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Gift, Thomas L. PhD*; Malotte, C Kevin DrPH†; Ledsky, Rebecca MBA‡; Hogben, Matthew PhD*; Middlestadt, Susan PhD‡; VanDevanter, Nancy L. DrPH§; St. Lawrence, Janet S. PhD*; The GCAP Study Group
From the *Centers for Disease Control and Prevention, Atlanta, Georgia; †California State University-Long Beach, Long Beach, California; the ‡Academy for Educational Development, Washington, DC; and §Columbia University School of Public Health, New York, NY
The GCAP Study Group is composed of the following members: Los Angeles, California: C. Kevin Malotte, DrPH; Michelle Larro, MA; Keisha Paxton, PhD; Lisa V. Smith, DrPH; Robert H. Settlage, MD, MPH; Robyn Davis, MPH, CHES; Gary A. Richwald, MD, MPH; Typhanye Penniman, MA; and James Gaines, BA. Prince George's County, Maryland: Susan E. Middlestadt, PhD; Rebecca Ledsky, MBA; Glen Olthoff, MPA; Jonathan Zenilman, MD; Gillian VanBlerk, MD, MPH; Chizoba Ukairo, MPH; Kondra Fulmer, BA; Sandi Mattson, BS; and Vida Johnson, BA. Harlem, New York: Nancy VanDevanter, DrPH; Cheryl Merzel, DrPH; Peter Messeri, PhD; Amy Bleakley, MPH; Isaac Weisfuse, MD, MPH; Alwyn Cohall, MD; Susan Blank, MD; Renee Mayer Cohall, CSW; Deborah Levine, ACSW; and Michele Peake, MA, MEd. Centers for Disease Control and Prevention and the National Institute for Mental Health: Matthew Hogben, PhD; Janet St. Lawrence, PhD; Thomas L. Gift, PhD; and Willo Pequegnat, PhD.
Correspondence: Thomas L. Gift, PhD, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE, Mail Stop E-80, Atlanta, GA 30333. E-mail: firstname.lastname@example.com.
Received for publication November 1, 2004, and accepted January 20, 2005.
Background: Persons who have been infected with chlamydia or gonorrhea (CT/GC) are at elevated risk for reinfection. The cost-effectiveness of interventions designed to encourage public sexually transmitted disease (STD) clinic patients to return for rescreening has not been well-evaluated.
Goal: The goal of this study was to conduct a program- and societal-perspective cost-effectiveness analysis of five interventions designed to encourage public STD clinic patients infected with CT/GC to return for rescreening 3 months after initial treatment.
Study: Researchers at two STD clinics collected cost data for the five interventions. These were combined with study data on return rates and CT/GC positivity rates among returning patients to compare the cost-effectiveness of the interventions.
Results: The cost per patient counseled with a brief recommendation to return, followed by a telephone reminder after 3 months, was higher than two interventions: a brief recommendation to return with no reminder and a $20 incentive, received on return. However, the brief recommendation with a telephone reminder yielded the highest return rate (33%) and was the least costly in terms of cost per infection treated ($622 program, $813 societal). In-depth motivational counseling that helped clients identify risk factors and provided reasons for returning was more costly than a phone reminder alone and was not more effective.
Conclusions: Phone reminders are more cost-effective than motivational counseling and improve return rates over a brief recommendation given at the time of initial treatment.
PEOPLE WHO HAVE BEEN DIAGNOSED with chlamydia or gonorrhea represent a high-risk group for reinfection. A recent study of patient-delivered partner therapy for women diagnosed with chlamydia in family planning, adolescent, sexually transmitted disease (STD), and primary care clinics or emergency or other hospital departments found that 4-month reinfection rates ranged from 12% to 15%.1 The Centers for Disease Control and Prevention (CDC) recommend advising women with chlamydia to be rescreened 3 to 4 months after treatment.2 The U.S. Preventive Services Task Force has not made a formal recommendation for rescreening infected patients, but notes that rescreening women may be valuable because of high rates of reinfection.3
The Gonorrhea Community Action Project (GCAP), a feasibility study funded by the CDC and the National Institute of Mental Health (NIMH), assessed several methods to encourage STD clinic patients diagnosed with chlamydia or gonorrhea to return for a repeat screening 3 months after treatment. This clinic-based intervention was a part of a larger study that analyzed gonorrhea prevention interventions targeted at STD clinic patients, healthcare providers, and members of community-based organizations in three communities (Central Harlem in New York City, NY, southwest Los Angeles, California, and Prince George's County, Maryland).4
The GCAP clinic intervention has been described in detail previously.4 Briefly, eligible patients were men and women between 14 and 30 years of age who were diagnosed with and treated for chlamydia or gonorrhea at either the Prince George's County STD Clinic (Prince George's County, Maryland) or the Ruth Temple Health Center STD Clinic (Los Angeles County, California). Both clinics serve high-prevalence communities.4 Enrollment began in April 2000 and concluded in July 2001. Eligible clinic clients provided written informed consent and were randomized to one of three intervention arms. In intervention 1, patients were given a verbal recommendation to return for a chlamydia and gonorrhea screening in 3 months and given a reminder card with five to seven reasons for returning. This was the standard of care (standard treatment). In intervention 2, patients were given a brief verbal recommendation and reminder card, but also informed they would receive a $20 incentive on their return (incentive). In intervention 3, patients received a verbal recommendation to return and reminder card, but also participated in a one-on-one 15- to 25-minute interview and counseling session with a trained interviewer that helped patients assess their own risk, identify barriers to returning, and provided the patient with reasons and motivations for returning. Patients in intervention 3 were also given a reminder phone call and mailed a letter 3 months after the counseling session to encourage their return (motivational counseling and reminder). In each intervention, patients who returned to the clinic provided a urine specimen that was screened for chlamydia and gonorrhea using a ligase chain reaction (LCR) nucleic acid amplification assay (LCx; Abbott Laboratories, Abbott Park, IL). Symptomatic patients and patients with positive test results were treated according to CDC guidelines.2 Table 2 lists the number of participants for each intervention arm from each site. There were no significant differences between the sites for any demographic or sexual behavior variables.4
The return rate among study participants in intervention 3 was higher than among those in intervention 1 or 2. For each intervention, there were no significant differences in return rates between the two sites or between men and women. To assess whether the significantly higher return rate for intervention 3 was attributable to the counseling or to the reminder, a second study began in Los Angeles in July 2001, which also consisted of three arms.4 Intervention 4 was the same as intervention 1 in all respects (standard treatment). Intervention 5 consisted of a brief verbal recommendation and reminder card plus a phone call reminder (reminder). Intervention 6 had the components of intervention 3 except that participants were not given either a letter or phone call to encourage their return for repeat screening (motivational counseling). Both phases of the study were approved by Institutional Review Boards at the CDC and at the individual study sites (Maryland Department of Health and Mental Hygiene, CA State University–Long Beach, and County of Los Angeles Department of Health Services). Enrollment ended in June 2002.
The cost variables used in the analysis are in Table 1A. Study staff who were specifically trained in time-motion methods and who used data collection forms that were uniform across the two sites tracked the amount of time necessary for clinic workers to deliver each of the interventions, including time for preparation, patient counseling activities, supervision, and quality assurance. Included in supervision and quality assurance time were direct supervision activities, chart review, review of audiotapes of the sessions, and employee meetings relevant to the interventions. During the study, study supervisory staff reviewed the audiotapes from the motivational interview sessions conducted as part of interventions 3 and 6. Initially, 100% of counseling sessions were monitored, but this was later reduced to 10%. Staff also recorded the amount of time required to place phone calls and prepare reminder letters. Staff collected wage and fringe benefit rate data for workers involved in the intervention; these were combined with the time expenditures to determine the labor costs associated with each intervention. Counseling staff and supervisors attended a 2-day workshop for training in the first three clinical interventions in September 1999. The cost of this training was not incorporated into the per-patient costs reported in the results.
We also estimated the costs of sequelae from infection with chlamydia or gonorrhea. The total cost of sequelae included the direct medical costs of treatment plus the lost productivity costs attributable to the sequelae. For women, the primary sequelae considered were pelvic inflammatory disease (PID) and its sequelae of chronic pelvic pain, infertility, and ectopic pregnancy. Literature estimates of the likelihood of sequelae and their lifetime costs were used. Averted costs were discounted at 3% per year.10,13–15 Productivity costs were also taken from the literature.16,17 For men, the sequelae considered were epididymitis and orchitis; we used literature-based estimates of their likelihood and cost for both the direct medical costs and productivity losses.10–13
We estimated the cost for supplies, postage, and office and counseling space used in the intervention (including supervisory and quality assurance activities) based on average commercial rental rates per square foot in the areas served by the clinics for commercial office space.18 Costs for utilities were approximated based on the average cost per square foot for commercial buildings in the appropriate region of the country.19
Patient time costs were estimated using mean income data for persons 15 to 29 years old.20 These wage data were adjusted by race, ethnicity, and sex-specific labor force participation rates to match the participants in the study.4 In addition to the time spent in the initial counseling, we assessed 2 hours of lost productivity (adjusted by the labor force participation rate) plus $5 in travel-related costs for each clinic visit.20 We applied this cost to both repeat screening and treatment visits.
All other costs such as those for sequelae, testing and treatment, and the cost of clinic visits for repeat screening and treatment if the repeat screening test was positive were taken from the literature.5–8,10–15
We conducted the analysis from two perspectives: program and societal. In the program-perspective analysis, only the intervention costs were considered. These included those for staff and overhead for the initial counseling, as well as direct medical costs related to testing and treatment of acute infection in patients who returned to the clinic. All sequelae and patient lost productivity and travel costs were omitted. In the societal perspective analysis, all costs were included, including those reflected in the program-perspective analysis, those attributable to sequelae of chlamydial and gonococcal infection, and those incurred by patients for healthcare visits and lost productivity. The only exception is that the incentive payments for returning patients in intervention 2 were counted in the program-perspective analysis but not in the societal-perspective analysis, because the net cost to society for the payments was zero. The program lost the money, but the patients gained it. Also, the incentives represented a transfer payment and were not in exchange for goods or services.
To determine the cost per infection treated for each perspective, we divided the costs described here by the number of infections detected in returning patients using patient return data from the study. For ease of comparison, we then calculated all of these values per 1,000 initial patients counseled.
Data on clinic breakdown by sex, return rates, and rates of infection among those returning were directly measured in the study (Table 1B).4 Test performance parameters were taken from the literature.31–34 We also used a literature-based estimate of the probability that a returning patient would have symptoms or signs if reinfected with chlamydia or gonorrhea, and we assumed that patients who were symptomatic would be treated presumptively and not recalled for treatment after test results. We assumed asymptomatic patients would be recalled by the clinic for treatment if their test results were positive; we used literature estimates of the rate of return for treatment.24–26
We used interventions 1 and 4 (the interventions closest to the existing standard of care) as the baseline to determine the number of infections averted for each intervention. We estimated the number of infections among the returnees using literature estimates of the sensitivity and specificity of LCR on urine specimens.31–34 We applied these values to the positivity rate for chlamydia and gonorrhea among those who returned for screening to estimate the prevalence of each infection. To estimate the number of infections in patients who did not return for screening, we assumed the prevalence of each infection was the same as in those who returned for screening and that patients were not tested or treated for the subsequent infections.
To facilitate sensitivity analysis, a decision tree was constructed using DATA Professional version 1.0 (TreeAge Software, Williamstown, MA). Sensitivity analysis ranges are provided in Table 1 (A and B). We determined the sensitivity analysis ranges by calculating the exact binomial 95% confidence intervals when we had sufficient data to do so.
For sensitivity analysis related to supervisory time associated with quality assurance, we determined the upper bound by calculating the 95% confidence intervals as described here based on observed supervisory and quality assurance time (which included monitoring 10% of counseling sessions). The lower bound was calculated by assuming that 5% of sessions would be monitored.
The return rates for the interventions are reported separately by patient gender in Table 1B. The sensitivity analysis ranges for the return rates are the 95% confidence intervals for the average return rates in each intervention for both genders combined adjusted for patient symptom status as described in the next paragraph. Because interventions 1 and 4 were identical in design, they were combined for the purposes of this analysis. Although the return rate for intervention 4 was lower than for intervention 1, the difference was not significant at P <0.05 At baseline, the gender-specific rates were used, but because the rates did not differ by gender at P <0.05 (using Fisher exact test) for any of the interventions, we examined the impact of using a combined average rate in sensitivity analysis. Because many of the interventions did not have significantly different return rates, we also examined the impact of setting the return rates equal for all of the interventions across the range of return rates in Table 1B. However, the return rate for intervention 5 (reminder) was significantly different from the return rates for interventions 1 and 4 (standard treatment; Fisher exact P <0.01) and intervention 2 (incentive; Fisher exact P <0.05). The return rate for intervention 3 (motivational counseling and reminder) was significantly different from that of interventions 1 and 4 (Fisher exact P <0.05).
To facilitate comparisons between the interventions, we calculated incremental cost-effectiveness ratios, which we determined by ranking the interventions from least to most effective using the number of chlamydial or gonococcal infections treated through repeat screenings as the outcome. We chose this outcome because the intervention combined men and women, making outcomes such as cases of PID averted or cases of epididymitis or orchitis averted impractical (however, as noted previously, PID, epididymitis, and orchitis costs were included in the societal-perspective calculations). The incremental cost-effectiveness ratios were calculated by determining the difference in total intervention cost between two interventions when applied to 1,000 index patients divided by the difference in chlamydial and gonococcal infections treated between the two interventions. When calculating the ratios, we omitted interventions that were dominated by the next most effective intervention (i.e., the omitted interventions were both less expensive and more expensive in terms of the cost per infection treated than the next most effective intervention).
The timeframe covered by our cost-effectiveness analysis would be the amount of time necessary to counsel 1,000 patients, which would depend on patient volume. We assumed all costs were linear (in other words, that the cost per patient counseled would be the same regardless of patient volume, all else being equal). The analytic horizon of the cost-effectiveness analysis was 10 years, by which time we assumed all sequelae costs would be incurred. All costs were adjusted for inflation to reflect 2001 prices using the Medical Care component of the Consumer Price Index for All Urban Consumers (CPI-U).35
Table 3 shows the weighted average return rates for each intervention (for both genders combined) as well as the number of chlamydial and gonococcal infections treated and intervention costs, standardized to a hypothetical cohort of 1,000 patients (given the gender breakdown in Table 1B, the patient mix would be 442 women and 558 men). Table 3 also shows the incremental cost per additional infection detected through repeat screenings performed for patients who returned. The results in Table 3 are based on baseline values in Tables 1A and 1B. The interventions maintain the same rank order in terms of overall cost and cost per infection treated regardless of perspective. The cost per patient counseled was lowest for interventions 1 and 4, regardless of perspective, although for intervention 2, it was very close to that of interventions 1 and 4 (only approximately 3% higher when considering total societal costs). When considering the cost per infection treated, intervention 5 was least costly, regardless of perspective. Intervention 5 was also the most effective, having the highest return rate for men and women.
Interventions 3 (motivational counseling and reminder) and 6 (motivational counseling) were dominated (i.e., they were more expensive in terms of total cost and also less effective) by interventions 2 (incentive) and 5 (reminder).
When chlamydia and gonorrhea prevalences were varied over the ranges in Table 1B, intervention 5 (reminder) remained the least costly in terms of cost per infection treated. At the lowest chlamydia prevalence examined, 3%, the total societal cost per infection treated for intervention 5 was $4,092 compared with $6,136 for intervention 3 (motivational counseling and reminder), the next most-effective intervention. Intervention 5 was also the most effective and the least costly in terms of cost per infection treated when the return rates for the other interventions were set at the top end of the ranges shown in Table 1B. These results were true for both the program and societal perspectives.
When the return rates for all five interventions were set equal to each other and varied across a range of 10% to 50% for both genders combined, they broke into two groups in terms of total societal cost: Interventions 1 and 4 (standard treatment), 2 (incentive), and 5 (reminder) were all within approximately 1% of each other at the low end of cost, with intervention 5 the most expensive of the group. Interventions 3 (motivational counseling and reminder) and 6 (motivational counseling) were 9% to 13% more costly than the low-cost interventions.
The effects of the sensitivity analysis on supervision and quality assurance time can be seen in Table 4. This table shows the cost per infection treated for both perspectives at both the baseline supervision and quality assurance costs and at the lower-end supervision and quality assurance costs from Table 1A. Although the cost per patient counseled, cost per returnee, and cost per infection treated decreased for all interventions relative to the costs in Tables 2A and B, the magnitude of the changes varied. In the program-perspective analysis, cost per infection treated dropped by 19% (for intervention 5) to 31% (for interventions 1 and 4). In the societal-perspective analysis, the reduction in intervention cost per infection treated was from 15% (for intervention 5) to 26% (for interventions 1 and 4). At the lower-end costs for supervision and quality assurance, the incremental cost-effectiveness ratios remained approximately the same, and the interventions that were dominated by others (interventions 3 and 6) remained dominated.
Other sensitivity analyses such as return rates for the interventions when varied individually affected the overall cost and effectiveness of each of the interventions, but did not create important threshold values.
In terms of cost per patient counseled, all of the interventions were more expensive than the baseline (interventions 1 and 4, standard treatment). The per-patient costs (for patients initially counseled, patients returning, and infections treated) can easily be calculated from Table 3 by dividing by the appropriate denominator. Intervention 5 (reminder) was markedly more expensive in terms of per patient counseled (regardless of perspective) than interventions 1 and 4, but the cost per infection treated was approximately half that of interventions 1 and 4. Much of the cost of intervention 5 was incurred because of its effectiveness—returning patients led to costs for testing and treatment that were not incurred by the less-effective interventions. Although more effective interventions averted more sequelae costs, this effect was muted in our analysis because we considered both men and women together. However, even when considering women alone, none of the interventions would be cost-saving. The cost per infection treated will vary depending on the prevalence of chlamydia and gonorrhea in returning patients; at the prevalence rates that were estimated among returnees, the program cost per infection treated (approximately $500 for intervention 5 at baseline prevalences) was comparable to that of some screening programs in other venues.36–38
We did not incorporate the effect of treatment on transmission to future sex partners. It is also possible that the patients who returned may have been more disposed to seek regular STD screening or other health care as a result of the interventions. Both of these considerations could be additional benefits (as well as program costs) of these interventions that were not modeled.
Because none of the interventions was cost-saving, looking at the relative societal costs of the interventions when the return rates are equivalent provides a useful additional way to compare them. If the interventions were equally effective at encouraging patient return, interventions 1 and 4 (standard treatment) would still be least costly. However, intervention 5 (reminder) would only be approximately 1% more expensive overall. This is because, as Table 1A shows, the counseling cost (either from the program or societal perspective) for the two interventions was similar. Because the reminder intervention had a significantly higher return rate than the standard treatment or incentive interventions, this would suggest that the reminder intervention might be a better choice than the other two, assuming that the additional case detection and treatment that it produces is worth the additional cost. To the extent it is more costly, it is so because it accomplishes what it is designed to do better than the alternatives.
Another consideration is that the return rate among men for intervention 2 (incentive) was high, but it was not effective in encouraging women to return (Table 1B). Because repeat screening recommendations typically focus on women, this would suggest that other alternatives may be worthwhile to consider.
The level of quality assurance and other administrative and supervisory activities in this research project were higher than would be experienced in actual practice. For example, the CDC guidelines for HIV counseling (which is similar in complexity to the motivational counseling used in this project, if not more so) recommend review of taped sessions twice monthly for the first 6 months of a counselor's employment, then monthly for the next 6 months, and quarterly thereafter.39 This would be a less intense and less costly level of quality assurance than was used in GCAP. Therefore, the low supervision and quality assurance cost columns of Table 4 may reflect costs that might be typical of the basic level of quality assurance recommended by the CDC for a similar intervention.
We did not include the one-time training costs in the costs reported in Tables 3 and 4. These costs would be apportioned over the number of sessions that counselors would complete before retraining became necessary or before they stopped counseling (as a result of assuming other duties or employee turnover). During the 26-month GCAP project period, retraining was not needed. Had training costs been apportioned among the total number of patients enrolled in the intervention, the additional labor cost per patient counseled would have been approximately $3.35. Although this would increase the intervention cost, total cost would still fall if training costs were considered along with lower supervision and quality assurance: program-perspective cost per infection treated would drop by 17% to 25%, and societal-perspective cost per infection treated would drop between 8% and 11%, depending on the intervention (results not shown).
The limitations and caveats discussed previously4 apply also to the findings of this cost-effectiveness analysis. The cost per patient counseled is subject to variation depending on the amount of supervision and quality assurance that would be needed to ensure adequate intervention delivery and the rate of sequelae in treated and untreated repeat infections. Another limitation is that some patients may have become reinfected, developed symptoms, and sought care at a point other than the study clinic. This would make the actual "return rates" higher than those observed in the study and would change the cost per infection treated, particularly when considering the societal perspective.
It is striking that the cost per infection treated (from either perspective) was lowest for the most effective intervention. Although intervention 3, the motivational counseling and reminder intervention also had return rates significantly greater than interventions 1 and 4 (standard treatment); its higher cost per patient counseled makes intervention 5, the reminder intervention, a more cost-effective option.
This article has been cited 2 time(s).
© Copyright 2005 American Sexually Transmitted Diseases Association
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BRIDGEWATER — If you're trying to relive your glory days, just looking for some fun and a nice day out, or if you really think you've got "the stuff," the Somerset Patriots want you.
The Atlantic League Championship Somerset Patriots will be holding open tryouts for the team from 9 a.m. to 12 noon on April 6 at TD Bank Ballpark. That's the morning of the Patriots' Fan Fest celebration.
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Bali Daily
Around 500 education experts from 48 Asian countries gathered for a conference in Nusa Dua, Bali, on Wednedsay to discuss the advancement of universities toward internationalization.
At the three-day "Eighth QS Asia Pacific Professional Leaders in Education" (QS-APPLE) conference and exhibition hosted by the Bogor Agricultural University (IPB), experts shared the common view that Asian universities have gained better recognition worldwide in line with the rise of Asia in the global arena.
Mandy Mok, managing director of QS Asia Quacquarelli Symonds, said Asian universities had performed well in the world university rankings. The region had a total of 19 universities in the top 100 universities in the 2012 QS World University Rankings this year, with the University of Hong Kong leading the pack in 23rd place.
Singapore saw its two universities, the National University of Singapore and Nanyang Technological University, make it to the top of the rankings, she said.
"Universities in Asia are becoming more international, as seen in the rapid growth over the past few years of branch campuses in Asia from universities in the West," she said, adding that China now hosted 17 branch campuses compared to 10 two years ago, followed by Singapore with 18, up from 12 in 2009.
Freddy Boey, a professor at Nanyang Technological University, said that with the rise of Asia, several Asian universities had in recent years acquired top academic rankings and achieved international recognition on a par with many of their iconic Western counterparts.
In his presentation on Strategies for Academic and Research Excellence for Asian Universities: Perspective from Singapore, he highlighted several significant factors that gave universities a critical competitive edge and building platform to become world-class institutions.
"As countries worldwide have become increasingly more interconnected due to globalization, universities have undergone significant change. To achieve and maintain academic and research excellence in today's fast-paced knowledge economy, it is critical for universities to transcend traditional education."
Aman Wiranatakusumah, chairman of the Indonesian Board of National Education Standards, and former Indonesian ambassador for UNESCO, presented his views on strategies for the internationalization of higher education.
"It requires appropriate academic and professional qualifications, including the comprehension of the global language, multicultural understanding and better human or soft skills," the professor at IPB's department of food science and technology said.
"Looking toward internationalization, universities should establish more attractive and higher quality academic programs, better institutional capacity and stronger international networking."


