text:
Spearman correlation coefficient and P value for correlation are shown.
Kumbhani DJ, Cannon CP, Fonarow GC, Liang L, Askari AT, Peacock WF, Peterson ED, Bhatt DL, Get With the Guidelines Steering Committee and Investigators FT. Association of Hospital Primary Angioplasty Volume in ST-Segment Elevation Myocardial Infarction With Quality and Outcomes. JAMA. 2009;302(20):2207-2213. doi:10.1001/jama.2009.1715
© 2017
Author Affiliations: Cleveland Clinic, Cleveland, Ohio (Drs Kumbhani, Askari, and Peacock); TIMI Study Group, Brigham and Women's Hospital, Boston, Massachusetts (Dr Cannon); University of California Los Angeles Division of Cardiology, Ahmanson-University of California Los Angeles Cardiomyopathy Center, Los Angeles (Dr Fonarow); Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina (Drs Liang and Peterson); and VA Boston Healthcare System and Brigham and Women's Hospital, Boston, Massachusetts (Dr Bhatt).
Context Earlier studies indicate an inverse relationship between hospital volume and mortality after primary angioplasty for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, contemporary data are lacking.
Objective To assess the relationship between hospital primary angioplasty volume and outcomes and quality of care measures in patients presenting with STEMI.
Design, Setting, and Patients An observational analysis of data on 29 513 patients presenting with STEMI and undergoing primary angioplasty in the American Heart Association's Get With the Guidelines registry. Patients were treated between July 5, 2001, and December 31, 2007, at 166 angioplasty-capable hospitals across the United States. Hospitals were divided into tertiles (<36 procedures per year, 36-70 procedures per year, and >70 procedures per year) based on their annual primary angioplasty volume.
Main Outcome Measures Door-to-balloon (DTB) times, length of hospital stay, adherence with evidence-based quality of care measures, and in-hospital mortality.
Results Compared with low- and medium-volume centers, high-volume centers had better median DTB times (98 vs 90 vs 88 minutes, respectively; P for trend < .001). High-volume centers were more likely than low-volume centers to follow evidence-based guidelines at discharge. Length of stay was similar between the 3 groups (P for trend = .13). There was no significant difference in the crude mortality between the tertiles of volume (incidence rate, 3.9% vs 3.2% vs 3.0% for low-, medium-, and high-volume centers, respectively; P = .26 and P = .99 for low- and medium- vs high-volume hospitals, respectively). Sequential multivariable modeling using generalized estimating equations revealed no significant association between hospital primary angioplasty volume and in-hospital mortality (adjusted odds ratio [OR], 1.22; 95% confidence interval [CI], 0.78-1.91; P = .38 and adjusted OR, 1.14; 95% CI, 0.78-1.66; P = .49 for low- and medium- vs high-volume hospitals, respectively).
Conclusion In a contemporary registry of patients with STEMI, higher-volume primary angioplasty centers vs lower-volume centers were associated with shorter DTB times and more use of evidence-based therapies, but not with adjusted in-hospital mortality or length of hospital stay.
Several studies have demonstrated an inverse relationship between hospital primary angioplasty volume and mortality in patients presenting with ST-segment elevation myocardial infarction (STEMI).1- 5 Analysis of data by the National Registry of Myocardial Infarction 2 investigators between 1994 and 1998 indicated that high primary angioplasty volume hospitals (>33 procedures per year) had a 28% lower in-hospital mortality compared with low primary angioplasty volume hospitals (5-11 procedures per year).2 Another recent analysis using the same data set, but slightly different thresholds (<12 procedures per year, 12-36 procedures per year, and >36 procedures per year), yielded similar results.1
Based on these and other studies, current American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of patients with STEMI recommend that primary angioplasty in patients with STEMI be conducted by cardiac catheterization laboratories performing at least 36 primary angioplasties a year, as well as at least 200 total angioplasties a year.6
The majority of these studies were conducted before the regular use of stents and the routine use of newer adjunctive pharmacotherapy, such as dual antiplatelet therapy and glycoprotein IIb/IIIa inhibitors, both of which have been associated with better outcomes in these patients.7,8 However, more contemporary data supporting a relationship between hospital primary angioplasty volume and outcomes are not available.
Accordingly, we explored the relationship between primary angioplasty volume and patient outcomes (specifically, in-hospital mortality, door-to-balloon [DTB] times, length of stay, and the use of evidence-based therapies) in patients presenting with STEMI, using data from the AHA's Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) national database.
Details of the AHA's GWTG-CAD have been previously published.9,10 A detailed description is also available in the eMethods. For the purpose of our analysis, patients were included if the initial electrocardiogram showed new ST-segment elevation or a new left bundle-branch block. In addition, patients having a cardiac diagnosis of STEMI were also included. Admissions staff, medical staff, or both recorded self-reported race/ethnicity, usually as the patient was registered. Patients were assigned to race/ethnicity categories using options defined by the electronic case report form. Case finding was based on clinical identification of patients with CAD diagnoses or National Center for Health Statistics International Classification of Diseases, Ninth Revision identification of CAD diagnoses with clinical verification for data abstraction.
Participating institutions submitted the GWTG protocol for review and approval by their institutional review board. Because data were used primarily at the local site for quality improvement, sites were granted a waiver of informed consent under the common rule. Additional details about the data source are available in the eMethods.
At the time of the analysis, the registry included a total of 332 050 patients between July 5, 2001, and December 31, 2007. We excluded 274 364 patients without STEMI and 21 561 patients who did not undergo primary angioplasty. In addition, we excluded 1480 patients receiving thrombolytic therapy (except those patients who received rescue angioplasty), as well as 697 patients who were transferred out, to avoid double-counting, and to ensure accurate reporting of outcomes such as mortality and length of stay. To ensure adequate data quality, we excluded an additional 2686 patients from 30 hospitals that had 25% or more missing data on past medical history. We excluded 11 hospitals with 425 patients that had missing site characteristics data. We also excluded 1324 patients who were treated at 122 hospitals that submitted less than 30 primary angioplasty cases over the 6-year duration of the study, because this represented underreporting, with the possibility of selection bias. Patients who were transferred in were included, resulting in 29 513 patients.
The chief independent variable was hospital primary angioplasty volume. Primary angioplasty was defined as angioplasty performed as primary reperfusion therapy for acute STEMI. Annual primary angioplasty volume for each hospital was calculated as the total number of primary angioplasty patients in a hospital after baseline × 4 divided by the total number of quarters the hospital has been submitting data after baseline. Given that the latest ACC/AHA guidelines recommend that every hospital perform a minimum of 36 primary angioplasty procedures annually,6 we divided hospitals into tertiles of volume as low (<36 procedures per year), medium (36-70 procedures per year), and high (>70 procedures per year). Total angioplasty volume was similarly calculated. Again, hospitals were divided into tertiles based on ACC/AHA recommended thresholds as low (<200 procedures per year), medium (200-400 procedures per year), and high (>400 procedures per year).6
The primary outcome measure was in-hospital mortality. Secondary outcome measures included median DTB times, the proportion of patients meeting the ACC/AHA guideline–recommended 90-minute DTB time, and length of hospital stay. The DTB time and length of stay were calculated only for patients who were not transferred in to the hospital.
To compare differences in the quality of care between the 3 groups, adherence with evidence-based medical therapies in eligible patients, such as the acute use (within 24 hours) of aspirin and β-blockers; the use of aspirin, β-blockers, clopidogrel, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blocking (ARB) agents, and statins or lipid-lowering drugs at discharge; and smoking cessation counseling in current smokers, were assessed. All or none adherence was also compared between the 3 groups with a composite performance measure encompassing 6 key quality of care measures (patients discharged while taking aspirin and β-blockers, acute myocardial infarction and patients with angina receiving aspirin within 24 hours of presentation, patients with documented left ventricular dysfunction discharged while receiving an ACE inhibitor or ARB, smoking cessation counseling in current smokers, and patients with a low-density lipoprotein cholesterol level >100 mg/dL [to convert to mmol/L, multiply by 0.0259] who received lipid-lowering drugs).
