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Thomas K. Houston, MD, MPH; Jeroan J. Allison, MD, MSc; Marc Sussman, MHA; Wendy Horn, PhD; Cheryl L. Holt, PhD; John Trobaugh, MFA; Maribel Salas, MD, PhD; Maria Pisu, PhD; Yendelela L. Cuffee, MPH; Damien Larkin, MA; Sharina D. Person, PhD; Bruce Barton, PhD; Catarina I. Kiefe, PhD, MD; Sandral Hullett, MD, MPH
Grant Support: By Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation (RWJF Finding Answers grant 59741), with direction and technical assistance provided by The University of Chicago; a Veterans Affairs Hypertension Stories grant (I01 HX000492-01; Dr. Houston); and the Agency for Healthcare Research and Quality Storyguides project (1R18HS019353-01; Dr. Allison).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1487.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Houston (e-mail, firstname.lastname@example.com). Data set: Not available.
Requests for Single Reprints: Thomas K. Houston, MD, MPH, University of Massachusetts Medical School, Quantitative Health Sciences, 55 North Lake Avenue, Worcester, MA 01605; e-mail, email@example.com.
Current Author Addresses: Drs. Houston, Allison, Barton, and Kiefe; Mr. Trobaugh; and Ms. Cuffee: University of Massachusetts Medical School, Quantitative Health Sciences, 55 North Lake Avenue, Worcester MA 01655.
Mr. Sussman, Drs. Horn and Hullett, and Mr. Larkin: 1515 6th Avenue South, Birmingham, AL 35233.
Dr. Holt: University of Maryland, SPH Building, Valley Drive, College Park, MD 20742-2611.
Dr. Salas: 1800 Concord Pike, Box 15437, Wilmington, DE 19850-5437.
Drs. Pisu and Person: Medical Towers 612, 1717 11th Avenue South, Birmingham, AL 35205.
Author Contributions: Conception and design: T.K. Houston, J.J. Allison, C.L. Holt, J. Trobaugh, M. Salas, M. Pisu, S.D. Person.
Analysis and interpretation of the data: T.K. Houston, J.J. Allison, C.L. Holt, M. Salas, S.D. Person, B. Barton, S. Hullett.
Drafting of the article: T.K. Houston, J.J. Allison, J. Trobaugh, Y.L. Cuffee, D. Larkin.
Critical revision of the article for important intellectual content: T.K. Houston, J.J. Allison, W. Horn, C.L. Holt, J. Trobaugh, M. Salas, M. Pisu, S.D. Person, B. Barton.
Final approval of the article: T.K. Houston, J.J. Allison, J. Trobaugh, M. Salas, M. Pisu, Y.L. Cuffee, S.D. Person, S. Hullett.
Statistical expertise: J.J. Allison, S.D. Person, B. Barton.
Obtaining of funding: T.K. Houston, J.J. Allison, M. Salas.
Administrative, technical, or logistic support: M. Sussman, W. Horn, D. Larkin, S. Hullett.
Collection and assembly of data: J.J. Allison, W. Horn, M. Salas, S. Hullett.
Houston TK, Allison JJ, Sussman M, Horn W, Holt CL, Trobaugh J, et al. Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized Trial. Ann Intern Med. 2011;154:77-84. doi: 10.7326/0003-4819-154-2-201101180-00004
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© 2016
Published: Ann Intern Med. 2011;154(2):77-84.
Appendix: Sensitivity Analysis
This article has been corrected. For original version, click "Original Version (PDF)" in column 2.
Storytelling is emerging as a powerful tool for health promotion in vulnerable populations. However, these interventions remain largely untested in rigorous studies.
To test an interactive storytelling intervention involving DVDs.
Randomized, controlled trial in which comparison patients received an attention control DVD. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. (ClinicalTrials.gov registration number: NCT00875225)
An inner-city safety-net clinic in the southern United States.
230 African Americans with hypertension.
3 DVDs that contained patient stories. Storytellers were drawn from the patient population.
The outcomes were differential change in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months.
299 African American patients were randomly assigned between December 2007 and May 2008 and 76.9% were retained throughout the study. Most patients (71.4%) were women, and the mean age was 53.7 years. Baseline mean systolic and diastolic pressures were similar in both groups. Among patients with baseline uncontrolled hypertension, reduction favored the intervention group at 3 months for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Patients with baseline controlled hypertension did not significantly differ over time between study groups. Blood pressure subsequently increased for both groups, but between-group differences remained relatively constant.
This was a single-site study with 23% loss to follow-up and only 6 months of follow-up.
The storytelling intervention produced substantial and significant improvements in blood pressure for patients with baseline uncontrolled hypertension.
Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.
Appropriate management of hypertension reduces adverse health outcomes, but many patients do not adhere to treatment. A lack of understanding of the long-term consequences of this asymptomatic condition may contribute to poor adherence.
This randomized, controlled trial assigned 299 African Americans with hypertension to receive usual care or view 3 videos that presented stories of real patients with hypertension. Among patients who had uncontrolled hypertension at baseline, those assigned to view the stories had better blood pressure control than those assigned to usual care.
Storytelling can be an effective way to teach patients about hypertension and improve blood pressure control.
—The Editors
African Americans are 21% more likely than white persons to die of heart disease and 49% more likely to die of stroke (1). Despite many attempts to close racial and ethnic gaps in risks for cardiovascular diseases, such as hypertension, important disparities persist (2). Motivated by these findings, we sought to develop and test a novel, evidence-based, and culturally appropriate intervention to improve blood pressure control in African Americans.
Blood pressure control is complex for any patient with hypertension and requires long-term adherence to medication, diet, exercise, and medical follow-up. This complexity contributes to the widely documented poor control among patients in general (3) and African Americans in particular (4). African Americans are more likely to have hypertension, less likely to achieve control, and more likely to have end-organ damage than white persons (4). These differences in blood pressure control are partially explained by identifiable barriers, such as unhealthy diet and lack of exercise promoted by environmental factors (5), limited access to clinicians and medicine, distrust of the medical system (6, 7), and poor medication adherence (8, 9). However, interventions to overcome these barriers have had mixed results (10).
Programs that target vulnerable populations may fail for several reasons, including lack of cultural relevance. Although the resulting intervention may be conceptually sound, the lack of cultural relevance may decrease effectiveness (5). Emerging evidence suggests that storytelling, or narrative communication, may offer a unique opportunity to promote evidence-based choices in a culturally appropriate context. Stories can help listeners make meaning of their lives (11, 12), and listeners may be influenced if they actively engage in a story, identify themselves with the storyteller, and picture themselves taking part in the action (13). Because narrative communication can break down cognitive resistance to behavior-change messages (14), we hypothesized that it would be a suitable mechanism for addressing the persistent and troubling disparities in hypertension control.
We designed the Culturally Sensitive Intervention: Birmingham trial to improve hypertension control among low-income, inner-city African Americans by using an innovative storytelling intervention. According to our conceptual model (13), stories drawn from the community and told in patients' natural voices would be used to inform and inspire positive health behavior change. Using the strategies that emerged from patient interviews, we developed a narrative-based intervention delivered by interactive DVDs and tested this intervention in a randomized trial.
We conducted a randomized, controlled trial in which 299 patients received a series of 3 DVDs, delivered at baseline, 3 months, and 6 months. Outcomes were ascertained at randomization (month 0), short-term follow-up (month 3), and end of follow-up (months 6 to 9). All patients had physician-diagnosed hypertension and were randomly assigned with equal probability to the intervention or comparison group. Patients could be enrolled at baseline with either controlled or uncontrolled hypertension; we included patients with controlled hypertension to determine whether the intervention would be useful in maintaining control.
Patients in the intervention group received DVDs that contained patient stories. The comparison group received an attention control DVD that covered health topics not related to hypertension. Our main hypothesis was that patients in the intervention group would experience more favorable changes in blood pressure than those in the comparison group. The institutional review boards of Cooper Green Mercy Hospital and University of Alabama at Birmingham, Birmingham, Alabama, reviewed and approved our protocol and consent procedures.
Intervention development and the subsequent trial were conducted in the Cooper Green Mercy Hospital clinics, an inner-city, safety-net health system in Birmingham, Alabama, that serves a large population of African Americans with a high burden of cardiovascular disease. Patients were recruited from the Alabama Collaboration for Cardiovascular Equality TRUST project, an observational study funded by the National Heart, Lung, and Blood Institute. We included patients aged 18 to 80 years who self-identified as African American or black; had received a diagnosis of hypertension, confirmed by medical record review; had at least 2 visits with a Cooper Green primary care physician in the past year; were not pregnant and did not have dementia, schizophrenia, bipolar illness, or any other serious acute or chronic medical comorbid condition that would interfere with study participation; and provided written informed consent.
The intervention was delivered on an interactive DVD, rather than online or on a CD-ROM. On the basis of a national survey (15), which found that 88% of U.S. households have DVD players, this technology was thought to be more prevalent than Internet access in our sample. We began the DVD development by seeking stories from patients within the local community. Patients who represented a range of experiences (men and women, older and younger persons, and those with controlled and uncontrolled hypertension) were purposefully selected for 6 focus groups. On the basis of a carefully developed guide, moderators solicited personal experiences about hypertension, including talking with physicians; receiving medications; and strategies used to improve medication adherence, diet, and exercise. These first-stage focus groups were used to identify high-priority content and prescreen potential storytellers for subsequent videotaped interviews.
We reviewed the audiotapes and selected 14 hypertensive patients for the video production interviews, on the basis of their clarity and persuasiveness. The interviewers, using a prepared, open-ended interview guide with optional prompts based on focus group content and the Health Belief Model (16, 17), encouraged the patients to tell their stories.
We amassed 80 hours of video interview footage. Each interview was broken into discrete story units of 1 to 3 minutes each that focused on a single message. Two research assistants rated each story unit for strength and clarity of behavior-change content on the basis of the Health Belief Model (16, 17). Ratings were then used to select high-priority story segments, which were edited into a documentary-style movie that retained the character of each storyteller.
The intervention DVDs contained 2 sections, "Storytelling" and "Learn More." For example, the first intervention DVD featured 3 storytellers who described living with hypertension, gave lessons they had learned about how to best interact with their physicians, and offered strategies to increase medication adherence. Although common themes pervaded all of the stories, each storyteller brought a different focus and set a different tone (Appendix Figure). The Learn More section of this DVD addressed the question, "What is blood pressure?," and taught patients to express their concerns and questions to their physicians (Appendix Figure). The Learn More sections in subsequent DVDs focused on avoiding hidden sodium and getting adequate exercise. Material from the DVDs can be viewed online.
After baseline screening and blood pressure measurement, patients were classified as having controlled or uncontrolled hypertension according to the guidelines in the Seventh Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. Patients in these subgroups were assigned in blocks of 10 to either the intervention or comparison group. The comparison group received an attention control DVD, which contained videos taken from "Healthy Habits Action Minute" (television messages produced locally in Birmingham, unrelated to hypertension), in addition to usual care. The attention control was designed to account for changes in attitudes and behavior that might result from social exposure, in which patients receive additional services and attention from study personnel. All participants watched the first DVD in the clinic. The booster DVDs were mailed to each patient's home. Although we cannot confirm that the patients watched the DVDs, all respondents self-reported their watching patterns. Participants were allowed to choose which stories and Learn More sections they wished to watch and in what order. We tracked intervention delivery by measuring the total amount of time patients spent watching the DVD at both baseline and follow-up.
Our primary outcome was change in blood pressure, with readings taken immediately before random assignment (baseline), at short-term follow-up (month 3), and at the end of follow-up (months 6 to 9). Blood pressure was measured with an OmROn HEM907XL automated BP monitor (Omron Healthcare, Kyoto, Japan) according to protocols approved by the World Health Organization. Research assistants underwent intensive training with competency certification before collecting data. The assistants took 3 blood pressure readings, separated by 30 seconds, and lifted the patient's arm between measurements. Before the first reading, the patient sat quietly in a room for 5 minutes. For blood pressure end points, the last 2 readings were averaged. Patients were instructed to avoid caffeine, vigorous exercise, or smoking for 30 minutes before measurement. The CARDIA (Coronary Artery Risk Development in Young Adults) Web site (www.cardia.dopm.uab.edu) provides our entire, detailed protocol.
In-person and telephone interviews were also conducted, using computer-assisted technology, to collect patient demographic characteristics, current medications, and measures of intervention engagement. Comorbid conditions were ascertained from a review of medical records before study enrollment.
We compared baseline patient characteristics by study group to characterize the patient sample and examine the adequacy of randomization. Because of the stratified randomization scheme, separate analyses were conducted for patients with baseline controlled or uncontrolled hypertension in addition to the overall intention-to-treat analysis.
To test our main study hypothesis, we used a segmented longitudinal data analysis. Random-effects models accounted for repeated outcome measurements (systolic and diastolic blood pressures) being nested within patients. The study was divided into 2 distinct periods, from random assignment (baseline) to follow-up at 3 months and from follow-up at 3 months to follow-up at 6 to 9 months. Our models used a fixed effect for the intervention versus the comparison group, 2 fixed effects for time, 2 group–time interactions, and a random intercept that reflected the clustering of observations with patients. The regression coefficients were estimated by using a generalized least-squares algorithm, an approach that assumes data are missing at random.
The group variable was coded as 1 (intervention) or 0 (comparison). The first time variable was coded as 0 for baseline, actual calendar time for 3-month follow-up, and 0 for 6- to 9-month follow-up. The second time variable was coded as 0 for baseline, 0 for 3-month follow-up, and actual calendar time for 6- to 9-month follow-up. Separate group–time interactions were created for each period.
For these parameters, the group coefficient represented baseline differences for the intervention versus the comparison group, the first time variable represented change in the comparison group over the first period (baseline to 3 months), and the second time variable represented change in the comparison group over the entire study period (baseline to 6 to 9 months). The group–time interactions captured the main intervention effect. The first interaction represented the change over time for the intervention versus the comparison group during the first period, whereas the second interaction represented the change over time from baseline to the end of follow-up, with positive values favoring the intervention group in both cases. The main hypothesis testing was conducted on an intention-to-treat basis. The overall analyses and those stratified by baseline blood pressure control group were all performed by using Stata, version 11.1 (StataCorp, College Station, Texas).
