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1 de Vos et al. Implementation Science (2015) 10:95 DOI /s Implementation Science RESEARCH Open Access A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care Maartje L. G. de Vos 1,2, Sabine N. van der Veer 3, Bram Wouterse 1,4, Wilco C. Graafmans 5, Niels Peek 9, Nicolette F. de Keizer 3, Kitty J. Jager 3, Gert P. Westert 6 and Peter H. J. van der Voort 7,8* Abstract Background: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards. Methods: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs. Results: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), ) or compared to control group (OR 0.67; 95 % CI ). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI compared to baseline and OR 0.65; 95 % CI compared to control group). Conclusions: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up. Trial registration: ISRCTN: ISRCTN Keywords: Multifaceted feedback, Critical care, Quality improvement, Bed occupancy, Nurse-to-patient ratio * Correspondence: 7 Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands 8 TIAS School for Business and Society, Tilburg University, Tilburg, The Netherlands Full list of author information is available at the end of the article 2015 de Vos et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
2 de Vos et al. Implementation Science (2015) 10:95 Page 2 of 9 Background Organizational aspects are associated with clinical outcomes in the intensive care setting. A low nurse-topatient ratio is associated with unfavorable outcomes [1 5]. In addition, several studies show that a high bed occupancy rate is associated with an increased mortality and also with an increased refusal rate for new appropriately referred patients [6 8]. The bed occupancy rate and the nurse-to-patient ratio are not only relevant clinical issues but also important management tools as they are related to efficiency and costs of intensive care departments [9]. Based on these arguments, national and international societies published guidelines that include recommendations on bed occupancy rates and nurse-to patient ratios [10, 11]. The adherence to these guidelines intends to improve the efficiency and efficacy of intensive care treatment. It is, however, well known that the adherence to guidelines in clinical practice is, in general, limited and improvement in the adherence to guidelines is hard to achieve. Several factors that limit guideline adherence can be distinguished [12]. Performance feedback is a well-established tool to facilitate guideline implementation and to improve the adherence to guideline recommendations. It was shown that feedback reports combined with other strategies as part of a multifaceted intervention were more successful than feedback reports alone [13, 14]. In addition, performance feedback was especially effective in improving the clinical processes of care [14], but data on organizational aspects is lacking. In the intensive care setting, several studies addressed the impact of multifaceted feedback on clinical processes [15 17]. However, no studies concerning multifaceted feedback for organizational standards in the critical care setting are available. Based on these arguments, we conducted a cluster randomized controlled trial (RCT) among Dutch intensive care units (ICUs) to study the effect of a multifaceted feedback intervention on the adherence levels to guideline-based organizational standards, in particular bed occupancy rates and nurse-to-patient ratios. Methods Context: organizational standards for intensive care in The Netherlands All Dutch ICUs are closed-format and the majority has an intensivist on call 24 h a day [18]. In 2006, the Dutch Society for Intensive Care (NVIC) developed an evidence-based guideline. This guideline focused on the organizational aspects of intensive care and incorporated several standards [10]. One of these standards is that the bed occupancy rate during a shift should not exceed 80 %. Another standard is that within a shift, no more than two patients should be assigned to one ICU nurse (i.e., a nurse-to-patient ratio of at least 0.5). Both standards were based on evidence that showed crossing these thresholds leads to unfavorable patient outcomes measured as mortality or complication rates. To ensure that the guideline s target users, the intensivists, agreed with the standards, the guideline was formally endorsed in a general assembly of the society members. In addition, subsequent to guideline publication, two performance indicators were introduced to monitor adherence to the two standards, one related to bed occupancy and one regarding nurse-to-patient ratio [19]. These indicators were part of a set of 11 structure, process, and outcome indicators [20]. Data of these indicators were collected in the Dutch National Intensive Care Evaluation (NICE) quality registration [21]. ICUs participating in this national registry received a standard quarterly benchmark report on all indicators, including the adherence to these two standards, as a part of the regular service. Multifaceted feedback intervention (InFoQi program) The intervention strategy was an improved NICE feedback reports containing data on 11 indicators. These feedback reports were extended by incorporating the results of a barrier analysis of NICE participants and systematic literature reviews [13, 14, 22]. One of the identified barriers showed a lack of confidence in data quality of the feedback reports. In addition, difficulties in the interpretation of the feedback report hampered quality improvement (QI) activities [22, 23]. The systematic reviews suggested that feedback might be more effective when provided at least monthly in both written and verbal form, when it is combined with the development of a QI plan, and when the feedback has an educational component [13, 23]. Based on this analysis, each intervention ICU during 1 year (1) received monthly and quarterly feedback reports, including information on adherence to the two organizational standards, (2) established a multidisciplinary QI team, (3) received two educational outreach visits. Figure 1 (left side) graphically displays the intervention; a detailed description was published elsewhere [24]. The intervention did not provide explicit tools for professionals to improve bed occupancy rate or nurse-to-patient ratio. The monthly report focused on the ICUs own adherence to the standards over time. For example, run charts with occupancy rates per nursing shift three times daily were provided with the 80 % standard visualized as a red horizontal line. The extensive quarterly report focused mainly on comparing an ICU s adherence level with a benchmark, which was the average adherence level of a group of comparable ICUs. For example, box plots summarizing the nurse-to-patient ratio per week for an individual ICU compared to other ICUs with a similar volume of admitted patients with the guideline-based standard of 0.5 are clearly projected. The monthly reports and the extensive quarterly benchmark reports also contained
