text:
Spheris Reports Third Quarter 2008 Results
Financial Highlights--Third quarter of 2008
Net revenues for the third quarter of 2008 were $44.7 million comparedwith $48.9 million in the third quarter of 2007. The decrease in net revenueswas due primarily to the impact of net lost business and lower averagepricing.
Operating income for the third quarter of 2008 was $1.2 million, or 2.7%of net revenues, compared with operating income of $1.5 million, or 3.1% ofnet revenues, in the third quarter of 2007. The decrease in operating incomewas due to lower net revenues, accelerated technology investments to furtherdevelop and enhance our product and service offerings, as well as costsassociated with the expansion of our global capacity. These costs werepartially offset by operational cost savings from increased utilization of ourglobal production workforce and speech recognition technologies, in additionto other cost savings initiatives.
The Company defines Adjusted EBITDA as earnings before interest, taxes,depreciation and amortization, and other expense or income. Adjusted EBITDAfor the third quarter of 2008 was $7.0 million, or 15.7% of net revenues,compared with $7.6 million, or 15.5% of net revenues, in the third quarter of2007. The decrease in Adjusted EBITDA was due primarily to the impact oflower net revenues and the accelerated technology investments described above.
Adjusted EBITDA is a financial measure not computed in accordance withUnited States generally accepted accounting principles, or GAAP. Please referto the "Supplemental Financial Information" and related note contained in thispress release for further discussion and reconciliation of Adjusted EBITDA toGAAP financial measures.
Financial Highlights--First Nine months of 2008
Net revenues for the nine month period ended September 30, 2008 were$141.1 million compared with $151.8 million in the prior-year period. Thedecrease in net revenues was due primarily to the impact of net lost businessand lower average pricing.
Operating income for the nine month period ended September 30, 2008 was$1.0 million, or 0.7% of net revenues, compared with operating income of $6.1million, or 4.0% of net revenues, in the prior-year period. During the firstquarter of 2008, the Company recorded $1.3 million of expenses relating to atransaction that was not consummated. Excluding these transaction costs,operating income would have been $2.3 million, or 1.6% of net revenues, forthe nine month period ended September 30, 2008. In addition to the impact ofthe transaction costs, the decrease in operating income was due primarily tolower net revenues as described above, accelerated technology investments tofurther develop and enhance our product and service offerings, as well ascosts associated with the expansion of our global capacity. These costs werepartially offset by operational cost savings from increased utilization of ourglobal production workforce and speech recognition technologies, in additionto other cost savings initiatives.
Adjusted EBITDA for the nine month period ended September 30, 2008 was$18.7 million, or 13.3% of net revenues, compared with $24.3 million, or 16.0%of net revenues, in the prior-year period. Excluding the $1.3 million oftransaction related expenses noted above, Adjusted EBITDA would have been$20.0 million, or 14.2% of net revenues, for the nine month period endedSeptember 30, 2008. The decrease in Adjusted EBITDA was primarily due to theimpact of lower net revenues, accelerated technology investments, andtransaction costs described above.
Commenting on the third quarter 2008 results, Steven E. Simpson, Presidentand Chief Executive Officer of Spheris, stated, "The third quarter andyear-to-date results reflect the challenges in today's marketplace, but weremain encouraged by opportunities we are seeing. As our technologydevelopments progress, we continue to accelerate the efficiencies gained fromboth our speech recognition tools and global resources. We have receivedpositive feedback as a result of successfully demonstrating the new featuresand functionality through an intensive pilot program that led to signing asignificant new account."
Simpson added, "Even though we are pleased with the products coming out ofdevelopment, our goal remains to be the first to market with an end-to-endclinical documentation technology and service offering."
Balance Sheet Highlights
As of September 30, 2008, the outstanding indebtedness under the Company'ssenior secured credit facility was $77.3 million and the outstandingindebtedness under the Company's senior subordinated notes was $125.0 million.
Liquidity Highlights
As of September 30, 2008, Spheris held $9.9 million in unrestricted cashand cash equivalents and had $17.7 million of borrowing capacity under theCompany's senior secured credit facility. During the first nine months of2008, the Company generated $1.0 million of cash from operating activitiescompared with $9.8 million during the same period in 2007. The decrease incash generated from operating activities was attributable to the year overyear change in operating performance, timing of wages and benefit payments,and the current period payment of certain security deposits, as offset by thefavorable impact of improved collections on accounts receivable.
Investor Conference Call and Webcast
Spheris will host a conference call on November 13, 2008, at 8 a.m. CT.The number to call for this interactive teleconference is (303) 262-2130.Following the conference call, the audio replay will be available for one weekby dialing (303) 590-3000 and entering the confirmation number, 11111017#.The live broadcast of Spheris' quarterly conference call will be availableonline at www.spheris.com and http://www.videonewswire.com/event.asp?id=52756on November 13, 2008, at 8 a.m. CT. The online replay will be availableshortly after the call and will continue to be available for 30 days.
About Spheris
Spheris is a leading global provider of clinical documentation technologyand services to more than 500 health systems, hospitals and group practicesthroughout the U.S. Spheris offers a highly advanced, Web-based technologyplatform blended with Spheris' outsource services. Spheris employsapproximately 5,000 skilled medical language specialists supporting theCompany's clients through a secure network. Using a Follow the Sun(sm) servicestrategy, customer support is provided 24 hours a day, 365 days a year with anemphasis on verifiable quality, turnaround time and pricing. Spheris'corporate headquarters is located in Franklin, Tenn. For more information,please visit www.spheris.com .
Forward-Looking Statements
This press release contains statements as to the Company's beliefs andexpectations of the outcome of future events that are forward-lookingstatements as defined within the meaning of the Private Securities LitigationReform Act of 1995. These forward-looking statements are subject to risks anduncertainties as described in the filings made from time to time by theCompany with the Securities and Exchange Commission, including, withoutlimitation, the following: (i) the effect our substantial indebtedness has onour ability to raise additional capital to fund our business, to react tochanges in the economy or our business and to fulfill our obligations underour indebtedness, including our ability to meet financial covenants and otherconditions of our senior secured credit facility and indenture governing oursenior subordinated notes; (ii) our history of losses and accumulated deficit;(iii) our ability to effectively manage our global production capacity,including our ability to recruit, train and retain qualified medical languagespecialists and maintain high standards of quality service in our operations;(iv) our ability to adapt and integrate new technology into our clinicaldocumentation platforms to improve our production capabilities and expand thebreadth of our technology and service offerings; (v) our ability to maintainour competitive position against current and future competitors, including ourability to gain new business with acceptable operating margins and ongoingprice pressures related to our technology and services and the healthcaremarkets in general; (vi) the reluctance of potential customers to outsource orchange providers of their clinical documentation technology and services andits impact on our ability to attract new customers and increase revenues;(vii) financial and operational risks inherent in our global operations,including foreign currency exchange rate fluctuations and transfer pricinglaws between the United States and India; (viii) our ability to attract, hireor retain technical and managerial personnel necessary to develop andimplement technology and services to our customers; (ix) the effect on ourbusiness if we incur additional debt and assume contingent liabilities andexpenses in connection with future acquisitions or if we cannot effectivelyintegrate newly acquired operations; and (x) our ability to adequately protectour intellectual property rights, including our proprietary technology and theintellectual property we license from third parties.
Note to Supplemental Financial Information
The Company defines Adjusted EBITDA as earnings before interest, taxes,depreciation and amortization, and other expense or income (includingmark-to-market adjustments related to the Company's derivative financialinstruments). Adjusted EBITDA is a financial measure not computed inaccordance with United States generally accepted accounting principles, orGAAP. The Company believes that this non-GAAP measure, when presented inconjunction with the comparable GAAP measure, is useful to both management andinvestors in analyzing the Company's ongoing business and operatingperformance. The Company believes that providing the non-GAAP information toinvestors, in addition to the GAAP presentation, allows investors to view theCompany's financial results in the way management and the Company's seniorlenders view the Company's operating results. Management believes AdjustedEBITDA is useful as a supplemental measure of the performance of the Company'soperations because it isolates the Company's operating performance from theaccounting impact of the Company's financing strategies, tax provisions, anddepreciation and amortization. Additionally, since Adjusted EBITDA is asignificant component of certain financial covenants under the Company'ssenior secured credit facility agreement, management believes Adjusted EBITDAis useful for investors to better assess the Company's compliance with thesefinancial covenants. Management believes Adjusted EBITDA should be consideredin addition to, but not as a substitute for, items prepared in accordance withGAAP that are presented in this press release, as the items excluded in thepresentation of Adjusted EBITDA are significant components in understandingand assessing financial performance. A reconciliation of Adjusted EBITDA tothe nearest comparable GAAP financial measure is provided above. AdjustedEBITDA, as presented, may not be comparable to similarly titled measures ofother companies.The Company takes no responsibility for updating the information containedin this press release following the date hereof to reflect events orcircumstances occurring after the date hereof or the occurrence ofunanticipated events or for any changes or modifications made to this pressrelease. SPHERIS INC. Condensed Consolidated Statements of Operations (Unaudited and Amounts in Thousands) Three Months ended Nine Months Ended September 30, September 30, 2008 2007 2008 2007 Net revenues $44,749 $48,943 $141,074 $151,795 Operating expenses: Direct costs of revenues (exclusive of depreciation and amortization below) 31,673 35,144 102,775 108,804 Marketing and selling expenses 400 1,186 2,276 3,755 General and administrative expenses 5,640 5,028 17,337 14,939 Depreciation and amortization 5,862 6,039 17,720 18,172 Total operating costs 43,575 47,397 140,108 145,670 Operating income 1,174 1,546 966 6,125 Interest expense, net of income 4,681 5,280 14,379 16,133 Loss on debt refinancing - 1,828 - 1,828 Other (income) expense 820 (149) 1,438 330 Net loss before income taxes (4,327) (5,413) (14,851) (12,166) Benefit from income taxes (1,736) (1,872) (5,569) (4,638) Net loss $(2,591) $(3,541) $(9,282) $(7,528) SPHERIS INC. Condensed Consolidated Balance Sheets (Amounts in Thousands, Except Share Amounts) (Unaudited) September 30, December 31, 2008 2007 Assets Current assets Unrestricted cash and cash equivalents $9,902 $7,195 Restricted cash 309 309 Accounts receivable, net of allowance of $1,387 and $1,569, respectively 30,514 33,595 Deferred taxes 4,635 3,386 Prepaid expenses and other current assets 5,365 4,460 Total current assets 50,725 48,945 Property and equipment, net 12,830 12,747 Internal-use software, net 1,712 1,932 Customer contracts, net 1,987 13,968 Goodwill 218,841 218,841 Deferred taxes 4,557 - Other noncurrent assets 5,808 3,689 Total assets $296,460 $300,122 Liabilities and stockholders' equity Current liabilities Accounts payable $2,911 $4,237 Accrued wages and benefits 12,540 18,130 Current portion of long-term debt and lease obligations 387 35 Other current liabilities 8,510 4,324 Total current liabilities 24,348 26,726 Long-term debt and lease obligations, net of current portion 199,907 191,761 Deferred tax liabilities - 92 Other long-term liabilities 4,742 4,857 Total liabilities 228,997 223,436 Commitments and contingencies Common stock, $0.01 par value, 100 shares authorized, 10 shares issued and outstanding - - Other comprehensive income 181 564 Contributed capital 111,600 111,158 Accumulated deficit (44,318) (35,036) Total stockholders' equity 67,463 76,686 Total liabilities and stockholders' equity $296,460 $300,122 SPHERIS INC. Condensed Consolidated Statements of Cash Flows (Unaudited and Amounts in Thousands) Nine Months Ended September 30, 2008 2007 Cash flows from operating activities: Net loss $(9,282) $(7,528) Adjustments to reconcile net loss to net cash provided by operating activities: Depreciation and amortization 17,720 18,172 Amortization of acquired technology 162 486 Deferred taxes (5,898) (5,198) Change in fair value of derivative financial instruments 1,311 (10) Amortization of debt discounts and issuance costs 630 602 Loss on debt refinancing - 1,828 Other non-cash items 471 305 Changes in operating assets and liabilities, net of acquisitions: Accounts receivable 3,081 (345) Prepaid expenses and other current assets (991) (1,031) Accounts payable (1,326) (872) Accrued wages and benefits (5,590) (993) Other current liabilities 3,090 4,369 Other noncurrent assets and liabilities (2,385) (4) Net cash provided by operating activities 993 9,781 Cash flows from investing activities: Purchases of property and equipment (4,241) (3,086) Purchase and development of internal-use software (748) (558) Purchase of Vianeta, net of cash acquired - (1,547) Net cash used in investing activities (4,989) (5,191) Cash flows from financing activities: Proceeds from debt 7,288 71,320 Payments on debt and lease obligations (202) (76,051) Debt issuance costs - (583) Net cash provided by (used in) financing activities 7,086 (5,314) Effect of exchange rate change on cash and cash equivalents (383) 836 Net increase in unrestricted cash and cash equivalents 2,707 112 Unrestricted cash and cash equivalents, at beginning of period 7,195 6,323 Unrestricted cash and cash equivalents, at end of period $9,902 $6,435 Supplemental Schedule of Non-cash Investing and Financing Activities: Purchases of property and equipment and internal-use software through lease obligations $1,019 $- SPHERIS INC. Supplemental Financial Information (Unaudited and Amounts in Thousands) Three Months Ended Nine months Ended September 30, September 30, 2008 2007 2008 2007 Net loss $(2,591) $(3,541) $(9,282) $(7,528) Depreciation and amortization 5,862 6,039 17,720 18,172 Interest expense, net of income 4,681 5,280 14,379 16,133 Loss on debt refinancing - 1,828 - 1,828 Other (income) expense 820 (149) 1,438 330 Benefit from income taxes (1,736) (1,872) (5,569) (4,638) Adjusted EBITDA $7,036 $7,585 $18,686 $24,297
SOURCE Spheris
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Chapet, Assorted Flavors moistures dry lips , gives soothing protection and has silky smoothing formula. It also helps prevent and temporarily protects chafe, chapped, cracked and wind wind burned lips.
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text:
Beef Okra And Potato Kebabs
|Fingerling potatoes
|8 , cut in half lengthwise
|Chopped fresh parsley
|2 Tablespoon
|Prepared horseradish
|1 1⁄2 Tablespoon
|Whole grain dijon mustard
|1 1⁄2 Tablespoon
|Worcestershire sauce
|1 Tablespoon
|1 1⁄2 Teaspoon
|Olive oil
|2 Teaspoon
|Freshly ground black pepper
|1⁄4 Teaspoon
|1⁄2 Teaspoon, divided
|Chopped red bell pepper
|1 Cup (16 tbs) (1 Inch Square Pieces)
|Okra pods
|16 Small
|8 , peeled and halved
|Boneless sirloin steak
|1 Pound, trimmed and cut into 1-inch cubes
|Yellow squash
|1 Medium, halved lengthwise and cut into 1/2-inch slices to make 2 cups
|Cooking spray
1. Place potatoes in a saucepan, cover with water. Bring to a boil. Reduce heat, and simmer 1 5 minutes or until tender, drain. Cool.
2. Combine parsley, horseradish, Dijon mustard, Worcestershire sauce, sugar, olive oil, and 1/4 teaspoon black pepper in a large bowl, stirring well. Stir in 1/4 teaspoon salt. Add potatoes, bell pepper, okra, shallots, beef, and squash, toss well to coat. Cover and chill for 1 hour.
3. Prepare grill.
4. Thread the vegetables and beef alternately onto each of 8 (10-inch) skewers. Sprinkle the kebabs evenly with the remaining 1/4 teaspoon salt. Place kebabs on grill rack coated with cooking spray, and grill for 10 minutes or until desired degree of doneness, turning occasionally.
Recipe Summary
Rate It
Nutrition Rank
Nutrition Facts
Serving size: Complete recipe
Calories 1913 Calories from Fat 656
% Daily Value*
Total Fat 76 g116.5%
Saturated Fat 25.2 g126.1%
Trans Fat 0 g
Cholesterol 213.2 mg71.1%
Sodium 1486.9 mg62%
Total Carbohydrates 193 g64.2%
Dietary Fiber 31.7 g126.6%
Sugars 49.8 g
Protein 131 g261.4%
Vitamin A 206% Vitamin C 490.2%
Calcium 42.4% Iron 80.3%
*Based on a 2000 Calorie diet