As a secondary analysis, we examined age-related differences in systolic blood pressure response to the intervention at 3 months in patients 65 years or older versus those younger than 65 years. Longitudinal models were estimated in the same manner as for testing the main hypothesis, with interaction terms that allowed different responses by age category. These multivariate models were used to predict differential change over time in systolic blood pressure from baseline to 3 months for older versus younger patients.
Because random-effects models assume that data are missing at random, this type of analysis is vulnerable to bias from loss to follow-up. The Appendix describes our 3 main approaches to examining the potential effect of loss to follow-up.
This work was performed as part of Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, with direction and technical assistance provided by The University of Chicago. The funding source approved the study design but was not involved in the trial execution, analyses, or production of this report. In addition, Dr. Houston was supported by a Veterans Affairs Hypertension Stories grant and Dr. Allison by the Agency for Healthcare Research and Quality Storyguides project during manuscript preparation. These agencies were also not involved in any phase of the study.
We randomly assigned 299 African American patients and retained 230 (76.9%) for both short-term and end-of-study follow-up (Figure 1). The mean elapsed time from random assignment was 3.6 months (SD, 1.9) for the 3-month follow-up and 7.8 months (SD, 2.3) for the final follow-up. Most patients (71.4%) were women, and the mean age was 53.7 years. Only 16.1% reported annual household incomes of at least $16 000. In general, between-group differences in baseline characteristics were small (Table 1). At baseline, mean systolic blood pressure was 133 mm Hg (SD, 22) for the comparison group and 133 mm Hg (SD, 24) for the intervention group. Mean diastolic blood pressure at baseline was also similar in both groups.
Table 1.
Our longitudinal data analyses estimated differential change over time for the intervention versus the comparison group (Figure 2). Although significant changes were associated with the intervention within the overall study population (Figure 2, right), these changes were driven by the patients with uncontrolled hypertension (Tables 2 and 3). Patients with baseline controlled hypertension experienced no significant differential changes in blood pressure over time. Among patients with uncontrolled hypertension, reduction from baseline to 3 months favored the intervention group for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Similarly, blood pressure reduction in these patients from baseline to 6 to 9 months also favored the intervention group for systolic (6.43 mm Hg [CI, 1.41 to 11.45 mm Hg]; P = 0.012) and diastolic (4.22 mm Hg [CI, −1.08 to 9.53 mm Hg]; P = 0.119) blood pressures.
Left. Unadjusted data points and model fit curves for systolic and diastolic blood pressures in the intervention and control groups over time. Middle. Smoothed model fit curves for systolic and diastolic blood pressure point estimates and 95% CIs (shaded areas) from random-effects models that compared both groups over time. Curves are displayed on a truncated scale of blood pressure to provide detail. Right. Estimated differences for point estimates and 95% CIs from group–time interactions in random-effects models that compared both groups over time. Negative deflection favors the intervention group, and the nonoverlap of the 95% CI (shaded area) with the zero difference line (dashed line) indicates statistical significance.
Table 2.
Table 3.
Subgroup comparisons by age were limited by the small number of patients who were 65 years or older (43 patients). These patients experienced a slightly larger advantage in blood pressure reduction than younger patients (9.78 mm Hg vs. 6.31 mm Hg), but the differential response was not statistically significant (3.19 mm Hg [CI, −16.29 to 22.68 mm Hg]).
We also examined intervention delivery and engagement. All patients in the intervention group who responded confirmed watching at least 1 video segment from each of the 3 DVDs. These patients spent an average of 87.5 minutes (SD, 29.0) watching the intervention DVDs over the entire study. Viewing patterns had no relationship with changes in blood pressure.
Finally, we examined loss to follow-up (Appendix). In aggregate, our findings suggest that loss to follow-up did not heavily bias the main study findings.
To our knowledge, this is the first randomized trial of a culturally sensitive storytelling intervention for hypertensive African Americans. In a sample of 299 randomly assigned patients, we found that differences in blood pressure favored the intervention group, and the significance of these differences was driven by the positive effect among those with uncontrolled hypertension. Patients with uncontrolled hypertension who were assigned to the intervention group experienced an 11–mm Hg greater reduction in systolic blood pressure than the comparison group. Meaningful advantages were also found for diastolic pressure among patients with uncontrolled hypertension. Blood pressure subsequently increased in both groups; however, the relative advantage for the intervention group was maintained until the end of follow-up. The intervention did not increase maintenance of control among patients with controlled hypertension at baseline.
We compared our findings with those from previous pharmaceutical, nonpharmaceutical, and behavioral hypertension treatment trials. According to data from the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), chlorthalidone, amlodipine, and lisinopril decreased systolic blood pressure by between 10.5 and 12.3 mm Hg and diastolic blood pressure by between 8.6 and 9.3 mm Hg over 5 years (18). Appel and colleagues (19) reported that an 8-week intervention to improve dietary behaviors of patients with hypertension led to decreases of 11.4 mm Hg in systolic blood pressure. In a systematic review of 11 studies of behavioral interventions (20), the Cochrane collaboration found that the mean reduction in systolic blood pressure for the intervention groups was −0.57 mm Hg (CI, −1.22 to 0.08 mm Hg) compared with the control groups. Thus, our intervention produced greater changes than many behavioral interventions and performed similarly to nonpharmaceutical and pharmaceutical interventions.
Hinyard and Kreuter (21) reviewed narrative communication as a mechanism of behavior change and concluded that the evidence was limited. Narrative communication for health promotion takes many forms, including storytelling, entertainment education, and testimonials (21, 22). Storytelling can change attitudes and behavior by decreasing cognitive resistance (13). Patients can "enter" the world of the characters and become absorbed in the narrative content, rather than focusing on the embedded subtext of behavior change (23, 24). Identification with the characters is promoted by homophily, or perceived similarity between the characters and the patient (25).
Although we lack direct evidence about the mechanisms through which our intervention worked, we offer some guarded speculation. A parasocial interaction, created by the homophily between patient and storyteller, may have rendered the viewers more susceptible to behavior-change messages and suggested new ways of interacting with family and health care providers (22). In a previous work on hypertension (26), we translated patient stories into reenactments by using trained actors in a high–production quality studio. To maximize the parasocial interaction in this trial, we enhanced the realism of the current intervention by taping real patients in the actual hypertension clinic instead of using actors in a studio.
Our study has limitations. Our study patients were all from an inner-city area in the southern United States with a large African American population, and the intervention may not apply to other populations. However, even though the narrative content may not be directly relevant to other racial or ethnic groups, storytelling has universal application; many cultures have rich storytelling traditions. In addition, our findings should be easily adaptable to chronic conditions besides hypertension.
We previously noted that blood pressure increased after 3 months in both the intervention and control groups. However, the increase in blood pressure was most pronounced among those with baseline controlled hypertension, which suggests regression to the mean as a possible explanation. Regardless, this indicates a need for future interventions with more sustained power of behavior change. Although we had good retention at 6 to 9 months, adjustment for covariate imbalances introduced by dropout actually strengthened our findings.
We found that patients with uncontrolled hypertension who received a storytelling intervention with culturally sensitive messages that promoted hypertension control benefited from this intervention. Additional studies are needed to clarify the mechanisms though which storytelling works, address more long-term follow-up, and test similar interventions for different populations and conditions.
Because random-effects models assume that data are missing at random, they are vulnerable to bias from loss to follow-up. To examine the potential effect of loss to follow-up, we used 3 main approaches.
First, we compared baseline characteristics for the patients who remained at 3 months with those of patients who were lost to follow-up; separate comparisons were made for the intervention and comparison groups (Appendix Table 1). The chi-square test was used for categorical variables and the t test was used for continuous variables.
Appendix Table 1.
Second, we accounted for loss to follow-up by using inverse probability weighting. This analysis was conducted only for change in systolic blood pressure from baseline to 3 months and only for patients with baseline uncontrolled hypertension. For these models, we captured the intervention effect as a group–time interaction. Negative interaction values indicate a greater reduction in blood pressure over time in the intervention group than in the comparison group. A logistic regression model that predicted the probability of being retained in the analysis at 3 months was used to develop the weights. Predictor variables included age, income, and blood pressure. These covariates were chosen because they were at least marginally associated with retention at 3 months (Appendix Table 1). The multivariate models were estimated by using the STATA generalized linear latent mixed module, with adaptive quadrature and robust standard errors. This module was necessary to allow weighting to be combined with the random effects that represented the clustering of observations within patients. We ran the models with and without inverse probability weighting for systolic and diastolic blood pressures (Appendix Table 2).
Appendix Table 2.
Finally, we performed a series of sensitivity analyses to determine how various assumptions about the missing data would change the intervention effect at 3 months for systolic blood pressure. The covariates for these models were structured as previously described, and analyses were similarly limited to patients with uncontrolled baseline blood pressure. Estimation was performed by using the generalized least-squares method, again accounting for the clustering of observations within patients as a random effect (Appendix Table 3). Model A treated missing blood pressure data as missing, model B carried forward the last value in the case of missing values, models C through F allowed 3-month outcomes for those with missing data to increase or decrease by 5% compared with baseline for each individual patient, and model G was titrated to illustrate a complete absence of any intervention effect.
Appendix Table 3.
Of the 299 patients who were randomly assigned, 76.9% were available for analysis at both follow-up points. With the exception of 1 patient, all loss to follow-up occurred during the first study period. Patients were more likely to be lost to follow-up if they were younger or had lower income or higher baseline blood pressure (Appendix Table 1). These patterns were similar in both the intervention and comparison groups. Appendix Table 2 presents the main longitudinal models, weighted by the inverse probability of patients being retained in the study at 3 months. Differential change over the first study period favored the intervention group for both systolic (−10.25 mm Hg [CI, −20.04 to −0.46 mm Hg]; P = 0.040) and diastolic (−7.43 mm Hg [CI, −12.71 to −2.12 mm Hg]; P = 0.006) blood pressures. Accounting for loss to follow-up with inverse probability weighting did not significantly alter the magnitude of the main effect or the precision of its estimate.
Appendix Table 3 presents the results of sensitivity analyses in which we varied the assumptions about change in blood pressure for patients lost to follow-up. These analyses were limited to systolic blood pressure, the first study period, and patients with uncontrolled baseline blood pressure. Model A, which treated missing data as missing, yielded a mean 9.40 differential advantage over time for patients in the intervention group. These results are similar to those from the main model presented in Table 3. Model B carried forward the baseline values. Models C through F show the expected intervention effect if missing values were carried forward with increases or decreases of 5% in varying combinations for the 2 study groups. To completely negate the intervention effect, it was necessary to assume that missing systolic blood pressure values increased by 12% from baseline for the intervention group and decreased by 12% from baseline for the comparison group. In aggregate, our findings suggest that loss to follow-up did not heavily bias the main study findings.
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Story 1: Dedria - Houston : Researchers developed an interactive DVD that allowed patients to browse other patients' stories and select desired content. Presented here are excerpts from the DVD stories, which were each 4-8 minutes in length. Users could navigate to a set of "learn more" brief expert presentations on topics such as diet and exercise.
Story 2: Herman - Houston : Researchers developed an interactive DVD that allowed patients to browse other patients' stories and select desired content. Presented here are excerpts from the DVD stories, which were each 4-8 minutes in length. Users could navigate to a set of "learn more" brief expert presentations on topics such as diet and exercise.
Story 3: Julia - Houston : Researchers developed an interactive DVD that allowed patients to browse other patients' stories and select desired content. Presented here are excerpts from the DVD stories, which were each 4-8 minutes in length. Users could navigate to a set of "learn more" brief expert presentations on topics such as diet and exercise.
Jeffrey Cohn
Albert Einstein Healthcare Network, Philadelphia, PA
January 21, 2011
Role of the principle of positive deviance.
To the Editor: I found the article by Houston et al. (1) to be quite interesting. I feel certain that the use of storytellers from the patient population was critical to the success of this intervention. What was missing from the article, and what I think the success of the intervention can be attributed to, was the role of the principle of positive deviance.
The concept of positive deviance has been defined as follows: "In every community there are certain individuals or groups (the positive deviants) whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers. These individuals or groups have access to exactly the same resources and face the same challenges and obstacles as their peers (2)." In other words, we don't need to discover new approaches to help patients deal with their chronic diseases. Somewhere out there are already are people who have somehow figured things out for themselves and are achieving better results. It is up to us as a healthcare community to help our patients discover these practices and facilitate their application to their own circumstances. The positive deviance approach has been successfully applied to childhood malnutrition (3), hand hygiene (4), and, in my institution, MRSA transmission (5).
I believe the storytellers represented positive deviants in the community. Whether it be through videos, dialogues, social networking, or any other means, the more we help to connect the positive deviants with the broader patient population, the more self-discovery of the positive deviant can occur by the very people whose behaviors need to change.
1. Houston TK, Allison JJ, Sussman M, Horn W, et al. Culturally appropriate storytelling to improve blood pressure. Ann Intern Med 2011;154:77-84.
2. http://www.positivedeviance.org/about_pd/index.html
3. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329:1177-1179.
4. Marra AR, Guastelli LR, de Ara?jo CMP, et al. Positive deviance: a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:12-20.
5. http://www.plexusinstitute.org/news-events/show_news.cfm?id=1664
None declared
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Though problematic, the Nolan expedition would pale in comparison to coming events. For nearly 40 years, Louisiana had been an extension of the vast empire of New Spain until being returned to France in 1802. Struggling to suppress a slave revolt in the Caribbean, Napoleon was left with no better option than to sell France's Louisiana territory to the newly formed United States.
See the rest of the story in this week's Advance-Guard.