Volume was analyzed both as a categorical (tertiles) variable as well as a continuous variable. The hospital was the unit of analysis for assignment to a hospital-volume group. However, the patient was the unit of analysis for the evaluation of clinical variables and mortality. The patient and hospital characteristics, crude in-hospital mortality, and adherence to the evidence-based therapies were compared across the hospital primary percutaneous coronary intervention volume tertiles.
The mean (SD) and percentages are reported for continuous and categorical variables, respectively, except for DTB time, where medians (interquartile ranges [IQRs]) are reported. Because volume tertiles is an ordinal variable, Cochran-Mantel-Haenszel row mean scores and Cochran-Mantel-Haenszel nonzero correlation tests were used to test the trend of categorical variables and continuous variables over the primary percutaneous coronary intervention volume tertiles, respectively.
Sequential multivariable logistic regression, using generalized estimating equation approach to take into account within-hospital clustering, was performed to study the relationship between volume and the different outcomes.11 Several additional analyses (described in the eMethods) were conducted, including using different volume thresholds, volume as a continuous variable, and all patients presenting with STEMI. All statistical analyses were performed using SAS version 9.1 (SAS Institute, Cary, North Carolina). All P values were 2-tailed, with statistical significance set at .05. All confidence intervals (CIs) were calculated at the 95% level.
A total of 29 513 patients with STEMI were treated with primary angioplasty at 166 hospitals across the United States. Hospital annual primary angioplasty volume ranged between 9 and 225 patients, with a mean of 59.8 and a median (IQR) of 49 (27-78) patients. Of the 166 hospitals, 65% (108) met the ACC/AHA recommended minimum of 36 primary angioplasties per year. Annual total hospital angioplasty volume ranged between 39 and 1264 patients, with a mean of 389 and a median (IQR) of 301 (192-552) patients. Baseline characteristics of the study population are shown in Table 1 and admission, laboratory data, and hospital characteristics are shown in Table 2.
Compared with low- and medium-volume centers, median DTB times were the lowest in high-volume centers (98 vs 90 vs 88 minutes, respectively; P for trend < .001). The proportion of patients meeting ACC/AHA guidelines of DTB time of 90 minutes or less was highest in the high-volume centers (44% vs 50% vs 53%, respectively; P for trend < .001). After adjusting for patient and hospital characteristics, patients presenting to low-volume hospitals (odds ratio [OR], 0.72; 95% CI, 0.54-0.96; P = .03) but not medium-volume hospitals (OR, 0.96; 95% CI, 0.72-1.28; P = .79) were less likely to achieve a DTB time of 90 minutes or less when compared with high-volume hospitals. In the subgroup of patients who achieved a DTB time of 90 minutes or less, mortality was similar between low-, medium-, and high-volume hospitals (2.7% vs 2.8% vs 2.4%, respectively; P for trend = .35).
Mean (4.6 vs 4.5 vs 4.7 days) and median (3 days each) lengths of stay were similar between low-, medium-, and high-volume hospitals, respectively (P for trend = .13).
By multivariable analysis, medium-volume hospitals (OR, 2.53; 95% CI, 1.08-5.92; P = .03) but not low-volume hospitals (OR, 1.73; 95% CI, 0.78-3.86; P = .18) were more likely than high-volume hospitals to give aspirin acutely (within 24 hours) to eligible patients (eTable). There was no difference between low-volume (OR, 0.94; 95% CI, 0.49-1.79; P = .85) and medium-volume (OR, 1.50; 95% CI, 0.79-2.87; P = .22) hospitals compared with high-volume hospitals in the acute use of β-blockers in eligible patients. Low-volume hospitals were less likely than high-volume centers to prescribe aspirin (OR, 0.46; 95% CI, 0.28-0.78; P = .004) and β-blockers (OR, 0.61; 95% CI, 0.39-0.95; P = .03) at discharge to eligible patients. They were also less likely to prescribe lipid-lowering therapy in patients with a low-density lipoprotein cholesterol level of more than 100 mg/dL (OR, 0.65; 95% CI, 0.44-0.97; P = .04), ACE inhibitors or ARBs to eligible patients (OR, 0.79; 95% CI, 0.62-1.00; P = .05), and to counsel current smokers regarding smoking cessation (OR, 0.54; 95% CI, 0.37-0.78; P = .001). All or none adherence with 6 key quality of care measures was also less likely in the low-volume hospitals compared with the high-volume hospitals (OR, 0.68; 95% CI, 0.49-0.94; P = .02).
The overall in-hospital mortality was 3.2% (incidence rate, 3.9% vs 3.2% vs 3.0% for low-, medium-, and high-volume centers, respectively). In the unadjusted analysis for in-hospital mortality, there was no difference between low-volume (OR, 1.21; 95% CI, 0.87-1.69; P = .26) or medium-volume hospitals (OR, 1.00; 95% CI, 0.77-1.31; P = .99) compared with high-volume hospitals. After sequential multivariable analysis, there was no difference between the 3 groups and the adjusted mortality. Furthermore, there was no relationship between volume as a continuous variable and mortality (Spearman correlation coefficient = –0.004, P = .95) (Table 3 and Figure).
Various other thresholds were also tested; however, none of these demonstrated a significant volume-outcomes relationship. For instance, using thresholds of 25 or less procedures per year, 26 to 50 procedures per year, and 50 or more procedures per year yielded mortality rates of 3.7% vs 3.2% vs 3.2% for low-, medium-, and high-volume hospitals, respectively. The multivariable adjusted ORs were 1.06 (95% CI, 0.74-1.52; P = .74) and 1.09 (95% CI, 0.78-1.52; P = .62) for low- and medium-volume hospitals compared with high-volume hospitals, respectively. When tertiles were defined as less than 12 procedures per year, 12 to 36 procedures per year, and more than 36 procedures per year, there were only 2 hospitals (with 68 patients) that performed less than 12 procedures per year, thus resulting in mortality rates of 1.5% vs 3.9% vs 3.1%, respectively.
When all 30 837 patients were included (ie, including hospitals that submitted <30 cases during the entire study period), there was no difference between low-, medium-, and high-volume hospitals in in-hospital mortality (3.5% vs 3.2% vs 3.1%, respectively; P for trend = .12). When patients who were transferred in were excluded (n = 9183), there was again no difference in the crude in-hospital mortality between the 3 groups (3.8% vs 3.2% vs 3.1%, respectively; P for trend = .08).
Although patients not undergoing primary angioplasty were excluded from the primary analysis, they constituted 30.1% of patients presenting with STEMI. Of these, 13.1% received thrombolytics, 8.2% received both thrombolytics and angioplasty, 3.1% had missing data, and the remaining were medically managed. Patients who did not undergo primary angioplasty had a significantly higher mortality (11.8%) compared with patients undergoing primary angioplasty (3.2%), and for these patients, low- and medium-volume hospitals had a higher crude mortality than high-volume hospitals (14.2% vs 12.9% vs 10.7%, respectively; P for trend < .001). In multivariable-adjusted analysis, low-volume hospitals (OR, 1.51; 95% CI, 1.15-1.99; P = .003) but not medium-volume hospitals (OR, 1.29; 95% CI, 0.98-1.69; P = .07) had higher in-hospital mortality compared with high-volume hospitals.