text:
Today, I got paper thrown at me because I didn't agree with my classmate's conspiracy theory that Brian Griffin's death was planned by the illuminati. FML
By Amy / Thursday 5 December 2013 05:25 / Australia - Adelaide
Top comments
By DocBastard
You had paper thrown at you? PAPER?? NO!!! The horror! Anything but the paper! What will the bullies do next? Whisper vaguely inappropriate obscenities in your direction?
Too many negative votes, comment buried. Show the comment
I thought you were talking about brian in family guy. I was confused there... Yup I know nothing :/
it is Brian from family guy...
It's always the illuminati...
By ChenEighty
They had perfect right! Brian Griffin was a danger to the sanctity of the government. Clearly.
Beat me to it. Guess I'll cut out now.
Brian Griffin hit by a car, Brian O'Connor killed in car accident a few days later. Totes illuminati bros!
By sunnyray812
A belief is a belief. Your classmate should've accepted that instead of throwing things at you like a little kid.
I read this and thought of some friends joking around when OP walks up and acts like a douche saying that's not true and gets all serious so they threw a paper ball at him. That would explain the situation better. Or OP was getting trolled.
Too many negative votes, comment buried. Show the comment
The Illuminati doesn't existttttt
Why so many ttttttts?
U don't understand. If PMRants decides to use this comment, he's gonna have a tough time pronouncing all those T's.
That's right! We don't exist.
Just add, "That's what the government wants you to think." at the end of every statement to make it sound like a conspiracy.
Your comments were already creepy before that!
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text:
Toronto Police are asking for help in tracking down a sexual assault suspect near Jane and Finch.
Police say on June 6 at around 12:30 p.m. a woman was sexually assaulted on the pathway near Tobermory Drive and Potsdam Road.
The suspect is described as having dark-brown skin, 25-30, 5'5″, 150 lbs., black eyebrows, with black hair, long on the top, short at the sides and back with a pointy nose.
He was wearing a long brown/orange T-shirt with a black-and-blue circular logo on the front, black baggy pants and white underwear under the pants.
Police have now released a composite sketch of the suspect with the hope someone can identify him.
Anyone with information is asked to contact police at 416-808-3100, Crime Stoppers anonymously at 416-222-TIPS (8477) or online at www.222tips.com.