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Jul 16, 2012 0
Game Notes: Panthers, Bears, Bengals, Browns
This off-season, we spent some time watching each and every NFL team again, trying to pinpoint strengths and weaknesses with players we might have missed in the rush of the regular season. The intention was to feel more confident in our analysis for what turned out to be our biggest player profiles ever.We spent more time on some teams than on others, and even the teams we spent the most time on we were only able to watch a handful of games. But we thought it might be cool to publish a series of blogs detailing what we saw from the teams we watched with our raw notes.
These notes were never intended for publication, so forgive grammatical errors or the occasional poor language. Nor were they intended to be comprehensive, or definitive takes on fringe players (especially WRs, who are difficult to watch on TV angles). We simply thought it'd be a neat way to show a little extra insight into some of the players that we might not have felt like we had a great grip on this season.
Carolina Panthers
Week 2 – GB
Cam Newton
- Panthers came out chucking the ball. Deep shots to Jeremy Shockey first two plays. They [...]


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Next year's art lineup is already stacked with the Columbus Museum of Art's look at Mark Rothko's work from 1940 to 1950 (Feb. 1-May 26), and the Wexner Center's latest announcement of its winter and spring season is adding to the excitement for 2013. Below, the highlights. Check out the full list here or watch the video above.
On screen:
James Acheson: Costume Designer
7 p.m. Jan. 19
Costume designer James Acheson will discuss his work on projects like Dr. Who, Time Bandits, Brazil, The Last Emperor, Dangerous Liaisons and Restoration. Visitors can also expect to hear about his role in digitizing the costumes Sam Raimi's Spiderman series and the upcoming Superman movie "Man of Steel."
"Creature from the Black Lagoon" 3D Digital Restoration
Jan. 3 and 5
Don't miss the chance to see Hollywood's most storied monster fins in 3D.
On the walls:
"More American Photographs" Winter 2013 (Jan. 27-April 7)
An exhibition of photographs taken between 1934 and 1944 as part of the Farm Security Administration's initiative to document the poverty stricken citizens of the States.
"Josiah McElheny: Towards a Light Club" Winter 2013 (Jan. 27-April 7)
Josiah McElheny, a former Wexner residency artist, uses projected film, mirrors and glass sculptures to explore modern ideas of utopia. The artist's most recent film "The Light Club of Vizcaya: A Woman's Picture," which is an adaptation of a 1912 novel by a German expressionist writer will be available for viewing in a dramatic, cathedral-like installation space that is partly made of colored glass block windows.
"Paul Sietsema" Spring 2013 (May 4- Aug. 4)
L.A.- and Berlin-based artist Paul Sietsema creates and films drawings and sculptures that tap into themes of authorship, material and history. This survey exhibition is billed as "the most comprehensive account of artist Paul Sietsema's body of work to date."
"Shimon Attie: Metro.PAL.IS." Spring 2013 (May 4- Aug. 4)
Eight 65-inch flatscreen monitors project footage of members of Palestinian and Israeli communities in New York reading a document, created by artist Shimon Attie, that combines sections of the Israeli Declaration of Independence and the Palestinian Declaration of Independence.
On stage:
Jeff Mangum with Tall Firs and Briars of North America
8 p.m. Jan. 14
Neutral Milk Hotel's Jeff Mangum promises and evening of song, including many a beloved favorite from "In the Aeroplane Over the Sea."
Gilad Hekselman 4tet
8 p.m. Jan. 18
The fickle New York Times has stamped its seal of approval on the music of this group, named for its young Israeli jazz guitarist.