3 de Vos et al. Implementation Science (2015) 10:95 Page 3 of 9 Fig. 1 Elements of the multifaceted feedback intervention (InFoQI program) and the quarterly standard feedback reports in the control group information on four other clinical indicators next to the two organizational indicators. For the remaining five indicators of the set of 11, no intervention was defined. In each intervention ICU, a multidisciplinary QI team was formed with at least one intensivist, one nurse, and a representative of the ICU management. They had to be available for a minimum of 4 h per month to perform study activities. We suggested adding a data manager as an additional member of the QI team. The teams main tasks were to discuss the feedback in a monthly meeting, to formulate a local QI action plan, to initiate and evaluate QI activities, and to share the results with their colleagues. Finally, each ICU in the intervention group received two educational outreach visits by two study investigators (MV and SV). The visits aimed to increase the confidence in data quality, to facilitate correct interpretation of data that was presented in the feedback reports, to translate these data into QI initiatives, and to identify opportunities for improvement. The ICUs in the control group did not receive any of these interventions except the quarterly standard benchmark reports (Fig. 1, right side). Study design In a clustered RCT, the hypothesis was tested that ICUs receiving the multifaceted feedback intervention improved their adherence to the two organizational standards more than ICUs receiving standard feedback reports only. Dutch ICUs were randomized to either the intervention or the control arm [24]. The Institutional Review Board of the Academic Medical Center (Amsterdam, The Netherlands) in accordance with Dutch and European legislation deemed formal IRB approval and patient consent was not necessary because the intervention did not directly involve patient care. The trial was registered at Current Controlled Trials (www.controlled-trials.com; ISRCTN ). The study results are reported according the CONSORT statement for cluster randomized trials [25]. In- and exclusion criteria ICUs were eligible to participate in the study if they were planning to participate in the Dutch NICE, which included monthly submission of indicator data to the database. ICUs were excluded when they were not able to allocate resources to perform necessary study activities
4 de Vos et al. Implementation Science (2015) 10:95 Page 4 of 9 such as establishing a local multidisciplinary QI team. The medical managers of all participating ICUs signed a consent form to formalize leadership support. Study endpoints The primary study endpoints were defined as the following: (1) Adherence to the standard for ICU bed occupancy rate. The ICU bed occupancy rate was defined as the proportion of shifts with a bed occupancy rate 80 % or below (with lower proportions implying higher adherence levels). We calculated bed occupancy rate as the maximum number of patients simultaneously treated on any moment during an 8-h nursing shift divided by the number of operational beds in that same shift. A bed was defined as operational when monitoring and ventilation equipment as well as nursing and medical staff is available. (2) Adherence to the nurse-to-patient ratio of 0.5 or above. A higher proportion of nursing shifts with a ratio above 0.5 implied higher adherence levels. The nurse-to-patient ratio was calculated by the maximum number of patients simultaneously present on any moment during an 8-h nursing shift divided by the number of registered qualified ICU nurses in that same shift; student-nurses were not included in this calculation. Randomization and blinding Allocation was based on a stratified randomization with a block size of four. ICUs were stratified by patient volume (more/less than the national median number of ventilated, non-cardiac surgery admissions) and whether they had participated (yes/no) in a pilot study to evaluate feasibility of indicator data collection [19]. An independent researcher blinded to group assignment generated the allocation list using a computer-generated randomization scheme. It was impossible to conceal study arm allocation from participating ICUs or from those providing the reports or outreach visits due to the nature of the intervention. Data collection The total study period lasted 16 months starting at randomization to 3 months after sending the last feedback report. These 16 months consisted of a 2-month runin period, which was the period between randomization and the first outreach visit, directly followed by 14 months of follow-up. The study period for control ICUs was equally defined as a run-in period for the first 2 months after randomization with a follow-up period of 14 months. The data were collected locally by the participating ICUs and uploaded monthly to the national database. The data were commonly recorded per nursing shift using dedicated software. The data included admission and discharge times and dates of individual ICU admissions, the number of operational beds, and the number of qualified nurses per shift. The ICU bed occupancy rates and nurse-to-patient ratios per shift were centrally calculated from the uploaded raw data. The NICE registry assured the quality of submitted data by means of periodical on-site data quality audits and automated data range and consistency checks [21, 26]. Data on QI activities in the intervention ICUs were extracted from the local QI action plans as formulated during outreach visits. Immediately after inclusion in the study, we interviewed one representative per participating ICU by phone to record whether their unit had any QI infrastructure available (e.g., a quality manager), and how they handled the standard quarterly feedback reports at study baseline. We repeated this interview at the end of follow-up. Statistical analyses The unit of analysis was the individual nursing shift. Each ICU had three nursing shifts per day. The effect of the intervention on the proportion of shifts with a bed occupancy rate below 80 % was analyzed with logistic regression analyses. We used generalized estimation equations with an autoregressive correlation structure to account for clustering of shift occupancy observations within ICUs. The same procedure was followed to analyze the proportion of shifts with a nurse-to-patient ratio above 0.5. The change in proportions was analyzed by testing for the effects of group (intervention versus control), study period (baseline versus follow-up), and the interaction between group and study period. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs. In addition, the ratio of these ORs for improvement at follow-up (OR intervention/or control) was calculated [27]. This ratio of ORs should be interpreted as the OR of changes at follow-up in the intervention group adjusted for changes at follow-up in the control group. A ratio of ORs > 1 implied that improvement at follow-up is larger in the intervention group than in the control group. In all analyses, we adjusted for covariates defined as type of shift (day, evening, and night) and seasonal fluctuation in admission levels by including calendar month dummies for both indicators. In addition, to adjust for differences in organizational structure between the study arms, we used two covariates on the ICU level. In the analyses for the bed occupancy rate, these two covariates were availability of an emergency bed (yes/no) and hospital type (academic or teaching/non-teaching). For the nurse-to-patient ratio, the covariates we added were the proportion of newly admitted mechanical ventilated patients and hospital type.