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ORLANDO, Fla. - Two Maui representatives took top honors at the 34th Health Occupations Students of America, or HOSA, Leadership Conference in Orlando, Fla., from June 19 to 23.
Lahainaluna student Leslie Garo earned first place in the prepared speaking event, while Kristine Saguid of University of Hawaii Maui College earned first place in the extemporaneous health poster event. Garo also earned a National Recognition Program award.
A group of 185 Hawaii HOSA students, teachers and chaperons traveled to compete with students from 49 states and Puerto Rico in 32 health and medical events. Hawaii members were recognized in 32 events and earned 17 top-three medalists and 50 top-10 finalists. In total, 67 students received awards, compared to 37 last year.
Other Maui students who received recognition and awards included a group from Kamehameha Schools Maui, which earned fifth place in the biomedical debate team event. Members are Christian Fernandez, Michael Gorman, Alex Guerrero and Makai Mann.
Lahainaluna's Ho'o Cabanilla and Kirsten Gilchrist earned 10th place in extemporaneous speaking and extemporaneous writing events, respectively.
Charmaigne Joy Oliveros of University of Hawaii Maui College earned seventh place in the medical spelling event.
Lahainaluna's Lorrie Dumayas earned an honorable mention in the veterinary science event.
Maui High's Donna Larita Marie Paz earned a $1,000 HOSA scholarship, a National Recognition Program award and a Barbara James Service Award for logging 100 community service hours.
Kamehameha Schools Maui's Kailee Tabaco earned a Barbara James/Presidential Service Award for logging 250 or more community service hours.


