TSC were not normally distributed, therefore the Wilcoxon test was used in this analysis. The average percent score change for each HOBIC measure was calculated (mean score at discharge minus the mean score at admission, divided by the mean score at admission), and results are reported in the Table. Because the large population might assure statistical significance, effect size (the standardized difference of the mean—how many standard deviations by which the 2 groups differed) is reported to capture the relative magnitude of changes in health status. Data analysis was conducted using SAS (SAS Institute Inc, Cary, NC) at the Institute for Clinical and Evaluative Sciences.
The patients' age ranged from 14 to 106 years, with a mean of 65.2 years (SD = 17.9), demonstrating the majority of patients were older. Few young teenage patients were found in the database. Slightly more women (51.7%) than men (48.3%) comprised the sample. Patients in this sample were housed primarily in community hospitals not affiliated with academic health sciences settings.
The changes to admission and discharge mean scores on the HOBIC outcome measures as well as the magnitude and significance of changes over the course of the hospital stay are shown in the Table.
At time 1 (within 24 hours of admission), patients had a mean score of 5.84 (SD = 9.62), indicating that they had a high need for assistance with ADL. This suggests that maximal assistance was required, such as weight bearing support with more than 1 helper or weight bearing support for more than half of the ADL being performed. Patients required the most assistance with bathing, transferring on and off the toilet, walking, general toileting, and personal hygiene. They needed less assistance with mobility while in bed and eating. By discharge, patients showed a statistically significant improvement in their ability to perform all of these ADL, with the mean score decreasing to 4.39 (SD = 8.53), although still needing extensive assistance requiring 1 helper.
At admission, patients had a mean score of 1.06 (SD = 0.95) indicating that symptoms of pain were present and being exhibited to the nurse. By discharge, a statistically significant change was noted, with pain symptoms no longer being present and visible (see the Table). In addition, statistically significant changes in the intensity of pain that patients reported to nurses were noted between admission and discharge, with the observed mean scores decreasing over time from 3.39 (SD = 3.74) to 1.69 (SD = 1.69).
Overall, patients in this study had some minimal fatigue on admission, reporting diminished energy but retaining the ability to complete normal day-to-day activities. On discharge, significant improvements were noted with patients reporting little or no fatigue symptoms (see the Table).
For several of the health outcomes studied, patients were not assessed as experiencing the symptom either at admission or discharge. Despite this, the mean scores showed a change, indicating that an improvement in the outcome took place over the duration of the hospitalization (ie, bladder continence, dyspnea, nausea). This suggests that the measure was capturing some degree of change in patient conditions.
On admission, patients in this study did not report having a fall in the 90 days prior to admission, and no falls were reported at discharge. In addition, patients did not have any reported pressure ulcers either on admission or discharge. The HOBIC scores for pressure ulcers and falls are not reported, as their incidence was low.
The mean score on TSC showed a small but statistically significant change from 4.17 (SD = 1.26) on admission to 4.32 (SD = 1.21) on discharge as reported in the Table. This suggests that patients' ability and knowledge needed to manage their own health, symptoms, and prescribed health plan demonstrated improvement during their time in the hospital.
Several of the patient health outcomes examined in this study showed substantial differences in the effect sizes when mean scores from admission to discharge were compared. This may indicate that nursing care interventions are one of the factors contributing to the desired effect on clinical outcomes. Specifically, the effect sizes for pain intensity and frequency were moderately high at 0.52 and 0.41, respectively, suggesting that nursing management of pain symptoms through interventions including effective pain medication management and patient education may have contributed to an improvement in these outcomes from the time of admission to discharge. This is consistent with evidence reported in a recent quantitative systematic review of literature that identifies the importance of patient education in promoting effective self-care management of pain.26
A moderately high effect size (0.46) was also found for nausea, whereas moderate effect sizes were noted for fatigue (0.36) and dyspnea (0.36) outcomes for patients in this study, indicating that nurses' assessment and treatment of these symptoms may be having a moderately positive impact on improving symptoms prior to discharge. Clinical trials employing behavioral nursing interventions that include problem-solving approaches for symptom management and improved physical functioning targeted to patients with pain and fatigue have been found to reduce symptom burden such as fatigue levels, improve patient quality of the life, and demonstrate the "value-added" role of nursing care.27,28
Smaller effect sizes were noted for the outcomes of ADL (0.16), bladder continence (0.11), and TSC (0.12), suggesting that although nursing interventions had some impact on each of the outcomes, the magnitude of that effect was not as strong as for the other patient health outcomes reported earlier.
Acute care patients in this study experienced improved ADL; decreased pain frequency and intensity; a decline in symptoms of fatigue, dyspnea, and nausea; and improved bladder continence. In addition, patients' ability to manage their health and health care improved by the time they were discharged. These findings are similar to research evidence that links these health outcomes to nursing care and nursing interventions.7–9,11,18,25–28 No change in pressure ulcers was noted among patients in this study, which may reflect the characteristics of the acute care population examined in these data. In addition, the patients in this study had not experienced a fall within the 3 months leading up to their admission nor while hospitalized. This may indicate that the interRAI falls measure used in the HOBIC is not sensitive for patients in these settings as it does not appear to relate to treatment or observable health status within the acute care hospitalization.
Nursing interventions play a central role in acute care hospitals in the management of patient symptom control, the performance of ADL, and self-care ability at discharge. Improvements in ADL and pain control are recognized care achievements that result from nursing care interventions, highlighting the intended effects of the process of nursing care.24 On the basis of the findings in this study, interventions to improve symptom control and the performance of ADL and self-care ability at discharge in patients in acute-care settings could be hypothesized to improve both patients' quality of care and readiness for discharge. These specific nursing interventions also could improve patient overall length of stay and potentially reduce the costs of health care.
The sensitivity of the health outcome measures to change was evaluated by comparing the mean scores obtained at 2 distinct points in time. The results of this study indicate that the HOBIC outcomes detect change in patient outcomes over time, specifically from admission to discharge. A moderate effect size was identified for the outcomes of pain intensity, pain frequency, and nausea, whereas a moderate to small effect size was noted for the remainder of outcomes observed in this study (ie, ADL, fatigue, dyspnea, TSC, and bladder continence). Similar patterns of change were reported in a pilot study using several of these outcomes,20 providing further evidence that with the exception of falls, these instruments are sensitive to change in outcome status in acute care patients. Patients in this sample from within acute care hospitals were older, further validating the interRAI AC as an appropriate measure of health outcomes for this population.
Standardized health outcome indicators offer a mechanism for evaluating both the effectiveness and quality of care provided in health care settings. These data provide the opportunity to determine the significance of nursing interventions and the care provided by different groups of nursing care providers on patients' health and health status. Clinical leaders involved with the HOBIC data collection in Canada describe a number of organizational benefits attained from having these data.29 These include the opportunity for data comparability from one admission to another and from admission to discharge, as well as having access to a standardized admission database for review of the effectiveness of nursing interventions used in their organizations.29 Having access to clinical databases also provides staff nurses with the ability to assess how a patient's status has improved over their stay and managers with information relating patient needs to nurse staffing.29
In an era of health care accountability and a rapidly changing health care environment, the need to demonstrate quality care is of central importance to health care administrators. Mechanisms that provide readily available information about patient care quality in terms of the process and outcomes of the delivery system are essential components of effective health care. These data highlight the achievements that have been evidenced from the implementation of a health outcomes database in Canada. Future studies should explore direct linkages between nursing resources and nursing care interventions and health outcomes across multiple health care sectors.
clinical outcomes; databases; nurse-sensitive outcomes; outcomes assessment
© 2013 Lippincott Williams & Wilkins, Inc.
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For more information about this meeting, contact Dmitri Burago, John Roe.
|Finiteness of central configurations and Smale's 6th problem (joint with A. Albouy)
|Geometry Luncheon Seminar
|Vadim Kaloshin, PSU
|The 6th Smale problem for the XXI century is about finiteness of planar central configurations for any combinations of positive masses. The problem was first posed by Chazy in 1918, then by Wintner in 1941. Hampton-Moeckel in 2004 gave a computer assisted proof of finiteness for 4 bodies. We show that the number of central configurations of the 5 body problem is finite, except perhaps if masses certain algebraic relations. We also give a purely analytic proof of Hampton-Moeckel result for 4 bodies. This is a joint work with Alain Albouy.
Room Reservation Information
|Room Number:
|11 / 10 / 2010
|12:15pm - 01:30pm