text:
CALL US FOR BEST DEAL!! Artavilla Emporium has been in the cycle industry for over 50 years. We ride and race so understand your needs. We provide Sales, Service, Spares, Apparel and Accessories. Get Expert Advice with every bike sold.
Store type: Bike Shop
Address: Cnr Station & Main Streets, Cobram, VIC 3644, Australia show on map


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Majestic Pet Universal Waterproof Back Seat Cover - Black
A clever deal seeker from TX snagged this deal before you could.
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- Features
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- Description
- Majestic Pet Products Grey Universal Waterproof Back Seat Cover provides a protective barrier on the back seating area of your vehicle. It is now easy for you to stay safe while hanging out in the back seat with your pet, by creating slits in the center of the seat cover for seat belts to be worn while the cover is installed. This cover has two adjustable nylon straps that attach to the rear headrest, making for easy installation.
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text:
Lowongan UI/UX Designer Sebangsa
Staff (non-management & non-supervisor)
Teknologi Informatika
Semua Jenjang
Purna Waktu / Full Time
Sebangsa, an Indonesia – made social media platform for communities is looking for UI/UX Designer!
Tanggung Jawab Pekerjaan :
Responsible for designing and improving mobile apps interaction and visualization, includes creating visual assets that will be used by Front End Programmer
Work in team with Front End and Back End Programmer to develop a highly usable mobile app interfaces that deliver a great user experience
Persyaratan Pengalaman :
At least 1 year(s) experience in related field
Keahlian :
Preferably a candidate who has a background in IT / Design and have an adequate understanding of UI / UX Design, especially mobile application
Fresh Graduates are welcome to apply, however an experience in making UI/UX Design (for personal projects, commercial) is mandatory.
Familiar with design software SketchApp, Photoshop, or Illustrator
Familiar with wireframe and/or quick prototyping tools like Invision, Balsamiq, or Zeplin
Creative, good sense of design layout, design trends and typography
Kualifikasi :
Passion to learn new skill, good in communication
Strong interpersonal skill, confident and trustworthy
Willing to work in South Jakarta


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Latest reply
on Aug 28, 2012 7:31 PM by Nik
M5000 Memory Config Rules
todd s
Aug 28, 2012 5:55 PM
Iv'e been reading the M5000 Service Manual, XSCF Manual and I'm unclear about the memory configuration rules. Our M5000 is configured as a single domain with half of the server populated. 2 CPU boards and 4 Memory Boards. Each board has 8 x 2GB dimms for 64GB total. We would like to add another 2 Memory Boards (each 8 x 2GB).
This is where the confiusion is, the Configuration Rules say each XSB must have 1, 2 or 4 Memory Boards. But in a UNI-XSB configuration is the whole server one XSB? Can I just add the new memory boards to the next two open slots on the other half? Or do we have to move one of the CPU Boards to the other half of the server? Or is this not possible at all?
Thanks for any info.
I have the same question
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Re: M5000 Memory Config Rules
Aug 28, 2012 7:31 PM
in response to
todd s
One XSB on M5000 must include:
- 1 or 2 CPU board ( 2 or 4 CPU corresponding)
- 1 - 4 MemBoard
- 1 IO board.
It's look like you server have only one IO board so you can confgiure only one XSB and can't add additional MemBoard.
M5000 can consist 1 or 2 XSB ( depending of configuration. Main limitation - number of IO boards)
You can buy 1 additional IO-board and 2 ( or requird number ) MemB.
Move one CPU board to another half of ther server and configure additional XSF.
XSB 0 ( uni-mode) : 1 CPU-Board ; 4 MemB ; 1 IO
XSB 1 ( uni-mode) : 1 CPU-Board ; 2 MemB ( new) ; 1 IO (new)


text:
Jual Obat Pembesar KLG
Vimax Asli Canada
Vimax Asli Canada
How Would You Feel (Paean) - Ed Sheeran
Shape of You - Ed Sheeran
Human - Rag'n'Bone Man
Castle on the Hill - Ed Sheeran
I Don't Wanna Live Forever (Fifty Shades Darker) - ZAYN & Taylor Swift
Chained To the Rhythm (feat. Skip Marley) - Katy Perry
It Ain't Me - Kygo & Selena Gomez
You Don't Know Me (feat. RAYE) - Jax Jones
Be the One - Dua Lipa
Play That Song - Train
Love - Lana Del Rey
Paris - The Chainsmokers
Ciao Adios - Anne-Marie
Scared to Be Lonely - Martin Garrix & Dua Lipa
Helium - Sia
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- Youtube video cannot be found!