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The NextWeb - Sun Startup Essentials will be there and sponsoring the startup rally again.
By Stewart Townsend on Jan 13, 2010
Get ready for the 5th edition of The Next Web Conference! The Next Web brings together the best audience and companies from Europe and the US to discuss the future of the web. Read More
April 27+28+29 / Amsterdam
The Next Web Startup Rally
Last year over 250 startups signed up for The Next Web Startup Rally. After multiple jury rounds the 24 finalists we're selected to present on main stage during The Next Web Conference. This changed the lives of many entrepreneurs. And thanks to last years Startup Rally sponsor Sun it was free of any charge for the Startups.
This year it is the fifth edition of The Next Web Conference, it is a special year for us and we're reinventing ourselves by raising the bar again. Behind the scenes we're working on an even bigger and more prestigious Startup Rally then last year.
I hope to see you all there but in the meantime enter The Startup Rally now


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For Immediate Release
September 21, 2009
Illinois receives nearly $350,000 to improve health of school children
Federal grant helps combat childhood obesity and promote physical activity
The Illinois State Board of Education has been selected by the U.S. Department of Agriculture to receive a nearly $350,000 nutrition grant to combat childhood obesity and promote an active lifestyle. Funds from the Team Nutrition Training grant will be used to help children develop good nutrition and physical activity habits for healthier lifestyles.
"This funding will boost efforts to improve the eating and exercise habits of Illinois' schoolchildren and fight childhood obesity,'' said State Superintendent of Education Christopher A. Koch. "Good nutrition and physical activity go hand in hand with learning and will benefit students well beyond their school years.''
The Illinois State Board of Education will administer funds during a two-year Grant period through the Illinois Team Nutrition Training (TNT) Project with plans to focus on three initiatives:
- Provide training and resources to school food service staff to help them increase the amount and variety of whole grain products offered to students in the school breakfast programs. The 2005 Dietary Guidelines for Americas (DGAs) recommend that half of the grains consumed be whole grains but studies show that children consume only one third of the recommended level.
- Provide the opportunity for 20 Illinois elementary schools to apply for a mini-grant of $3,500 for training and technical assistance in the HealthierUS School Challenge, a national recognition program for schools that excel at supporting student wellness. The initiative aims to help reverse the childhood obesity epidemic. Overweight children are at greater risk for developing heart disease, Type 2 diabetes and other chronic diseases.
- Improve after-school wellness activities, nutrition and snacks through 10 mini-grants of $2,000 to eligible after-school programs. Funds will also go toward developing training to successfully integrate nutrition education and physical activity into after-school programs. Across the country, 20 percent of K-8 students are enrolled in after-school programs.
The $348,404 Team Nutrition Training Grant is a key component in the efforts of the USDA's Food and Nutrition Services (FNS) to enhance children's lifelong eating and physical activity behaviors by incorporating the principles of the Dietary Guidelines for Americans and MyPyramid. Illinois is one of 18 states to receive the grant that expires Sept.30, 2011.


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"You have helped me in so many intangible ways! I have grown in my knowledge and wisdom by reading your excellent materials and viewing your videos. I have passed along insight to my friends and family. I'm proud, blessed and happy to be an avid (ardent, dedicated, enthusiastic, keen) Catholic!"
"The gravest obligation requires the acceptance and practice, not of the religion which one may choose, but of that which God prescribes and which is known by certain and indubitable marks to be the only true one."


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Everything old is new again
As for the "new" theatre space, it's actually something old. Once the site of Katz's Bakery, which flourished in the late '60s and remained in business until 1989, the LFT (www.LibertyFreeTheatre.org) has big plans to repurpose the somewhat decayed interior, and I was excited to be given a sneak peek. The space is cool, the project is underway, and the future, rising from the past, looks bright. To participate in making the dream a reality, visit the web site, or call 845/798-1527 to contribute.
Along the same vein, I had to remind myself that singing sisters Ann and Nancy Wilson (AKA Heart) have been topping the charts since rising to fame in the mid-1970s with a string of smash hits, selling more than 30 million albums worldwide. While their popularity has never really waned, the ladies have grown and evolved over the years and remain (according to Wikipedia) one of "the most commercially enduring hard rock bands in history." Inducted into the Rock and Roll Hall of Fame earlier this year, Heart is currently on tour with Jason Bonham (son of the late, great drummer John Bonham) and the tribute to his dad—"The Led Zeppelin Experience," which thousands attended last Saturday night on the grounds of Bethel Woods (www.bethelwoodscenter.org). Led Zeppelin is widely considered one of the most successful and innovative rock bands in history, so the double bill made perfect sense. Hardly an "imitation," I would call the "experience" the Mother of all cover bands, and with Bonham at the wheel, the band (and Heart) was amazing. Zeppelin is also in the Rock &Roll Hall of Fame, and the museum states that the band was "as influential in the 1970s as the Beatles were in the decade before them."