Similarly, the crude mortality for all patients presenting with STEMI (irrespective of management strategy) was higher in the low- and medium-volume hospitals compared with the high-volume hospitals (7.4% vs 6.0% vs 5.3%, respectively; P for trend < .001). In multivariable analysis, low-volume hospitals compared with high-volume hospitals had a higher mortality (OR, 1.52; 95% CI, 1.16-2.00; P = .003). There was however no difference between medium- and high-volume hospitals (OR, 1.23; 95% CI, 0.95-1.58; P = .12).
There was a strong association between total and primary angioplasty volume (Spearman correlation coefficient = 0.57, P < .001). Patients presenting to low total angioplasty volume hospitals (total annual angioplasty volume, <200) had a higher crude mortality compared with medium-volume (total annual angioplasty volume, 200-400) and high-volume hospitals (total annual angioplasty volume, >400) (3.5% vs 3.3% vs 3.0%, respectively; P for trend = .05). However, after sequential multivariable modeling, there was no difference in mortality between low-volume (OR, 1.20; 95% CI, 0.82-1.75; P = .35) and medium-volume hospitals (OR, 1.26; 95% CI, 0.94-1.68; P = .12) compared with high-volume hospitals.
Our analysis of contemporary data from approximately 30 000 patients presenting with STEMI at 166 hospitals across the United States indicates that compared with low-volume hospitals, high-volume hospitals have shorter DTB times, have a larger proportion of patients who achieve ACC/AHA recommended DTB times of 90 minutes or less, and demonstrate greater adherence with evidence-based therapies and recommendations. However, there was no difference in the length of stay or unadjusted or adjusted in-hospital mortality between low-, medium-, and high-volume primary angioplasty hospitals. There was also no difference in the adjusted mortality based on the total angioplasty volume of hospitals. Medium-volume hospitals performed as well as high-volume hospitals for all quality of care measures assessed.
Our results, especially with respect to in-hospital mortality, are contrary to other published registry studies in patients with STEMI.1- 5 One of the main differences is that our study reflects more contemporary practice. Angioplasty techniques and adjunctive pharmacotherapy have seen substantial improvements over the past few years, and there has been a significant standardization of these practices nationwide.12 In addition, evidence-based therapies are much more widely adopted and practiced.13 A similar discrepancy between older and contemporary registries has been noted for surgical procedures as well. With standardization of processes of care for surgical procedures, several of the earlier observed differences in mortality between hospitals based on surgical volume are no longer significant.14- 16
The thresholds that we used to classify hospitals into low, medium, and high volume are different from prior studies. Although we did not specifically study all reported thresholds individually, we examined various thresholds other than the primary analysis of less than 36 primary angioplasties per year, 36 to 70 primary angioplasties per year, and more than 70 primary angioplasties per year, but did not find an association between primary angioplasty volume and mortality. In addition, we did not find an association between volume as a continuous variable and mortality, making it unlikely that other thresholds would significantly alter our findings. Lower thresholds tended to further reduce the sample size in the low-volume group, thereby further reducing the power of this study to detect any difference between the groups.
We opted to use thresholds based on minimum primary angioplasty volume recommendations by the ACC/AHA.6 We did not observe any difference in in-hospital mortality between hospitals that followed these recommendations vs those who did not (<36 primary angioplasties per year vs ≥36 primary angioplasties per year). This is reassuring because our registry indicates that more than a third of US hospitals do not achieve the recommended minimum of 36 procedures annually.
For our primary analysis, we excluded hospitals submitting less than 30 procedures over the study period. This was performed to minimize selection bias and to account for hospitals that had participated for a short time or inconsistently. Even when these patients were included in the analysis, only 745 (2.4% of the total population undergoing primary angioplasty) were treated at hospitals performing less than 12 primary angioplasties annually. In contrast, the study by Cannon et al1 found that 17.5% of similar patients in the National Registry of Myocardial Infarction 2 registry were treated at hospitals performing less than 12 primary angioplasties annually. This may represent another reason for our failure to demonstrate a volume-outcomes relationship for in-hospital mortality. Rather than our study being inconsistent with earlier data, it is conceivable that with the incorporation of volume as a metric based on those earlier studies, fewer hospitals, particularly those participating in the GWTG-CAD registry, were functioning as true "low-volume" hospitals, with a resultant reduction in mortality differences between these hospitals based on volume.
The higher mortality in low-volume hospitals for all patients with STEMI and for patients who did not undergo primary angioplasty noted in our study is hypothesis-generating and warrants further investigation. It is plausible that lower-volume centers were being more selective in taking patients with STEMI for primary angioplasty.
One of the reasons our findings are important is that procedural volume is increasingly being used as a surrogate for quality of care.15,17 Some organizations have set standards for urban hospitals to meet before they would contract the care of their employees with them. These include minimum volumes for several procedures including angioplasty.18 Our study makes a case against such volume criteria.
Compared with low-volume centers, our finding that high-volume centers are more adept at achieving shorter DTB times, as well as in adhering to evidence-based therapies in patients with STEMI, is likely an indicator of better systems of care in these hospitals. Further analysis and quantification of these systems could enable standardization of health care delivery across hospitals.19 Because numerous studies have linked shorter DTB times and greater adherence to evidence-based medications with better outcomes,6,20- 22 there are probably multiple reasons why a difference in in-hospital mortality between low- and high-volume hospitals was not observed, despite seeing a difference in DTB times and the use of evidence-based therapies between these hospitals. For instance, most of these studies assessed mortality over a longer period. Measurement of in-hospital mortality alone may thus represent inadequate follow-up. Additionally, in-hospital mortality may not be the most sensitive discriminant of quality.23 From a statistical perspective, we could be underpowered to detect a difference in mortality between low- and high-volume primary angioplasty hospitals. To demonstrate a significant 0.9% difference in mortality between these 2 groups with 80% power, the low-volume tertile should have at least 6675 patients.
We acknowledge the limitations of our study. In addition to data being submitted voluntarily by participating hospitals, data were also collected by medical chart review and are thus dependent on the accuracy and completeness of documentation and abstraction. The GWTG-CAD is primarily a quality improvement registry and was not specifically designed to address the causal implication of hospital volume and mortality. Our analysis reflects a subgroup analysis performed in the context of hospitals actively engaged in quality improvement, without a control set. Analysis of data from a control group of hospitals, not in the GWTG-CAD registry, with low primary angioplasty volume is thus necessary to strengthen our findings. Another significant limitation is the inability to adjust for individual operator volume. It is conceivable that low-volume hospitals may be performing as well as other hospitals because they have 1 or 2 high-volume operators. Several studies have demonstrated a relationship between high-operator volume for angioplasty and improved outcomes,4,5 although that difference seems to be getting smaller as well.24 Finally, data on total ischemic (symptom-to-door) time was not available. This would have enabled a more complete evaluation of differences in systems of care between hospitals, such as ambulance triage and prehospital electrocardiogram.
In a contemporary registry of patients with STEMI, higher-volume primary angioplasty centers compared with lower-volume centers were associated with shorter DTB times and greater use of evidence-based therapies, but not with adjusted in-hospital mortality or length of hospital stay. Further studies corroborating our findings with the use of stents and newer adjunctive pharmacotherapy are necessary, including longer-term follow-up.
Corresponding Author: Deepak L. Bhatt, MD, MPH, VA Boston Healthcare System and Brigham and Women's Hospital, 75 Francis St, PBB-146, Boston, MA 02115 (firstname.lastname@example.com).
Author Contributions: Dr Peterson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kumbhani, Askari, Bhatt.
Acquisition of data: Cannon, Fonarow, Peterson.
Analysis and interpretation of data: Kumbhani, Cannon, Fonarow, Liang, Askari, Peacock, Peterson, Bhatt.
Drafting of the manuscript: Kumbhani, Bhatt.