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Trucker CB Radio Slang for a rookie trooper or trooper-in-training.
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by irishbrodude January 18, 2010
A nickname for a dearly loved son. Given to the son when is really young. Only used by parents who are unbelievably caring and loving. The family is nearest you can be to perfect. Usually the first or only born.
Me and little bear went to the park today.
by Meetcatmemeercatme May 11, 2015
(proper noun) a naked bear with animal friends.
Did you used to watch that show little bear?
You mean that naked bear with the animal friends?
Yea, that.
You mean that naked bear with the animal friends?
Yea, that.
by awko taco December 27, 2011


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Top Definition
A British band who, in the 80s and then the 90s, helped to start and then define grindcore music. They are still generally regarded as the genres primogenitors. Grind is basically short and fast, with very sludgy guitars and bass and shouty/growly vocals. Short in the extreme sense - Napalm Death's best known record, 1987's Scum, contained 28 tracks in 33 minutes, the longest being just over 2 minutes, and the shortest being 4 seconds. Because of these aspects, grind has obviously never really gotten through to the mainstream. Napalm Death are still going today (Feb 2004).
Napalm Death? Yeah, I've heard them...they're fucking strange. Bloody heavy though!
بواسطة sabdo فبراير/شباط 8, 2004
Trending Now
Can you define these popular missing words?
Are the BEAST!!! they can smack the living shit outta pussy rock groups such as Creed, Korn and Pimp Shitzkitt.
Breed to Breathe.........
بواسطة Brother_Number_One أغسطس/آب 18, 2003
amazing grindcore band, they are the actual invetors of grincore since the drummer on both sides of the scum album was the first to use the word.
they don't have really brutal lyrics but the sound they create is brutal.
amazing live!
they don't have really brutal lyrics but the sound they create is brutal.
amazing live!
i was listening to napalm death and thought i was being hit with a hammer!
بواسطة brutaldeath أغسطس/آب 30, 2007
Amazing grindcore band. One of the first of the kind. Have influenced many other bands.
death metal has brutal/sick lyrics. napalm death might not have brutal lyrics, but, like my friend says... Listening to them is like getting smashed in the face with a sledgehammer!
بواسطة brutalcal نوفمبر/تشرين الثّاني 7, 2007
The best, most awesome band on the face of the earth.
Napalm Death Rules!
بواسطة Chief Rottingham مايو/أيار 21, 2003
You could've chosen better words than "awesome". It makes you sound like a pansy.
Napalm Death could kick your ass.