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Glaucoma-linked Gene May Help Insulate Optic Nerve »
"Researchers are making progress toward understanding how some cases of glaucoma begin. A new study from the National Eye Institute reveals that myocilin—a protein linked to a significant fraction of glaucoma—is needed to insulate peri"...
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Alomide Consumer (continued)
Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.
Tell your doctor immediately if any of these rare but very serious side effects occur: eye pain, swelling in or around the eyes, warm feeling in the eye, vision changes.
A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any of the following symptoms of a serious allergic reaction: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.
This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.
In the US -
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
Read the Alomide (lodoxamide tromethamine) Side Effects Center for a complete guide to possible side effects
PRECAUTIONS: Before using lodoxamide, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients (such as preservatives like benzalkonium chloride), which can cause allergic reactions or other problems. Talk to your pharmacist for more details.
Before using this medication, tell your doctor or pharmacist your medical history.
After you apply this drug, your vision may become temporarily blurred. Also, this drug may rarely make you dizzy or drowsy. Do not drive, use machinery, or do any activity that requires alertness or clear vision until you are sure you can perform such activities safely. Limit alcoholic beverages.
During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.
It is not known whether this drug passes into breast milk. Consult your doctor before breast-feeding.
Alomide Consumer Overview
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Here is a collection of user reviews for the medication Alomide sorted by most helpful.
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GOP seeks to oust head of probe into IRS audits of conservative groups
WASHINGTON — The head of a criminal probe into allegations that the Internal Revenue Service targeted conservative groups and tea party supporters personally donated a total of $6,750 to President Barack Obama's election campaign and the Democratic National Committee, spurring Republicans to call for her removal.
Republicans said Thursday that political contributions by Barbara Bosserman, a prosecutor in the Justice Department's civil rights division, raised questions about her objectivity and the integrity of the investigation into the IRS.
Justice officials…


text:
Okara: 3 dacoits held after encounter
OKARA: Shahbore police on Sunday arrested three dacoits after an encounter at 31/4L village. On a tip-off, the police raided a house to arrest proclaimed offender Tasawar.
On seeing the police, the dacoits opened fire at the police. In retaliation, Tasawar sustained bullet injuries. Later, the police arrested Tasawar and his two accomplices. The police have registered a case.
The original article can be found at The News.
Tagged under: arrested, booked, Crime, Crime News, Dacoits, encounter, Okara, pakistan criminal check, Proclaimed Offender, The News


text:
Coolest Cars Cake 97
by Michelle
(Perth Western Australia)
I made this Cars Cake for my nephew Sam's 3rd birthday.
I purchased the ready made sponges from the shop, to save time you get 2 in packed (square). I needed the 2 packs. I placed one on top of each other and then cut on as the bottom. I then cut one in half and placed on top of each other and placed at the long end. With the last sponge I cut at an angle to shape the front window and back window and then used the off cut as the back spoiler.
I then made the a butter icing mix and coloured in red, blue, yellow and left some white. First coat was white to smooth out the crumbs and made my first layer of icing go on smoother. I piped on the red stopping to mark out the windows and eyes with a black icing pen. For the wheels I used Oreo biscuits then wrote the number 3 and Sam's name in the icing pen. I was thrilled with the finished product.
Return to Animated Character Cakes 2.
Coolest Cars Birthday Cake 28
by Julie A.
(Ontario, Canada)
I made this Cars Birthday Cake for my nephew Hadley's third birthday. My sister asked me to make this for her and I love to make cakes, especially for family so I figured why not?
I had no idea how to start and originally was going to make a red cake but decided to cover it with fondant and do the checkerboard racing flag idea around the outside with black fondant.
My daughter came up with the idea of the roadway for the car to sit on. I now only wish I had a "mater" to fill the empty space, maybe next time!
The cake is rainbow chip and the icing is homemade buttercream flavored with banana and chocolate. I make my own fondant, cause the kids like the marshmallow recipe better than the store-bought stuff and I find it much easier to work with. AND it's so easy to make!
Return to Animated Character Cakes 2.
Coolest Cars Birthday Cake 22
by Audra W.
(Barboursville, WV)
This Cars Birthday Cake design was done with the frozen transfer method. You can find any design you like online, or from a coloring book. There are many sites that offer free coloring book pages to print out and these are wonderful for making childrens' cake designs. I found this design online.
You take a piece of wax paper and tape over the image. Secure the image and wax paper to a cutting board, or another portable small hard surface, then using a #1 Wilton tip for piping, trace the complete design you want. (Remember that when you trace it and then lay it on your cake, it is going to be the opposite direction as it is now.) I used this website as a guide to get me started. It has a wealth of useful information. www.sdbytracy.com/frozbutter.htm,
I hope your cakes turn out wonderful. It really was easy to make.
Return to Animated Character Cakes 2.
Coolest Cars Birthday Cake 75
by Jennifer W.
(Trumbull, CT)
This Cars Birthday Cake started with a box mix. I baked the cake in 8 mini loaf pans and then cut the cakes to shape the individual cars. Using food coloring and Dunkin Hines White icing, I decorated each of the cakes.
The detail was added using store purchased gel icing tubes. My husband made the road out of plywood, painted it black and then added the road lines using white tape.
The cake was a huge success for my son's 5th birthday!
Return to Animated Character Cakes 2.
Coolest Cars Birthday Cake 31
by Amanda G.
(Chesterfield, VA)
This Cars Birthday Cake was my first (and second) attempt at make a car cake. I bought the car shaped cake pan at the store (I was not ready to carve, yet!)
The first cake I baked actually broke in half, so I had to make another one. The icing is homemade cream cheese, tinted with food coloring to give it the different colors. I think it turned out very well, and everyone at the party loved it!
Return to Animated Character Cakes 2.


text:
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text:
sort by best latest
Cynthianne Neighbors says
I think you can have more than one capsule for Amazon because I recently saw that on another hub. I have had trouble getting choices myself so besides having difficulty getting it to work (which I did) and choices, I have not used it much. I am not aware of anything allowing us to put any other kind of advertising. Good luck!
You can help the HubPages community highlight top quality content by ranking this answer up or down.
Hi Cynthianne, thanks for replying. It will be good for me then if I can have more than one capsule for promoting Amazon's products. With regards to promoting another merchant's products, I am not aware of it yet, but hopefully learn about it soon.


text:
Hi there! It's Cheiron here today with a simple to make card with a gift card holder on the outside. I made this little envelope pocket (I've included scoring measurements in the instructions) by folding and punching a 4″ X 5″ piece of paper. I've chosen a very simple design and made my own envelope using the Large Petal Background embossed in gold.
The sentiment was made by embossing a plain white strip of paper with gold powder. I then stamped the sentiment on top of the gold and embossed it in white. This design is great for any occasion, just by changing up the sentiment and paper that you use.
Find out how to make this card — click for complete supplies and instructions.
Hope you enjoyed this simple yet fun way to present a gift card, I have a feeling I will be making a few of these in the next few weeks!