Critical revision of the manuscript for important intellectual content: Kumbhani, Cannon, Fonarow, Liang, Askari, Peacock, Peterson, Bhatt.
Statistical analysis: Liang.
Obtained funding: Cannon, Fonarow, Peacock.
Administrative, technical, or material support: Askari, Peacock, Bhatt.
Study supervision: Cannon, Fonarow, Peacock, Bhatt.
Financial Disclosures: Dr Cannon reported receiving research grants from Accumetrics, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Sanofi-Aventis, Schering-Plough, Intekrin Therapeutics, Novartis, and Takeda; and advisor and equity from Automedics Medical Systems. Dr Fonarow reported receiving research grants from the National Heart, Lung, and Blood Institute; having consulted for Merck-Schering Plough, GlaxoSmithKline, Bristol-Myers Squibb/Sanofi-Aventis, and Pfizer; and receiving honoraria from Merck-Schering Plough, GlaxoSmithKline, Bristol-Myers Squibb/Sanofi-Aventis, and Pfizer. Dr Askari reported being on the speakers bureau of Bristol-Myers Squibb/Sanofi-Aventis and Daiichi-Sankyo. Dr Peacock reported receiving research grants from Abbott, Biosite, Heartscape, PDL, and The Medicines Company; and receiving honoraria from Abbott, Biosite, Inovise, and The Medicines Company. Dr Peterson reported receiving research grants from Bristol-Myers Squibb/Sanofi-Aventis, Schering-Plough, and Merck/Schering. Dr Bhatt reported receiving research grants from AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Heartscape, Sanofi-Aventis, and The Medicines Company; receiving honoraria from AstraZeneca, Bristol-Myers Squibb, Centocor, Daiichi-Sankyo, Eisai, Eli Lilly, GlaxoSmithKline, Millennium, Paringenix, PDL, Sanofi-Aventis, Schering-Plough, and The Medicines Company; being on the speakers bureau of Bristol-Myers Squibb, Sanofi-Aventis, and The Medicines Company; being a consultant/advisory board member of Arena, Astellas, AstraZeneca, Bayer, Bristol-Myers Squibb, Cardax, Centocor, Daiichi-Sankyo, Eisai, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, McNeil, Medtronic, Millennium, Molecular Insights, Otsuka, Paringenix, PDL, Philips, Portola, Sanofi-Aventis, Schering-Plough, Takeda, The Medicines Company, and Vertex; and providing expert testimony regarding antiplatelet therapy. Drs Kumbhani and Liang reported no financial disclosures.
Funding/Support: The Get With the Guidelines-Coronary Artery Disease is a program of the American Heart Association (AHA) and is supported by an unrestricted educational grant from Merck/Schering-Plough Pharmaceutical. Data collection and management were performed by Outcome Inc (Cambridge, Massachusetts). The analysis of registry data was performed at Duke Clinical Research Institute (Durham, North Carolina), which also receives funding from the AHA.
Role of the Sponsors: Merck and Schering-Plough had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. The AHA provides Get With the Guidelines program management with a volunteer steering committee and AHA staff. The manuscript was submitted to the AHA for review and approval before submission.
Disclaimer: Dr Perterson, a contributing editor for JAMA, was not involved in the editorial review of or the decision to publish this article.


text: Hey all. Just limped my 1977 K20 home. I think my clutch is fried. It won't engage. I had to put it in first without it running and start it standing on the brakes just to get home. I tried to shift and nothing. When i got home i checked the linkage and it looks fine. I just dont want to replace something that I dont need to. Any ideas/info would help. Thanks.

subset: commoncrawl


text:
Custom framing projects vary based on numerous factors but start at around $130, with custom jersey framing available for $379
For $2, receive $20 off Purchase Of $50 or More
framing studio specializing in oversized and shadow box framing also performs custom matting, pickup, and delivery
For $1, receive 15% Off Single or Multiple Framing
Custom framing services and original artwork depicting Chicago landmarks from a local artist
A Chat with Helendora Samuels Picture Framing, Inc.
$49 for $100 toward custom framing services
Use one of over 120 templates to create a personalized collage of your own photos, which will be printed on acid-free canvas and hand-framed
Transfer your treasured photos onto a unique wood, canvas, or burlap surface, preserving the memory and creating a cool rustic decor piece
Prints of custom alphabet artwork are made with original images of found objects in their natural environments
Canvas prints showcase your best photos of your dog or cat, letting you add striking pop-art effects or create sentimental collages
Professional in-studio photo session to capture lifetime memories with a canvas display or framed wall print
Your favorite photo is professionally printed on linen canvas to be hung on the wall as beloved element of decor
Upload a favorite picture from your computer or a social-networking site and get a photo on a crystal
Have your favorite image printed on a framed canvas by following a series of simple instructions
Eye-catching home signs let you customize and embellish over 100 designs, with finished results printed in long-lasting ultra-chrome inks
... landscape shot, or simply a photo of their favorite momento—and have the power to crop, rotate, color correct it to wall-worthy perfection, before framing it in either a black or espresso standard frame.
Made of cork, with wood framing
Baby blankets and frames with customized images and phrases make great baby shower gifts
Custom framed canvas prints for your game screenshots and photos
Have a family portrait or personal photo blown up and printed on high-quality canvas
Display up to 100 of your favorite photos with these chic collage prints, which come ready to hang in a stylish frame
Turn your personal pictures into stylized 60s pop art masterpieces, printed and framed on canvas
Prints of the famed street artist Banksy, each printed on canvas and framed, add a subversive touch to any living space
Sharp, colorful prints show stylized images of the locker room of your favorite pro team, featuring uniforms of star players
Alphabet photo art taken by noted artist can spell any word up to eight letters long; includes premade "Love" and "Home" letter-art prints
Customers upload a favorite image to be printed and stretched on a floating frame; it arrives ready to hang without any assembly required
Photos of loved ones, vacations, pets, and more printed onto durable canvas and hand-stretched across 1.5" thick wood framing bars
Show off your love for your favorite sports team with a personalized print of a sports bar with your name on it
Discover new restaurants, spas, things to do & more great deals added daily!
You can change your email preferences at any time
By clicking Continue, I agree to the Terms of Service and Privacy Statement
No Thanks
*Valid on 1 unit per transaction; max 1 Local or Getaways deal per customer. Max discount $30. New customers only. Exclusive and non-transferable. Ends 5/31/17. Full details: gr.pn/promofaq


text:
[quote user="MattMeyerBud"][quote user="JPizzack"]
I got Madden12 finally yesterday. Got a used copy on ebay for $22 shipped
It's alot harder than the previous one I had.
few things I noticed:
- opponent awareness in the secondary is much better. You really need a WIDE open receiver to throw to or else your pass will get batted down. Even the linebacks will knock down passes over their heads into the secondary
-almost every single other madden game, when on defense i would control a DE or a DT. But as dezz mentioned to me last week, the DE moves are kinda lame in this one. When i play a DT, its fairly easy to stop the run on the inside, and let your DEs cover the outside. But pass rushing never works at the ends!! so frustrating!! Oh, and when you DO pull off a swim move, your end rushes to the inside into a guard instead of to the outside, which would make sense when i rewatch the play lol.
-running is still the easiest part of offense. </p>
-the player cuts in preseason franchise is an awesome feature
-although i dont understand why it adds FAs automattically instead of saying "you need to have 4 safeties, etc.....and then it doesnt tell you it signs them either....oh, AND it cut Barden and Cruz without telling me. so i couldnt figure that out.</p>[/quote]
yea it depends on the coverage with who I control... I am either a DE, MLB, or saftey.
if u do franchise, you can sign all of those guys to bring em into camp. I actually gor bored of playing online yesterday and made a franchise so that I could get Bennett on the Giants lol....
then i traded around playerthat signed around the league and put peyton on the 9ers...
i can't play on allmadden, i just get skunked. Im starting to dominate all pro though so i'll make the transition soon
[/quote]Nice job on the ebay madden purchase!! Ebay rules. Last night on ebay.....I stole a Victor Cruz jersey with SB 46 patch for $38 shipped. Even after this many years on ebay, my blood pressure and heart still start pounding inside of 4 minutes. lol.