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Wading into an already divisive issue that shows no sign of quick resolution, Oregon Gov. John Ktizhaber has written to the CEO of St. Charles Medical Center-Bend, saying he's "troubled" by the hospital's moves to "influence the decisions of its workers" on whether to continue to belong to a service employees union.
Kitzhber wrote to St. Charles CEO Jim Diegel a week ago, the same day the Service Employees International Union filed an unfair labor practice charge against the hospital, accusing if of various efforts, including dismissal of union supporters, to influence a union decertificiation vote that had been scheduled for Wednesday of this week.
The National Labor Relations Board, which oversees labor elections and received the complaint, has postponed the election for up to five weeks and says it could be scrapped entirely, should an investigation substantiate the SEIU's claims.
Diegel wrote back to Kitzhaber two days later, on Sunday, defending the hospital's actions and calling it "a local issue between a private employer and its employees."
Here are the governor's and Diegel's letters, in full:
March 16, 2012
James Diegel
St. Charles Health Systems
2500 NE Neff Road
Bend, Oregon 97701
Dear Jim,
I have been following from afar the developments at St. Charles since the workers voted to form a union last year. As you know, I believe that a positive relationship with health workers ? as well as good wages and benefits ? is essential to build the stable, quality workforce we will need for the new health care delivery system.
I also believe that the decision to form, join or dissolve a union belongs to those who have a right to make that choice: the workers themselves. I am troubled, therefore, to learn that the hospital has taken steps to influence the decisions of its workers in this matter.
St. Charles is a leader in some of the most important and innovative health reforms in America. I hope that St. Charles can similarly lead the way in forging healthy and innovative partnership relationships with its employees. Kaiser Permanente was pioneer in this area. You can take it to the next level.
I urge you to reconsider the decision to intervene in the election. A ruling by the NLRB would send the wrong message concerning the collaboration we need to succeed in creating a new more efficient and effective health care system for our citizens.
John Kitzhaber, M.D.
March 18, 2012
Honorable Governor John Kitzhaber, MD
254 State Capitol
900 Court Street
Salem, OR 97301-4047
Dear Governor Kitzhaber,


text:
Overview of the Records
History of the Ship HANOVER
Index Terms
Administrative Information
Index to Personal, Corporate and Vessel Names
Detailed Description of the Records
The ship HANOVER sailed out of Bath, Maine with James Drummond as master.
Return to the Table of Contents
Restrictions on Access
Available for use in the Manuscripts Division.
Restrictions on Use
Various copying restriction apply. Guidelines are available from the Manuscripts
Division. See also: Mystic Seaport's copyright notice.
This collection is indexed under the following headings in the catalog of the G. W. Blunt White Library. Researchers desiring materials about related topics, persons or places should search the catalog using these headings.
Document Types:
Return to the Table of Contents
Preferred Citation
Coll. 219, Manuscripts Collection, G. W. Blunt White Library, Mystic Seaport Museum,
The following section contains a detailed listing of the materials in the collection.


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Four on-campus Summer Programs offer high school and college students opportunities to experience the Landmark College campus while gaining academic skills and strategies that improve their ability to learn and to be successful.
Student Life
Vermonters are known for their commitment to the environment and their love of the creative arts. You'll find both alive and well at Landmark College—where life is intensely interesting.
There's so much to do on campus and in the surrounding area. We have clubs, sports, activities and events, including theater productions, coffee house performances and pre-release movies. And, whether you love history, art, sports or nature, our Putney location gives you the chance to pursue your passion. Our campus shuttle service makes it easy to get to area shops, ski areas, nearby activities and cities, like Boston and New York.
When they're not in class, our students aren't sitting around — they're out rock climbing, taking photographs, jamming, dancing and more. Whatever your interests, you're likely to find others who share it at Landmark.
Learn all about Campus Life at Landmark College.


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by Jonathan Raban
Subtitled An American Romance, this engaging history of Montana, like many a love affair, is a story of dreams, deceit and heartbreak. Raban begins with the homesteaders who seized the U.S. government's 1909 offer of 320 free acres in the great plains of Montana and the Dakotas. Trouble was, they had been seduced by false promises of fertile soil made by railways and banks that wanted to sustain their own westward expansion. The settlers came, farmed and failed, victims of what Raban calls, the land's "dry, hollocky emptiness."
Combing the ruins of abandoned homes, sifting through diaries and photographs from the period, Raban does a fine job portraying the settlers' lives and the hopes that turned to despair. Many moved to Seattle (the British-born Raban's adopted home); those who still loved the land and chose to remain left a mixed legacy. In the book's final chapters, Raban notes the fierce self-sufficiency that infects the state's inhabitants today; its most virulent strain can be seen in the paranoid rage of the Militiamen extremists. His Montana is not Big Sky country, but a Bad Land indeed. (Pantheon, $25)
Picks and Pans Review: Bad Land
updated 01/27/1997 AT 01:00 AM EST
•originally published 01/27/1997 AT 01:00 AM EST


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I love the art but, not to critic or anything but the eyes seem lifeless to me, like the character is just going through the motions and not like God I want to be a protector or something
loved it!
WOW i love the colouirng so much!!
It looks like her name should be amber
beautiful ^^ gorgeous lighting specifically
Awesome details and coloring! How long did it take to make and what software did you use?
I like the armor it's awesome~
SO cool!!!!!!!!!!!!!!!!
Sua arte é muito bela! Espero poder aprender mais com elas!!! Parabéns!
SO cute :3 great Job
the colours just compliment each other. its just so inspiring
awesome colors!!
Epic !! I love the colors !!
This is simply MAGNIFICENT!!!
WOW!! This is amazing! I can't stop staring at how awesome it is! the is the best work I have ever seen this entire month! You are wonderful! The colors are great and the hair is so flowy and beautiful! And the ayes are so intimidating! If you're interested, I would really LOVE for you to join in my contest! PLease check it out!
Awesome details, excellent colours!
Looks like Erza Scarlet.
Superb work, the design and overall look of the piece is simply stunning, very well done. Looking forward to more Kirero.
Love it so much!
Hello! I'm here to let you know that this deviation has been featured in the news article Manga/Anime Monthly Features Vol. 34! Please be sure to check out and the article, as well as support the other artists that were featured!
Excellent use of colour.
Beautiful. Lovely colors and armor!
So beautiful. I love it!
I love the colors!!!
this is absolutely beautiful, amazing, great work
Good attention to detail. Pretty realistic. Loved the wasp.
is this for rage of bahamut game? I have that game and I think I saw this art there somewhere. its amazing
A great work !!
I love how the lighting here suggests the morning near sunrise...you can practically see the sun rising in her eyes
o_O So Much Detail
Really epic!
It's wonderful
It's wonderful
this one is epic!
So nice!
I'm wordless, this is so awesome!! Fav+
I really love the colors, lighting and the details.!!! Very pretty.
I love the composition and the glow that covers everything! Great job!
Extremely cool, amazing work. ^_^
Wow so colorful! I love your art!
really..i love you works *w*!♥
Amazing colors and shine. Perfect line art.
Amazing colors and shine. Perfect line art.
This is beautiful, and the resolution is amazing
LOVE the choice of colors, and the vibrancy of the piece! Gorgeous work!