text:
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電子シャワー法によるAIN薄膜の作製 AIN Thin Films Prepared by the Electron Shower Method
When AlN thin films are applied to surface acoustic wave (SAW) devices, c-axis oriented films and a-axis oriented films are necessary for the longitudinal wave and transversal wave, respectively. In general, when AlN thin films are prepared by sputtering and ion plating methods, the crystallographic orientation is dominantly c-axis; it is difficult to prepare films with an a-axis orientation.
In this study, AlN thin films were prepared by a new PVD method: the electron shower. It was found that a-axis orientation films could be prepared readily. The crystallographic orientation varied from a-axis to c-axis when the substrate voltage was changed from +20V to -400V. A high hardness (Hv 2200), high electrical resistivity (1013Ωcm) film was obtained at -200V.
- 表面技術 = The Journal of the Surface Finishing Society of Japan
表面技術 = The Journal of the Surface Finishing Society of Japan 47(2), 152-156, 1996-02
The Surface Finishing Society of Japan


text:
The New Zealand Maori side stands for more than winning rugby matches. It tries to reflect the spirit and values of the people
Matt Te Pou is sitting in the restaurant of a south Auckland hotel discussing his favourite game, rugby, and the team he has coached for more than a decade, the New Zealand Maori. He is, of course, also considering the match against the British and Irish Lions, to be played at Hamilton this Saturday. "Will Clive Woodward be prepared to play against us?" he asks.
The question, of course, has a context. Te Pou was discussing the style of football that comes naturally to the Maori; the creative, often flamboyant running game that is exciting to play and attractive to


text:
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Hotfrog NewZealand provides information regarding Kfc in Auckland. Kfc is located at 243-245 Great South Road, Auckland 1051 and provides Food and Dining services. Contact them on 09-520 5233 or by visiting them on their website http://www.kfc.co.nz/.
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Midwest City is located in Oklahoma county and has a population of 54,088.
The average in-state tuition for full time undergraduate students in paramedic schools in Midwest City during the 2009 - 2010 school year was $1,935.00. The average tuition was $6,795.00 for non-residents studying in Oklahoma.
Books and supplies for paramedic schools in Midwest City cost an average of $1,250.00. There is one paramedic college in Midwest City for students to choose from. Paramedic programs in Midwest City reportedly graduated 3 students in the 2008 - 2009 school year.
|Average Salary
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|Emergency Medical Technicians and Paramedics


text:
Invaluable cannot guarantee the accuracy of translations through Google Translate and disclaims any responsibility for inaccurate translations.
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Lot 382: White Jade
Autumn Asian Antiques and Fine Art
by Arcadia Auction House, Inc
October 22, 2016
Flushing, NY, USALive Auction
Past Lot
Looking for the realized and estimated price?
Description: White Jade Condition: Very Good Dimension: 2.5" H, 1.9" W
Browse more items


text: Hi everyone, What are your biggest challenges when it comes to making money online? For me, back in 2002 when I got online, it was finding the right path or the right opportunity that would lead me on the right track to success online. It took me 5 years to find the right program and being on the right track to making real money online.


text:
Fibs 101
This topic contains 1,380 replies, has 58 voices, and was last updated by moaied suhail 3 hours, 6 minutes ago.
December 18, 2016 at 10:52 pm #121306
james NMParticipant
- Topics: 1
- Replies: 71
Merry Christmas to all of you guys its being a great year of supporting and educating each other and i hope we will go on to support one another thanks raj for been a good teacherDecember 19, 2016 at 3:27 am #121316
Charles BoothParticipant
- Topics: 1
- Replies: 217
Thanks James Merry Christmas to you as well. I agree it has been great learning with you over the last year. There is as great community here at luck skourt like nol other blog on the denture lpinter fnet minm my opinion. It has bee a pleasure and an honor to interact with all of you! Look forward to another profitable year. Love yeah brother and sister,.January 10, 2017 at 6:33 pm #122881
hey guys, just to keep the topic a live, here is the fibo swing system making its stand on eur/jpy:
cheersJanuary 10, 2017 at 6:47 pm #122882
Aariff KadarParticipant
- Topics: 0
- Replies: 53
Goog Work Moaied. You are mastering the Fib setup like Raj.January 11, 2017 at 1:47 am #122895
Jordi PararolsParticipant
- Topics: 0
- Replies: 127
Thank you Moaied! Here is my view:
https://charts.mql5.com/13/710/eurjpy-w1-admiral-markets.pngJanuary 11, 2017 at 8:55 am #122910
thank you Aariff.
love your views Jordi.January 11, 2017 at 9:00 am #122912
N AParticipant
- Topics: 0
- Replies: 84
Thank you guys!January 11, 2017 at 9:06 am #122913
happy to see you N A; hope winter not to ruff where you live!!?? the news makes things look like the north pole is all over lol.January 11, 2017 at 9:49 am #122914
Hey guys,
I am not a really good with the Fibonacci system, but I think we have really nice opportunity to going short, base on Raj`s 1-6 steps.
So firstable we have strong support, then we have break down and now pull back on 78% – 86% Fibonacci.
What do you think?
P.January 11, 2017 at 10:58 am #122923
N AParticipant
- Topics: 0
- Replies: 84
Moaied, this winter is too heavy for Greece as in several European countries unfortunately because there are human victims of cold .. I live in Athens.
Primoz I think that we must wait for the next candle and for confirmation to go short. It is a great opportunity.
Thank youJanuary 11, 2017 at 3:07 pm #122930
Hi All,
Happy new year!
This is why I find Fibs very tricky but interesting also. These are my views
EURJPY https://charts.mql5.com/13/720/eurjpy-mn1-atc-brokers-2.png
EURJPY Weekly https://charts.mql5.com/13/720/eurjpy-w1-atc-brokers-2.png
I think we should be looking for long setups to be in sync with the market for EURJPY as it seems to be going up. Although some of the EUR pairs are still going down. What do you guys think?
ThanksJanuary 11, 2017 at 3:17 pm #122931
I pray for you and your family's the right needs to go throw this winter N A.
dear Primos, your charting is great; and its very tempting to go short in aud/chf, lots of green light for it with good reward; just that the CHF is rather weakening against other pairs which not good to go short; but will be a wast to miss.
guys do you give the go to short???January 11, 2017 at 3:26 pm #122932
I agree with you Shalewa, right now JPY is strengthening, and seems to make a retrace in its pairs.January 11, 2017 at 3:41 pm #122934
Aariff KadarParticipant
- Topics: 0
- Replies: 53
I am completely lost with Fib101.
Should be start trading based on our trend or against it?
EURJPY Monthly and weekly are confusing.January 11, 2017 at 3:57 pm #122937
you are right Aariff about the eur/jpy and fibo's.
right now after uptrend its in a side ways on daily, which usually break up for continuation, but this time in my view it will break down for a retrace; so lets see where will it break then we can do a down fibo or up fibo accordingly.
January 11, 2017 at 4:07 pm #122938
N A, I understand you totally. Wait for some good signal.
Moaied I dont know how to trade this for now, its not my trading style, but guys, you are experts for Fibs level, so I turn to you with this view.
Shalewa A about EURJEN, we are on range since 9. December. I think we must break this range, If we break under support level this range and also touch BLB, you can go short, this will be very good and strong short trade setup. If break above and also touch BUB, you can go long. So this is my view. I think will be strong break, because we are on range 1 Month! Support was tested 4 times, resistance was tested 3 times, for me looks ok.January 11, 2017 at 5:12 pm #122967
Raj VaidParticipant
- Topics: 2
- Replies: 503
I'll admit that the BB strategy has me at a loss. I know its a good strategy to follow, but I have never explored it long enough to comment on it. Therefore, I leave that one up to you guys who understand it better.
As far as E/J, I think you would still be waiting for some clearer direction, but when a pattern emerges, I like to take it. Please see charts for how to trade one of the fib strategies from previous posts.
Primoz – aud/chf chart is a sideways mess, but it is at resistance. Trade well.
Attachments:You must be logged in to view attached files.January 11, 2017 at 5:15 pm #122971
Thanks Raj,
I am not good on Fibs level, so I dont trade AUDCHF on that level…January 11, 2017 at 5:29 pm #122972
Hi Primoz,
It looks like a bullish flag to me when I drew the lines but as you as said, it could break either way. By the way, did you buy your drawing pen? If you did, what is the name of the software? I still use the MT4 lines but it is indeed a long line that cant be shortened 🙂 Thanks.January 11, 2017 at 5:39 pm #122973
Heeeeeeeey Raj!!!!!
You must be logged in to reply to this topic.