text:
Bend High tragedy: Student shoots, kills self
Police rush to scene; crisis teams called in
BEND, Ore. - A Bend High School student shot and killed himself in a modular classroom amid other students Friday afternoon, bringing police and medics rushing to the scene as the school was placed in lockdown for several hours, officials said.
The student fatally shot himself in a modular classroom around noon with a gun he brought onto the Sixth Street campus, Police Chief Jim Porter confirmed at a late-afternoon news conference.
Porter confirmed other students were present but declined to say how many or describe the type of weapon. He also did not identify the student, noting police policy regarding suicides. But he said the tragic situation was "contained immediately."
"The loss of any student is a tragedy," Bend-La Pine Schools Superintendent Ron Wilkinson said. "Our hearts go out to the family and friends, staff and students."
Wilkinson said the staff handled the crisis in an "awesome manner" and also had praise for students who were locked down on campus for at least two hours, with little information but plenty of reports flying via texts and social media about what happened.
"At first, I thought it was a drill," one student said of hearing the first loudspeaker announcement of the lockdown. "But he sounded scared -- and then he came on a second time and I realized it was real -- came on a third time, knew it was real."
Several parents expressed frustration to NewsChannel 21 on the scene about not being informed by police or authorities about what had transpired, sparking frustration and fear. Others were grateful their children had texted them from classrooms to say they were alright.
School district spokeswoman Julianne Repman said the Bend High campus will be closed all weekend due to the investigation, so churches or other groups that use the buildings will not meet there. Crisis counselors will be available for all who wish to speak with them on Saturday at Bear Creek Elementary School from 9 a.m. to 2 p.m.
School psychologist and Director of Special Programs Sean Reinhart urged parents and students "be vigilant and look out for signs" of young people at risk of suicide.
He spoke of hearing "individuals talk about wanting to die, wanting to kill themselves," acting hopeless or anxious, acting recklessly, or showing signs of withdrawal or feelings of isolation. He offered two numbers for those seeking help, one local -- 541-322-7500 -- and the national Suicide Prevention Lifeline, available at 1-800-273-TALK or www.suicidepreventionlifeline.org.
In a Facebook posting Friday night, Deschutes County District Attorney Patrick Flaherty offered thoughts and prayers to all touched by the "tragic and shocking events."
He noted that Deschutes County Behavioral Health offers 24-hour crisis intervention, by phone or face to face. The 24-hour phone line is 800-875-7364.
He also said the county's Victims' Assistance Program is working with Oregon Crime Victims Compensation and the school district to coordinate funding for extended counseling. More information is expected to be available through the school district on Monday.
In a release issued before the news conference, Bend police Lt. Kurt Koester did not identify the student, nor provide a gender or age, but said no one else was injured and there was no threat to the school or public. He said police and school officials worked to systematically release students from school.
Here's the complete announcement from Bend-La Pine Schools, posted to their Facebook page:
"Bend Police and Emergency Responders were called to Bend Senior High School shortly after a noon 9-1-1 call that a student had allegedly committed suicide on campus. The school is in lockdown at this hour as police investigate the situation. There is no further threat to students or staff and the building is secure. A crisis team has arrived on campus and is meeting with those affected.
"Staff will begin escorting students out of the building, by wing, to their vehicles, buses, and off campus - for pedestrians and bike riders - at approximately 2:35pm. Student pedestrians and drivers will exit campus via the 6th Street and Clay campus exit. Parents can pick up their students at the Presbyterian Church on 9th Street. Campus will remain closed to visitors through the weekend.
"Students, staff or community members who would like to meet with counselors, at no cost, can drop in to Bear Creek Elementary School between 9am – 2pm tomorrow.
"All evening activities are cancelled at Bend Senior High.
"Our hearts go out to the students, staff and our community at Bend Senior High School.
"Normally, the District and law enforcement would not share public information regarding a suicide, but due to the circumstances, the District felt it important to share this sad information with families and the community," the announcement concluded.
Koester said the investigation was being assisted by Oregon State Police and the Deschutes County District Attorney's Office.
Earlier, the district had said, "Police report that there is no further danger to students or staff at the school."
Ninth Street was closed and monitored by staff, according to initial scanner reports, which also indicated crisis workers were arriving on scene.
We will have more details immediately as available on KTVZ.COM and a full report tonight on NewsChannel 21 at Five, Six, Ten and Eleven.


text:
Eva Longoria before heading to Mexico to celebrate her birthday.
Goldie Hawn got an award at an event hosted by
Dr. Oz and his wife.
Hugh Jackman sure has seemed happier lately.
Jenny McCarthy at an event yesterday.
Josh Lucas putting all those divorce issues behind him at a premiere.
Julia Roberts headed to her kids' school.
Kate Bosworth loves on Kevin Spacey.
Chris Klein plays count Kaley Cuoco's money in her see through purse.


text:
Giving Thanks Part 8: Buffy Star Eliza Dushku Promotes Socially Responsible Travel
Posted by Malia Everette in Featured on 23rd November, 2010 | No Comments
The final post in an 8-Part "Giving Thanks" series, today actress Eliza Dushku receives accolades from Reality Tours Director Malia Everette. Read how Eliza is using her celebrity for good.
Read More...


text:
The book I love most is... An early captivation was Portnoy's Complaint by Phillip Roth. A laugh-out-loud high-powered rant, it's like being in the same room as a staccato stand-up comedian who never stops jabbering. Lots of other books, of course ... most recently, Billy Lynn's Long Half Time Walk by Ben Fountain and We Need To Talk About Kevin by Lionel Shriver. They both crank along wonderfully.
The book I'm reading right now is... The Unlikely Pilgrimage Of Harold Fry by Rachel Joyce, a tender, middle-class road story through England combining the heroic and the mundane in one rather neutral character. Joyce's great gift is to catch profound emotions in simple unaffected language. Good settings, too.
The book I'd like to read next is... Something factual like The Age of Austerity by Thomas Byrne Edsall.
The book that changed me is... It was actually the play, King Lear. I was lifted as high as I'd ever been and dropped as low.
Shakespeare opened up the glorious private thrill of literature.
The book I wish I'd never read is... Two that come to mind are The Da Vinci Code by Dan Brown and The Girl With The Dragon Tattoo by Stieg Larsson. Both suffered from a profound lack of credibility.
King Lear runs at the University of Auckland until March 30. See maidment.auckland.ac.nz for more info.


text:
Posted 6 years ago
(111 items)
This Brazilian t-shirt was owned and worn by John Lennon. It was given to guitar tech Richard Carlson at the Hit Factory recording studio in August 1980 during sessions for his final LP "Double Fantasy". He told Lennon that he liked the shirt... told him it looked "Cool"...and John gave it to him.


text:
Sport luxury or luxury sport - which style floats your boat? It was a well-worn catchphrase by the end of Holden's new VF Commodore launch.
Last weekend the Calais was revealed across the Ditch, and Holden has now unveiled the SS derivative to coincide with its United States launch at the Daytona 500 where it will be rebadged as a Chevrolet SS Sports Sedan.
Like the Calais, the SS has gone upmarket inside and out. But walking a similar line to the HSV Senator, this sporting derivative doesn't have in-your-face styling. Instead it's almost regal athleticism.