5 de Vos et al. Implementation Science (2015) 10:95 Page 5 of 9 To account for correlation between the two study endpoints, we performed a secondary analysis in which we added nurse-to-patient ratio as an additional covariate in the analysis for the bed occupancy rate, while also adding bed occupancy rate as a covariate in the analysis for the nurse-to-patient ratio. Sample size calculation To determine the minimally required number of ICUs completing the trial, we used an analysis of the NICE registry data from 18 ICUs in First, we ranked these 18 ICUs by the percentage of shifts with a bed occupancy rate exceeding 80 % (i.e., failure rate). We than applied the achievable benchmarks of care method to determine what would be an achievable improvement by calculating the difference in failure rate of ICUs in the upper half of the ranking (23 %) and the failure rate among all units (44 %) [28]. This amounted to an absolute reduction of 21 %, corresponding to a relative reduction of 48 %. Calculations based on the Binomial distribution showed that we needed 23 ICUs to detect this difference with 80 % power at a type I error risk (α) of 5 %. In this calculation, we took into account an intra-cluster correlation of 0.28, which we estimated from the 2008 national data. We used SPSS version 16.0 for all statistical analyses. Results Participating ICUs From the 78 ICUs that submitted data to the national database, 46 ICUs were preparing to collect and submit the organizational indicators concerning bed occupancy and nurse-to-patient ratio. Thirty of these 46 ICUs provided consent to participate in the study. Fifteen units were assigned to the intervention arm and 15 to the control arm (Fig. 2). The ICUs were included consecutively between January 2009 and November Two ICUs from the intervention group were excluded from analysis and four from the control group because they failed to provide valid data throughout the study period. Finally, 24 ICUs were included in the analyses, Fig. 2 Flow diagram of ICUs and shifts through the trial. ICU intensive care unit, NICE National Intensive Care Evaluation, QI quality improvement
6 de Vos et al. Implementation Science (2015) 10:95 Page 6 of 9 with a total of 33,582 nursing shifts for bed occupancy and 33,655 shifts for nurse-to-patient ratio. Table 1 presents the baseline characteristics of the included ICUs and shifts. Effect of the multifaceted feedback intervention Over the study period, the multifaceted feedback intervention showed no effect in the study end points compared to standard feedback reports alone. Table 2 shows the decline in the proportion of shifts with a bed occupancy rate below 80 % compared to baseline for intervention compared to control ICUs (OR, 0.88; 95 % confidence interval (CI), ). The proportion of shifts with a bed occupancy rate below 80 % is higher in follow-up compared to baseline for the control ICUs, but the ratio of change during follow-up between intervention and control ICUs was not statistically significant (ratio of ORs, 0.67; 95 % CI, ). The proportion of shifts with a nurse-to-patient ratio below 0.5 showed a non-significant reduction during follow-up compared to baseline for intervention ICUs (OR, 0.72; 95 % CI, ). The ratio of change in intervention versus control ICUs was not statistically significant (ratio of ORs, 0.65; 95 % CI, ). The secondary analyses in which the additional covariates were added did not change the final conclusion. Quality improvement activities All intervention ICUs established a QI team and received two educational outreach visits. Variation in the number of initiated QI actions during the outreach visits varied between ICUs, ranging from zero to four actions aiming to improve bed occupancy rate, and zero to ten actions related to increasing nurse-to-patient ratios. Table 3 shows examples of QI actions; most QI actions investigated the quality of the data and the low adherence to the guideline standards, rather than changes in the processes of resource planning. During the study period in the control group, two ICUs established a local QI team, while in one ICU, this was discontinued. In addition, four control ICUs reported to have started using the standard quarterly benchmark reports. Discussion This study shows that the intervention with extended feedback reports, QI teams, and educational outreach visits did not lead to a significant improvement in the adherence to guideline-based standards for bed occupancy rates and nurse-to-patient ratios in the Dutch intensive care setting compared to standard feedback reports alone. To our knowledge, this is the first study that evaluated the effect of a multifaceted feedback intervention on the adherence to organizational guidelines in Table 1 Baseline characteristics of participating ICUs and included shifts in the InFoQI program Intervention Control ICU level characteristics Number included in analysis Academic or teaching hospital 9 5 Cardiac surgery center 2 2 Emergency bed available 8 8 Participated in indicator pilot study 5 3 Shift level characteristics Number included in analysis Bed occupancy rate 18,063 15,519 Nurse-to-patient ratio 18,061 15,594 Number of operational beds a 13.6 (8.1) (7.7) Bed occupancy rate a 75.6 (2.0) 79.5 (2.2) Percentage of shifts adhering to standard for bed occupancy rate b 50 % 43 % Number of qualified nurses a 7.1 (4.5) 6.6 (5.5) Nurse-to-patient ratio a 0.72 (0.3) 0.69 (0.3) Percentage of shifts adhering to standard for nurse-to-patient ratio 76 % 74 % ICU intensive care unit, QI quality improvement Values are mean (standard deviation) of day, evening, and night shifts together Expressed as the proportion of shifts with bed occupancy rate below 80 % Expressed as the proportion of shifts with nurse-to-patient ratio above 0.5
7 de Vos et al. Implementation Science (2015) 10:95 Page 7 of 9 Table 2 Results of the multifaceted intervention program on study end points Organizational indicators Proportion of shifts with bed occupancy rate below 80 % Proportion of shifts with nurse-to-patient ratio above 0.5 Crude outcome a Intervention (%) Control (%) Crude effect of intervention compared to baseline b Main effect (95% CI) P value Adjusted c effect of intervention compared to baseline Main effect (95% CI) P value Crude effect of intervention compared to control group d Main effect (95% CI) P value Adjusted c,d effect of intervention compared to control group Main effect (95% CI) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 0.17 CI confidence interval a Percentages of shifts in follow-up that adhere to the guideline recommendations for each indicators b Odds ratio for improvement in follow-up period for the intervention group compared to baseline period c Bed occupancy rate adjusted for type of shift, month of the year, availability emergency bed, and academic/teaching or non-teaching unit. Nurse-to-patient ratio adjusted for type of shift, month of the year, ratio of newly admitted mechanical ventilated patients in a shift and academic/teaching or non-teaching unit d Ratio of odds ratios for improvement in follow-up between groups, calculated as odds ratio of the intervention divided by the odds ratio of the control group P value the critical care setting. Our findings are in contrast with improvements shown in adherence to clinical guideline standards after implementation of a multifaceted feedback approach [15 17]. Apparently, organizational improvements are more difficult to achieve than clinical improvements. This discrepancy may have several reasons such as study design, difficulties in changing organizational indicators, and the type of intervention. Study design The lack of effect may in part be explained by weaknesses in the study design. First, the control group also received feedback on adherence levels, which diluted the contrast between the two study arms. This lack of contrast could not be avoided because all ICUs in our study already participated in the national registry with regular performance feedback in some form. Another limitation is that we had to exclude six of the ICUs from our analysis due to absent or incomplete data, which may have limited the power of the study. This relatively large drop out may be due to the time-consuming and manual recording of operational beds and qualified nurses (three times daily) in ICUs without a patient data management system. However, the power analysis indicates that sufficient ICUs in our analyses remained. Strength of our study is the use of a cluster randomized design. In addition, we investigated the potential achievable improvement prior to the study for both study end points by using actual data and a validated method [28]. Organizational versus clinical indicators It is shown that the bed occupancy rate and nurse-topatient ratio are difficult to change. These organizational issues are difficult to influence by nature, as they need change in the number of admitted patients or the number of nurses. Changing the admission rate may be difficult because a large proportion of admissions are unplanned. In order to increase the number of nurses, it is necessary to search for new employees in a short supply market or to Table 3 Type and examples of planned QI actions as formulated during outreach visits and the number of QI plans (n = 13) in which they appeared Type of action Bed occupancy Nurse-to-patient ratio Understanding low or high variation in performance Investigate low performance Adjust (process of) resource planning Verifying unusually high or low occupancy rates in specific shifts 9 8 Investigate effect of daily operating-room schedule on bed occupancy rate 2 4 Introduce labeling of the best patient in each shift who could be discharged in case of an emergency admission a Some hospitals had combined ICU-recovery nursing shifts, which may interfere with the registration of nurse-to-patient ratio b Student-nurses are not taken into account for the nurse-to-patient ratio Develop standard registration procedure for combined intensive care recovery nursing shifts a Investigate the number of student-nurses in shifts with a ratio below the lower threshold b Take on additional part-time nurses or share nursing capacity with medium care to increase nursing team s versatility