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Based on the topics and statements provided by the participants before the event, a detailed curriculum will be created. Preliminary suggestions on the part of Rosa Luxemburg Foundation include the following:
• Debate and theoretical background on political participation;
• The presentation of examples for citizens' participation in infrastructure projects (e.g.
in Berlin's energy and water supply management), social work ("Kiezmütter") or
economic planning (citizens' budget for Berlin-Lichtenberg); • The debate surrounding direct democracy and public referenda, as well as alternative
constitutional committees;
• Citizens' participation in urban planning and the presentation of protest campaigns in
this field (Mediaspree, "Recht auf Stadt")
• Reports on the formation of student parliaments, on organizing student protests, as
well as on unemployed persons' parliaments and unions;
• Debates with representatives from unions and Germany's Die Linke party on
workers' rights, reduced working hours and minimum wages; introduction on human
rights campaigns such as the "Clean Clothes Campaign"; • Gender debates in politics and in the workplace, presentation of various feminist
• Migration and international solidarity ("Boats4People" campaign); • Strategies and techniques of mobilization, for increasing participation and for


text:
on November 14, 2013 - 12:01 AM
Killing family pet is a despicable act
I am utterly disgusted by the Sloan man who was charged with beating and shooting his dog. My heart breaks for this poor dog, who allegedly was viciously killed in his own home by someone who was his caregiver. I wonder if this was the first time? And it was witnessed by the poor son – something that child will never forget.
I'm so very tired of hearing the excuse that this happened because alcohol was involved. This man is more than old enough to take responsibility for his actions. Own up to it. If convicted, he should be banned from owning any future pets. He should also be evaluated by Child Protective Services. Hopefully the judge will sentence him to jail time, substance abuse classes, anger management classes, family therapy and a hefty fine. No animal should ever be treated like that.
Lynn Pasternak


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Spoilers: WWE Main Event Taping Results
There are probably about 4,000 to 5,000 fans in attendance. It's a good looking crowd, good sounding crowd already.
We're a month away from Mania 29 and they still play the Mania 28 video before events.
Dark Match
1. The Uso's defeated the Prime Time Players. The Uso's won with a double superkick and a Superfly Splash.
Michael Cole no longer uses Kerwin White's old theme. He comes out to more of a contemporary rock sound now
WWE Main Event
Wade Barrett introduced a clip to Dead Man Down.
1. Randy Orton beat Wade Barrett. Orton won with an RKO in a solid 10-12 minute match. The crowd was white hot for Orton.
2. Cody Rhodes beat Zack Ryder. Rhodes won a short match with CrossRhodes.
They are advertising that Brock Lesnar and Paul Heyman will answer Triple H's challenge Monday on Raw.
3. Sin Cara beat U.S. Champion Antonio Cesaro in a non title match. Sin Cara won with a Frankensteiner. A really good match with some exciting spots. Cesaro's thigh wraps are back. This concluded the Main Event taping.
Credit: Zach Zimmerman & ProWrestling.net


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|Boxing Champions | Boxing Schedule | Boxing Video | Boxing History | Pound For Pound | Lounge | The Wire | Arcade
Undisputed Champion
Join Date: Apr 2009
Posts: 3,209
Quoted: 647 Post(s)
Rep Power: 14
Points: 10,108,511.05
Bank: 0.00
Total Points: 10,108,511.05
I think I had the tools to be a pro or a very good AM, but I didn't have the right behaviour mentally, before the fights I was thinking too much about everything (who is watching the fight, who is my opponent, can he punch?) EXCEPT focusing on my fight.
My trainer always said, you have to focus on your fight, your performance, your game, not the guy you are fighting or the tards and *****es around the ring, he was right, but it's not easy.
So I often underperformed and lost when I shouldn't have, the funny thing is I did better in the hardest fights, and beat some good fighters.
Undisputed Champion
Join Date: Jul 2010
Posts: 1,682
Quoted: 0 Post(s)
Rep Power: 10
Points: 6,227.16
Bank: 73,626,851,565.12
Total Points: 73,626,857,792.28
after i graduated college i boxed for 6 months and had 1 exhibition match in front of a crowd. i naturally fought like mike tyson with the peekaboo guard but minus the speed and power. i wish i could have done it longer to try out a different style but i found a job don't have time for it anymore. i would love to go back to it though. i miss punching the bags.
My skin I get it
Join Date: Jan 2011
Location: Las vegas
Age: 22
Posts: 3,192
Quoted: 74 Post(s)
Rep Power: 12
Points: 100,000,001,480,110,912.00
Bank: 34,983,895,706,341,416.00
Total Points: 134,983,897,186,452,320.00
I boxed for 2 years before my accident and son was born I had good speed I had some pop enough to keep a guy honest but by no means a big puncher I was so athletic tho I just did a lot of thing wrong and made up for em with speed trying to be Roy jones lol it was my childhood fantasy lol but I had pretty go technique to just wish I would have stuck with it better and stayed training hard but I somewhat lost my devotion and winded up not caring but I still watch every fight I can and try to learn as much history as possible lol
Join Date: May 2012
Posts: 242
Quoted: 0 Post(s)
Rep Power: 0
Points: 107,972.46
Bank: 0.00
Total Points: 107,972.46
Undisputed Champion
Join Date: Dec 2010
Location: Espana
Posts: 7,133
Quoted: 631 Post(s)
Rep Power: 22
Points: 1,000,010,000,174,674.25
Bank: 0.00
Total Points: 1,000,010,000,174,674.25
SRR by Triangle Theory
Join Date: Jun 2004
Posts: 14,424
Quoted: 205 Post(s)
Rep Power: 19459
Points: 123,477.91
Bank: 612,654,255,996,954,624.00
Total Points: 612,654,255,997,078,144.00
Undisputed Champion
Join Date: Apr 2010
Posts: 2,977
Quoted: 0 Post(s)
Rep Power: 12
Points: 38,251,630.48
Bank: 0.00
Total Points: 38,251,630.48
I dont box but i've kickboxed and done some mma sparring , i mostly just train and compete in bjj now ..Anyway , i sparred a few times it's really fun. I had a good jab and head movement. One thing for sure , body shots are no fun lol. Any man that steps in the ring ( or the cage ) deserves all the respect in the world.
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text:
Discovering MyHeritage: start the family communication stream
News you want to share with your family? Messages? Announcements? Information?
Keep everybody on board sharing information that relates to you or any present or past member of your family, and write and record family history as you do it.
To keep a constant communication stream, use the bar right below the "Family news" headline in the family site home page. There you can write updates of anything you might by doing, thinking or planning, anything you want to tell others about, like how you like your new family dog!
Furthermore, discover all the possibilities that you can find in
the Activities tag in the main menu of your MyHeritage site. This tag works something like a "family communications center". Here is a brief introduction to its features:
* News articles: Find the Articles page and upload news of family interest. You can include attachments if you like for more details.
* Message boards: Enter messages of any kind. Ideal for quick announcements, small notes, even gossip! People are able to reply to your messages, so you can get feedback (you can set up email alerts when someone replies).
* Polls: Create a poll and leave certain family matters on the hands of the majority's decision. Which one was our best family holiday? Summer in the mountains? Christmas at the lake? The next one to come? Let everybody decide!
* Recipes: Develop the family cookbook uploading recipes. It's a great tool as someone is always asking for that recipe that have been running in the family for years. Have a look at our previous post about this feature for more details.
* Links: Share the websites you would like to recommend. The link to the travel agency that really worked for you, where to buy online nice and cheap baby's clothes, or even the most curious thing you've seen in the Web.
* Guestbook: Visitors can leave messages and say hello to everybody in the Guestbook page of your family site.
All the activity happening in these features will be constantly announced in the family site home page, so be sure that everybody will be on board.
And spread the word among your family about the possibilities in the "Activities" tag! Invite all to start a family communication stream that can help you strengthen the bonds and develop a real sharing community. That's what family is all about, isn't it?
Search for your ancestors:
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A homosexual raising heterosexuals? Meet siblings Seamus and Phoebe Bradfield!
Too often in the fight for equal rights, we hear the phrase "What about the children?" being passed around. This is especially the case in regard to opponents of marriage equality. Recently I had the privilege of interviewing Seamus and Phoebe Bradfield, two siblings who with their brother Cormac, were raised by their father who happens to be gay. He came out when they were children. Due to family issues the three moved in with their father.
For most of their childhood they were raised in a same-sex couple household. Knowing them personally I have had the privilege to interact with them on numerous occasions, and I won't lie, the love they have for each other and their father is something that most families would be lucky to have. I have never seen such a close-knit family and there is a lot many can learn from their example.We discussed growing up with a gay father, how it effected them as individuals and a family, and also what they thought of the current legislation that is in place here in Australia.
There are those who say gay parents only bring up gay children, and looking at the Bradfield siblings this is definitely not the case. They feel that they are just like any other family if not closer then most and feel due to the fact that they have been brought up by a gay father are far more accepting then most. The bond they have for each other is unbreakable and to put it quite simply, anyone who would dare accuse their father of being a bad parent for being gay, would definitely get a good serve from all three of the Bradfield siblings.
I wanted to interview this family for the simple fact that too often we hear same-sex parents are inferior next to heterosexual parents, and in the case of the Bradfields, this is definitely not the case. I feel these kind of stories are important for the film as this is yet another example of how even though their father might be gay, his love for his children is just like that of a heterosexual father, if not stronger.
Their story is just one of many featured in 'Love Like Yours'
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In Atlanta filming Devil's Knot, the actress popped into Bistro Niko where she had dessert first, and then ate quiche Parisienne.
"She was very cute," an onlooker tells PEOPLE. "She had cookies, madelines and hazelnut brittle, which seemed to hit the spot."
The tasty times continued for Witherspoon, who brought husband Jim Toth and kids Ava and Deacon with her to the Atlanta Fish Market on Sunday, where a dining guest says she approached the hostess desk with a "Hey y'all!" greeting.
The source says after eating sushi, Witherspoon's children entertained themselves by checking out the live lobsters in the restaurant's huge tank. As for the actress, she skipped sushi in favor of the restaurant's jumbo lump crab cakes.
– Jennifer Bradley Franklin
Spot a celebrity? Tweet us your sighting— People magazine (@peoplemag) August 7, 2012
@peoplemag with #CITA and it could appear on PEOPLE.com!