Distinguishing features over the Calais on the outside are black aprons front and back, along with different 20-inch alloys.
The launch car also had an understated small rear-lip spoiler. Holden says there will be an option for a larger wing.
"We've taken a great existing form and brought it up to another level," chief designer Richard Ferlazzo said.
"The surfacing is more flamboyant and contemporary, way more sophisticated. We've succeeded in putting in more action and detail.
"One of our main goals was to improve aerodynamic performance and as a result many visual elements are much bolder. There's also more embellishment in terms of chrome highlights. Headlamp and tail lamp treatments are layered, complex and intricately detailed."
Discreet styling flows inside. Large colour blocks have been ousted. Soft leather and suede are now the materials of choice throughout the cabin. Carbon fibre-look touches, red stitching, SS lettering and a light grey colour scheme create a classy ambience. There is also an option for a predominantly black interior with grey stitching.
Chrome pieces are also used throughout, with the smaller, brighter inserts designed to catch more light.
Best of all is the chunky, leather-wrapped, flat-bottom, sports steering wheel which feels wonderful in your hands.
It's now armed with cruise-control buttons - rather than being mounted on a stalk.
Taking pride of place inside is a 20cm touch-screen colour display for the sat-nav, stereo and climate-controlled aircon.
Chief designer for colour and trim Sharon Gauci said the lighter cabin emphasised the Commodore's new sophistication - with the bling primarily on the outside. "It's not over the top. We really wanted the emphasis on sports luxury," she said. "The new VF interior environment is designed to go above and beyond traditional customer expectations.
"With VF, we aimed to create the ultimate interior for the price point with a harmonious and cohesive approach to our colour and trim strategy."
Prices and drivetrain details will be revealed closer to launch in May.
Commodore VF - what we know
Holden and parent company General Motors are understandably playing their cards fairly
close to the corporate chest as they drip-feed information to car fans. They split up the launch of the Calais and the Chevrolet SS so both the Americans and Aussies had
something for show and tell as your paper was being delivered overnight, General Motors was taking the covers off its Chevrolet SS in the US.
While powertrain and pricing options are still off the table, more will be revealed in coming weeks. Holden was very keen to demonstrate the Calais high-tech trickery, and judging by the interior of the SSV from our cunningly acquired photos, it looks like the
Commodore shares a host of these high-end features. Here's what we know:
Reverse traffic alert which warns of passing vehicles when reversing out of spaces.
Blind spot alert to warn of obscured vehicles when changing lanes.
Auto-park assist which effectively parks the car automatically, the driver just operating the pedals. It works for parallel or 90-degree parking.
Keyless entry with push-button start.
Electric park brake, which frees up space in the centre console.
The electric window controls have been moved from the centre console to the doors.
Boot opening button is also now on the driver's door, rather than the glovebox.
Cruise control buttons are mounted on the steering wheel, rather than the stalk.
Slick 20cm colour touch-screen with "Pandora" (digital radio) and "Stitcher" (music) applications.


text:
Tuesday Night Dinner
- Sponsors:
- Location:
- Falcone-Arena House
- When:
- Contact:
Kennedy, Ruth Anne
- Email:
- Phone:
Great company, wonderful food, and a fun, relaxed environment are waiting for you every Tuesday night. Friends are waiting to join you at the Falcone-Arena House kitchen, for a meal specially prepared by some of our wonderful chef-students. You are invited to also cook and help provide hospitality. The Falcone- Arena House is just behind Epworth dorm on East Campus, at the corner of Buchanan and Trinity. Contact Emma Miller (email@example.com).


text:
Lloyds bank
ADCB Q4 net profit surges 30pc, shares up
Abu Dhabi Commercial Bank (ADCB) posted a 30-per cent rise in fourth-quarter net profit, Reuters calculations showed on Thursday, sparking a late rally in the lender's stock. ADCB, the third largest bank in Abu Dhabi by market value, hMore…
New bank may join Northern Rock bid
New British bank venture NBNK is interested in joining the bidding for state-owned lender Northern Rock, sources said. The move raises the possibility that NBNK could combine Northern Rock with around 630 Lloyds bank branches it is also eyMore…


text:
Volume III
Editor's note: The Education Innovator will be taking a summer break. Please look for the next issue around August 29.What's inside...
University Park Campus School, Worcester, Massachusetts
What's New
U.S. Department of Education releases non-regulatory guidance on "Improving Teacher Quality State Grants;" OII launches new homepage index and supplemental educational services webpage; free educational resources available on the web; and evaluation of AUSL shows its second-year teachers help improve student test scores.
Innovations in the News
Eighty-five percent of Tennessee schools met Adequate Yearly Progress, plus information on charter schools, choice, and teacher quality.
University Park Campus School Revitalizes a Neighborhood and Its Children
In Worcester, the second largest city in Massachusetts, 44 neighborhood seventh graders have been going to school each weekday morning since the beginning of August. Unlike most children their age, they do not begrudge the extra class time cutting into their summer vacation. Instead, the children and their families are ecstatic to be given the chance to attend University Park Campus School and the chance for a possible full college scholarship if they achieve to high standards in high school.
Over a decade ago, Clark University realized that if the city around the campus continued on its track of economic and social decline, parents would hesitate to send their children to college there. As a result, the university participated in a series of renovations as a member of the University Park Partnership, a consortium of neighborhood residents, businesses, government agencies, churches, and the public schools which was created to combat the deterioration of the neighborhood. A few years later, the president of the university moved into one of the renovated houses a couple of blocks away from the campus, and with financial incentives, some faculty followed suit. Although the area had become less dangerous, it still lacked one important thing: a high-performing public school for local children.
University Park Campus School was developed by Clark University and the Worcester Public School District to be a public school of choice that would admit neighborhood students regardless of their academic standing. Applicants are admitted by lottery but, before they apply, they must accompany their parents to an informational meeting where they are told about the academic rigor of the school and the minimum of two hours of homework each night.
Seventy-eight percent of University Park students speak English as a second language, with Spanish, Albanian, Vietnamese, or Cambodian as their first language. This percentage is much higher than that of the district (36 percent) or of the state (14 percent). Seventy-three percent of University Park students qualify for free or reduced-price meals (compared to 30 percent in the state), and many of these students are those who had "slipped through the cracks" in their elementary schools. About 39 percent of the students are white; 34 percent are Hispanic; 18 percent are Asian; and 9 percent are African American.
When University Park opened the doors to its first class of seventh-graders in 1997, the school started the year with an "August Academy" to assess the incoming students' proficiency levels in reading, math, and English, and their social skills. The teachers found that one-half of the 35 students were reading at a third-grade level, and four of them could not read at all. Two years later, when the students started ninth grade, all of them were following an honors-level curriculum. The following year, on their initial attempt, all students passed the Massachusetts Comprehensive Assessment Exam (MCAS), a test in reading and mathematics required for graduation in Massachusetts.
June Eressy was the founding English teacher at the school. A seventh and eighth grade English/Language Arts teacher, she started teaching her students using picture books to "spark initial literary dialogue," since many of the students had such low literacy skills. As the year progressed, her students enthusiastically participated in literature circles and peer editing projects. Over the years, she has promoted writing and reading across the curriculum and has hosted a literary circle for parents.
University Park has added one grade each year for five years, and now has 220 students. In such a small school, teachers get to know their students. Between bag lunches and microwavable meals, during the short lunch period, teachers can interact informally with students. The small number of students enables teachers to ensure that each one is being coached to excel and reach his or her maximum potential throughout the academic year. University Park's teachers believe that all students can learn and are capable of high achievement. Teachers also put in many extra hours helping students in before- and after-school homework centers. One hundred percent of the teachers are licensed in the subjects they teach, and 93 percent of the core academic teachers are identified as "highly qualified."