8 de Vos et al. Implementation Science (2015) 10:95 Page 8 of 9 achieve flexible availability of nursing staff. In addition, to find money for this investigation, most ICUs are hampered by budgetary cuts in health care. It is also true that the two endpoints may co-interfere as an increasing number of nurses may increase the number of operational beds (providing that the unit can increase its beds and apparatus) and thereby improve both bed occupancy rate and nurseto-patient ratio. Intervention and quality initiatives The multifaceted intervention did not include practical tools to achieve improvements in the study endpoints. These practical implications had to be designed by the QI teams their selves. These tools might, for instance, have been extended information on patient admission and discharge logistics or tools to achieve flexible availability of nurses. However, our data show that most of the initiatives from the QI teams aimed to increase the confidence in data, which does not directly target the adherence to the guideline standards. This finding is in line with those of Bradley et al. [29]. They described that efforts in QI were most effective when physicians perceived that the data were credible, and this data credibility often took time to develop in a hospital [29]. In our prospectively performed barrier analysis, we found that the confidence in data was a barrier that had to be solved before this study could be able to achieve an improvement. Indeed, the process evaluation of our study did show an increase in confidence in indicator data quality [30], but the participating ICUs were apparently stuck in improving data quality and were not able to take a step beyond this issue. This finding suggests that the 14-month time frame of this study was too short to achieve a measurable effect. This is confirmed by the finding that the increase in confidence in the data took several months to occur. Consecutive initiatives after data improvement were, however, not often undertaken. In this respect, it is unknown whether the intensivists and nursing staff had enough latitude to change the relevant processes. In addition to the relatively short followup, as stated above, the feedback of organizational data may also be more difficult to explain. It may be true that recipients need more background information to correctly interpret data on their organizational performance [31]. The organizational indicators used in this study are based on evidence-based standards, but conflicting interests may have influenced the interpretation of the data and the initiation of QI activities. Economic targets and quality improvement targets may not be inline. For example, bed occupancy rates over 80 % can be economically beneficial but can have negative effects for the accessibility of intensive care facilities. Finally, another explanation for the observed outcomes could be that the ICUs in the intervention group showed better results at baseline compared to the control group, which results in limited room for improvement in the follow-up period or due to regression to the mean. Extrapolation and future steps From this study, it can be learned that an improvement in organizational aspects of a guideline in the intensive care setting is not easy to achieve in a 12-month episode. For organizational indicators, in contrast to clinical indicators, a distinct implementation approach might be necessary and more time might be needed. Although our study has been conducted within the domain of intensive care, our conclusions might be true in other settings as well. Also, it is unknown whether our results are true for other countries. Future studies are needed to gain insight on these questions. Conclusions Bed occupancy rate and nurse-to-patient ratio are important hallmarks for an efficient use of critical care resources and they are associated with clinical outcomes. Improvement of the adherence to guideline-based standards on these organizational issues in critical care was studied using a cluster randomized trial. A multifaceted feedback intervention using extensive feedback data, a local quality improvement team, and an educational outreach team appeared to be ineffective. The ICUs appeared to have limited confidence in the correctness of the feedback data. The ICUs appeared to be unable to take appropriate steps beyond improvement of data quality. Moreover, this study suggests that efforts to improve bed occupancy rate and nurse-to-patient ratio may require an intervention with practical tools for improvement and a longer follow-up. Competing interests The authors declare that none of them have financial competing interests. NdK, KJ, and NP are working at the KIK, which hosts the NICE registry. Authors contributions MdV and SV participated in the design of the study; they conducted the study and were involved in the analysis. They drafted major parts of the manuscript. KJ, NdK, WG, and GW participated in the design of the study and in drafting the manuscript. NP and BW were involved in the statistical analysis and in drafting the manuscript. PV participated in the design of the study and the coordination of the study. He drafted major parts of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank all personnel from the ICUs that participated in the study. We also thank Eric van der Zwan and Twan Koetsier for their assistance with data management tasks. We thank the Dutch Society of Intensive Care (NVIC) for their support. Funding This study was funded by the institutes own resources. Author details 1 Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, PO Box 90153, 5000 LE Tilburg, The Netherlands. 2 Center for
9 de Vos et al. Implementation Science (2015) 10:95 Page 9 of 9 Prevention and Health Services Research, National Institute for Public Health and the Environment, PO Box 1, 3720 BA Bilthoven, The Netherlands. 3 Department of Medical Informatics, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands. 4 Center for Public Health Forecasting, National Institute for Public Health and the Environment, PO Box 1,3720 BA Bilthoven, The Netherlands. 5 Health Strategy and Health Systems Unit, European Commission, Brussels, Belgium. 6 Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. 7 Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands. 8 TIAS School for Business and Society, Tilburg University, Tilburg, The Netherlands. 9 Health e-research Centre, The University of Manchester, Manchester, UK. 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Crit Care Med. 2012;40: Doig GS, Simpson F, Finfer S, Delaney A, Davies AR, Mitchell I, et al. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA. 2008;300: Carlson RW, Weiland DE, Srivathsan K. Does a full-time, 24-hour intensivist improve care and efficiency? Crit Care Clin. 1996;12: de Vos M, Graafmans W, Keesman E, Westert G, van der Voort PH. Quality measurement at intensive care units: which indicators should we use? J Crit Care. 2007;22: van der Voort PHJ, van der Veer SN, de Vos MLG. The use of indicators to improve the quality of intensive care: theoretical aspects and experiences from the Dutch intensive care registry. Acta Anaesthesiol Scand. 2012;56: Arts D, de Keizer N, Scheffer G-J, de Jonge E. Quality of data collected for severity of illness scores in the Dutch National Intensive Care Evaluation (NICE) registry. Intensive Care Med. 2002;28: De Vos ML, Van der Veer SN, Graafmans WC, de Keizer NF, Jager KJ, Westert GP, et al. Implementing quality indicators in ICUs: exploring barriers to and facilitators of behaviour change. Implement Sci. 2010;5: de Vos M, Graafmans W, Kooistra M, Meijboom B, Van Der Voort P, Westert G. Using quality indicators to improve hospital care: a review of the literature. Int J Qual Health Care. 2009;21: van der Veer SN, de Vos ML, Jager KJ, van der Voort PH, Peek N, Westert GP, et al. Evaluating the effectiveness of a tailored multifaceted performance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care. Implement Sci. 2011;6: Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Ann Intern Med. 2001;134: Arts DGT, De Keizer NF, Scheffer G-J. Defining and improving data quality in medical registries: a literature review, case study, and generic framework. J Am Med Inform Assoc. 2002;9: Madden JM, Graves AJ, Zhang F, Adams AS, Briesacher BA, Ross-Degnan D, et al. Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D. JAMA. 2008;299: Kiefe CI, Weissman NW, Allison JJ, Farmer R, Weaver M, Williams OD. Identifying achievable benchmarks of care: concepts and methodology. Int J Qual Health Care. 1998;10: Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. Data feedback efforts in quality improvement: lessons learned from US hospitals. Qual Saf Health Care. 2004;13: De Vos MLG, van der Veer SN, Graafmans W, de Jager KJ, de Keizer NF, Westert G, et al. Process evaluation of a tailored multifaceted feedback program to improve the quality of intensive care by using quality indicators. BMJ Quality and Safety; 2013;22: Pringle M, Wilson T, Grol R. Measuring goodness in individuals and healthcare systems. BMJ. 2002;325: Submit your next manuscript to BioMed Central and take full advantage of: Convenient online submission Thorough peer review No space constraints or color figure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistribution Submit your manuscript at
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The financing scheme, which a Moscow mayoral candidate Alexei Navalny has been using for his election campaign, violates directly the election legislation, Deputy Head of United Russia's Central Executive Committee Konstantin Mazurevsky told Itar-Tass on Saturday.