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Ervin Santana vs. His Critics – Part 3
John Cortez poses with Ervin Santana at the 2003 Carolina League-California League All-Star Game.
I'm a nobody.
And if you like Ervin Santana, you're a nobody too.
Thus spake Matt Hurst, Angels beat writer for the Riverside Press-Enterprise, in his latest salvo lobbed not only at Santana but also anyone who happens to support the kid.
"This is the Santana everyone knows," Hurst wrote in his August 28 blog. "This is the Santana nobody loves. This is the real Ervin Santana."
Nobody loves Santana?! Really?!
I like Ervin.
And I know quite a few people associated the Angels' minor leagues over the years who liked Ervin too.
One "nobody" was a diminutive deaf-mute named John Cortez.
John worked part-time as a batboy for the Rancho Cucamonga Quakes a few years ago. His moment of fame came when Los Angeles Times sports columnist Bill Plaschke wrote about the special relationship between John and NBA star Shaquille O'Neal, who at the time was playing center for the Los Angeles Lakers.
During the NBA off-season he'd work for Rancho Cucamonga. In 2003, Ervin was with the Quakes, and was named to the California League All-Star Game.
Before the game, John gestured that he wanted me to take a photo of him with his friend Ervin, who was wearing his All-Star jersey. For which Ervin gladly posed with a big smile. John's smile was just as big.
Presumably Matt wasn't including all of Planet Earth when he declared that "nobody" likes Santana. So who are the somebodies whose opinion apparently matters?
The beat writers?
If so … who cares.
The beat writers are reporters. Their job isn't to like or dislike someone. It's to report the story. If the newspapers were filled with articles only about players that sportswriters like, then I guess we'd never read articles about Garret Anderson or any other player who has cause to distrust the media.
Perhaps Matt meant Ervin's teammates.
I'm not privy to what goes on these days in the Angels clubhouse behind closed doors, so I can't answer that one. Coming up through the system, from what I saw Ervin sure seemed popular enough with his teammates. Looking back through the FutureAngels.com Photo Galleries, I see pictures of him hanging out with teammates. I never saw anyone run from him. So he can't be that bad.
Maybe Matt meant that his teammates are unhappy with Ervin's recent erratic performance.
Well, no kidding.
None of us are. Including Ervin, obviously.
In the middle of a pennant race, the Angels need to rely on consistent performance. Manager Mike Scioscia handed Ervin a second chance, in a high-pressure game August 17 at Boston. He pitched one of the most dominant games seen anywhere in the majors this year.
Yet Matt writes in his blog that this was not the "real" Santana. The "real" Santana, he claims, is the one who failed to get out of the first inning last night at Seattle.
Funny, because if we look at Ervin's career record, the "real" Santana is closer to the one we saw in Boston than the one who's struggled the last few months. Through 2006 in his minor league career (which began at age 17), Ervin has a 38-16 (.704) record with 487 strikeouts in 480 2/3 innings. In 2003, when he was named to the California League All-Star Game, his ERA was 2.53 in 20 starts at age 20. In 2005, he was promoted at age 22 directly from Double-A Arkansas to the majors. He started 23 games that year for the Angels, posting a 4.65 ERA in 133 2/3 innings. Last year, he had a 4.28 in 33 starts, spending the entire season in Anaheim.
On Monday's post-game show, John Lackey was asked about Santana. He didn't say he disliked Ervin. He did say Ervin's problem was too many pitches were finding the middle of the plate, but duly noted that Santana's stuff is electric when he has his location.
We saw that last night in Seattle.
The radar consistently clocked Santana's fastball at 95 MPH.
The problem, though, was that his fastball was finding too much of the plate, and it lacked movement.
Whether it's strictly mechanical or a lack of mental "toughness," that's for pitching coach Mike Butcher to figure out.
In any case, Ervin only gave more ammunition to the instant-gratification crowd whose loyalty goes as far as the last box score.
The irony is that these are the same people who constantly whine about the Angels lacking infinite patience with Bobby Jenks. Would they have Bill Stoneman ship out Santana only to see Ervin mature past his temporary problem and become the next Pedro Martinez with another organization?
Ervin told Times reporter Dylan Hernandez he was happy in Salt Lake, where "nobody bothered me." (Those pesky nobodies again …) So maybe that's what the Angels need to do — return him to Salt Lake.
The Bees have only six games left in the season, but they won the PCL Pacific North title last night and will probably face Sacramento (an A's affiliate) in the conference championship round next week.
Since Ervin probably won't get another shot at a major league start this year, why not send him to Salt Lake and let him participate in a pressure environment free of the major league media glare?
Maybe he'll regain his confidence, take that into the off-season, and report next spring to Tempe with a fresh perspective.
Let's keep in mind he's only 24 years old. Nearly all young pitchers go through growing pains. John Lackey was inconsistent his first two full seasons — he had a 4.63 ERA in 2003 and a 4.67 ERA in 2004. Certain fans on the Angels board called him "Lacknuts" and demanded the Angels dump him. Thank goodness Stoneman ignored them. Lackey was 26 years old a month after the end of that 2004 season, about two years older than Santana is now.
It would be pretty foolish to give up on a 24-year old kid with Ervin's stuff just because he's behind the maturity curve due to his upbringing in third-world squalor.
Matt also chose to call "ignorant" those who think positively of Santana, and although he chose not to name names it was pretty clear from the context he was referring to this blog.
In an era where newspapers are struggling to keep their readers, it does seem odd that a reporter would choose to insult those whose opinion differs with him, in particular a fan web site that in the past has been very supportive of his newspaper and his articles. This blog was pretty much the only fan site that spoke positively of Ervin when he was recalled from Salt Lake, noting that at Franklin Covey Field the hitter-friendly 4,500-foot altitude distorts pitchers' numbers. On the road in neutral parks, Santana had been effective in two starts. So I pointed out that Triple-A really wasn't going to make much difference other than to take off the pressure, and was proven right when he dominated at Boston. When Matt singles out the "Angels followers (I will save names to protect the ignorant) with blogs and filling up message boards that they believed in Santana and the guy everyone saw in Boston two starts ago was the real deal," the list of suspects is very short.
Bloggers by definition are subjective. They're not meant to be professional journalists. Blogs are opinions, no more.
When a reporter is given a blog, it lets him cross the line between journalistic objectivity and personal opinion. But the danger in that is it exposes to the world a reporter's personal biases. And when his readers learn of those biases, they'll start to wonder whether it slants the journalist's reporting. Matt called Ervin a "spoiled brat" in an August 23 blog that complained about Ervin granting an interview to someone other than one of the regular beat writers. Now Matt follows up by calling "ignorant" those who believe in Ervin despite his recent hiccup.
I doubt we'd have ever seen Jim Murray or Ross Newhan call their readers "ignorant" for the crime of disagreement.
But then I'm a nobody, so my opinion doesn't matter.
UPDATE 8/30/2007 5:30 AM PDT — An article on MLB.com suggests that Ervin might get another chance to start for the Angels on Monday.
Scioscia said the staff is weighing its options for Monday's starter against Oakland.
Ervin Santana, who yielded five runs on four hits and two walks while getting one out on Tuesday night, remains a possibility. Also under consideration are Dustin Moseley, following his superlative effort (5 1/3 innings, no runs, two hits) in relief of Santana, and Jered Weaver, who faced Hernandez on Wednesday and would be pitching on his normal day.
"There are some things we might be able to bring into Ervin's game to help him," Scioscia said, having reviewed video of Santana's starts with pitching coach Mike Butcher. "It's frustrating. Ervin's frustrated. Still, projecting his career, we're as excited as ever. He's got the potential to be very good for a long time."
Santana's issues are command-related, falling behind in the count. He thought the Mariners, Ichiro Suzuki and Adrian Beltre in particular, hit good pitches in his first-inning unraveling.
I wonder if this qualifies Scioscia as "ignorant" in Matt's eyes …
7 Comments
My family & I LOVE Majic.I got to know him when he was at Rancho. Great kid When we go to Angels & he sees us he always smiles & waves & usally drags other Rancho alums out to do the same.Im saddend that anyone would endlessly try to to stick a fork in this young man. Yes he is having some problems, He as had them in the past & was able to work through them.I try not to be thin skined when people bag on the players, But I will not tolerate kicking someone when they are down & working hard to improve.Im a Santana fan & will always be in his corner.
It seems like Ervin's only real problem is pitching on the road. He is 23-8 with a 3.26 ERA in 40 home starts for his career including 4-3 with a 3.84 ERA this year. He is 10-20 with a 7.19 ERA in 38 road starts for his career. Being that he is only 24, I think he still has the stuff to turn it around.
I foster the opinion that many of the "trade rumors" discussed in the papers and on the internet are gamesmanship Stoneman uses to motivate his own players to promote the "Angels". I believe that trade rumors involving Santana over the last year or so were intended to help Ervin mature, a tactic which may have gone a bit too far.
I, too, have followed Ervin's career for several years in the minors. I believe that Angels' management have projected him to be an Angels' "star" for many years to come. I find it incomprehensible that Stoneman, Scioscia, et al have, or soon will, give up on Ervin Santana.
Beat writers and the "media" seem to have the most problems with Ervin Santana. I used to wonder why certain players, particularly Latin players with English ability would boycott speaking to the media, or in Vlad Guerrero's case, use a translator even when he does have the ability to speak good English. It's pretty apparent now why. If you get on the beat writer's bad side, they will make things personal, and hammer you in the papers simply because they don't like you. The media's standard defense is, I'm only reporting the facts. But you look at their stories, and its just ridiculous how biased they are. One article advocated trading Ervin because he has so much baggage in LA. Really? We're talking about a post season hero, a guy who won 16 games last year, and suddenly he has so much baggage in LA that he needs to be traded? That's not honest reporting. That's one pissed off reporter who feels so important about himself, that he is offended when an athlete does not want to talk to him. Reporters with their own agendas, allowing their personal feelings for certain players to interfere with their work should be fired.
Let's not forget that Ervin is only 24 yrs old. He will have a very good major league career. In the spirit of buy low and sell high, we need to build him back up and get him to where he was in 2006. Maybe he just needs some time off and away from the game. Starting him on Monday makes no sense. Maybe in Sept when we've got the division and playoff implications sealed. in the regular season, you need 5 quality starters (which we have right now)…with Bart possibly coming. Maybe he can pitch in the playoffs for the Bees ?
I struggled to keep a straight face while reading Hurst's latest online tantrum. Gee Stephen, guess you must have hit a nerve.
As was aptly pointed out, why would a staff reporter for a major news outlet care what a bunch of armchair observers think? And why devote an entire blog to making sure that the whole world can tell the difference between the professionals and amateurs?
It really shouldn't be that difficult to differentiate the real pros from the posers, after all. Good reporters don't try to pass off a personal grudge as fact. They understand that it is unethical to use their press credentials as a bully pulpit. They are certainly too informed to equate English fluency with social superiority. Of course, they wouldn't soothe a bruised ego by resorting to name-calling.
How could anyone read the following professional assessment of pitching performance and fail to recognize the writer's incomparable knowledge and keen insight? "Sorry folks. . . .This is the Santana nobody loves."
Such an elegant piece of writing, too. Am I supposed to be impressed? Insulted? Hurt? Oh. Um, yeah. Sorry Matt. This sounds more like a playground taunt from a 10-year old than an opinion worth arguing about.
Sometimes, the only way to deal with a bully is to find bigger friends. Wouldn't it be great if Ervin's teammates boycotted the PE reporters? You know, just ignore the PE reporters like they didn't exist, while still talking to the other papers.
By the way, I'd rather be a nobody than a bigot.
Ervin is the future of angels and everyone in dominican republic appreciated his work……go ahead Magic Satana!!!!!!!!!!!!