subset: commoncrawl


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Ek Nanad Ki Khushiyon Ki Chaabi…Meri Bhabhi
11 Ek Nanad Ki Khushiyon Ki Chaabi…Meri Bhabhi Articles
How will Ek Nanad Ki Khushiyon Ki Chaabi… Meri Bhabhi end?2 years ago 0
The makers were shooting the last episode of the daily soap yesterday DJ Creatives decided to end Ek Nanad Ki Khushiyon Ki Chaabi... Meri Bhabhi coz… Read Article ▶
Why is Meri Bhabhi ending so abruptly?2 years ago 8
DJ's Creative Unit's show which began in June 2013, is shutting shop already and it's been barely 10 months Ek Nanad Ki Khushiyon Ki Chaabi... Meri… Read Article ▶
Who will replace Kanchi Kaul in Meri Bhabhi – Mansi Parekh or Shilpa Anand?2 years ago 1
Mrs Shabbir Ahluwalia is pregnant and hence is quitting the show, so who will replace her? Ek Nanad Ki Khushiyon Ki Chaabi... Meri Bhabhi's Shraddha… Read Article ▶
Meri Bhabhi: Will Shraddha Shergill get pregnant?2 years ago 1
The Shergill daughter is in love and all set to be married, we wonder if the makers will show her pregnant sometime soon... Shraddha Shergill aka… Read Article ▶
Shabbir Ahluwalia and Kanchi Kaul to be proud parents2 years ago 1
The couple is expecting their first child Shabbir Ahluwalia and Kanchi Kaul are a happy couple and seem to be on cloud nine. A couple of days back… Read Article ▶
Rakshabandhan special: Ram Kapoor and Natasha, Veera and Ranvijay – meet tellyland's best siblings!3 years ago 0
To celebrate Rakshabandhan, we take a look at the famous onscreen brother-sister jodis from your favourite TV shows.... Rakshabandhan is an occasion… Read Article ▶
Supriya Pilgaonkar: I never have high expectations of any TV show!3 years ago 0
The versatile actor says she misses comedy, but her fans' love makes her want to play mother in TV shows, the latest being Ek Nanad Ki Khushiyon Ki… Read Article ▶
Yogen Shah
Kanchi Kaul: Marrying Shabbir Ahluwalia was like marrying my best friend!3 years ago 0
Ek Nanad Ki Khushiyon Ki Chaabi...Meri Bhabhi is the comeback vehicle of the talented actor who was last seen in Ek Ladki Anjaani Si Kanchi Kaul… Read Article ▶
Star Plus
Meri Bhabhi's Esha Kansara keen on doing dance show3 years ago 0
Television actor Esha Kansara, currently seen in Ek Nanad Ki Khushiyon Ki Chaabi - Meri Bhabhi, says dance is her first love and she is eager to… Read Article ▶
Gym trainer Ripudaman wins MasterChef – Kitchen Ke Superstar3 years ago 3
The youngest contestant won the big battle by defeating Doyel Sarangi and Navneet Rastogi Delhi-based Ripudaman Handa's passion and love for cooking… Read Article ▶
Meri Bhabhi: There is no vamp in the show, claims producer!3 years ago 2
After eons of showing love-hate relationship between women, Star Plus comes up with a novel thought - so they say, but that's something we'll judge… Read Article ▶
Yogen Shah


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As the inventory gets near its usage age, blenders lab-produce products using different percentages of inventory components until the exact flavor profile of Seagram's 7 Crown is achieved. This inventory survey and lab blending is a constant process and is one of the reasons the flavor of Seagram's 7 Crown has remained consistent.
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Bran muffins are a good way to use up WIC cereals
I know several families who are being helped by the WIC (Women, Infants and Children's) Nutrition Program. It's a wonderful source for many essential staples including milk, formula, cheese, beans, rice, cereals, bread and more.
Someone asked me recently if I knew what they could do with an ever-growing cache of bran cereal, as nobody in their family cared for it as a breakfast item.
I had recently picked up a book at a yard sale, 'MORE Make Your Own Groceries' by Daphne Metaxas Hartwig, and noticed a recipe for a bran muffin mix that called for crushed up bran cereal flakes and dry milk, which is another WIC item not many people know what to do with. (BTW: the book is probably out of print, but if you can find it anywhere, it's a treasure trove of tricks for the firmly frugal.)
So that is today's recipe, not exactly a budget meal, but a nifty way to use up those WIC cereals. And along with a veggie omelet and fruit salad, it makes a good "breakfast for dinner" meal.
BRAN MUFFIN MIX (makes 1 dozen)
2 cups flour
¾ cup bran cereal, crushed
½ cup non-fat dry milk
4 tsp. baking powder
1 tsp. salt
½ cup vegetable shortening
½ cup sugar
½ cup chopped walnuts
Mix flour, bran, dry milk, baking powder and salt together a couple of pulses in a food processor. Cut in shortening until mixture resembles coarse meal. Blend in sugar and nuts. (This mix will keep in a plastic food storage bag for up to 2 months in a cupboard).
To use, combine mix with 1 egg and 1 cup of water and ½ raisins, if desired. Bake in greased muffin tins at 400 degrees for 15-20 minutes until tops spring back when lightly pressed.