He says, the election legislation contains a clear explanation of a voluntary donation, which is a gratuitous transfer by a Russian citizen of own monetary assets to a special election account of a candidate /paragraph 14, article 2 of the federal law" On Basic Guarantees of Election Rights and the Right to Participate in a Referendum for Citizens of the Russian Federation"/.
"Thus, the law bans the so-called two-stage schemes of making payments to election accounts, where monetary funds at first come from unidentified third parties to persons, clear for the candidate, and those persons later on in their own names transfer the monies, as their own ones - though it is not their money, to the candidate's election account," Mazurevsky said.
He added that the judicial practice had confirmed donations of the kind were illegal.
"The situation becomes that with use of this system of financing, electors not only know the true sponsors of the candidate, but it is a direct violation of the election legislation," he said.
"There is a major difference between Navalny's top-secret "student" account in the US and the special election account of a Moscow mayoral candidate: all operations with the latter must be most transparent, clear and public."
Earlier, LDPR's leader Vladimir Zhirinovsky promised to demand an investigation from Russia's Prosecutor General Yuri Chaika into origins of the money transferred online to Moscow's mayoral candidate Alexei Navalny. Zhirinovsky said the blogger's election account had 20 million roubles, and "the money arrives every ten minutes online via Yandex in parts of 10-15 thousand roubles. "We cannot see who is transferring money to him - Washington or Chukotka," Zhirinovsky said.
Navalny, in his turn, promised to publish all the data on donations for his election campaign. "We have already collected about 30 million roubles," he wrote in his blog and promised to report on exact sums and timing of the transfers.
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Ben Stokes gave England a firm grip on the first Test with bat and ball before Shakib Al Hasan's 5-79 revived Bangladesh…
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Lodge #501 Home
The Lodge computer has "crashed" and all email addresses were lost. (Whether the computer expired due to "natural causes" or under "suspicious circumstances" has yet to be determined.)
If you received the monthly newsletter and/or weekly updates via email, please send your email information to email@example.com. We will forward your email info to the Lodge secretary. By having an address list in two locations, we hope to prevent future problems.
October has arrived, and the trees and sumac are beginning to show their true colors. I love this time of year: cool, crisp days always make me feel like "going the extra mile". There are lots of events this month at the Lodge; why not come along for the ride? I encourage everyone reading this to attend our first "Trivia Night" on October 22. This promises to be a fabulous event, and the proceeds will benefit "Elkland" at Mercy-Joplin. Even if you don't want to be on a team, you can come out and enjoy the fun!
We have come a long way from May 22, 2011; however, the road has been a long and rocky one, filled with potholes and "speed bumps". We have lost many friends along the way, and their names remain inscribed on the tablets of love and memory, as well as in our hearts. And we have gained so many new friends on this journey. The members of the Webb City Lodge are the exemplification of "Brotherly Love" and "Fidelity". They opened their arms and the doors of their Lodge to us when we lost our Lodge home in the tornado of May 2011, and made us feel like "family". We owe them a debt of gratitude that can never be repaid.
We also greatly appreciate those at 4th Street Bowl who graciously "stepped up" to fill the void left by the loss of our building. Our legendary "Speed Bar" and "Slow Bar" are both gone, however the heart of Elkdom remains strong in Joplin.
Joplin Elks Lodge 501 is located at 1802 West 26th, in Joplin, Missouri. Lodge 501 was founded in 1899 and enjoys a heritage that is steeped with the best of Elk Traditions. Nestled in the Heart of the Ozarks in SouthWest Missouri, Joplin has a population of 46,000. The population within a 40 mile radius of Joplin is 400,000, making it Missouri's 4th largest metropolitan area.
We invite all guests of the web site to sign our guest book and please feel free to let us know how we are doing. Meetings are the second and fourth Thursdays of each month, and begin at 7pm.
Lodge Directions: 1802 W 26th Street Joplin MO
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Welcome to MuscleMecca Bodybuilding Forums
Do you love bodybuilding and events like Mr. Olympia and The Arnold Classic? Are you interested in Bodybuilding or Fitness or just builging muscle? If so check out and join our bodybuilding forum community! Musclemecca.com is one of the oldest and most popular bodybuilding, fitness forums! Some members of MuscleMecca include Phil Heath and Ronnie Coleman! We have thousands of bodybuilding videos, pictures and articles! We have many helpful bodybuilding enthusiasts to answer questions and give you advice on building your muscle! See You In The Bodybuilding Forums!
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30", 6ft 218 pounds
Right now 32" at 6' over 240lbs
When I did my show it was barely 30"
[April|MOTM] Braaq
thanks dridderz and Big Vic but miamiracing is talking pure shit the pec on the side of the camera in my avatar looks a little weird cuz I have my arm up with the camera, so miamiracing
[SIGPIC][/SIGPIC](21" inches guns!)