text:
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Interventions to improve the fracture prevention in nursing homes are needed.
Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n = 67) with ≥10 residents with a diagnosis of osteoporosis or recent hip fracture (n = 606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering.
No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P = .72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9–12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1–18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models.
Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.
Fracture prevention in nursing homes is important for several reasons. With the prevalence of low bone mineral density near 90%,1,2 and a high rate of falls,3 the nursing home population has one of the highest fracture rates at 13 fractures/100 person-years.1,4 In addition, 60%–75% of patients with an acute hip fracture spend time in nursing facilities.5 This group also has an elevated risk of subsequent fractures.6,7 Clinical trials suggest that bisphosphonates are safe and effective in nursing home residents.8 Although few clinical practice guidelines specifically address the nursing home population, pharmacologic therapies are recommended for most hip fracture patients and selected long-term care residents at the highest risk.9
Despite the importance of fracture prevention in the nursing home, previous studies have demonstrated low rates of evaluation and treatment.10–13 We reported that only one third of ambulatory nursing home residents known to have osteoporosis or recent hip fracture receive any osteoporosis pharmacologic therapy or external hip protectors.14 Moreover, there is substantial variation in the performance of nursing homes (range of 0%–85% of residents receiving therapies), suggesting that substantial improvements are possible in many facilities.14
Changing provider behavior is, however, a challenging proposition. Studies in other settings have identified interventions that are sometimes effective,15 such as contact with opinion leaders, audit and feedback,16 faxed reminders,17 and educational materials to providers and patients.18,19 Little is known about which interventions are effective in the nursing home.
We developed a multi-modal intervention to improve fracture prevention in residents with documented osteoporosis or recent fracture.
This analysis combines data from studies completed with the Quality Improvement Organizations in Arizona and North Carolina. The studies were approved by the Duke University and University of Alabama at Birmingham Institutional Review Boards. The Clinical Trial Registry number is NCT00280943 (http://www.clinicaltrials.gov).
The Minimum Data Set, a database of clinical and demographic information collected quarterly on all Medicare and Medicaid eligible residents, was used to identify nursing homes in North Carolina and Arizona, with at least 10 residents diagnosed with osteoporosis or a hip fracture within 180 days. Administrators from 67 of 249 eligible nursing homes agreed to enroll. The nursing homes were randomized within each state to receive the study intervention immediately (intervention group) or after the follow-up chart abstraction was completed (control group) using a random number generator.
Residents aged 50 years or older with either a history of hip fracture or a diagnosis of osteoporosis during a 6-month time period were identified. Residents had to be ambulatory or transfer independently, and have a length of stay of at least 4 weeks. In order to obtain a sample of residents most likely to be candidates for the full range of fracture prevention therapies, we excluded residents with active cancer, severe dementia, end-stage renal disease, extensive assistance in physical functioning, hospice care, or estimated life expectancy ≤6 months. Although fracture prevention may be warranted in many of the excluded residents, including them in our sample would lead to lower rates of response to the intervention because some residents would be deemed unlikely to benefit from most of the therapies.
Nursing home staff in the intervention group received: continuing educational modules on osteoporosis evaluation and treatment; audit and feedback; academic detailing from osteoporosis opinion leaders; case-based teleconference on osteoporosis quality improvement; and an osteoporosis toolkit. Control nursing homes had no further contact until after the study was complete, at which time they received a similar intervention. The intervention period began January 3, 2005 and it ended May 13, 2005 in Arizona and July 1, 2005 in North Carolina.
Two case-based educational modules for medical staff and nursing staff were developed and pilot-tested based on recommendations from focus groups.20 The modules could be completed over the Internet or on paper in less than 1 hour, and 1-hour CME/CEU (continuing medical education/continuing education unit) credit was provided. Recommendations in the modules were based on osteoporosis clinical practice guidelines9 and focused on secondary fracture prevention, including assessment for vitamin D deficiency; calcium and vitamin D supplementation; osteoporosis pharmacotherapy; hip protectors; and fall prevention. The director of nursing and all medical providers received at least 3 fax, e-mail, and telephone reminders to complete the modules.
Audit and feedback was provided on weeks 3, 8, and 18 to all administrators in the intervention group. The blinded report included graphics that compared their facility with other study facilities in the state (Figure). Because of privacy concerns, we did not supply the audit and feedback report to medical providers, but asked the administrator to do so.
Academic detailing to all medical providers was completed by osteoporosis opinion leaders. At least 3 attempts were made to reach each medical provider directly by telephone, and if unsuccessful, messages about the study were left.
Teleconferences were offered 4 times throughout the intervention period. Nursing staff and medical staff were invited to a case-based presentation on osteoporosis quality improvement via a faxed and mailed letter. One teleconference was audiotaped, and a compact disc sent to all medical providers.
Finally, a "toolkit" of materials was provided to each administrator. This included posters to hang in the facility and resident/family brochures. Fall prevention tools and links to osteoporosis clinical practice guidelines and patient information were provided on the module website.
Based on guideline recommendations, quality indicators for osteoporosis evaluation and fracture prevention were measured.9 The primary outcome variable was prescription of osteoporosis pharmacotherapy or hip protectors. We also measured a combined outcome variable of prescription of osteoporosis pharmacotherapy or hip protectors or calcium and vitamin D supplements. We included measures with and without calcium and vitamin D supplements because many practice guidelines do not recommend them as mono-therapy for secondary fracture prevention, and because high baseline prescription rates might introduce a ceiling effect. Total daily dose of calcium and vitamin D were not assessed because they could come from multiple sources and were difficult to abstract reliably. Facility fracture rates were an exploratory outcome measure.
Trained data collectors, blinded to intervention status, abstracted data from the medical record before and after the intervention. Data collectors reviewed prescriptions in a 6-month time period beginning at the first time a fracture or osteoporosis diagnosis was recorded in the Minimum Data Set. The entire medical record was reviewed for selected comorbidities, bone mineral density, and laboratory testing. A random 10% of charts was re-abstracted by a second data collector, and inter-rater reliability was maintained at >90%.
Facility characteristics were obtained from public use datasets (http://www.medicare.gov/NHCompare). Some resident characteristics were obtained from the Minimum Data Set.
Data were analyzed at the facility level. Nursing homes in Arizona and North Carolina were combined for the main analysis. The change in the proportion of residents receiving therapy between the pre- and postintervention periods was compared between the intervention and control nursing homes using t tests. All randomized facilities were analyzed regardless of their participation in the study. In order to adjust for characteristics that might impact prescription of osteoporosis therapies, multivariable logistic regression models with generalized estimating equation adjustment for repeated binary outcomes were constructed with backwards selection, using all variables with a baseline univariate P <.20 and variables with high clinical significance (age, race, state). The intervention time period by group interaction term was tested using chi-squared as a test of the impact of the intervention on prescription of therapies. This method accounted for the complex nesting of residents within providers and nursing facilities.
A prespecified exploratory analysis compared fracture rates in the intervention period between intervention and control facilities using t test. In order to examine the impact of participation in the intervention components, we constructed Generalized Estimating Equation models using backwards selection, with covariates significant at the ≤.20 level and the intervention participation variables.
Originally, we calculated that enrolling 128 nursing homes would provide 80% power to detect a 10% difference in the change in prescription of any fracture protection between the 2 arms. However, recruitment was challenging, and 67 nursing homes were ultimately enrolled. Post hoc, we determined that our sample size provided 80% power to detect a 17% difference, and 98% power to detect a 20% difference in the change in proportion of residents receiving any fracture protection in the intervention facilities compared with the control facilities.
Baseline characteristics of the 67 nursing homes and 606 residents are shown in Table 1. Intervention residents were more likely to be African American, younger, and use tobacco; and less likely to have previous fracture or dysphagia.
The use of fracture prevention strategies in the preintervention and postintervention periods is shown in Table 2. The primary endpoint of osteoporosis pharmacotherapy or hip protectors improved in intervention homes from 32.6% to 40.6% (difference 8.0%) and remained unchanged in control homes from 38.6% to 39.2%, (difference 0.6%), but the differences were not statistically significant (P = .72). The combined endpoint of osteoporosis pharmacotherapy or hip protectors, or calcium and vitamin D supplements showed a 7% improvement in both intervention and control homes, but baseline treatment rates exceeded 70%, suggesting a possible ceiling effect. Nonsignificant trends toward greater improvement in intervention versus control homes were seen for most other indicators. There were no significant differences in performance on the quality measures between the states.
Multivariable models testing the impact of the intervention on the primary and combined outcome measures were not statistically significant (odds ratio [OR] 1.0, 95% confidence interval [CI], 0.9–1.2, P = .18) even after adjusting for baseline factors that were imbalanced, including bed size, age, race, sex, previous fracture, insurance status, ambulatory status, gastrointestinal reflux, breast and endometrial cancer, dysphagia, and tobacco use. Incident fracture rates during the 6-month intervention period were similar between intervention (4.3%) and control facilities (4.1%), and were unchanged from the preintervention period. Fall rates were unchanged in the pre- and postintervention periods at 50%–51%.
Among the intervention facilities, participation in intervention activities was generally low except for audit feedback, which was provided to 100% of homes (Table 3). Intervention homes with at least 1 participant in the nursing educational module tended toward greater improvement in prescription of osteoporosis pharmacotherapy or hip protectors (19.5%) than either control homes (0.6%) or intervention homes without a nursing educational module participant (6.4%, P = .36). Participation in the medical provider educational module showed a similar pattern. In a multivariable Generalized Estimating Equation model including all covariates used above and participation variables, direct physician contact with the academic detailer (OR 4.5, 95% CI, 1.1–18.2, P = .03) and physician completion of the CME module (OR 4.8, 95% CI, 1.9–12.0, P = .001) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors compared with control nursing homes and intervention homes without participation. No significant associations were observed when calcium and vitamin D supplements were added to the primary outcome measure, although treatment rates in the follow-up period exceeded 80% for all groups, again suggesting a ceiling effect.
We demonstrated a small, nonsignificant improvement in the prescription of fracture prevention therapies after the implementation of a quality improvement intervention. Although our study cohort had high fracture risk given their fall rate (35% fell within 90 days) and previous fracture history (20%), prescription of fracture prevention therapies other than calcium and vitamin D remained low. The magnitude of provider behavior change is consistent with that found in similar osteoporosis quality improvement studies in other settings,21 but is likely insufficient to have an impact on fracture rates.
This study has several strengths. The multi-modal intervention included multiple proven techniques. We targeted not only medical providers, but also the nursing staff and administrator, who have considerable influence on decision-making. The study was randomized, outcomes assessment blinded, and powered to detect a clinically meaningful difference. Regulations for documentation in nursing homes make it unlikely that medication therapies were not recorded in the medical record. We included only residents with clear indications for osteoporosis therapy and the fewest comorbidities that would limit the applicability of clinical practice guidelines in the nursing home setting. Despite these strengths, there are several potential explanations for the lack of effect.
First, we had difficulty engaging nursing homes and providers in our study. Although previous research has shown that a large majority of Medical Directors and Directors of Nursing believe that fracture prevention is important and effective,22 we successfully recruited only about half of the number of facilities we had anticipated. Administrators most often cited staff turnover, regulatory survey demands, and competing clinical projects as reasons for not participating in the study. As a result, our final number of nursing homes allowed sufficient power to detect a 17% or greater improvement. After enrollment, few providers participated in the elements of our intervention despite repeated encouragement. The issues of engagement and timing have been shown to be important in behavior change interventions. It is clear that engagement was critical in this study, because those providers we successfully engaged were more likely to improve their osteoporosis management compared with those who did not participate. Providers who engaged in the intervention are likely to be more motivated, knowledgeable, and willing to change. This may partly explain the association between participation and improvement in our study. Previous studies have suggested that interventions work best when the timing of the intervention is soon after the triggering event;18 in our study, an intervention occurring sooner after a fracture may have been more effective in assisting providers to change their behavior. An important goal in future research is to either identify ways to engage a broader range of providers, or to use systems that do not require individual physician practice change to improve quality.
Second, there may be barriers to fracture prevention in the nursing home environment that were not sufficiently addressed by our intervention. In a survey of more than 1000 medical directors and directors of nursing, reimbursement issues, short length of stay, and regulatory oversight about the number of medications prescribed were endorsed as the primary barriers to adhering to osteoporosis practice guidelines.22 For example, a nursing home receiving a capitated reimbursement for the rehabilitation of a hip fracture patient has little incentive to add an expensive osteoporosis medication during their stay. Bone density scans are logistically difficult to obtain for frail residents, and Medicare reimburses for testing only every 2 years. These factors cannot be easily addressed by an intervention such as ours, and may require systems and health care policy change so that the goals of residents, administrators, and practitioners are better aligned.
Third, the osteoporosis guideline recommendations themselves may not be optimally suited for the frail nursing home population. Applying guideline recommendations to residents with competing comorbidities, surrogate decision-makers, and varying goals of care is challenging; for example, nearly 25% of our sample had peptic ulcer disease, esophagitis, or dysphagia that would preclude use of oral bisphosphonates (Table 1). Most fracture prevention studies included postmenopausal women, and generalization to frail older populations also is problematic, although previous surveys have shown that a large majority of nursing home medical directors believe that osteoporosis guidelines are relevant to their patients.22 Guidelines specific to the nursing home population that assist providers in determining residents most likely to benefit are needed.9
There have been relatively few published randomized trials of quality improvement initiatives in the nursing home to compare with our results. Effective interventions generally require on-site personnel or extensive provider involvement in intervention development.23 Other studies have shown a limited effect of group training sessions such as Quality Improvement Collaboratives24 and highlighted the lack of effective quality improvement infrastructure in nursing homes.25 To circumvent some of these issues, systematic interventions that remove the responsibility for providing preventive care from individual practitioners are needed. Examples of such interventions might include standing orders for osteoporosis care that are implemented routinely unless a provider or patient "opts out," or automated telephone reminders or letters to patients and families on discharge from the hospital after a fracture.
Fracture prevention remains challenging in the nursing home setting. Further studies are needed to identify effective means of changing clinicians' behavior and testing system-wide interventions that could prove more effective than traditional quality improvement approaches.
Supported by the Alliance for Better Bone Health, AG-11268, 3U18HS10389-06S1, K23 AG024787. The analyses upon which this publication is based were performed under Contract Number 500-02-AZ02 AZ0020, funded by the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. Publication No. AZ-8SOW-SS-061206-03.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