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Gretchen Kittelberger was once a slender gymnast whose lightweight frame played a key role in her success. Now, however, she's combining a Paleo diet and CrossFit to show off her muscle after qualifying for the CrossFit Games, reported the Baltimore Sun on July 19.
After five years transforming her body with CrossFit and a Paleo low carb diet, Kittelberger views the intense exercise program as an essential part of her life. But she admits the combination of strength-training, conditioning and cardio work isn't easy.
"You feel like you want to just lie on the ground and not move," Kittelberger admitted after a two-hour workout. However, she definitely feels that it's worth it after winning the Mid-Atlantic regional event in order to qualify for the CrossFit Games.
For the fourth time, the former gymnast will be doing squats with 200-pound weights rather than using her own body weight to perform flips on a balance beam. She marvels at how her body has changed.
"I can remember, when I first started, it being hard to clean 100 pounds," Kittelberger said. "Today … my clean and jerk is, like, over 200 pounds."
And to perform the move called a "clean and jerk," she has to make sure to eat clean as well. "I eat quality foods but don't measure the amount," she says in her CrossFit bio. "I eat 1-3 full cheat meals per week."
As defined by the official CrossFit nutrition guidelines, eating clean is based on the low carb Paleo diet. "Base your diet on garden vegetables, especially greens, lean meats, nuts and seeds, little starch, and no sugar."
Why the Paleo diet? "Modern diets are ill suited for our genetic composition. Evolution has not kept pace with advances in agriculture and food processing resulting in a plague of health problems for modern man."
But the Paleo and other types of low carb diets aren't just for exercisers. New studies have shown that low carb plans can boost weight loss while satisfying hunger.
One reason may be that low carb diets contain protein, which make dieters feel full on less food. Protein such as steak provides the taste known as umami. Researchers found that when dieters eat foods with umami, they feel more satisfied, reported Time magazine on July 21.
Study participants consumed either a high-protein soup with an MSG-enzyme combination that mimicked the taste of umami or a soup without the added flavoring. Researchers found that because the flavoring satisfied the appetite, dieters consumed less food.
As for the question of whether athletes such as Kittelberger can do well on a diet high in protein and restricted in carbohydrates, Dr. Stephen Phinney has conducted numerous studies showing the benefits of using fat and protein rather than carbs for energy. In an exclusive interview, he stated, "The concept that humans 'need a certain amount of dietary carbs for proper function of the body' has no basis in science. It is a myth perpetuated by the USDA and the dietetic establishment."
His research demonstrated the potential for improved performance for keto-adapted athletes. In doing so, he challenged the standard convention of carb-loading for athletes.
He and Dr. Jeff Volek have authored a book containing their research and studies on high fat low carb diets for athletes: "The Art and Science of Low Carbohydrate Performance." He notes that individual athletes continue to prove the merits of ketogenic diets. Example: "Low carb athlete Sami Inkinen at age 39 recently won the Wildflower Triathlon against a field of almost 1500."
Suggested Links
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Gamer's Notebook
Professor Layton and Bioshock Infinite
By Chris O'Neal 11/14/2013
The R&B hit-maker Boyz II Men knew it best when it sang, "It's so hard to say goodbye." No one likes an ending, however sweet it may be. After all, it only means that the chances to see your pet, significant other or hero again are slim to none, short of resurrection via Indian burial ground. So it is with sadness that we say goodbye to Professor Layton, the hero that puzzle masters everywhere called friend, mentor and, most of all, gentleman.
Professor Layton and the Azran Legacy is the sixth and final installment in the series featuring Hershel Layton and his boy apprentice. As with previous entries, Layton is pitted against a dire and foreboding enemy, only this time the actions of the previous adventures really come into play.
Artifacts found in Professor Layton and the Miracle Mask are the subject of continued investigation, but if you're thinking we're about to interrogate a criminal, think again. Layton deals in riddles and often the answers to the question are given in the form of a mathematical equation.
My favorite memory of the Layton series is from Professor Layton and the Curious Village. After watching a beautifully animated opening sequence (a trademark of the Layton series are animated sequences which could seamlessly fit into a television series), we approached a bridge with a man who refused to lower it unless we guessed how many matchsticks he had in his hand. Just lower the bridge, weirdo!
Quirky, lovable, interesting and smart, Professor Layton has always found a way to turn a mystery into a learning experience. Azran Legacy is no different; here you'll find puzzles to challenge your mind that are seamlessly melded into the narrative better than were previous attempts.
Since Miracle Mask, the Layton series has been a prequel. Technically, the character's stories ended with Unwound Future, but even so, the climax to Azran Legacy is fitting, touching and bittersweet. It's so hard to say goodbye.
After pulling oneself out of the depression that is knowing there won't be another installment in the Professor Layton series, take a step back and realize that this year's Bioshock Infinite (strong contender for game of the year!) is far from over.
Remember that game that had the whole Internet abuzz at one point? An experimental shooter that pitted the player against warped Americana is back with a two-part expansion — Bioshock: Burial At Sea offers up a new adventure in a familiar setting.
If you're like me and you thought the first Bioshock had an amazing cast of characters in a world of underwater whimsy, then Burial at Sea is probably what you've been waiting for. We return to Rapture, the Ayn Rand-inspired fallen utopia with a knack for warping its citizens.
Booker DeWitt, the war veteran/source of many a dimensional paradox, meets with Elizabeth, the time-child, in 1950s Rapture before its fall. On the Xbox 360, Rapture looks better than ever, sleek designs and underwater griminess that pops. Elizabeth, a teenager in Infinite, is now her parallel-dimensions self and is stunning in her portrayal.
Burial at Sea can be summed up thusly: Infinite's techniques meet Bioshock's original enemies. Splicers, the mutated city folk, are easily handled by the weaponry from Infinite, but when it comes time to face a Big Daddy — the massive tank of an underwater guardian — Booker's sky-hook and powers are just as useful as a long stick.
Where Burial At Sea falls short is in length. At only 90 minutes, it feels like watching a short film. There is a second part to this story, but at $15 for the first installment, are we expected to pay $30 for a three-hour experience? 2K and Irrational believe you should — and face it, most of us will.
My suggestion is to wait until the DLC is bundled together as an inevitable game of the year edition. It might take a while, but if multiple dimensions exist as they do in Bioshock Infinite, you may already be playing the expansions somewhere in time.
Professor Layton and the Azran Legacies will be available for the Nintendo 3DS and 2DS in 2014.
Bioshock: Burial at Sea is available now for the PC, Xbox 360 and Playstation 3, $15.
Chris O'Neal has several copies of Boyz II Men's Cooleyhighharmony. Follow him on Twitter @agentoneal.
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Bob Anderson will be back in Kansas City and Overland Park next week for the midwest premiere showing of A Long Run at the Glenwood Arts Theater in Overland Park, Thursday April 10 at 7:30 P.M.
A Long Run chronicles Bob's 50 races covering 350 miles at 7 min pace, Bob's 50 years of running, thinking about running, writing about running, and promoting running, including creation of Runners World Magazine and the Double Road Race Federation.
A Long Run tells one man's story, but it's every runner's journey. Bob Anderson's amazing life connects us to icons like Bill Rodgers, Billy Mills and Paula Radcliffe but also to the low-budget thrill of a community 5K. The gorgeous cinematography captures The Avenue of the Giants, the San Francisco landscapes and the vistas of Fort Bragg. And the smoothly intertwined stories - his 50-race challenge, the magazine, the running boom - are handled with Olympic-caliber pacing.
After the film they will have a Q&A panel discussion with Bob Anderson, race director Bruce Gilbert and several key people who shape the sport of Running.
Visit http://overlandpark.brownpapertickets.com/ for tickets.
After the film, meet Bob Anderson at the Sheraton Hotel at 9 A.M. Friday April 11 for a free Do The Double training run. Get ready for the Double Road Race which is coming to Overland Park June 29.
If you would like to be notified when Ryan publishes an article, click "subscribe".
You can also find him at his BLOG, on twitter at @Trijayhawkryan , on FACEBOOK, at www.Man-Versus-Triathlon.com or www.SetThePaceMedia.com for triathlon coaching and consulting.


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Jazz at the Chimes has announced its next show, a March 16 performance by Grupo Falso Baiano. It's the first concert of 2014 for the Oakland series. Here are the details.
The historic, architecturally stunning Chapel of the Chimes will be the backdrop for an uplifting musical journey to Brazil. Grupo Falso Baiano performs a blend of traditional Brazilian choro music with modern influences of jazz, flamenco and samba. Choro is Brazil's first national music, born in the cafés of Rio in the late 1800s, and reflects the melding of Latin American and African rhythms with a melodic and harmonic structure most closely resembling Baroque Classical music. GFB's unique exploration of choro spans nearly 100 years, including everything from traditional to contemporary classics, as well as original arrangements and jazz-influenced reinterpretations.
Grupo Falso Baiano began as a trio in 2003 with members Brian Moran (seven-string guitar), Zack Pitt-Smith (reeds) and Ami Molinelli (percussion). GFB later evolved into a quartet when Jesse Appelman (mandolin) joined the lineup in 2006. The concert will be followed by a reception where the public can meet the musicians, purchase CDs and enjoy refreshments.
Want to keep up with the best in Bay Area jazz and blues?
Subscribe to us: Have our jazz and blues Examiner columns sent to your inbox. Click the SUBSCRIBE button on this page. It's free. (And we won't spam you or give out your information.) Bookmark us: http://www.examiner.com/jazz-music-in-oakland/brian-mccoy. CONTACT ME FOR YOUR JAZZ AND ARTS GRANT WRITING NEEDS