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Please browse through the routes/points, pricing pages to understand where you may want to plan to go down river and where you can plan to be picked up.
If you wish to contact us: Call 616-528-4077 or e-mail firstname.lastname@example.com to schedule a trip. Please visit our Facebook page.
We will be adding additional content to this website that will help you plan and entire day of recreation, if you wish. We will be adding information about walking/biking trails, parks. Maybe take a walk or bike ride before or after a ride down river. Maybe after paddling, maybe a meal and drink at a downtown restaurant or brewery is on order.


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Nordic Conference Reflects on Current and Future State of Wetlands
6 December 2011: An international conference on "The Future of Wetlands" brought together experts from several European countries, the Europarc Federation and the Secretariat of the Convention on Wetlands of International Importance (Ramsar Convention) to: reflect on the current state of wetlands and the failure to reach the 2010 biodiversity target; explore why wetlands are relevant; identify more efficient and sustainable solutions; and increase political commitment for the future.
The conference, held on 25 October 2011, in Helsinki, Finland, was organized by the Government of Finland with support from the Nordic Council of Ministers, the Ministry of the Environment and the Metsähallitus Natural Heritage Service.
According to the Ramsar Secretariat, the countries represented were Estonia, Finland, Iceland, Latvia, Norway, the Russian Federation, and Sweden. Participants heard presentations on: the achievements of and future challenges for the Ramsar Convention; how to put the "green" into green wetland economy; and the state of wetlands in Finland. The ensuing discussion focused on the ecosystem services that Europe's wetland infrastructure provides to societies. [Ramsar Press Release]


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UNCCD Invites Youth to Send Submissions on Their Views on Land
April 2012: The Secretariat of the UN Convention to Combat Desertification (UNCCD) has invited children and youth to submit their views on land, including on why taking care of the land matters and what youth are doing about it.
Submissions can take the format of: short video clips (less than 3 minutes) uploaded on youtube.com; pictures of field activities; and compelling articles of no more than 700 words. The best contributions from each region will be compiled and broadcast during the World Day to Combat Desertification, which will take place on 17 June, on the sidelines of the UN Conference on Sustainable Development (UNCSD, or Rio+20).
The theme of the 2012 World Day to Combat Desertification is: Healthy soil sustains your life, LET'S GO LAND-DEGRADATION NEUTRAL. This theme was selected in connection with the UNCCD's call for Rio+20 to agree on a target for halting land degradation.
Submissions must be sent to the UNCCD Secretariat by 11:59 pm GMT on 18 May 2012. [UNCCD Webpage]


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Telefunken U47 and U48
Telefunken U47 and U48 microphones with selectable polar patterns.
Welcome, Log in
Telefunken U47 and U48 microphones with selectable polar patterns.
Since its original development in 1946, the TELEFUNKEN U 47 has been the microphone of choice for generations of recording professionals. The first condenser microphone to offer selectable polar patterns (cardioid and omni), the original U47 also featured the famous M7 capsule which had been developed in 1928 by Georg Neumann. To this capsule was added an amplifier built from military surplus VF-14 tubes (they had been used in field and aircraft radios), and BV8 output transformer. The combination of these components created a sonic quality that was absolutely unheard of in the English speaking world of the mid-1940s when darker sounding, less detailed ribbon microphones were the standard. The introduction of the U47 brought a new level of fidelity to the audio world, and is still considered to be one of the finest microphones ever produced.
Upon first glance of the new U47 from TELEFUNKEN Elektroakustik, it's easy to see the "family resemblance." The large, chrome head grille houses our newly manufactured M7 capsule. Its matte nickel finished body houses a new BV8 output transformer and our new VF-14k vacuum tube; a "plug and play" replacement for the rare VF-14M tubes found in the original. The classic "TELEFUNKEN" diamond logo proudly adorns the front of the body tube. All of these accoutrements show that this microphone means business.
Whether you are recording a symphony, a "crooner," or any facet of modern music, you'll find a great tool in the U47. Its authoritative mid-range and extended low-end response dance from your ears... much as a vintage wine dances from the palate. Everything, from vocals to the loudest of guitar sounds, full on orchestral recording, beautiful backing vocal arrangements, or a chamber ensemble will benefit wildly from the rich and vibrant tone of this stunning microphone.
Find out why engineers, producers, and artists all over the globe have made the new U47 from TELEFUNKEN Elektroakustik their go-to microphone.
For more info, visit the Telefunken website: TELEFUNKEN Elektroakustik
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Single Article Purchase:
Evaluation of Right Hemicolectomy for Unexpected Cecal Mass
Riseman JA, Wichterman K.
Arch Surg. 1989;124(9):1043-1044.
Published online September 1, 1989
Choose criteria for pricing info
Want online access for an institution? Learn More/Request Quote >
Obtain AMA PRA Category 1 Credit™ by reading an article and completing an online quiz. Quizzes are available to AMA Members, subscribers, and those who have purchased tokens.


text:
About This Activity
J-Hawk Soccer Club Player Registration - Please contact the club for Scholarship needs - You can still choose to mail in our registration form - more information can be found on our website - www.jhawksoccerclub.com Please never hesitate to call or email with questions, email@example.com or Matt Carver, club president and director of coaching, or Renee Carver, the club registrar, at (h) 515-334-9061. J-Hawk Soccer Club Mission Statement: The J-Hawk Soccer Club exists to provide a low-cost, volunteer led and volunteer coached soccer experience to youth in the Urbandale community, where players learn the importance of citizenship, teamwork, positive attitude, effort, fundamentals, and sportsmanship, in a safe and welcoming environment. - J-Hawk Soccer Club Vision Statement: Our vision is to provide the highest quality soccer experience to all interested youth in Urbandale community, regardless of their financial means. - Character Counts Initiative – The J-Hawk Soccer Club is pleased to continue is focus on character development during the spring. We strongly feel that lessons regarding character are a key component in each player's development. - Jerseys – Reversible jerseys, shorts, and socks may be purchased at Soccer Connections, located at 3233 100th St. in Urbandale, telephone 515-270-8141. The combined cost of the full uniform is just over $30. - Please never hesitate to call or email with questions or recommendations, firstname.lastname@example.com or Matt Carver, club president and director of coaching, or Renee Carver, the club registrar at (h) 515-334-9061
Online DonationsClick here to donate to J-Hawk Soccer Club Booster Donations
Organizer Info
Map & Direction
Walker Johnston Park - lower fields 9000 Douglas Avenue Urbandale, IA 50322Get Directions


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As the title states, I'm stuck again. No walkthrough, console command, or series of button strokes for cheats will get me out of this dilemma, again. This time I've been "stuck" with yet another big green pixel right in the middle of my brand new LCD screen. Bad luck? The worst. Four out of four LCD flat panels I've purchased have had these "stuck" or dead pixels, and of course there are not enough to the companies eyes to warrant a return.
The last three were almost excusable. The pixels were located almost in the corners to the sides, this last one however, is right "dead" center of my display. It makes me furious. I'm not wealthy by any means, and I know that I'm certainly better off than many folks. It's not very often I can afford decent gifts for my family like this, and when it goes down like this I actually lose some sleep over it.
The UPS man stops by around 2:00pm ish, and I scurry to the door to greet him with the big box, giddy inside. I thank him and head to my significant others pc set up, rip the 3000lbs crt monitor off the desk and send it to the old barn with haste. After fetching the new LCD out of the box, and placing it on her desk, everything was ready, and I fired it up. Hit the power button, and grabbed a cig off my desk, to come back to see the pretty windows 7 logo, and a great big fat green pixel just to the left of it! Horror, hate, anger, fear! Oh shit, if I were force sensitive, there would be a dark lord at my heals about to snag a new apprentice, I pushed it away.
The significant other finally gets home, I was at the first of the day filled with excitement, now I don't know what it is, self pity? Naa, embarrassment? Nope not quite right. Just plain old bad I guess. She does her routine, and finally heads to her pc to do her usual, and sees the new display, and of course the same feelings I had at the beginning of the day were visually present. Then she starts it up. I know she saw it, I know she felt worse for me than she did for herself, but she didn't say a word. I didn't prod her because I knew, that she knew, I already felt like shit about the entire ordeal.
Well, that's my story. What do you folks think? It pisses me off right to the core when these manufacturers tell me that my display is fine, and is only considered defective with 5, or 8 or however many said company states to be defective. But a big green gleam'r right in the middle of my screen, thats pretty obtrusive.