text:
As supporters of a rival team hurled racial abuse, Nicky Winmar, a brilliant Aboriginal player of Australian rules football, walked over to them, lifted his jersey and pointed defiantly to his skin. It was a defining moment in Australian sport, and it sparked robust action by football authorities to stamp out racism. That was in 1993. Now, nearly two decades on, the Australian Football League(AFL) and rugby league are engulfed in an ugly racism row, after three sporting veterans in one week used language that many Australians believed had been consigned to the past.
The controversy broke last weekend, when it emerged that Andrew Johns, a former rugby league Test captain, had referred to an Aboriginal player, Greg Inglis, as a "black cunt". Inglis is on the Queensland squad; Johns was – until that remark – assistant coach of New South Wales.
The two teams were preparing to play their fiercely contested State of Origin, an annual best-of-three match series which is the highlight of the rugby league calendar. Timana Tahu, a half-Aboriginal, half-Maori player, withdrew from NSW in protest. Johns had no choice but to fall on his sword.
There was another claim, made by an Aborignal elder but subsequently strongly denied both by Tahu and by the management of Andrew Johns, that Johns had racially abused other indigenous Queensland players during a pep talk at the NSW training camp.
Rugby league bosses must have inwardly groaned: this was the last thing they needed after recent revelations that one leading team, the Melbourne Storm, had for years paid their players above the maximum permitted. The Storm were stripped of their 2007 and 2009 premiership titles, fined $A500,000 (£290,000) and banned from accruing competition points this season.
Then it was the turn of AFL, or Aussie rules. Addressing a mid-week charity lunch in Melbourne, Mal Brown, a former player and Western Australia coach, recalled poor lighting at a fundraising match against Victoria 15 years ago. "It actually disadvantaged us," he said. "We couldn't pick any of the cannibals. All the good black fellows, we couldn't pick them because [we] couldn't see them in the light... we didn't even get any white shirts to put on them."
This drew laughter from the audience, but horrified another former AFL great, Garry Lyon. "You've just put us on the back page of every paper tomorrow," he told Brown. As it turned out, the story made at least one front page. Brown defended his remarks as "totally in jest", but then apologised, saying: "People told me it wasn't humorous and I've made a dickhead of myself. Now I accept that."
On Friday, AFL – the sport that vowed to reform itself after the Winmar incident – was once again dragged into the mire. At a function in South Australia, a former Aussie rules star, Robert DiPierdomenico, described another former player, Gavin Wanganeen, as "not bad for an Abo". He was promptly suspended as the face of Auskick, an AFL programme aimed at encouraging children to play the sport.
The irony, as some commentators pointed out, is that all three men – Johns, Brown and DiPierdomenico – have worked hard to train young indigenous players. Yet they appear not to grasp the niceties of language, or the offence it can cause. Brown protested that in the past "cannibal" and "little black buggers" had been used as terms of endearment.
Johns said in his latest apology: "I look forward to sitting down with Timana and learning from him what is acceptable when it comes to sensitive issues like this." As one columnist noted: "You have to shake your head. We have made it through slavery, through colonisation, through apartheid... and we still need to be told in person that calling somebody a 'black cunt' is unacceptable."
- More about:
- New South Wales
- Rugby League
- Shane Warne
- South Australia