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What Is "Your" Race?
America is preoccupied with race statistics--perhaps more than any other nation. Do these statistics illuminate social reality and produce coherent social policy, or cloud that reality and confuse social policy? Does America still have a color line? Who is on which side? Does it have a different "race" line--the nativity line--separating the native born from the foreign born? You might expect to answer these and similar questions with the government's "statistical races." Not likely, observes Kenneth Prewitt, who shows why the way we count by race is flawed.
Prewitt calls for radical change. The nation needs to move beyond a race classification whose origins are in discredited eighteenth-century race-is-biology science, a classification that once defined Japanese and Chinese as separate races, but now combines them as a statistical "Asian race." One that once tried to divide the "white race" into "good whites" and "bad whites," and that today cannot distinguish descendants of Africans brought in chains four hundred years ago from children of Ethiopian parents who eagerly immigrated twenty years ago. Contrary to common sense, the classification says there are only two ethnicities in America--Hispanics and non-Hispanics. But if the old classification is cast aside, is there something better?
What Is Your Race? clearly lays out the steps that can take the nation from where it is to where it needs to be. It's not an overnight task--particularly the explosive step of dropping today's race question from the census--but Prewitt argues persuasively that radical change is technically and politically achievable, and morally necessary.
Kenneth Prewitt is the Carnegie Professor of Public Affairs at Columbia University. His books include The Hard Count: The Political and Social Challenges of Census Mobilization. He served as director of the U.S. Census Bureau from 1998 to 2001.
"In one of the best discussions of the social construction of race and the U.S. Census Bureau's role in that social construction that this reviewer has seen, Prewitt goes way beyond the typical discussion by demonstrating the policy implications of the social construction and shifting definitions of race. . . . This detailed history and policy analysis is an absolute requirement for race scholars and policy analysts alike."--J. Hattery, Choice
"This book will inform historians on important aspects of what census measurement says about the past, but it also may provide a bridge to what students will write about American society decades from now."--Stephen E. Fienberg, Journal of American History
"This book will inform historians on important aspects of what census measurement says about the past, but it also may provide a bridge to what students will write about American society decades from now."--Stephen E. Fienberg, Journal of American History
"What Is Your Race? is a fascinating and thorough account of an American institution that has had a powerful influence on policy and society."--Ryan Allen, New Books in Education
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Competition for Islamic Terrorism Cluelessness Prize: Carter and Stewart TieTuesday, January 13th, 2015
People can argue about who the worst president of the United States was, but it is hard to dispute that the president who has done and said more idiotic things since leaving office is – hands down – Jimmy Carter.
And yet in a segment on "The Daily Show" with Jon Stewart on Monday, Jan. 13, Jimmy Carter seemed to be in a competition with his host to show who is more clueless about Islamic terrorism. The competitors tied for the prize. It might have been amusing to watch, if it wasn't so painful.
Carter was on the show ostensibly because the Carter Center has an exhibit opening tomorrow at the Museum of Natural History, "Countdown to Zero, Defeating Diseases."
But for most of the just-under eight minute segment, Carter and Stewart discussed the rise of extremist violence, even though the words "Charlie Hebdo" or "kosher grocery store" or even "ISIS" or "al Qaeda" were never mentioned.
Despite accounts by other media that Jon Stewart asked Carter about what happened in Paris, the conversation actually went a bit differently.
It was Stewart who set the tone, suggesting that religion really has nothing to do with the violence that the world has been witnessing.
After a brief discussion about the Carter Center's humanitarian efforts in Africa, Stewart asked the former president whether he was disheartened, given the "great optimism" following the Camp David Accords.
Carter admitted he was disheartened, but then, veering the only time into a direct reference to the recent events in Paris, he commented on the fact that "the Palestinian leader and the Israeli leader both marched in the front line together in Paris."
"We still have a hope for peace," Carter said, "but it's a distant hope."
With that, Carter launched into his prescription for giving life to that hope: Israel has to withdraw from the West Bank and Gaza (perhaps he forgets that all Israelis, living and dead, left Gaza almost a decade ago). Oh, and also "East Jerusalem," Israelis have to leave there as well.
And what do the Palestinian Arabs have to do? "The Palestinians have to make sure that they commit themselves, without equivocation, to the freedom of Israel to live in peace alongside of them."
Carter insisted that it was the United States which has to "be in the forefront of demanding that both the Palestinians and the Israelis come together and accept a reasonable solution to the problem." His solution, of course.
Stewart then kind of slid into a more generalized history discussion of terrorism in the Middle East, allowing Carter to preen over bringing Sadat and Begin together.
After pointing out that "this extremism" was around at the time of Camp David, Stewart then shares his insight: "I view 'this extremism' as a kind of pretext, this idea that it's a religious backing, seems a pretext for just powerless…they're angry, nihilistic, and if they did not have the religious part, it would be something else, they would use something else as a pretext to be violent in this way."
In other words, Stewart views the ISIS and al Qaeda members as simply the latest iteration of the school yard bullies: angry guys who feel powerless and are just using religion as a front, but they could just as easily use membership in a gang, or anything else to justify their "extremism."
But Carter gives Stewart a tiny little bit of blowback. Instead of agreeing with Stewart, Carter veers down his familiar path of blaming Israel.
Carter responds to Stewart, essentially saying that religion is behind the "extremism" (most people call this terrorism), but it is all Israel's fault for insulting the religion of these easily angered folks.Lori Lowenthal Marcus


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Start Date: Sep 01, 2010
End Date: Aug 31, 2013
Analyize currently available DNA sequence information and develop effective molecular tools for detection of the pathogen. Continue obtaining sequence information on the pathogen by cloning additional portions of the genome. Inoculate diverse potato germplasm with zebra chip via grafing or psyllid feeding and rate tubers for disease. Test weeds and alternate hosts for the putative pathogen.


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Spiral Dreams by Jose-Garel-AlvoeiroWatch
©2011-2016 Jose-Garel-Alvoeiro
This wonderful work is a Favourite I have collected from my +devwatch of #TheFavouriteShowcase and it's featured here [link]
Thank you so much for submitting your amazing art to the group!
What beautiful work, love the shape and textures
warm and wonderful - i love it
nice job
Neat and nice work!
Nicely done
great work!
nicely done
the colors are beautiful and the designs are amazing!
Splendid abstract love the colouring.
The stringed instrument was a great touch! Such imagination!
the texture of the paper and wax crayons are so precious, the colors softness singing with the harmony of sweet curved shapes, is like drawing a melody, full of passion and mystery....great work, my friend
Nice draw.!!!! such a great piece of work.!!
Great lines and colors.