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Bluefield State College Gives 11 Musical Instruments to Bluefield High School Band (w/photo)
CreatedFriday, August 27 2010
Created byJim Nelson/Media Relations - (304) 327-4103 email@example.com
Bluefield State College recently gave 11 musical instruments to Bluefield High School. BHS Band Director Bobby Jenks (left) accepted the instruments from Don Kensinger (center, BSC professor emeritus) and Paul Rutherford (right, BSC Purchasing Director) during a brief ceremony at BSC. The instruments had been in storage at BSC for several years and can now be used by current and future BHS band students.
(Bluefield)—Eleven band instruments, many of which have not been used for more than 40 years, will soon be making sweet music again. Bluefield State College recently transferred the instruments, which had remained in storage at the college since the 1960s, to Bluefield High School. The donation was the latest in a series of music-related collaborative activities involving the College and the high school. Last year, BSC donated a concert grand piano to Bluefield High, and earlier this year, the US Air Force jazz ensemble "Nighthawk" presented a clinic for BHS band members before performing at BSC during a Black History Month program.
Bluefield High Band Director Bobby Jenks noted the timeliness of the most recent gift. "We can now put instruments into the hands of students who need them, but currently don't have them," he explained. "This is a wonderful initiative on the part of the college and it really helps us."
Don Kensinger, music professer emeritus at Bluefield State College, and Paul Rutherford, BSC's Director of Purchasing, proposed the donation several weeks ago. "These instruments had been in storage, some for more than 50 years," Rutherford commented. "Since BSC was no longer using them, we thought it would be best to donate them to Bluefield High School to be used and appreciated. The College is permitted by state law to transfer unneeded surplus equipment to any city, county or state agency."
"We discussed the idea with Bobby and he was very enthusiastic about it," Kensinger added. "We are grateful that these instruments will give some young musicians an opportunity to practice and perform."


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Rajinikanth attends a special screening of Dasavathaaram.
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'The Dude' shows in Brattleboro SaturdayMarch 23,2013BRATTLEBORO — The full Dude Experience will be available Saturday as Latchis Arts brings the cult classic ''The Big Lebowski'' to the big screen.
Latchis Arts is doing its part to give Dude fans a full Dude experience, and moviegoers are urged to wear their bathrobes, like the Dude. Or you could buy one that night, fluffly white Latchis Hotel bathrobes will be on sale for $65. A portion of each sale will go to support the efforts of Latchis Arts.
Since the Dude is a big fan of White Russians, the Flat Street Brewpub will offer White Russians for sale in the lobby.
As for bowling, free game vouchers will be provided by Brattleboro Bowl, while supplies last.
Raffle tickets will be on sale to benefit Latchis Arts.
The movie will be shown at 9 p.m. at the Latchis Theater with admission by donation, suggestion $10, to benefit Latchis Arts.MORE IN This Just InBARRE TOWN Firefighters faced a collection of adverse conditions as a house on Granitville Road... Full StoryWILLISTON Police are asking for help identifying the man who tried to steal roughly $800 worth ... Full StoryNEWBURY Police said somebody stole booze and change from a Welch Road residence. Full Story
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- Wireless broadband developments in Southeast Asia markets
As of 2013, the 10 ASEAN nations had a total of over 700 million mobile subscriptions, with the CAGR from 2003-2013 reaching 24%. This Digitimes Research Special Report analyzes the various mobile broadband markets in ASEAN and looks at the respective trends in 4G LTE development for those markets.
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This Digitimes Research Special Report provides a 2015 forecast for the global tablet market and analyzes the strategies of key market players such as Google, Apple, Intel, and Microsoft.
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This Digitimes Research Special Report analyzes the strategies of key China-based major panel makers BOE, Tianma and IVO for attacking the different market segments through technology and pricing, and their relationship to local vendors Huawei, Lenovo, ZTE, Xiaomi and Coolpad.


text:
Wildervanck Syndrome
National Organization for Rare Disorders, Inc.
It is possible that the main title of the report Wildervanck Syndrome is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.
General Discussion
Wildervanck syndrome, also known as cervicooculoacoustic syndrome, is a rare genetic disorder that primarily affects females. The disorder is characterized by a skeletal condition known as Klippel-Feil syndrome (KFS); abnormalities of certain eye (ocular) movements (i.e., Duane syndrome); and/or hearing impairment that is present at birth (congenital).
In individuals with KFS, there is abnormal union or fusion of two or more bones of the spinal column (vertebrae) within the neck (cervical vertebrae). Duane syndrome is characterized by limitation or absence of certain horizontal eye movements; retraction or "drawing back" of the eyeball into the eye cavity (orbit) upon attempting to look inward; and, in some cases, abnormal deviation of one eye in relation to the other (strabismus). In some affected individuals, additional physical abnormalities may also be present. In most cases, Wildervanck syndrome appears to occur randomly for unknown reasons (sporadically).
Supporting Organizations
Alexander Graham Bell Association for the Deaf and Hard of Hearing
- 3417 Volta Place NW
- Washington, DC 20007-2778
- United States
- Tel: (202)337-5220
- Fax: (202)337-8314
- Tel: (866)337-5220
- Email: firstname.lastname@example.com
- Website: http://www.agbell.org
American Academy of Audiology
- 11730 Plaza America Drive, Suite 300
- Reston, VA 20190
- Tel: (703)790-8466
- Fax: (703)790-8631
- Tel: (800)222-2336
- Email: firstname.lastname@example.com
- Website: http://www.audiology.org
American Society for Deaf Children
- 800 Florida Avenue NE
- 2047
- Washington, DC 20002-3695
- Tel: (866)895-4206
- Fax: (410)795-0965
- Tel: (800)942-2732
- Email: email@example.com
- Website: http://www.deafchildren.org
Genetic and Rare Diseases (GARD) Information Center
- PO Box 8126
- Gaithersburg, MD 20898-8126
- Tel: (301)251-4925
- Fax: (301)251-4911
- Tel: (888)205-2311
- Website: http://rarediseases.info.nih.gov/GARD/
Hearing Health Foundation
- 363 Seventh Avenue, 10th Floor
- New York, NY 10016-3904
- United States
- Tel: (212)257-6140
- Fax: (212)257-6139
- Tel: (866)454-3924
- Email: email@example.com
- Website: http://hearinghealthfoundation.org/home
Let Them Hear Foundation
- 1900 University Avenue, Suite 101
- East Palo Alto, CA 94303
- Tel: (650)462-3174
- Fax: (650)462-3144
- Email: firstname.lastname@example.com
- Website: http://www.letthemhear.org
NIH/National Eye Institute
- 31 Center Dr
- Bethesda, MD 20892-2510
- United States
- Tel: (301)496-5248
- Fax: (301)402-1065
- Email: firstname.lastname@example.com
- Website: http://www.nei.nih.gov/
NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases
- Information Clearinghouse
- One AMS Circle
- Bethesda, MD 20892-3675
- Tel: (301)495-4484
- Fax: (301)718-6366
- Tel: (877)226-4267
- Email: email@example.com
- Website: http://www.niams.nih.gov/
For a Complete Report
This is an abstract of a report from the National Organization for Rare Disorders (NORD). A copy of the complete report can be downloaded free from the NORD website for registered users. The complete report contains additional information including symptoms, causes, affected population, related disorders, standard and investigational therapies (if available), and references from medical literature. For a full-text version of this topic, go to www.rarediseases.org and click on Rare Disease Database under "Rare Disease Information".
The information provided in this report is not intended for diagnostic purposes. It is provided for informational purposes only. NORD recommends that affected individuals seek the advice or counsel of their own personal physicians.
It is possible that the title of this topic is not the name you selected. Please check the Synonyms listing to find the alternate name(s) and Disorder Subdivision(s) covered by this report
This disease entry is based upon medical information available through the date at the end of the topic. Since NORD's resources are limited, it is not possible to keep every entry in the Rare Disease Database completely current and accurate. Please check with the agencies listed in the Resources section for the most current information about this disorder.
For additional information and assistance about rare disorders, please contact the National Organization for Rare Disorders at P.O. Box 1968, Danbury, CT 06813-1968; phone (203) 744-0100; web site www.rarediseases.org or email firstname.lastname@example.com
Last Updated: 12/21/1969
Copyright 2011 National Organization for Rare Disorders, Inc.
This information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. Learn how we develop our content.
Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.