About 35" at 260
[MOTY] - 3rd 2008
Originally Posted by Limpboy
thanks dridderz and Big Vic but miamiracing is talking pure shit the pec on the side of the camera in my avatar looks a little weird cuz I have my arm up with the camera, so miamiracing
no worries buddy
[OCT 08,FEB 09|MOTM] DriDDeRz
[2008 MOTY|2nd]
My Inbox is always open for Questions & help regarding anything
im 30 at 205
not big ..
look at my avatar :)
28/29.. Gotta wear 32-34 Jeans though :(
waist is 28 - 28.5ish
Some tall guys at the Mecca with very small waists!
Just one Dick's opinion!
my waist be too big for me britches
30 inches
34-35 at 6'3"
i got measured at a tailor for a tux and they had 35 I was on my carbup weekend so it might have been off a bit :keke:
too big.
The biggest difference between you and me is you're you, and I'm me. I always win. Sorry bro.
Dammit, I wanna be like you guys when I grow up
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I'm testing a Web Application which has search functionality embedded in a Java Applet (i.e. the applet displays 2 dropdown boxes which read their elements from a database).
When using Silkperformer 3.5 to record some traffic, when I navigate to some pages having the applet, it works fine. On other pages, however, the Search Applet Drodowns do not get properly loaded - hence I cannot any scenarios for these pages.
Would anyone have some suggestions on what the problem might be, and how I can get around it ?
(By the way - my company is working on getting 4.5, but until that time, I'm stuck w/ 3.5)
Thanks in advance,
Joe V.
Forum Rules


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Recent Comments
- Guillaume (1 day 4 hours ago): Hi Yair, I successfully use screencapture along with imwrite to save a screenshot of a maximized figure, however I can see some funny results on the bottom and left edges of the...
- Yair Altman (3 days 13 hours ago): Sliders in figure-based (not web-based) UI are Java objects whose parent is a dedicated Matlab container that is automatically created when you use the javacomponent function....
- Xiaoyang Liu (3 days 13 hours ago): Hi, I was wondering how to set the slider as a child of the MATLAB figure. This will allow the figure WindowKeyPressFcn work while the slider has the focus. Apparently I cannot...
- Yair Altman (3 days 16 hours ago): Thanks for the update, Christoph
- Yishai E (3 days 20 hours ago): Hi Yair, I'm trying to access some hidden properties (Matlab 2015b, Win7), the following code gives me an empty jTabGroup: % Prepare a tab-group consisting of two tabs...
- Christoph Feenders (3 days 21 hours ago): update: the issue is fixed in R2016b. The position of flags in h.BrushData now corresponds to data-points in h.XData and h.YData (irrespective of data-point visibility...
- Yair Altman (7 days 1 hour ago): @Sebastian – I agree that this is confusing. I am not aware of a way to avoid this.
- Sebastian (7 days 1 hour ago): I'm not sure if this is a common problem. But some of our clients (including me as well) are confused about the behavior of the figure toolbars when docked. In later...
- Yair Altman (7 days 3 hours ago): JMI is just a connector from Java to Matlab, it is not the Matlab engine. You still need the Matlab engine in order to do any Matlab processing with JMI. Note that in R2016b,...
- Anonymous (7 days 3 hours ago): If jmi is used,do we require Matlab then? And do all functionalities available inside Matlab can be accessed using jmi?
- Yair Altman (7 days 16 hours ago): @Amaury – this seems to be something specific to the MongoClient class. You should probably ask about this in the MongoDB forums.
- Yair Altman (7 days 16 hours ago): @Royi – setBounds is not a field but a method (that accepts either a java.awt.Rectangle object or 4 int values as input parameter(s)). As far as I can tell, it still...
- Yair Altman (7 days 17 hours ago): @Stijn – try adding pause(0.5) after the drawnow. If it works then you can play with the pause duration to find the minimal duration value that works well on your specific...
- Stijn Helsen (8 days 3 hours ago): I wanted to use the maximize function to get the size of the screen on which a figure is shown (using multiple screens). And "manually" (step by step) this works,...
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Category Archives: Listeners20 relevant articles found:
Enabling user callbacks during zoom/pan
Matlab zoom, pan and rotate3d modes hijack the user's figure callbacks, but this can be overridden.
Using linkaxes vs. linkprop
linkaxes has a built-in limitation, so using linkprop may sometimes be beneficial.
Undocumented HG2 graphics events
Matlab's new HG2 graphics engine includes many new undocumented events that could be used in various ways.
Property value change listeners
HG handle property changes can be trapped in a user-defined callback.
Waiting for asynchronous events
The Matlab waitfor function can be used to wait for asynchronous Java/ActiveX events, as well as with timeouts.
Setting axes tick labels format
Matlab plot axes ticks can be customized in a way that will automatically update whenever the tick values change.
Blurred Matlab figure window
Matlab figure windows can be blurred using a semi-transparent overlaid window – this article explains how
Categories: Figure window, GUI, Java, Listeners, Medium risk of breaking in future versions, Undocumented feature
Tags: GUI, Java, JavaFrame, Undocumented feature
2 Comments
Tags: GUI, Java, JavaFrame, Undocumented feature
2 Comments
UDD and Java
UDD provides built-in convenience methods to facilitate the integration of Matlab UDD objects with Java code – this article explains how
UDD Events and Listeners
UDD event listeners can be used to listen to property value changes and other important events of Matlab objects


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Description: Oasthouse 30 Metres to North of Dambridge Farmhouse
Grade: II
Date Listed: 14 January 1991
English Heritage Building ID: 178440
OS Grid Reference: TR2493857223
OS Grid Coordinates: 624938, 157223
Latitude/Longitude: 51.2697, 1.2233
Location: Staple Road, Wingham, Kent CT3 1LT
Locality: Wingham
Local Authority: Dover District Council
County: Kent
Country: England
Postcode: CT3 1LT
Incorrect location/postcode? Submit a correction!
Explore more of the area around Wingham, Kent at Explore Britain.