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Just copy and paste the code below to embed this station in your blog, website or social profile.
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Safe Harbor to host open house
Citizen Staff Reports 09/17/12
Safe Harbor is hosting an open house to share information about the agency's programs on Thursday, Sept. 20, from 1 p.m. to 4 p.m. at its business office, 2006 Bremo Road, Suite 201.
Representatives from the agency will be available to answer questions about the services offered to support those impacted by sexual and/or domestic violence as well as the work being done to promote healthy relationships and healthy sexuality.
The event is scheduled in conjunction with Give Richmond's Amazing Raise, a 36-hour online fundraising competition. Organizations with the greatest number of unique donors (those who give gifts of $50 or greater) during the 36-hour time frame from 6 a.m. Sept. 19 to 6 p.m. Sept. 20 will be awarded grants up to $20,000.
Additional bonus awards will occur throughout the event. Safe Harbor is vying for the Afternoon Sprint contests held from 2 p.m. to 2:30 p.m. and 3 p.m. to 3:30 p.m. Sept. 20.
For details, call 249-9470. For more information on the Amazing Raise, visit http://www.giverichmond.org
County plans Fourth of July event
Henrico County Recreation and Parks will present "Red, White, and Lights" at Meadow Farm Museum/Crump Park July 4.
Henrico County has hosted a Fourth of July celebration annually since 1981, but this year's event will offer a later start time and expanded hours and be highlighted by new entertainment.
The free event will begin at 4:30 p.m. and will feature the Richmond Symphony, a laser-light show, patriotic performances, and family activities. > Read more.
Tuckahoe YMCA to host Refugee Community Resource Fair
The Tuckahoe Family YMCA and ReEstablish Richmond will host the third-annual Refugee Community Resource Fair Saturday, June 18, from 10 a.m. to noon at the YMCA, 9211 Patterson Avenue in Henrico. The event is designed to provide refugees in the region information about jobs, local businesses, housing, health care, education and more.
As part of its strategic plan, the YMCA of Greater Richmond works to identify, address and eliminate economic, geographic and cultural barriers. > Read more.
Weekend Top 10
For our Top 10 calendar events this weekend, click here! > Read more.
Henrico Police seek woman involved in suspicious situation
Flying Squirrels, Sciencetellers kick of summer reading programs at Henrico libraries
Henrico Restaurant Week raises $2k for VHBG
Henrico Schools to participate in USDA summer food service
Business in brief
- More News
Print Edition
Jun. 16, 2016Click here to read the print edition.
Weekend Top 10
Muse Paintbar opens at Willow Lawn
Weekend Top 10
Restaurant watch
Weekend Top 10
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Obituary – Paulette McLennan Smith
Obituary – Robert W. Dement, Sr.
Obituary – Blanche T. Cerveny
- More Obituaries
County plans Fourth of July event
Tuckahoe YMCA to host Refugee Community Resource Fair
Short Pump Park grand opening planned June 25
- More Community
'Good old days' were good – for some
Of character and parenting
Opinion: Rename school for late Henrico officer
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Varina HS to host Basketball Skill Development Academy June 20-23
Strawberry visits Tuckahoe Little League
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CalendarInnsbrook After Hours continues its 31st year with the "Return of the Red Eye Summer Tour." Headlining the tour are Slightly Stoopid and SOJA. Special guests are The Grouch &… Full text


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Changing Lives Everyday...
More people trust their eye surgery to the doctors of Barnet Dulaney Perkins Eye Center than anywhere else in Arizona. Over the last 35 years, we have become one of the largest Cataract, Retina and Glaucoma practices in the nation, providing state-of-the-art surgical and medical ophthalmologic care through-out the state of Arizona. In addition, we are considered a premier provider for vision correction options such as LASIK and the ICL Implantable Contact Lens.
A career in the Eye Care industry could provide you with long-term employment stability. Proven within our organization, many employees have been here for 10, 20 and some even over 30 years.
Barnet Dulaney Perkins Eye Center is currently seeking a detail oriented, reliable, and motivated Patient Services Representative who is able to multi-task in a fast-paced, high-volume work environment. This position will be responsible for performing all insurance verifications, pre authorizations, checking in and out patients, making appointments, answering phones, and may cross-train in other responsibilities. Must be able to work a flexible schedule typically working between 7:30am to 5pm. Occasional Saturdays
HS Diploma / GED
Must be able to communicate clearly and professionally
Medical Front Desk Experience preferred
BDPEC offers a very generous and comprehensive total rewards package to include company medical, dental and vision insurance for employees, up to 19 days of paid time off per year, a 401(k), flexible spending account plan, and training opportunities.
To learn more about Barnet Dulaney Perkins Eye Center and our career opportunities, please visit our website at www.goodeyes.com.
Pre-employment drug and background screening required prior to employment.
Barnet Dulaney Perkins is an Equal Opportunity Employer.
Copyright 2013 Barnet Dulaney Perkins Eye Center | Privacy Policy


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Skydiving.com now has a network skydiving location serving Lanett and Chambers County in Alabama. Call Skydiving.com at 1-800-617-7948 for details, free information and specials on skydiving in Lanett, AL today!
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Sign up for our newsletter and receive updatesand specials on skydiving across America!


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By Borders Rugby Television
Stuart Cameron talks with Linda Lawson, the daughter of Bill McLaren, on the first anniversary of the death of the great rugby commentator. www.BordersRugby.net
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19 Eastgate Peebles Peeblesshire EH45 8AD View with Google Maps
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A listing of exclusive buyer agents can be found at
the Web site of the National
Association of Exclusive Buyer Agents.
Why choose a buyer's agency? While any agent will
arrange property showings, suggest sources of financing, provide
accurate information, explain the forms and agreements, and monitor
the entire process, a buyer's agent should perform services for
you that the seller's agents can't, such as show you reasons not
to buy a particular property; negotiate the best price and terms
for you; include contingencies in the contract that protect you,
rather than the seller as in most standard contracts; and keep confidential
any information that could hurt your bargaining position.
Other types of agencies
What if the house you want is listed by the same agent or firm that's
representing you as buyer's agent? In that case, you can agree to:
Perhaps the best way out of this dilemma is simply
to terminate your agreement with that buyer agent and find another
buyer agent not affiliated with that firm, according to exclusive
buyer agent Roy Flanders, owner of ProBuyer Associates of Nantucket,
"Designated agency is a loser for consumers,"
says Flanders, who has been licensed for over 25 years and an exclusive
buyer agent for more than 10 of those.
The designated agency or transaction broker concept,
Flanders says, "is being pushed by the mega-brokers who want
to keep both sides of the transaction," and works to the detriment
of both seller and buyer. He says keeping information private within
an office is too difficult.
"Designated agency is nothing but a new way to
describe disclosed dual agency," he says. "It's really
nothing more than a more lofty sounding name to still allow the
mega brokers to capture a buyer and still do an in-house sale and
keep both sides of the transaction and all of the commission. It
is designed to circumvent the potential loss of a buyer who wants
true fiduciary representation."
You get what you pay for
One thing hasn't changed: Almost without exception, the seller is
going to pay an average of 6 percent of the sales price to a real
estate firm. Most sellers agree to allow the listing agent to split
the commission with the buyer's agent, which means the seller is
paying the buyer's agent to represent the buyer against the seller.
While many people think that whoever is paying the lawyer or agent
is the one getting the best representation, courts have made clear
that paying an agent does not automatically mean the payor is the
Why would a seller agree to allow half of the commission
to go to a buyer's agent who is representing a buyer against the
seller? Simple -- the seller wants to sell. And as some real estate
agents note, the transaction really funds the commission. Yes, the
seller is paying the commission, but the house might be 6 percent
cheaper if no agent were involved, so the buyer is really paying
the commission in the increased price of the home. The whole idea
here is fairness: If the buyer is bringing the money to the table
to buy the house, shouldn't that buyer get representation? Finally,
after nearly a century, the answer is yes.
"The struggle is over. Buyer agency is here.
We still need to educate the consumer, but buyer agency has come
of age," says REBAC's Branton.
Christopher Cruise is
a senior mortgage banker and freelance writer based in Silver Spring,
-- Updated: June 9, 2006
* Mortgage rate may include points. See rate tables
for details. Click
here. * To see the definition of overnight averages click
Bankrate.com ®,
Copyright © 2016
Bankrate, Inc., All Rights Reserved,
Terms of Use.