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Marmot Variant Vest - Men's
Where to Buy
Retailers' Descriptions
Here's what other sites are saying:
Wear the insulated, stretchy Variant vest on climbing excursions, ski trips or other cold-weather adventures where core warmth and mobility are key.
On Sale. Free Shipping. Marmot Men's Variant Vest FEATURES of the Marmot Men's Variant Vest Thermal R insulation Polartec power stretch in back Zip hand pockets
- Moosejaw
Marmot Men's Variant Insulated Vest - The Variant Vest from Marmot promotes the simple core values of weather-resistant warmth and mobility. Nylon ripstop shell fabric and Thermal R insulation protect your torso, while Polartec Power Stretch in back offers plenty of give, creating a surprisingly warm garment that never feels bulky. Thermal R is a unique combination of multi-channel and hollow fibers designed to provide maximum warmth while reducing the adverse effects of perspiration, condensation and humidity. The fine multi-channeled fiber transports away moisture while the hollow fibers provide excellent loft with minimum weight. This insulation is resilient with an excellent warmth to weight ratio. The durable Power Stretch outer layer is wind- and abrasion-resistant while the soft inner layer pulls moisture away from your skin keeping you dry, warm and comfortable. The Marmot Men's Variant Vest will soon be your favorite piece of gear for cold weather, high energy activities.
- Outdoorplay
The Variant's core values are simple: weather-resistant warmth and mobility. Nylon ripstop DWR-treated shell fabric and Thermal R(TM) Eco insulation protect the torso; Polartec(R) Power Stretch in back offers plenty of give. The vest has an elastic drawcord hem, making heat retention a cinch.
- Rocky Mountain Trail
The versatile Marmot Men's Variant Insulated Vest adds core warmth to any activity from winter skiing to summer climbing. Thermal R is Marmot's go-to synthetic insulation for high-endurance sports, and Polartec Power Stretch ensures total mobility whether you're hiking up a mountain or snowboarding down it. The double ripstop shell provides double the durability without the weight, and an athletic fit helps you layer shells over the Variant with ease.
- Backcountry.com
Marmot Men's Variant Vest
currently retails for:
$63.00 - $139.95
$63.00 - $139.95


text: Login| Account| 0 items in cart Home » Store FEATURED PRODUCT The End The end times have seen a great amount of interest within the last two decades, but there hasn't been a comprehensive overview of biblical prophecy and eschatology for more than five decades. This book will provide a solid biblical foundation for Christians to explore the essential truths around this topic—the end of the world. Purchase Popular Resources Feasts of the Bible Celebrating Biblical Feasts In Your Home or Church The Fall Feasts of Israel All orders are transacted in the United States and ship from San Antonio, Texas. Added donations are placed into our General Fund to be used for missionary support and ongoing ministry expenses and will be receipted from the United States. To make a donation to our Canadian ministry, please visit: http://give.cjfm.org Browse by Format Bimonthly paperBooksCalendarCDsDVDsGentile TractsJewish TractsGiftsPostersStudy Guides Browse by Topic Dr. Gary HedrickDr. Charles HalffMessianic PerspectivesCJFM ResourcesAnti-SemitismApologeticsBiblical Archaeology & HistoryBiblical LanguagesChristian Living FaithCommentariesDiscipleshipDispensationalismHermeneuticsJewish BelieversJournalsJudaicaMessianic StudiesMiddle East StudiesProphecyReferenceSalvationTheology, Doctrine, & Bible StudyDVDsMusicTracts & Other Items Help & Information Your Account Returns & Exchanges Contact Us Privacy Policy USA (800) 926-5397 CAN (866) 232-3353


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You've set up your budget, paid off debts, and started saving for the future – both for yourself, and for your children's education. So what's left? The one remaining debt you thought would hang over your head for years and years to come – your mortgage. It may seem like an impossible feat, but there are ways to pay off your home years before the end of your loan. Increase your payment. It can be as simple as rounding up from $846 to $850 or even $900 each month. Not only will the added payments help chip away at your total principal amount, but the more of your mortgage you pay down each month, the more goes toward principal instead of interest. You could easily shave a few months off the life of your loan just by rounding up a few dollars each month. Make extra payments. If you receive extra income such as a holiday bonus, commission check, or even your income tax return, put it toward your mortgage. Make sure any extra payments you make will go toward principal only, and also check for any penalties for early repayment of your loan. There will be time to spend it on splurges like a vacation when your house is paid off! Pay bi-weekly instead of once a month. If you pay half your mortgage every two weeks, instead of once a month on the due date, you'll actually make one extra payment each year. Over time this can shave about six years off a 30-year mortgage! Again, you'll want to be sure bi-weekly payments are allowed in the terms of your loan and that your extra payment will go toward the principal amount. Refinance your loan. If you have a standard 30-year fixed mortgage, you may be able to refinance with a 15-year loan and only pay a slight bit more each month. Several factors come into play in this scenario, but WPCU's mortgage originators will show you sample payments and options.
If you're ready to take the next step, meet with a member of WPCU's mortgage team at your Member Center to see which option may be the best for you. Our experts can help you on your way to being totally debt free! Call (937) 912-7000 to schedule your appointment today!
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Add a Little Sequin to Your Holiday WardrobeLiz Stanley
This season it's all about sequin, glitter and metallics. On my own blog today I posted about some favorite metallic bags and clutches but I'm really crushing on this gold sequin top. You could pair this beauty with practically anything and be instantly party ready (bonus: it's under $35!). Keep reading to see where to get it…
Find it here at H&M for $34.95
Article Posted 5 years Ago


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Truth in Advertising
Uploaded 09/15/2011
In chat the other day I suddenly got to thinking about old advertisements and how they try so meticulously to skirt the real issues - especially when it comes to cleaning products and what consumers REALLY need them for.
Remember the old Stick-ups commercials? The air freshener you just peel the back off of and stick to any counter or wall for long-lasting freshness? Those commercials are among the first that come to mind here, when I talk of truth in advertising.
A lady goes into the bathroom and a gigantic pile of mildew rises up like a tsunami wave. Of course, that's not what we're REALLY trying to conquer when we think of bathroom odors. If this bitch were that much of a stickler when it came to housekeeping, her towels and sink and tub would be gleaming on a weekly basis.
No, what we need some extra bleach/air freshening power for are those everyday odors and germs NO ONE ever wants to talk about in commercials, yet are the very cardinal reasons we look to purchase those products.
Hell, if you disclosed that within the advertisement, peeps would probably be a lot more likely to run out and stock up on this shit to begin with. Let's drop the mildew and mold encroachment and show some typical cleaning housewife talking about what's REALLY bugging her:
A coach steps into the locker room and a gigantic smelly sock busts out of the locker to suffocate him. Come on, now - a team of athletic males palin' around the locker room and you're worried about a fucking sock or two?? Just go the distance already and show a huge ballsac swingin' from the ceiling:
What? Is that a bit too embarrassing for manly men, for the real cause of their disgusting stank to be revealed? Keep on telling the masses it's all about a few socks and sneakers, and we'll let them continue to wonder why chicks prefer not to go down on them.
But of course, it's always o.k. to have about 50 vaginal itch / yeast / stank commercials in a row, which I personally blame for the multitude of smelly puss jokes out there, while peeps think it strange I always complain about disgusting nutsacs and how the city bus smells like a penis - as if they have NO clue what it's about.
Yes... for once I'd like to see a male hygiene product on TV, like all-new "Sak Spritz" or some shit like that.
In the meantime, I love to laugh at commercials, and the guessing game peeps have to play when it comes to how well this shit might REALLY take care of what you'd buy it for - unless it comes to the mother of all problems, which is apparently the female genitalia, of course. So I'm inviting anyone to make a cute fake advert for some bullshit product for the truth in advertising theme here, especially since I'll probably make more myself as the days go by.


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Thanks, everyone, I'll hang in there.
Eating crap, I felt fine. Giving up grains, legumes and sugar, I feel like crap. And it isn't the "carb flu" that others describe; it's just this stupid bloating and gas pain that's been pretty constant for the last few days. Not sharp pains, just that uncomfortable feeling of pressure, like I literally have a balloon in my belly. No constipation. No diarrhea. No headaches or nausea or body aches. No fatigue.
I'm not worried about losing weight in a hurry, I figure that will come with time. I just don't want to feel bad as a result of eating in a way that is more healthy than the way I was eating.
If it helps, the type of diet I ate before my foray into PB was basically PB but with added junk. I already ate butter. I already drank full-fat milk. I already ate fatty cuts of steak like Ribeye. I already ate leafy green veggies. I already fried my eggs in coconut oil. I already ate full-fat homemade yogurt. I already ate bacon. My body was used to that stuff already. So the only thing that has changed in my diet was getting rid of breads, chips, cereal, root beer, candy, desserts, pasta, peanut butter. I haven't added anything, I've just taken things away.
I could understand the tummy trouble if I was bombarding myself with all kinds of new foods, but I'm not. It just seems counterintuitive that eliminating foods that are supposed to make me feel bad but never actually did is causing me to feel bad eating foods that never caused me problems before.
So what have I been eating the past week? Lots of eggs. Pork sausage. Salad with lots of fatty dressing (olive oil based) and chicken. Maybe an apple a day. Milk. Ground beef stir fry with bean sprouts, garlic, cabbage and onions flavored with tamari and Chinese 5 spice powder. Pork chops fried in coconut oil. Tonight it's shrimp scampi drowned in butter and garlic, sans the spaghetti. Yogurt with some frozen raspberries. All stuff I ate before, just minus the toast, the croutons, the rice and the pasta. Didn't bother me before, but now it does.
I guess what I'm saying is I don't want to end up having to give up milk too. And cheese. And tomato sauce. And cabbage. And onions. And potatoes. And fruit. Just to feel better when I felt fine before I even thought of PB. I want to be healthy, and I do want to lose weight, but I also want to feel healthy.
Dmac24 wrote:
Convince yourself with science and facts
The fact is I don't feel good, regardless of what the science says I should be feeling. That's my frustration. I guess I expected too much too soon, but reading over all of the PB success stories it's difficult not to have high expectations. Since I already felt fine I didn't expect to feel tons better, but I certainly didn't expect to feel worse--I just expected to lose some weight and miss bread in the process. I'll scale my expectations back a bit. Patience is not something I do well, obviously. It's only been 5 days. It's only been 5 days...
No one has mentioned that they had this gas/bloating issue when starting PB, or how long it lasted, so I guess I'm unusual. I know I'm being a baby about it, and if it only happened for say, an hour after dinner, I don't think it would bother me. But it's all day for the last three days. I'm getting tired of it.
But I'll stick with it and hope it goes away, and when/if it does, I'll be sure to update. In the meantime, I'll take all your kind words of encouragement to heart.