The following building shall be added to the list:
9/402 Oasthouse 30 metres to
North of Dambridge
Oasthouse. c.1800 re-roofed c.1873. Red brick in Flemish bond with hipped peg
tiled roof and brick eaves cornice. A T-shaped building of 2 storeys and
basement comprising storage range and 2 kilns. North elevation has 2 wooden
casement windows with cement cills and cambered head linings to ground floor
windows. Basement has openings with wooden lintels. 4 circular iron ties. First
elevation has loading door to lst floor, 2 circular iron ties and cambered
opening to ground floor with iron bars. West elevation has 1st floor loading
door and a brick dated 1873 with further bricks initialled IR, MR, FR, MR, IR, HR
and HR which probably refers to a refurbishment. 5 bays storage with tie beams,
collar beams, ridge piece and through purlins. 2 kilns, one retaining its drying
floor. Probably when built there was one kiln to the south but after 1873 part
of the storage to the east was partitioned off to form another kiln. Instead of
a court a projecting gable served both kilns.
Listing NGR: TR2493857223
This text is a legacy record and has not been updated since the building was originally listed. Details of the building may have changed in the intervening time. You should not rely on this listing as an accurate description of the building.
Source: English Heritage
Listed building text is © Crown Copyright. Reproduced under licence.


text:
Budgeting Basics
Most people would rather stick pins in their eyes than draw up a budget. They may have a point. If you're the type of person who always has plenty of cash, knows exactly where every penny goes, and never has trouble paying bills, skip this lesson. You're either too rich or too smart to need it. For the rest of us, unfortunately, making -- and sticking to -- a budget is the essential tool for ensuring that our money gets used the way we need it to.
Money talks: October 24th 2011
This week we focus on the crisis in Europe, after the weekend's summit yielded little more than a plan to meet again on Wednesday
"T" Sounds
Starfall's excellent interactive treatment given to the letter "T t", with emphasis on the sound of the letter. Several examples and very clear pronunciation.
The Line (O) and (F) - Crossword
Online crossword on the topic of The Line coordinate geometry. Solutions are provided. Crossword may be printed in hard copy as a homework exercise.
This health education program explains alopecia including the different types of hair loss, the causes, and the treatment options. It also reviews normal hair growth. This resource is a MedlinePlus Interactive Health Tutorial from the National Library of Medicine, designed and developed by the Patient Education Institute.
Skull Tutorial
This tutorial module consists of a series of digitized images of the skull, illustrating bones, foramina, bony landmarks, and protuberances which were converted into Macromedia Flash for online distribution. The objective for creating the courseware was to stimulate more active self-directed learning. The rationale was to integrate skull osteology into a structured format that is readily accessible for local and distance learning and self-assessment. Active learning was achieved by creating twel
Changes in Maternal Physiology
An interactive animation that enables the user to see physiological changes in a woman during pregnancy and postpartum. Guide questions - How does a pregnant female adjust physiologically to the metabolic and nutritional requirements of the growing fetus? How does the fetal-placental unit obtain a sufficient blood supply? How soon after parturition do the maternal metabolism and reproductive function return to those typical of the non-pregnant state? University of Cincinnati College of Medicine
Wuthering Heights - Character Quiz
Take this short quiz to test how well you know the characters in the novel.
Weather Sayings Quiz
The pupil will learn about weather lore. The pupil will find out that there are many weather sayings. Pupils will explain in their own words a number of the sayings.
Daphnia heart and eyes
Anterior end of Daphnia showing beating heart - note moving eyes and other body structures.
Advanced Audio Blog S4 #18 - Top 10 Japanese Songs: Sōranbushi
Learn Japanese with JapanesePod101.com! You're having a hard time getting motivated to do your Japanese homework, and you are doing everything in your power to procrastinate. You flip around the Japanese television channels, you enjoy a few snacks, and you even start cleaning your Japanese apartment. When your roommate notices that you're avoiding your work, [...]
Leage of gentlemen
Thomas Jensen
A project for using cnx.org
Some Rights Reserved
Exploring the Moon
Future astronauts return to the lunar surface in this animation. For larger resolution and downloads see: http://www.nasa.gov/multimedia/videogallery/
Golden lion tamarin
The golden lion tamarin, a monkey, is endangered because of habitat loss and resultant inbreeding.
Les technologies et leur risques - Josquin Debaz
Une conférence de l'UTLS au Lycée
Les technologies et leur risques par Josquin Debaz (sociologue)
Lycée professionnel André Jurénil (59 Denain)
Une conférence de l'UTLS au Lycée
Les technologies et leur risques par Josquin Debaz (sociologue)
Lycée professionnel André Jurénil (59 Denain)
Snippet from Finn Family Moomintroll
This is the preface from the book Finn Family Moomintroll by Tove Jansson. The video includes text, narration, and images. The book is listed on the corestandards.org website as part of the suggested reading material for grades K-1. (03:45)
Sample performance tasks for this story include:
Students identify the points at which different characters are telling the story in the Finn Family Moomintroll by Tove Jansson. [RL.1.6]
CSR as a Quality Enabler
"Sustainability" is about more than being environmentally or socially responsible. The story of Tchibo Coffee shows that it can also give customers consistent quality.
Potters and Warlords in an Afghan Bazaar: Violence and Political Mobilization in Afghanistan Today
Noah Coburn Central Asian Studies Post-Doctoral Fellow and lecturer in anthropology, U-M; and researcher, United States Institute of Peace 04.05.2011


text:
WednesdayOct 26, 2016
Quotes: 53419
Authors: 9969
Thomas Alva Edison (February 11, 1847 - October 18, 1931) was an American inventor and businessman who developed many devices that greatly influenced life around the world, including the phonograph and a long lasting light bulb. Dubbed "The Wizard of Menlo Park" by a newspaper reporter, he was one of the first inventors to apply the principles of mass production to the process of invention, and therefore is often credited with the creation of the first industrial research laboratory.
Edison is considered one of the most prolific inventors in history, holding 1,093 U.S. patents in his name, as well as many patents in the United Kingdom, France and Germany.
I have learned through bitter experience the one supreme lesson to conserve my anger, and as heat conserved is transmitted into energy, even so our anger controlled can be transmitted into a power that can move the world.
Mohandas Karamchand Gandhi
People change and forget to tell each other.
Lillian Florence Hellman
They teach in academies far too many things, and far too much that is useless.
Johann Wolfgang Von Goethe
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text:
1. The Cemetery Church of All Saints located in Sedlec, Czech Republic, seems normal enough…
2. …until you actually get inside.
3. Adorned with the skeletons of an estimated 40,000 human bodies, the Sedlec Ossuary has become one of the Czech Republic's creepiest tourist attractions.
4. When the plauge struck Europe in the 14th century, mass graves were built in the Sedlec cemetery to accommodate all the bodies.
5. In the 15th century, the Hussite Wars added to the mounting body count.
6. When an actual church was constructed on the cemetery grounds in the 1400s, a small ossuary* was built below the chapel to house the bones of those buried in the mass graves.