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Performing Arts
|Community Asian Theatre of The Sierra
Community Asian Theatre of the Sierra (CATS) promotes diversity in the arts…
|Phone: (530) 273-6362
|Happy Birthday USA
Wednesday, July 3 – 7:30 pm / Gates open at 6:00 pm
Unless you've…
|Nevada County Fairgrounds, 11228 McCourtney Road Grass Valley, CA
Map it
|Phone: (530) 265-6124
|InConcert Sierra
InConcert Sierra presents music of great composers showcasing the finest guest…
|P.O. Box 205, Nevada City CA 95959
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|Phone: (530) 273-3990
|LeGacy Productions
LeGacy Productions is a family owned and operated small business theatre based…
|Nevada City, CA
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|Phone: (530) 913-2826
|Miners Foundry Cultural Center
The foundry dates to 1856 and for many years provided metal and steel fabrication…
|325 Spring St, Nevada City, CA 95959
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|Phone: (530) 265-5040
|Music in the Mountains SummerFest
Music in the Mountains (MIM)…
|530 Searls Ave., Nevada City, CA 95959
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|Phone: Box Office - (530) 265-6124 Business Office - (530) 265-6173
|Nevada County Arts
In May of 2009 the Arts Collaborative of Nevada County was designated by the…
|Phone: (530) 278-5155
|Nevada County Concert Band
Every year, the Nevada County Concert Band (NCCB) brings back to life an era…
|P.O. Box 1444, Nevada City, CA 95959
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|Phone: (530) 272-6228
|North Columbia Schoolhouse Cultural Center
The North Columbia Schoolhouse Cultural Center gives the rural San Juan Ridge…
|17894 Tyler Foote Road, Nevada City, CA 95959
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|Phone: (530) 265-2826
|Off Broad Street Theatre
Fun is the key word at Off Broadstreet. Our goal is to bring you an unforgettable…
|305 Commercial Street, Nevada City, CA 95959
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|Phone: (530) 265-8686
ALL ABOARD!Click here to read our daily travel blog


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In the dog days of summer, the fewer minutes spent under a blow dryer, the better. And who has time to wash her long locks every single day, blow them out, and style them? The truth is that women everywhere are embracing their "second-day hair" with aplomb. If you haven't done so yet, free yourself from the confines of your bathroom vanity mirror and start enjoying more of your free time with these hairstyle suggestions, tips, and tricks.
Kate Hudson's Waves
Kate Hudson's waves are gorgeous and take more than a minute to create. But there's one product that will make them last into the next day...
Photo: WENN.
Psssssst Dry Shampoo
Dry shampoo will absorb the extra oil at your scalp to revive your waves and make them red carpet ready.
$6.99 at Drugstore.com.
Lily Cole's Headband Style
Lily Cole's headband style is perfect for next day styling. Headbands deliver a pretty focal point away from less than perfect tresses. A shiny touch-up will finish the look.
Photo: WENN.
John Frieda 100% Shine Glossing Mix
Pick up shine spray at your local drugstore and give your hair the chance to shine through a day of not showering.
$5.99 at Drugstore.com.
Ashley Tisdale's Ponytail Perfection
A ponytail can be just the thing for hair that seems unsalvageable. Use a simple trick to do messy on purpose...
Photo: WENN.
Conair Brush for Teasing & Shaping Styles
Backcomb your roots and pony to add volume and texture to otherwise limp strands.
$2.99 at Drugstore.com.
Sheridan Smith's Side Bun
Sheridan Smith is a British actress known for her work on popular sitcoms made across the pond. Her side bun is just the thing for hair that's gone astray on the second or third day after styling. Use the product on the next slide to give it a piecey, pulled together vibe.
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Scenes of Snowfall in Ann Arbor
December 23, 2013 | by Rachel Reed
Winter at the University of Michigan can mean trudging through blizzards to get to class; building the iconic Block M out of freshly fallen snow; or even, if you were around at the right time, taking a sleigh ride with friends.
We've put together a slideshow of some of our favorite wintertime memories on campus throughout the years.
Images courtesy of the Bentley Historical Library


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Is it possible to transform a flat surface into a paraboloid
such that there is no strain in the circular in the circular cross section (direction vector A)?
If the answer is yes, is it possible to calculate the shape of such a flat surface?
Where can I find more information to solve this kind of problems?


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There is a book on Integrated planning "SAP BI Integrated Planning for Finance". I would like to know how is this book?
Is it good for beginners with many screen shots??
Pleasse let me know.
I have this book.
It is quite good.It is almost like the SAP IP training material with all the step by step process.
Let me know if you ahve any specific area you want furhur info.
Hi Sanjana,
Thanks for your reply.
I do have the SAP course material. I would like to have some example with simple explanation. Is it worth buying this book. As I am slightly new to IP, I would like to have some screen shots and example.
please advise...
Hello Bill,
Half the book talks about creating the Info object,realtime cube, transformation rules etc.
That book did not help much in my current Cost center planning applciaitons.
If its only fromt he knowledge perspective,My opinion is that SAP training material is better.
Thank you for the information.
I need SAP BI Integrated Planning for Finance book immediately.i have tried in SAP Press but it takes 7days for delviery.May i get your emai ld.thanks.
Hi Bill,
did you check out a small piece of the book at http://www.sap-press.de/download/dateien/1290/sappress_netweaver_bi_integrated_plan.pdf ?
The book has quite good step-by-step tutorials for standard functionalities. I found it a good introduction. And yes you have many screenshots and learn which check box means what.