University Park's core curriculum requires students to be diligent about their studies. All classes taught at the ninth grade level and above are either at an honors or Advanced Placement level. Math, science, English, and history are required each year, and students also must take three years of Spanish. Classes are 60 minutes and 90 minutes (for the classes that prepare students for the MCAS exams). Art, music, and physical education specialists take over classes on Wednesday mornings, and the core teachers use that time to discuss their students' progress. According to the school's leadership, this common planning time is an essential ingredient to the success of the model.
The school also has a support system in place so that students have the resources necessary to meet the school's high expectations. Students are allowed to rewrite their essays as many times as necessary in order to receive satisfactory grades. Teachers believe this instructional strategy improves students' writing skills and maintains their interest and enthusiasm for the subject. Teachers keep parents informed about expectations and encourage them to send their children to University Park's before- or after-school homework help sessions.
The strong commitment to academics pays off. In 2004, all University Park tenth grade students passed the English/Language Arts portion of the MCAS, with 85 percent scoring proficient and advanced, with no one failing. On the math MCAS, 88 percent of tenth graders scored proficient and advanced, with no one failing. Students' scores in both subject areas of the MCAS have consistently qualified the school as one of the top 10 percent of schools in the state, and the school was recently named the top-performing urban high school in Massachusetts.
Not only is the entire tenth grade class doing well on standardized tests, but University Park is succeeding also in closing the achievement gap for Hispanic students. In 2003, 100 percent of the tenth grade Hispanic students met or exceeded the state standards in English language arts, and, in math, 93 percent of tenth grade Hispanic students met or exceeded state standards on the MCAS.
University Park does not expect students' learning to end with high school. All the members of its first two graduating classes went on to college, and 80 percent of them went to four-year institutions. There is a strong emphasis, starting in seventh grade, on going to college. Clark University maintains a close partnership with University Park, providing the school with student teachers and university resources, such as the libraries and gymnasiums. In addition, students are encouraged to enroll in classes at Clark University during their junior and senior years. To be eligible for these classes, students must have an honor roll average and must be academically mature enough to be enrolled as a regular college student. Students who complete these courses receive college credit, and, when they graduate from high school, they can enter college with advanced standing. The strongest incentive to do well is the waiver of tuition at Clark University for those University Park graduates who are admitted to the university through its regular application process.
University Park is not just a place where academics flourish; the school is just as proud of its "social curriculum." The school's expectations for student behavior, and the students' expectations for each other, are high. Students and staff are expected to model behavior and respect; community service is part of the special Wednesday schedule; and older students often work with seventh-graders who appear to be having trouble adjusting.
In 2001, founding teacher June Eressy received a Milken Family Foundation National Educator Award for her "expert instruction and high expectation," and in 2003, she was appointed principal of the school. Called upon often to share her experience and expertise, Ms. Eressy presented the school's college preparatory program to the College Board in February of this year.
University Park's reputation for successful student achievement has grown so that now the school, along with Clark University and Jobs for the Future, co-sponsors a professional development institute for school teams from early college high schools across the country. At the institute, University Park teachers share their "strategies for student success" with the teams, which include the school leader and the lead teachers responsible for designing middle school and high school curricula from each participating school. The institute can be considered an "apprenticeship for excellence" because participants observe the University Park teachers in action during the August Academy. The last day of the institute is devoted to "Planning Your Own Exemplary School" so that the school team members can work together to apply what they have learned to their particular school setting. The institute also includes an intensive follow-up program of individual consultation, an online forum, and residencies at University Park Campus School during the school year.
University Park Campus School is a school of choice in the Worcester Public School system. It is a partner in The Education Alliance at Brown University, where the Northeast and Islands Regional Educational Laboratory, one of 10 regional laboratories funded by the U.S. Department of Education, is a content provider. The University Park before- and after-school homework centers are funded by a 21st Century Community Learning Centers grant to Massachusetts from the U.S. Department of Education.
Resources: Note: The featured program is innovative and has a history of results; however, it does not have evidence of effectiveness from a rigorous evaluation.
What's New
From the U.S. Department of Education
The U.S. Department of Education has released a revised version of the Highly Qualified Teachers: Improving Teacher Quality State Grants Non-Regulatory Guidance MS Word (1.17M) The new guidance introduces new questions and expands upon others in the January 2004 version. For example, five new questions are included in the guidance under "Section H—Private School Participation." Under Title II, Part A, private school teachers are eligible to receive professional development benefits and services. (August 3)
From the Office of Innovation and Improvement (OII)
OII has revamped the index to its homepage (the links in the black "bubble" at the top of the page). The Education Innovator can be found under "News," and links to new "Publications" and "Supplemental Services" pages have been added. The new Supplemental Services page includes links to service providers, state contacts, and resources, in addition to "supplemental educational services" in the No Child Left Behind Act. (August 15)
Educational Resources
With many schools opening this month, teachers are referred to free resources with lesson plans and ideas for enriching content in core academic subjects. Two such resources are: 1) The Library of Congress and 2) FREE, the Federal Resources for Educational Excellence website sponsored by the U.S. Department of Education, which includes information from across 30 federal government agencies. Another free resource is the Helpforschools' "Education on the Web" site with links to over 3,000 sites in more than 500 categories to help teachers and administrators. Helpforschools.com is a project of the U.S. Department of Education-funded Region VII Comprehensive Center at the University of Oklahoma. (August 10)
The Academy for Urban School Leadership (AUSL) (see Innovator, May 23, 2005) conducted an evaluation of the Iowa Test of Basic Skills (ITBS) scores of students taught by AUSL second-year teachers in under-performing Chicago Public Schools. On the May 2005 ITBS, about 30 percent of the students taught by AUSL second-year teachers were at or above national norms, up from about 24 percent in 2004. This gain is greater than that of students taught by non-AUSL counterparts in the same schools and at the same grade levels. (August 9)
Innovations in the News
Adequate Yearly Progress
Tennessee schools have been working hard to bring up their test scores as evidence of student achievement. Statewide, 85 percent of Tennessee schools met the No Child Left Behind benchmarks for Adequate Yearly Progress. In 2003, 47 percent of the state's schools were on a "target" or "high priority" list. [More-Leaf Chronicle] (August 4)
According to recent data, only three schools in the Richmond School District (IN) made Adequate Yearly Progress, a requirement of No Child Left Behind. As a result, Richmond High School started reaching out to failing students through summer school and mailings with tips on how to succeed in school. Five hundred and ten students completed summer school, and 90 percent of the students were able to meet academic goals that they previously were unable to meet during the school year. [More-Palladium-Item] (August 9)
In Chatham County (NC), 11 of the 15 high schools made Adequate Yearly Progress (AYP). The superintendent commended all the schools in the district for their diligence in working with students throughout the school year. To meet the AYP standards, the administrators and teachers have "found innovative ways of helping" students, such as the countywide Saturday Academy for third, fifth, and eighth graders. [More-Chatham Journal] (July 22)
Charter Schools
In Albuquerque (NM), West Mesa and Rio Grande, two high schools on the "in need of improvement" list will offer students the option of transferring to charter schools. Mileage reimbursement from Title I funds will be available for students so they can get to these schools. The Albuquerque Board of Education Strategic Action Committee has been working on improving the relationship between charter schools and Albuquerque Public Schools. School administrators and representatives of charter schools have met to discuss how they can help each other and improve communication. [More-Albuquerque Tribune] (August 9)
An OII Charter School Program grant was awarded to a proposed charter middle school for grades five through eight in Charlottesville (VA) that will have an arts-infused curriculum. The school is scheduled to open in 2006 with a parent board, two-hour tutorials in core subjects each morning, and a focus on using the arts to help at-risk students. [More-Daily Progress] (August 3)
Competition among schools is changing the focus of some traditional public schools. Cartwright Elementary School in Phoenix (AZ) lost 1,200 students to area charter and private schools. The school has instituted the back-to-basics Pride Program of challenging courses in reading, writing, and arithmetic to draw students to the school. [More-PHXnews] (August 5)
Schools in Fort Myers, Cape Coral, and other Florida cities and towns are welcoming students who have chosen to attend their schools. One parent chose his child's school because the family lives across the street and two family members work at the school. Another mother chose her daughter's school because her daughter would have the same teacher who had taught her when she was a girl. [More-News-Press] (August 5)
Teacher Quality
Kathleen Quick joined top educators from across the nation to share ideas for raising student achievement during the Teacher-to-Teacher Summer Workshops sponsored by the U.S. Department of Education in six locations across the nation. Workshop sessions covered reading, mathematics, science, history, and the arts, and experts spoke about strategies for teaching students with special needs. [More-Citizen News] (August 10)
Last Modified: 08/13/2009


text:
Elizabeth Forrestal, PhD, RHIA, CCS, FAHIMA
Professor Emerita
BA, French, University of Minnesota, Minneapolis
Post-Baccalaureate Certificate, Health Information Administration, College of St. Scholastica, Duluth, Minnesota
MA, Organizational Leadership, College of St. Catherine, St. Paul, Minnesota
PhD, Higher Education, Georgia State University, Atlanta, Georgia
ECU faculty member and Chair 1996 through 2010. Prior faculty appointment: Medical College of Georgia, Augusta Georgia (1990-1996)
Courses Taught
Evaluation Methods in Health Informatics
Managed Care in Health Systems
Professionalism in Health Information Management
Health Care Reimbursement
Health Data Structures
Health Service Coding
Topics in Health Information Management
Quality Management in Health Care
Management of Health Information Services Department and Seminar
Recent Publications (formerly last name, "Layman")
Forrestal, E.J. 2014(July-September). Foundation of evidence-based decision making for health care managers – part II. meta-analysis and applying the evidence. Health Care Manager, 33(3):230-244.