*Ossuary (n.): A container or room into which the bones of dead people are placed.
7. In 1511, a half-blind Cistercian monk was charged with the job of exhuming the bones of thousands.
8. It wasn't until 1870 that František Rint, a woodcarver, was employed by the Schwarzenberg family to arrange the remains in the ossuary.
9. The result is the terrifyingly beautiful church of human bones known as the Sedlec Ossuary.
Giant chandelier.
Bone goblet.
Candlestick holder.
Crest of the Schwarzenberg family.
Preview Your Response
In The News Today
- A powerful magnitude-6.1 earthquake struck Italy Wednesday night, hours after a smaller magnitude-5.5 quake struck the same region.
- Police are investigating after someone destroyed Donald Trump's Hollywood Walk of Fame star with a sledgehammer early Wednesday.
- Apple has delayed shipping its new wireless Airpods headphones that were supposed to go out to iPhone 7 users this month. 🎧
- Donald Trump bashed Hillary Clinton for going to an Adele concert after critics slammed him for promoting his new hotel.


text:
Slaanesh's Plaything
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post #1 of 2 (permalink) Old 11-25-08, 02:40 PM Thread Starter
Looking to buy Old Noise marines
Hello there. I am looking to buy old Noise marines the metal ones with the Guitar like weapons. Would really like some Champs with the large claw hands or just the large claw hands.
They can be in any condition.
They can be in any condition.
post #2 of 2 (permalink) Old 11-26-08, 12:59 AM
Damn.. use to have 2 of them.
If i find any others in my old collection. Ill send them this way
If i find any others in my old collection. Ill send them this way
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- May 14, 2013
- 73 views
- 4 comments
I ordered the b/o/g/o pop chef offer as a gift for two of my daughters.What came was a deluxe set which the operator told me to divide myself between them.
I said that is not what I ordered, and wanted two separate boxes. The supervisor said they no longer have that offer and I said that I would like to return the item and I wanted full credit. She said I could do whatever I like. I called my American Express to file a complaint and they will investigate.
I don't think I should be responsible for return shipping when I didn't get what I ordered and paid for the first shipping I paid for.I will definitely think a long time before shopping here again.
More Review Details
- Monetary loss:
- $34
- Product or service
- Pop Chef
- Review category
- Shopping
Nov 13, 2013
popchef website sale is a big fraud. they took my money before i saw the new total charge on my account. i returned the product and they took my money its all a scam....beware.
Jul 03, 2013 Orange, California
not only is this company a rip off but their employees gave me all the wrong information.
the advertisement says $10 plus $5.99 for shipping and bonus (pay shipping) i clicked the option to not take the bonus and they still charged me the additional shipping.
i called CS and they girl said it wasnt in the system yet so to call in 4 hrs because it takes that long to process.
I called back an hour later to ask how i can cancel it (even though i had a order number) they said i coudlnt until it showed in their system. and she said to call back 4 hrs later... i call back 4 hours later and this other *** now tells me to call back the NExT business day which is MOnday. so apparently they are close july4-8.. this is ***.. if you have a electronic system of taking an order there should be a way to cancel the order or email the request or soemthing NOT have to call back every few hours because they keep giving me the wrong information.
May 30, 2013 Richmond, Virginia
Me too. I order this kit for 10.00 + you get 30 pc , when it came I got the kit, put not the 30 PC. They said it was the wooden stick, which the website didn't they say. It all a slam. I was disappointed.0 0 Reply
May 20, 2013
That stinks! This is exactly why when I see something on TV that I possibly am interested in, I first read online reviews & then I wait for it at Walmart or Walgreens so at least there is no problem returning it.0 0 Reply
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Click the link below to view the package:
NC State '12 -- NCAA 16 Hyatt Air/Land Package
NOTE: This is NOT the team hotel, as they are at the Sheraton City Center.
The Sheraton has 600 fewer rooms than the Hyatt and did not have any space available for fan travel.
The Hyatt is about 7 blocks from the Edward Jones Dome and 12 blocks from the team hotel.
Game tickets are not included and can be purchased by calling the Wolfpack Club directly at 919-865-1500.
A land only and hotel only options will be available soon.


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Ajay Chaudhary is an Indian TV actor.He is best known for playing the lead role of ACP Abhay Singh in Colors TV show Phulwa and got popularity from colors show Uttaran. Next on his list he will be seen playing in Box Cricket League for Lucknow Nawabs .
Shere Bangla National Stadium, Mirpur ,10/28/2016, 09:30 (IST)
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|Cane Corso Italiano
|08-17-2016 (10 Weeks)
|Champion bloodlines:
|Champion sired:
|Show potential:
|$2100 USD Buyer tips
|Shipping area:
|United States
|What's included:
|Registered/registerable, Current vaccinations, Veterinarian examination, Health certificate, Health guarantee, Pedigree
|Additional information:
|Jade is an adorable feisty formentino girl she is
her mamma's mini me! She had a great blocky head,
big bone, thick neck, shoulders and wide
chest! She is a powerful formentino female pup
with alot of personality! She is playful and loves
looks and people. She is one of the more dominant
puppies out of her littler, with alot of
confidence! She has some of the best bloodlines
out there! Angelic's Fendi out of Reproduction
Champion/ Grand Champion SACCI, Ch. ICCF, Ch.
ARBA, Ch. NAKC (Rarities), Ch. IABCA Red
Rock Canyon Apollo!!! and a Jones granddaughter!!
Sire is Champion Scandifio & Virgil's Thunder
struck! who is out CH Scandifio's rocking in the
USA and grand-sire Scandifio's Nino!! Sky is the
limit! These are two very powerful dogs, with huge
bone, wide chests, and amazing heads, Not to
mention great movement and structure and awesome
temperaments to top it all off!...This is a epic
match up and is an amazing bunch of pups! Every
pup is hand raised in our home, we are animal
lovers who fell in love with the Cane Corso breed!
These pups would make a great addition to any
loving home :) All puppies come complete with
vaccines and regular de-wormings, with a 1 year
health guarantee, lifetime breeder support, a
puppy packet with pic's and pedigree of parents,
socializing and training info, food, collar
and toys. Our puppies are AKC registered. Contact
Angie for more info and availability or to set up
an appointment 951-295-1208
|Member Since: September 17th, 2006
|Location: Ontario, CA, United States
|Telephone: 951-295-1208
|Website: http://www.loveabbull.com
All of our puppies are hand raised in our home, & are all very
Contact Angie via e-mail
View all listings by Angie