text:
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text:
Over the last few years there has been an increase in drug shortages. In 2011 over 267, correct? What's going on?
Dr. Benjamin: That's right. Well, there have been a lot of different reasons for an increase in drug shortages just in the past 2 years, but where we really started to see drug shortages escalate was between 2007 and 2011 where there were 267 new shortages. There was a quadruple increase in the number of shortages, there were supply issues, there were raw material issues, there were manufacturing issues and quality issues. In the last 2 years when we have had the worst shortages, the main reasons for them were quality problems at the manufacturing level and lack of capacity to fill in the gap created by quality problems that prevented the release of drugs.
Can you go into detail about quality problems? What is one of those things that you are seeing?
Dr. Benjamin: Some of that stuff is on our website. We report the quality problems that we are able to learn about, things like glass particles and metal shards in injectable products, and other issues related to the quality of an injectable drug. These are mainly injectable drugs that are problematic with shortages. The quality control is so very demanding and specific for a drug that you are putting in someone's vein, that quite often there are problems in the manufacturing. There is a very rigid quality control process to detect those. They are going to happen, but hopefully if your manufacturing processes are good, you will not have too many. For some reason recently, there have been a lot more problems and it has caused recalls, it has caused shutdown of lines in the plants, and it has caused plant shutdowns. All of these actions compromise the ability of a pharmaceutical manufacturer to produce drug products.
What are the drugs that are affected the most?
Dr. Benjamin: Well, we have been tracking that over the past 6 years and the lead drug classes change every now and then, but the top 8 are always the top 8 and that is the central nervous system drugs. Those are the drugs for pain, for fever, for anesthesia, for arthritis, for reversing narcotic overdoses, for seizures, so this is a very important class of drugs used by many people. That is the top one now, but we have also seen a time when chemotherapy drugs, drugs used for treating cancer, were in the top class. The anti-infections, the drugs used to treat everything from HIV to just a common skin infection, these have also been in shortage. The electrolyte caloric and water balance, what we call the drugs that are usually given to people in the hospital when they are dehydrated, when their electrolytes are out of balance, or when they cannot eat by mouth, all of these have been in shortage. That has particularly affected pediatric patients.
It seems like a of those drugs are in shortage. What has not been in shortage?
Dr. Benjamin: Almost every class of drug has been affected.
What has it been like for pharmacists and for hospitals that have to deal with the shortage? Are they using alternatives that are as effective as the drugs that are on shortage?
Dr. Benjamin: Well, I will talk about pharmacists first because where we get the most feedback is from our members, and pharmacists are very frustrated and concerned about this whole situation. They spend a lot of extra time trying to obtain products for their patients and keep the communication lines open with physicians, nurses, and other care providers who need to use these drugs. I think that the last survey we did showed that a pharmacist is spending, on average, 9 extra hours a week; that is almost 2 extra hours a day just on trying to get drug products, working on shortages. Pharmacy technicians, in addition to that, are spending an additional 8 hours a week. So, we have got a lot of personnel time devoted to something that is essentially a procurement function and not patient care.
I did read that it is costing over $260 million.
Dr. Benjamin: An additional $260 million in labor, just to deal with shortage. That is the projected annual estimate. Yes.
Just because they are spending more time?
Dr. Benjamin: Yes. They are spending more time, they have added FTEs, and they have added personnel, all just to deal with shortage personnel. I talked with someone yesterday whose main job is simply to make sure that the drugs are on the shelves when the patients need them.
If they do not have it, do you have to find a substitute?
Dr. Benjamin: If they do not have it, the pharmacists are also working with the medical staff to try to figure out what do with what we have. It's funny because our pharmacists do say instead of talking with physicians about what is the best drug for this patient, now we are asking what do we have and how can we use it to take care of the patient. It is what you have left, not what the best thing is.
How is it impacting patient care?
Dr. Benjamin: The patients we have spoken to are very alarmed, especially the cancer patients because it is very stressful to deal with a diagnosis of cancer, but imagine adding on top of that the fact that the drug you need to treat your disease is not available. There are really not that many therapeutic alternatives among the cancer drugs. They are very targeted at particular types of malignancies or hematology type disorders so it is not like antibiotics, where if I do not have one there is another that is similar. For pediatric patients, especially neonates, newborns who cannot eat, if the nutritional supplements that are needed to feed them through IV are not available, they will fail to thrive. Vitamins that the same neonates need to help them build their bones, calcium; these have not been available either. It has been very concerning to the pediatric community; both physicians and pharmacists alike are concerned about these patients. These are just two examples. A lot of different patients have been affected, but oddly enough, there are still patients who do not know that there are drug shortages other than just reading an article in the paper because I think their pharmacists and physicians have done a pretty good job of taking care of them with what they have.
Doesn't that mean that they do not know that they are going to pay more for something than they usually would?
Dr. Benjamin: We have heard that. We have heard that because the drug of choice is not available, or the drug in the insurance company's first tier of payment is not available, that patients have to shoulder additional out-of-pocket expenses for the drugs that are available. But at least their drugs are available. I believe Premier, which is a group purchasing organization, did a survey on how much additionally hospitals have to spend for drugs, and I think they projected $200 million annually in additional costs to hospitals to buy more expensive therapeutic alternatives.
How do we fix it? Have there ever been any deaths associated with the drug shortage that you know about?
Dr. Benjamin: I do not know that there have been any studies. We have heard anecdotal reports that there have been deaths. We certainly know that there has been harm. The Institute for Safe Medication Practices did a survey in which hospitals reported harm or an impact on patient safety resulting from drug shortages. 1 in 4 of those hospitals reported an error as a result of drug shortages and 1 in 5 reported adverse outcomes on their patients because of drug shortages.
That is a huge number.
Dr. Benjamin: It is an impact on patients. The impact on patients, the impact on the finances of a hospital, and the additional labor costs; this is what affects hospitals as an organization. So it has had an impact on hospitals in that way as well.
Is there anything that the FDA is doing to crack down on the third parties trying to hoard drugs?
Dr. Benjamin: I am not sure that we have a good way to gauge how much hoarding is going on. We know it is going on, but we cannot tell who and to what extent. A certain amount of stock piling by an organization is understandable; especially if you have patients already on these therapies and you want to continue their therapy. But, we have urged our members not to overstock a lot of these products because it takes them out of the supply chain and makes them unavailable to others who might also need them.
Can you talk about the gray market?
Dr. Benjamin: Well, these are nontraditional third party distributors who have sources for obtaining products in short supply. I am not sure what they are, but somehow they manage to have product to offer that is on our shortage list and there is a premium charge for buying these products. We really discourage our members and anyone else from resorting to the gray market as a source of drugs in shortage because we have no way of knowing where the drugs came from, how they have been handled, how they have been stored, and there have been reports of counterfeiters introducing products into the market that are in shortage. I think the most recent one was counterfeit Adderall.
What is the worst that could happen?
Dr. Benjamin: The best thing that could happen to you is that it does not work. The worst thing is it is adulterated or deteriorated in some way and might actually cause you harm.
How can we control something like that from happening?
Dr. Benjamin: Well, you had asked about FDA. The FDA has no authority over distribution; they do not have any authority over people who sell drugs, only over manufacturers. What we tell our members are just do not buy from them. If they do not have a market for what they are selling, then they will not stay in business. We do not believe that the gray market is causing shortages. I have heard that as a hypothesis, but we believe that it is a symptom of drug shortages.
What do we do now to warn the hospitals and pharmacists that there are drug shortages?
Dr. Benjamin: We have maintained a drug shortages web resource center since 2001, over 10 years, and we depend on our members to alert us whenever there is a shortage so that we can post it there and provide information about alternative agents and perhaps other sources to obtain the drug. We post that information as soon as we get it, but it is never soon enough because by the time a member reports a shortage to us, the shortage has already evolved. We know that that information is important; it gets the most hits of any page on our website. However, we think that the new shortage legislation which will require manufacturers to report this information to FDA will be way more timely and way more helpful to practitioners and the whole healthcare community.
What part in the decision did your organization play? You said you got 90% of what you guys were looking for, right? What were those 90% and what was that 10% that you guys did not get?
Dr. Benjamin: Our most important plank in that platform was early notification by manufacturers to the FDA of any production problem that might cause a drug to not be available. We did not ask manufacturers to determine if it would cause a shortage, we just wanted them to report anything. The FDA in their oversight role could tell from where they sit nationally whether or not the drug would cause a shortage. They know how many people make the drug and they know where, at any time, in regulatory procedures all those companies are. The earlier the FDA knows, the more they can do to either prevent or to mitigate a shortage.
What do you think is the next step and what do you think that patients should know about the shortages and about the new law?