text:
Tajdar-e-Haram - RC Week 163
Your original file link
(Owner of the Sacred Place , Have Your Blessings on us)
Ya Mustafa , Ya Mujtaba, Irham Lana
(Oh Prophet Mustafa , O Chosen One, have mercy on us)
Mera Zikar O Fikar Hai Bas Yehi , Sallu Elehi Wa Alehi
(My thoughts and rememberance are " Peace and Blessings Upon Our Prophet" )
Ya Sahib al Jamal Ya Sayed Ul Bashar
(Oh Owner of Tenderness and Master of Mankind)
Nice islamic mix sis.......... i really love this type of muzic.....gazal .......great work.....
thnx Psnp ...this not ghazal ...this qawali ..
This is sooo great You did a great work.
thnx pumpkin......
Awesome mix with original style
...good job!!
thnx bro .....
Cool mix cutiepiezsounds really greatgreat job
superb mixing
awesome mix sis.... great tracks and well mixing.... love it....
Great remix Cutie sis
Great chosen tracks
Great mixing
Love it
Thanks for presenting this mix esp. with the translation Great use of tracks and awsome mixing keep rocking with more
hmmmmmm this is such a lovely mix i never heard before very nice tracks used by you cute i am loving this one
I tried to find some pictures for your mix and religion but sadly couldnt find anything or maybe i searched for smth really wrong..
But the mix is really nice!!! Keep up the great job and you'll go far!
words precious ...no worry ...u say all so thnx
nice mix buddy.
thnx Noah
Very nice remix cutiepiez
Great job and well done
Love it so much
Thnx melmex
Such a great music!!! Thanks!! I love it! Bravo!!!!
thnx to u ....
great mix cutiepiez..
track is so cool...interestin music
very good transition...
u mix it very well..
Thnx Reed
Super Kawwali mix...Great...m loving it...really sweet...
thnx bro
what a lovely sweet Rmx sounds simply amazzing and love it so very much and this is your best mix so fare for me just perfectly mixed well done send it to my favs and expect super awesome mixes to come in the coming weeks keep ROCKING RC...
thnx... i try speak more like you expert not me


text:
Vacmaster Professional 14 Gallon/ 6.5 Peak HP Wet/Dry Vacuum
About this itemBringing Vacmaster Professional and Industrial strength into your home. For the DIY'er who want the best with large capacity, great tools and easy mobility.
"Nobody wants to spend more time cleaning up than is necessary. This powerful Vacmaster™ professional wet/dry vac will make short work of any job. Sludge, debris, standing water, wood scraps - nothing's too tough for Vacmaster™. Powerful motor and efficient design make Vacmaster™ easy to handle, use and store. Count on Vacmaster™ for quick cleanup in even the most brutal conditions. 6.5 Peak horsepower motor comes with a crushproof 10' hose. Extra large tank drain for easy disposal of contents, 18' Foot power cord and blower feature. If it does not need to be picked up, blow it away as most Vacmaster™ units convert quickly to a powerful blower, perfect for patios, sidewalks and driveways. The best wet/dry vac for your money. Accessories: fine dust cartridge filter, foam filter, accessory bag, 14 -Inch professional floor brush, 14 -Inch squeegee nozzle, crevice tool, 8 -Inch utility nozzle, air/noise diffuser, contour handle with air control."
Assembled Country
Assembled Size
18.5" x 18.5" x 26.2"
Component Country


text:
Originally Posted by Micho22
But i saw people with diffrent eye colors that was so cool one women had a dark brown and a green eye
I know 3 ppl with that.. 1 of them, right eye is brown and left is half brown and green split down the middle.
Black hair dark brown eyes
Brown Brown
Dark brown hair and dark brown eyes and blonde pubic hair.
Dark brown eyes, brown hair.
Brown hair & green eyes...the carpet matches the drapes
Hazel Eyes and Black Hair
Brown hair and green eyes ^_^
Dark brown hair and dark brown eyes.
Blue grey eyes and at the moment dark hair with a red shine to it
Originally Posted by Sasunarufan13
Blue grey eyes and at the moment dark hair with a red shine to it
I never realized you were a girl until right now
grey/blue eyes, red/blond hair
Dark brown eyes and brown hair with red highlights
Black and Blonde hair(am I a freak? :] ), Grass greeeeeen eyes
Brown hair with a few blonde highlights(natural) and green eyes
Black eyes, black and white hair...
Dark Brown Hair : brown eyes.
Eyes: Greenish blue.
Hair: Dirty blonde.
Brown hair, green eyes.
Blue-green eyes and dark brown hair.
Forum Rules


text:
iHerb Customer Reviews
Savings of: $6.25 (23% off)
Excellent Taste
Posted by Reviewer2836613 on Jun 08, 2010
I'm allergic to milk, eggs, whey, soy protein powders. Rice protein sits in my stomach like a rock. This beef protein powder digests really well for me and it tastes great great. Not too sweet and with a rich chocolate flavor. Who would have known that beef and choclate taste really good together. Great for low carb and high protein routines. At about a $1.30 ( Iherb price plus shipping) a serving this product is a real bargain. I hope Iherb keep this product in stock.
Incredible nutrition
Posted by Reviewer2301387 on Nov 10, 2009
This is a new and awesome product. I suggest always mixing it a blender in a smoothie. It does not dissolve or mix well otherwise. I do not eat much red meat becasue I do not prefer it, but here is my answer to the great protein nutrition red meat provides.
This stuff is the best! Please don't ever stop carrying it
Posted by Reviewer1876628 on Dec 15, 2012
I am allergic to pea, rice, egg white, soy and whey proteins, leaving me with no way to get my necessary protein daily. Digests easily, haven't found any issues in the first 3 weeks of using it. My naturopath is concerned with the fact that it shows "white chocolate" which is really just wax and sugar, and there isn't a lot of info on the label. I would love to get some more in-depth info on this product.
Love it
Posted by Reviewer2221903 on Mar 04, 2010
Enough satisfying protein, love the taste! I would have gave it 5 star but personally you only get 2 weeks worth's and its kinda pricey. Wish they had it in a larger size.
Beef Protein Powder is a Score!
Posted by Reviewer2247103 on Jul 23, 2012
Taste not bad, not great, but I'd trade some taste any day for a clean product like this -- no added sugars or sugar alcohols (which just cause GI problems for many, including me), no extra junk! If you add a bit of extra raw cocoa powder and a few frozen raspberries, it's really quite good (I blend with unsweetened coconut milk by So Delicious, which I get at Whole Foods, but I've seen it elsewhere by the cold almond milk). As others have said, best texture if you use a blender. I think people generally expect too much in the taste of these types of products - if they offer what you're looking for in nutrition and agree with your system without being offensive in taste AND they don't include a bunch of questionable ingredients, then it's a score as far as I'm concerned.
Beef Protein
Posted by Reviewer3055813 on Feb 13, 2010
I would not have bought this protein if I had realized it was high in Iron. I have a very high hematocrit.
Real taste
Posted by Reviewer2674984 on Sep 17, 2011
Good tasting and creamy.
Tasty protein powder, and no soy or milk
Posted by herbana on May 22, 2014
Very good chocolate flavor, and if you're a meat eater, it's great protein from something you know you can eat without a bad reaction. No soy, no milk proteins. The only downside is the cost, but you get what you pay for when you're avoiding cheap soy.
very good
Posted by Reviewer1047861 on Aug 04, 2011
very happy with the product
very good
Posted by Reviewer1149496 on Jun 11, 2011
excelent taste and quality


text:
La Crosse police arrested a 20-year-old woman on several drug charges on Sunday.
Police were patrolling the 400 block of Caledonia Street because of reports of possible narcotics trafficking when an officer noticed a car parked with three people in it, according to the police report. Police say it was a suspected drug buy.
A police officer followed the car, which had a loud muffler noise, and pulled it over on the 200 block of Avon Street, the report states, and then called for a K-9 unit.
Rhena Rouse, the rear passenger, told officers where they could find the drugs when the K-9 unit started searching the car, the police report said. Police found meth in a compact in her purse in the back seat, along with .22 grams of meth in her boot, .52 grams of synthetic marijuana and drug paraphernalia in a bra. According to the police report, Rouse said the drugs were not hers and they belonged to her boyfriend, but would not name him.
Rouse faces several charges, including possession of meth, possession of drug paraphernalia, possession of synthetic cannabis, and possessing a prescription without having a prescription.
A La Crosse County judge set a $1,000 signature bond for Rouse on Monday afternoon.