text:
Friends only - ✖
02 September 2009 @ 11:25 pm
Friends only
30 comments —
lunacchi on September 3rd, 2009 06:42 am (UTC)
HI~ i was just looking at arama, and it seems you like gocchin too. i do too ^-^ i am a big fan of haropuro, i was wondering if it would be okay to become friends.
goto on September 3rd, 2009 06:48 am (UTC)
Hey! sure i'll add you :]
Also a big fan of H!P (more so the older girls though..) and of course Gocchin.
Also a big fan of H!P (more so the older girls though..) and of course Gocchin.
kusen on September 7th, 2009 05:49 am (UTC)
Hey~ You are very cool! I wish to befriend you and become close
Kisses xOxO
Kisses xOxO
(Deleted comment)
goto on November 7th, 2009 12:26 am (UTC)
of course!
Also I dunno if you know me but I'm Mr. Goto from AHS lol
Also I dunno if you know me but I'm Mr. Goto from AHS lol
glider on March 12th, 2010 08:22 pm (UTC)
lmfao omfg is that like ganguro maki??
add me. :|
add me. :|
goto on March 15th, 2010 05:44 pm (UTC)
glider on March 16th, 2010 12:14 am (UTC)
oh man. are those for real legit? she looks presh I just never would've guessed Maki would go all ~ganguro yamanba chick~ on us. even if it was like a million years ago lmfao.
ty for the add ♥
ty for the add ♥
crazymaxwell on August 29th, 2010 08:39 am (UTC)
jodie26 on March 15th, 2010 08:17 pm (UTC)
hey, thanks for sharing info on aramatheydidn't :)
add back? :D
add back? :D
jodie26 on June 18th, 2010 10:32 pm (UTC)
hey :), i love all your user pics :):):)
ilovekuu4ever on August 19th, 2010 06:57 am (UTC)
crazymaxwell on August 29th, 2010 08:38 am (UTC)
goto on September 16th, 2010 08:53 pm (UTC)
why haven't i ever seen this comment before?
k so replying nearly 3 weeks later cool...i'll add you now lol
k so replying nearly 3 weeks later cool...i'll add you now lol
crazymaxwell on September 16th, 2010 09:12 pm (UTC)
HAHA very nice
prismboy on September 16th, 2010 07:48 am (UTC)
Yo! I think it's about time we added each other, right? ;)
I'm surprised it took us this long to add each other :P
sayu_k on December 27th, 2010 07:29 am (UTC)
*passing by* Oh, look it's a girl smoking! *falls down* Erm... what is the name? *reaches glasses that fell to the floor* free....free? *takes some times to time. Gets up. Eyes shining*
FREE² *jumping around*
add? *-*'
FREE² *jumping around*
add? *-*'
mysweetestlove on January 14th, 2011 03:03 am (UTC)
Added. :)
Added. :)
allisonmunroe on April 20th, 2011 01:09 am (UTC)
hey hun


text:
Larry C. McCallister
Larry C. McCallister
|Professions: Counseling, Mental Health Counseling, Psychotherapy
|License Status: I'm a licensed professional.
|Primary Credential: Licensed Professional Counselor - 72738
|Secondary Credential: LPC - 4840
Billing and Insurance
Click here to ask this therapist for billing and insurance information.
See other therapists in Corpus Christi, TX.
I use a client-centered developmental approach when working with children and families. I have received a degree in counseling from Oklahoma City University. I also have an education degree that I think is very important in helping children and families. My strongest beliefs/passions is that play is the way that children learn and and express their feelings.
Email or Call Larry C. McCallister at 1-800-651-8085 ext. 16080
More Info About My Practice
I have extensive training in play therapy and sandtray therapy.
My Therapy Focus
Focus of my therapy work is developing a collaboration between family members and treating the identified client as an important part of successful therapy. Play therapy is my area of specialization.
Theoretical Influences that Guide My Work
I have a background of Family & Child Studies which focused on parenting and child development.
Services I Provide
- Individual Therapy & Counseling
- Marriage, Couples, or Relationship Counseling
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Ages I Work With
- Children
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Client Concerns I Treat
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- Adlerian Psychotherapy
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- Sand Tray / Sand Play Therapy
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Profoundly fascinated with the human body and movement, I focus on inspiring people to take care of their physical fitness and health—and to move well every day. Absence of movement equals standstill of life. Establishing an ongoing movement practice goes far beyond mere gym and workout routines; it is rather a way of life, and a return to human nature.
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text:
guy drains his main vein.4.19 / 5.00 5,999 Views
( Original ) Nesia Legend of Cosieda Episode 1
The first episode of my original anime3.95 / 5.00 2,015 Views
Godians Fight
Two Men Fight to the Death!4.15 / 5.00 1,901 Views
Ok it was really and I mean really good ( like all the other reviews) but why were they green? Is this a re-creation of Matrix with green Smith and Neo? I don´t get it...
But it was a great flash movie, so keep up the good work :D
w00t! ^_^
this was so kewl!!!
its like 1 of proxide flashes and der fuggin good make more!! :D
Hmm, thats not the first time I heard the name "proxide" so I may just have to look into that to resolve my curiosities.
Holy Shit!
Nice creation. But what's up with the fact that almost everything is green?
I really love when artists use sound and improvise their work around that, it just seems like so much effort was put into it and works really well! Even better that you used sprites which is even more limiting than working around the sound! Great work!
Shwingin' Matrix Movie!
The fight was a great scene in the movie, and you just made it better! But where was the part where Neo spins around on the staff and kicks all the Agents?