Dr. Benjamin: The next step in our view is that we need to study the fundamental causes of drug shortages in a lot more depth so that we can understand fully what causes them to happen. Why drug shortages occur, what are the main causes, what are all the other little contributory factors, so that we can recommend effective solutions. If we do not really know everything we need to know we will just continue to slap Band-Aids on the problem and will not get at the root cause. The reason we recommended early notification by the FDA was because we knew it worked. The FDA told us that if we know in time, there are things we can do; we knew that that was going to be a valid, or at least temporary, solution. Now is the time to really take a deep dive into all the data and all the information people have about drug shortages and work with manufacturers, with suppliers overseas of raw material and active pharmaceutical ingredients, with the supply chain, with physicians, with everybody that has a stake in this so that we can come up with lasting solutions.
Let's talk about Doxil. There is only one company in the United States that makes it. Why is that?
Dr. Benjamin: I believe it is because Doxil uses a unique drug delivery system, and I think it is proprietary to one company, so one company makes it. They distribute it overseas as well, and there may be more than one; it is possible to have more than one manufacturing site, but in this case, there was one company, one manufacturing site.
Is there anything that patients can do to protect themselves?
Dr. Benjamin: Well, I have encouraged patients who have called me to monitor our website and look for any notifications of shortages of their own products and to discuss with their physician how they would handle it if there was a shortage of their product. This is particularly true of products, as you mentioned, that have one company, one manufacturing site, or maybe only two, or that are injectable products; those are the ones that are most frequently affected. Try to have a proactive plan. ASHP has assisted a lot of individuals and groups with trying to find alternative methods of obtaining products in the past. Our ability to do that is limited. We work with the FDA, but I think a proactive plan of what can we do, at minimum discussing it with your physician and finding out you do not have worry about it, would ease your mind. It is better to know if what you are taking is at risk of a shortage and to get ready for it.
It quadrupled you said?
Dr. Benjamin: From 70 to 267 in 5 years.
Where do you think we are going to be in the next couple of years?
Dr. Benjamin: Well, there is good news. There are only 97 new shortages right now, and last year at this time there was many more. I cannot give you the number, but I can find it if you needed it. We are encouraged by this downward trend of new shortages in the first six months since the President signed the bill into law. We hope it keeps up and we would like to see it be doing a little bit better than that. We would like to see shortages go down to the past levels; we usually maintained around 40 or 50 and that was kind of a low, steady level. As I said, quality problems happen and people take care of them, but we will be monitoring to see what happens when all of the legislation that has to do with shortages is implemented. We hope it will help. When shortages occur pharmacists and physicians get together and they try to develop prioritization protocols that make sure that the most needy patients get the scarce supply. So, this essentially is rationing.
How do you make this decision?
Dr. Benjamin: It is done usually with the hospital ethics committee, the medical staff, and pharmacy. It is a very difficult decision. It is similar to what you do with solid organ transplant. Who gets the kidney? Who gets the heart? Who gets the lungs? I mean, it is a very difficult decision. It has been quite stressful for all the care providers involved and certainly mostly for the patients.
Do the patients know that they are on a certain list when they hear about a shortage?
Dr. Benjamin: What we have heard that practitioners are doing is whenever a patient's drug is in shortage and there is an alternative therapy or the patient will have to get a lesser dose or the patient will have to skip maybe a cycle of his drug, the physician and pharmacist, either or both, can discuss this with the patient and tell them what the potential effect on their care might be, how it might affect the outcome of their disease, and what we are going to do now moving forward. We have heard that patients have really been drawn into and engaged in their own care and in these decisions.
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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Whether you are planning on celebrating this St. Patrick's Day by wishing for a little "luck o' the Irish" or trying to find the fabled "pot of gold", there is no denying that Irish themed food will be on menus everywhere. It's not unusual to see Guinness stout or Irish whiskey in the description of an item on a menu or a "wee bit" of green food coloring mixed into a pitcher of your favorite frosty brew. A few of these items will also be making an appearance at my dinner table along with a leprechaun jokes and clover leaf crafts from my son!
My first recipe, Beef & Guinness Pot Pie, might just be a little "pot o' gold". There is something that is so comforting about a fresh pot pie right out of the oven. In this particular recipe, the deliciously dark undertones of the Guinness, give the sauce a smooth, rich taste and makes it perfect for dipping the flaky, buttery pie crust. Tender vegetables and melt in your mouth beef bring all of the comforts of a "made by mom" pot roast dinner within one amazing little dish. The low and slow cooking process used for the filling allows for the flavor of the Guinness to make its way into every tender little vegetable and piece of beef and allows for the sweetness of the carrots and molasses to reduce any bitterness from the brew. These pot pies can be baked right away, or if you are a planner for busy weeknights, they can be made ahead and frozen for future use. Just add 20 minutes onto the bake time and tent foil over the top of the pie crust for the first 30 minutes of baking. It's so easy, and much more appealing to come home to at the end of a busy work day than any pre-made frozen microwaveable meal!
After indulging in those little pots of goodness, you may find yourself craving a little something sweet. This frozen yogurt is simple and won't put too much strain on your belt! This is also the part of the meal where the green food coloring comes into play with my recipe for Mint Chocolate Chip Frozen Yogurt. I started using Greek yogurt a few years ago instead of making an ice cream base simply because I was in a hurry and I have been hooked ever since. It takes away the hassle of having to cook the base and let it cool before attempting to put it into your ice cream maker, and instead you have a deliciously frozen soft serve treat in a few minutes or a scoopable bowl in a few hours. However, when I first began experimenting, I discovered a problem. Sometimes my frozen yogurt would freeze so hard that I would have to let it sit on the counter for 30 minutes before serving it. I did a little research and found that there were 3 things that you can add to ensure that your frozen yogurt stays scoopable…fat, sugar and alcohol. I have enlisted the help of all 3 in this recipe by using 2% Greek yogurt, granulated white sugar, and vanilla vodka. When my son eats this recipe, I leave out the alcohol and opt to add a few extra tablespoons of sugar or heavy cream. Also, if the use of food coloring makes you uncomfortable, you can always leave it out, it won't have any effect on the flavor, but for our little St. Patrick's Day themed meal, I knew I had to use it!
Beef & Guinness Pot Pie
- 4 tablespoons olive oil
- 6 tablespoons all purpose flour
- 1 teaspoon kosher salt
- 1/2 teaspoon cracked black pepper
- 1.5 lb beet stew meat
- 1 cup diced yellow onion
- 1/2 cup diced carrots
- 1/2 cup diced celery
- 8 oz sliced mushrooms, I used crimini
- 1 1/2 teaspoon caraway seed
- 1 tablespoon rosemary, dried
- 1 tablespoon whole grain mustard, or country style
- 2 teaspoons molasses
- 1/2 teaspoon kosher salt
- 1/2 teaspoon cracked black pepper
- 1-12 ounce can of Guinness
- 1 tablespoon cornstarch (plus one tbsp water to make a slurry when ready)
- 2 pre-made, ready to roll pie crust dough sheets
- egg wash (1 egg, 2 tbsp water whisked together)
Place meat, flour, and first amounts of kosher salt and pepper in a resealable plastic bag. Shake until all evenly coated.
In large, heavy bottom sauce pan, heat the first amount of olive oil until shimmering over high heat. Add meat and brown on all sides. Don't over crowd the pan, cook in batches if necessary. Do not cook the meat through all the way, just until golden brown. Remove the meat from the pan and set aside. Add second amount of olive oil, garlic, and vegetables. Stir and cook over medium heat until onions are translucent and vegetables are tender. Add caraway seed, rosemary and the second amount of salt and pepper. Add the mustard and molasses and stir until well coated. Add the Guinness to the pan and be sure to scrape all of the browned bits off of the bottom of the pan. Add the cornstarch slurry and stir until mixture begins to thicken. Reduce heat to low and let simmer for 30 minutes, stirring occasionally.
While mixture is simmering, preheat your oven to 375 degrees. Roll dough sheets until 1/8 inch thick and lightly trace the outline of your ramekins or baking containers. Cut the dough, leaving enough for a 1 inch overhang on the edges. Scoop 1 cup of beef mixture into ramekins. Top each one with pie crust and cut a slits to vent. Using a pastry brush (or a paper towel when in a pinch), brush each pie crust with egg wash. Place the ramekins on a baking sheet to catch any spills. Bake 45 minutes or until crust is light golden brown. Remove from the oven and let stand for 10 minutes before serving. Enjoy!
Serves 4.
Mint Chocolate Chip Frozen Yogurt
- 2 cups – 2% Greek yogurt, plain, well chilled
- 1 teaspoon peppermint extract
- 1 teaspoon vanilla extract
- 1 tablespoon vanilla vodka (or plain)
- 5 tablespoons sugar, white granulated
- 3/4 cup dark chocolate chips, finely chopped
Place the bowl of your ice cream maker in the freezer for 24 hours before beginning. In a medium bowl, combine well chilled Greek yogurt, peppermint and vanilla extracts, vodka and sugar. Stir until sugar is dissolved, about 1 minute. Place the mixture into the ice cream maker according to the manufacturers instructions. With 5 minutes left in the churn time, add the chopped chocolate pieces. Finish the churning process and remove the mixture from bowl and place it into a freezer safe container. Let the mixture firm up for 1 hour before serving. Enjoy!
Serves 4


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Samsung Galaxy Ace 2 and Galaxy Mini 2 UK launch details unveiled
Officially announced by Samsung yesterday, the Galaxy Ace 2 and Galaxy Mini 2 will be both available in the UK soon, as several British mobile operators have confirmed they'd offer the handsets.
The Galaxy Ace 2 will be available via O2, Orange, T-Mobile and Three.
Only Three says when customers should expect to see the smartphone hitting the shelves, and that's sometime in April – the same time the operator will introduce the Samsung Galaxy Mini 2.
Speaking of which, the Galaxy Mini 2 will also be released by T-Mobile.
The Samsung Galaxy Ace 2 and Galaxy Mini 2 run Android 2.3 Gingerbread. The new Ace features a 3.8 inch WVGA display and a dual-core 800MHz processor, while the new Mini comes with a 3.27 inch HVGA display and a single-core 800MHz processor.