text:
UNC senior "bandit" LB Norkeithus Otis has "the talent to potentially fill" a "tweener" hybrid role in the NFL, according to CBS Sports' Derek Stephens.
Alabama redshirt sophomore David Cornwell will transfer.
Stanford RB Christian McCaffrey confirmed that he will enter the 2017 NFL draft.
Ole Miss redshirt senior QB Chad Kelly (knee) accepted an invitation to the Senior Bowl.
USF HC Willie Taggart will be Oregon's next head coach, according to ESPN's Brett McMurphy.
Clemson junior QB Deshaun Watson was named the winner of the Johnny Unitas Golden Arm Award.
Tennessee received a verbal commitment from five-star 2017 T Trey Smith.
CBS Sports' Dennis Dodd hears that Oklahoma OC Lincoln Riley "killed it" during his interview for Houston's head-coaching position.
Bleacher Report's Matt Miller reports that Stanford junior RB Christian McCaffrey will declare for the 2017 NFL Draft.
ESPN's Sam Khan Jr. reports that Houston has interviewed Alabama OC Lane Kiffin, former LSU HC Les Miles, OC Major Applewhite and DC Todd Orlando for their open head-coaching position.
The Oklahoma Supreme Court has ruled that the videotape of Oklahoma redshirt sophomore RB Joe Mixon punching a woman from summer 2014 is part of the public record.
Alabama senior ILB Reuben Foster was named the winner of the Butkus Award.


text:
Re: Weekly Picks & Meal Club for 2013
thorman52 wrote:Lord help me, I hope I'm asking at the right place. Doesn't seem to be a place to ask questions so I'll try here. It's about the Weekly Picks contest. I wanted to pick Tony Stewart for 1st place but his name is not on the list. But it might be. Tomy Blissi (?) is at the bottom and Tony's name might be under my taskbar which is hidden. Is that possible? How do I see his name to pick him? Do I need a bigger screen?
Just joined and looking around this seems like a fun site. It is real clean and organized well. Still trying to find all the features though.
Just checked and Tony is there 2 names below Tomy Blissi whoever he is....
Thank you to those who took a step forward to save the rest who stand still.


text:
STAT has proven that he's all talk and no game again so far. He hasn't looked bad, but that 3rd foul was just the mark of an idiot.
Melo needs to learn that Lin gets the ball to the man who's moving, not the man who stands stagnant with a defender in front of him. Melo needs more looks, but he has to make the shots come to him.
Lin is struggling with the double team off picks and it's slowing us down. Late shots in the 24 with no movement. Not good.
What's with the free throws?
What's with the late doubles?
What's with the Knicks?
They just look...............................bad.


text:
By Sharna Johnson: CNJ staff writer
PORTALES — The State Fire Marshal's Division is investigating three commercial fires in Portales that occurred over a 10-day period at the request of local authorities.
The latest was Sunday afternoon at Portales Valley Mills.
Portales Police Capt. Lonnie Berry said Sunday's fire appeared to have started on the second floor of the building, which was used for storage of records and unoccupied at the time of the fire.
The fire caused minimal damage. A firefighter injured battling the blaze was treated at a local hospital and released, officials said.
The State Fire Marshal's Division, which falls under the PRC, only assists in investigations at the request of local authorities, according to Paul Carbajal, spokesman for the Public Regulations Commission, on behalf of fire investigators.
Evidence from the three fires has been sent to a crime lab in Albuquerque where it will be analyzed, Carbajal said.
"The investigation is still pending," he said. "As far as the detailed information of this investigation, we can't make any comment because the investigation is still ongoing.
"Everything's on the table, and it's a process of elimination at this point. To protect the integrity of the investigation and to protect the evidence that's being collected, we don't want to give out premature information and then we have to backtrack (as the investigations develop)."
The roof of Big Valley Ford's repair shop in Portales burned Friday, and on March 27 a fire destroyed Dollar General and a Trader Horn's True Value Hardware warehouse.
Local fire officials don't believe there is a connection between the three blazes.
"None of them are looking like they are connected," Portales Battalion Chief Lance Hill said Monday. "It's really hard to say yes or no, one way or the other. Right now, there's nothing that we have seen to actually connect it."
The state division's five fire investigators investigate an average of 300 fires a year around the state.
Carbajal said investigators have noticed an increasing trend of suspicious fires in rural communities this year, something which typically is uncommon outside larger, more urban areas.
"We're noting a trend and it could be economically related, we don't know," he said. "But our state is not unique (regarding these types of fires)."


text:
Submit News
Hacker Who Leaked Nude Scarlett Johansson Photos Gets 10 Years in Prison
Jason Mick
December 17, 2012 10:00 PM
Recipient E-mail
Sender E-mail
Chris Chaney pleads guilty to hacking over 50 celebrities' smartphones for fun and profit
Between November 2010 and October 2011, there were a rash of hacking of high-profile celebrities smartphones. Starlets like Scarlett Johansson, Christina Aguilera, Mila Kunis had sexually explicit or provocative pictures
stolen from their devices
and released onto the internet.
In Scarlett Johansson's case fully nude pictures, meant to be seen by then-husband Ryan Reynolds were exposed for the world to see. She recalls, "I have been truly humiliated and embarrassed."
But intrusions weren't the work of a team of savvy hackers; they were the twisted hobby-horse of a single man, according to federal prosecutors -- Christopher Chaney, a 35-year-old Jacksonville, Fla. resident.
On Monday, justice
was served
U.S. District Judge S. James Otero
weighed a seemingly remorseful Mr. Chaney versus tearful celebrities like Ms. Johansson, who comments, "I find Christopher Chaney's actions to be perverted and reprehensible."
The federal judge gave the hacker a prison sentence of 10 years after pleading guilty of several criminal counts
under the Computer Fraud and Abuse Act
of 1986 (
) -- unauthorized access to a computer and illegal wiretapping. (In the U.S. only federal agents are allowed to wiretap people.)
Mr. Chaney could have faced a maximum sentence of 60 years in prison, but the sentence he did receive wasn't exactly lenient either. Prosecutors were only seeking a sentence of 6 years, but Judge Otero was concerned that Mr. Chaney hadn't truly changed his ways and needed longer away from the world of electronics. According to the Judge, prosecutors presented evidence that Mr. Chaney continued to pursue and harass women online after his arrest in October 2011.
In all, Mr. Chaney's "Operation Hackerazzi" breached the smartphones of 50 Hollywood and music industry celebrities. But he was also alleged of hacking into some close acquaintances phones, including send a nude picture of a former co-worker to her father.
Chris Chaney claims he sorry for all the hacking and denies accusations that he hacked into real-world acquaintances' devices. [Image Source: AP]
Mr. Chaney does not deny hacking the celebrity phones, but was apologetic. He, however, refused to admit to hacking his acquaintances phones, insisting he never did that. He comments, "I don't know what else to say other than I'm sorry. I could be sentenced to never use a computer again and I wouldn't care."
The Judge is quoted as telling him, "It's hard to fathom the mindset of a person who would accomplish all of this. These types of crimes are as pernicious and serious as physical stalking."
Now he will spend a better part of the next decade of his life behind bars (although he could get out early if gets parole).
AP on Google News
"Vista runs on Atom ... It's just no one uses it". -- Intel CEO Paul Otellini
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text:
Beauty Prep School
Bold Lips That Won't Budge
Camera A by Jack Pearce; Camera B by Kenny Wu; Makeup Expertise by Theo Kogan; Beauty Contribution by Annie Tomlin; Styled by Melissa Ward Schorsch; Photographed by Amelia Alpaugh
We can honestly say that we've never met a bold lip we didn't love. There's something about a bright, dramatic color that just fills our makeup-loving hearts with glee. What's not so lovable? That gleeful color's tendency to slip and slide all over your face as you try to do normal human things like eat, talk, and breathe.
Fortunately, there is a way to have your bold lipstick cake and eat it, too. In this video tutorial, you'll learn the secrets of making that shade stick to your lips, as well as how to make application a snap. Whether you need help creating a base or when exactly to use that lipliner (it's not when you think), watch and learn so you can become the lipstick ninja you were always meant to be.