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Forget His Binders Blunder, Romney's Record on Hiring Women Speaks for ItselfKatie Allison
As the mother of three daughters aged ranging from toddler to teenager, my interest in how the two men currently vying for the U.S. presidency express their views on women's issues is fundamental to how I will cast my vote. Issues such as equal pay, personal reproductive freedom, and sexual harassment and violence against my gender matter to me not just because I am an American woman, but more importantly, because I am raising three American women.
While there are certainly many other distinct differences between the various economic, social and political positions espoused by Governor Romney and President Obama, the candidates' divide on issues of specific concern to me as a feminist mother is particularly stark. Examples: President Obama is pro-choice, while I believe that Governor Romney's election would pose a threat to my reproductive freedom, and to that of my girls in the future. Governor Romney has also promised to withdraw public funding for Planned Parenthood, an organization which I believe serves a profoundly important role in meeting American women's healthcare needs. Additionally, President Obama in 2009 signed the Lilly Ledbetter Fair Pay Restoration Act, while Governor Romney's campaign has made clear that had he been president when the Ledbetter Act was ready to be signed, he wouldn't have put (ceremonial) pen to paper.
These political issues and others like them are the ones that I care about in a very personal way. But you know what I don't care about? Not even one tiny little bit? I don't care that candidate Romney inadvertently dropped a word or two out of a single sentence during last week's debate with President Obama, although much of the country seems a bit obsessed with Romney's minor, tongue twisted screw-up.
Here's what Gov. Romney said
"…we — we took a concerted effort to go out and find women who had backgrounds that could be qualified to become members of our cabinet.
I went to a number of women's groups and said, "Can you help us find folks," and they brought us whole binders full of women.
I was proud of the fact that after I staffed my Cabinet and my senior staff, that the University of New York in Albany did a survey of all 50 states, and concluded that mine had more women in senior leadership positions than any other state in America."
Yep, sure enough, Governor Romney stumbled, misspoke, tripped up — call it what you will — when he referred to "binders full of women" while giving a conversational-style, narrative answer to a question, when what he clearly meant to say was, "binders full of women's resumes," or "binders full of resumes from women." However, in the heat of the nationally televised moment, he messed up and instead bumbled out an admittedly amusing turn of phrase.
While I don't consider his verbal stumble substantive in any way, I totally do get that Gov. Romney's accidental "binders full of women" remark offered an irresistibly meme-worthy moment during the debate, not to mention one that seemed tailor made for social media fun. But while it was entertaining, Romney's blunder wasn't remarkable. In our modern American political landscape, just about every televised presidential debate series has managed to produce its own iconic meme moment – be it humorous or quirky or incisive.
For example, back in 1980, candidate Ronald Reagan cut his opponent, Walter Mondale down to size with, "There you go again," But then in 1988, Walter Mondale caught the meme wave himself when he asked Gary Hart, "Where's the beef?" (In that same debate, Mondale stumbled and announced that he planned to "stand up FOR special interest groups," when he obviously meant to say "against." The audience erupted into laughter.) In the 1988 vice presidential debate, Lloyd Bentsen created an instant classic of a put-down when he haughtily dismissed Dan Quayle with, "You're no Jack Kennedy." Then there's my personal favorite — Admiral James Stockdale's opening statement in the 1992 VP debate in which he asked of no one in particular, "Who am I? And why am I here?," while in the 2000 presidential debates, we heard about Al Gore's now SNL-famous "lockbox."
And now, this time around we have Romney's "binders full of women." It's an inarguably funny visual, so I understand the initial chortling all over the Web, but if pundits and voters can get past the funny to the context in which Gov. Romney made his verbal fumble, they will realize that what he was actually saying isn't really very funny at all. In fact, in my view, it's rather concerning. And while I love a good pop culture snarkfest as much as the next Gen X mom, gender equity issues in the workplace as expressed by the guy who wants to be Your Next President are really too important to be reduced to nothing more than a clever Tumblr or a trending Twitter hashtag. The words that candidate Romney did manage to get out as intended during the second presidential debate deserve a closer look.
Looking beyond the single word he dropped ("resumes"), Gov. Romney was making the claim that at the beginning of his tenure as Massachussetts' governmental CEO, the issue of equal representation by women in his new administration was so very important to him that he specifically directed others to identify a sufficient number of potential female candidates for his cabinet consideration. During the debate, Gov. Romney made this specific claim enthusiastically and assertively, as if it mattered a great deal to him that we voters recognize his commitment to women's representation as a fundamental part of his management style.
Now I don't know about you, but this whole scenario that Gov. Romney so energetically described in answer to a question about fair pay for women sounded odd… downright weird even — far weirder than his awkward , single " binders full of women" slip of the tongue. Remember, Mitt Romney didn't take office in 1972, he became governor of Massachusetts in 2002. Is candidate Romney saying that in the year 2002, after having spent an adult lifetime operating within multiple spheres of business and politics, he wasn't well acquainted with enough professional peers of the opposite gender to staff his higher level cabinet positions without asking for those now-infamous binders full of potential female candidates? Most governors take office with a pretty clear idea of whom they'll be putting in place in these key positions, offering the coveted slots to both men and women pulled from the newly elected governor's own network of political, personal and professional contacts. If Gov. Romney's network truly included so few women that he needed other people to go out and find enough qualified female candidates for him to consider, well, that says something to me – something far more notable than his accidentally hilarious verbal fumble .
As it turns out, Governor Romney actually didn't ask anyone to bring him the binders full of women, as he assertively claimed in the debate. In fact, he passively allowed them to be presented to him by a non-partisan, Massachusetts women's political group seeking to raise the number of women working in higher levels of state government. Once pressured to consider hiring women, and with those damn binders on his desk, Governor Romney did indeed tap multiple women to fill cabinet roles, but I'm left wondering what his administration would have looked like without the pressure from the external women's caucus to hire both genders.
Perhaps it would have looked something like the senior leadership team at Bain Capital, the private equity firm which Romney founded and headed up until the late 90s. Bain did not have a single female partner until after Romney left in 1999. Yep, you read that right; not one single woman made partner at Romney's own company for the entire time he served as CEO. And again, this wasn't in some distant era, this was in the '80s and '90s.
As we head into the final weeks of this important presidential contest, I'm ready to stop hearing the jokes about candidate Romney's meaningless verbal snafu. That meme's 15 minutes are more than up by now. Instead, as a mother, a feminist and an American, I'd like to see our national conversation become less fixated on the word or two that Gov. Romney failed to utter, and more animated around the concerning words that he DID say that night.


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public void printReport(String name, List stuff, PrintService printer) {...}is (to me) far better than
public void printReport(String name, List stuff) { ... PrintService.getInstance().print(name, stuff); }The obtaining of the reference to PrintService is buried in the method, with no indication in the method signature that it was needed. It also makes things much harder to test. If I have a parameter, I can substitute any other implementation of the same interface (ie. MockPrintService) easily. If it's a singleton, I cannot prevent the code trying to use the production implementation. -- DarrenHobbs
class ObjectUsingPrinter { public: ObjectUsingPrinter(Printer printerToUse= PrinterService::Singleton()); }This way it can be clearly defaulted and UnitTested without every subsystem in the entire system knowing how to bind to a printer. In my world, though, a singleton is a service access point and most cases will not create the object. It is instead set by some context that knows how to resolve the default printer against all the possible selection mechanisms. -- AnonymousDonor
class SingletonWithinContext? { class Holder { Holder(context) { instance = instantiateForContext(context); } SingletonWithinContext? instantiateForContext(Context c) { if (c instanceof TestContext?) { // do this... } else { // to the other... } } ...... }One could go a step farther and say that any class requesting a singleton instance would pass itself as a context. The instance instantiated would be dependent on the class type (or inherited type) of the caller. The Context type would be nothing more than a marker class, with not methods or fields. If, later, you determine that a different singleton instance is needed for a caller, change the callers Context base type. Which singleton instance is instantiated can be based on a Mapping of Context type to Singleton instance type. -- JeffLowery