Kulesher, R., & Forrestal, E. 2014. International models of health systems financing. Journal of Health Administration, 3(4):127-139.
Forrestal, E.J. 2014(April-June). Foundation of evidence-based decision making for health care managers – part I: systematic review. Health Care Manager, 33(2):97-109.
Zeng, X., Forrestal, E.J., Cellucci, L.W., Kennedy, M.H., & Smith, D. 2013(October-December). Using electronic health records and data warehouse collaboratively in community health centers. Journal of Cases on Information Technology (JCIT), 15(4, Special Issue), 45-62
Forrestal, E. (2013.) Chapter 20: Research methods. In K.M. LaTour, S.E. Maki, & P.K Oachs (Eds.), Health information management: Concepts, principles, and practice, 4th ed. (pp. 545-606). Chicago, IL: American Health Information Management Association.
Forrestal, E. (2013, Winter). Leading by design. Perspectives in Health Information Management. http://perspectives.ahima.org/leading-by-design/
Cellucci, L.W., Layman, E.J., Campbell, R., & Zeng, X. (2011, Fall). Integrating healthcare ethical issues into IS education. Journal of Information Systems Education (JISE), 23(3), 215-224.
Casto, A. B., & Forrestal, E. (2013). Principles of healthcare reimbursement, 4th ed. with on-line instructors' manual and student workbook. Chicago, IL: American Health Information Management Association.
Forrestal, E.J., Cellucci, L.W., Zeng, X., Kennedy, M.H., & Smith, D. (2013). Health information technology collaboration in community health centers: The Community Partners, HealthNet, Inc. In S. Sarnikar, D. Bennett, & M. Gaynor (Eds.), Cases in Health Information Technology for Patient Care Management, (pp. 171-196). Hershey, PA: IGI Global.
Layman, E.J. (2011, October-December). Decision making for health care managers and supervisors: Theory into practice. Health Care Manager, 30(4), 287-300.
Casto, A. B., & Layman, E. (2011). Principles of healthcare reimbursement, 3rd ed. Chicago, IL: American Health Information Management Association.
Layman, E., Bamberg, R., Campbell, C., & Wark, E. (2010, Spring). Environmental scanning: Allied health leaders' selection of strategic information. Journal of Allied Health, 39(1), 11-19.
Layman, E.J. (2009, October-November). Human experimentation: Historical perspective of breaches of ethics in U. S. health care. Health Care Manager, 28(4), 354-374.
Layman, E. (2009, Summer). Research and policy model for health informatics and information management. Perspectives in Health Information Management 6:1-7. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_044319.pdf
Layman, E.J. (2008, April-June). Ethical issues and the electronic health record. Health Care Manager, 27(2), 165-176.
Layman, E. (2008, March-April). Training health care personnel to work with health care data. North Carolina Medical Journal, 69(2),159-162.
Rosenthal, D.A., & Layman, E. (2008, February 13). Utilization of information technology in eastern North Carolina physician practices: determining the existence of a digital divide. Perspectives in Health Information Management, 5(3). Available at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036774.html.
Layman, E.J., & Watzlaf, V.J. (2008). Health informatics research methods: Principles and practice. Chicago, IL: American Health Information Management Association.
Casto, A. B., & Layman, E. (2009). Principles of healthcare reimbursement, 2nd ed. Chicago, IL: American Health Information Management Association.
Layman, E.J. (2007, April-June). Job redesign and the health care manager. Health Care Manager, 26(2), 98-110.
Layman, E., & Bamberg, R. (2006). Coping with a turbulent healthcare environment: An integrative literature review. Journal of Allied Health, 35(1), 50-60.
Bamberg, R., & Layman, E. (2006). Chapter 3: The development of allied health leaders for dean positions in schools or colleges of allied health. In A. Columbus (Ed.), Advances in psychology research, volume 41 (pp. 53-73). New York, NY: Nova Science Publishers.
Layman, E. J., & Bamberg, R. (2005, July-September). Environmental scanning and the health care manager. Health Care Manager, 24(3), 200-208.
Shah, M. A., & Layman, E. (2005, January-March). Using a multi-pronged approach to implement organizational performance improvements. Health Care Manager, 24(1), 48-54.
Bamberg, R., & Layman, E. (2004, Summer). Approaches to leadership development used by deans of allied health. Journal of Allied Health, 33(2), 113-124.
Layman, E. (2003, January-March). Health informatics: Ethical issues. Health Care Manager, 22(1), 2-15.
Layman, E. (2006). Chapter 16: Research methods. In K. M. LaTour & S. Eichenwald Maki (Eds.), Health information management: Concepts, principles, and practice, 2nd ed. (pp. 437-487). Chicago, IL: American Health Information Management Association.
Layman, E., Bamberg, R., & Jones, H. P. (2002, Winter). Filling the position of lead administrator in schools of allied health: The experience of search committees. Journal of Allied Health, 31(4), 197-204.
Layman, E., & Watzlaf, V. (2002, June). Manuscript characteristics affecting reviewers' decisions for journals in health information management. Proceedings of the Leslie Blide Memorial Research Forum of the Assembly on Education of the American Health Information Management Association, Chicago: American Health Information Management Association, Tab 12.
Bamberg, R., Layman, E., & Jones, H. P. (2000, Winter). Leadership progression in schools of allied health. Journal of Allied Health, 29(4), 196-202.
Layman, E. J., & Guyden, J. A. (2000). Renewal versus burnout: A career blueprint. Health Care Manager,18(3), 52-62.
Awards and Certification
Legacy Award of the Triumph Awards of the American Health Information Management Association and the Foundation of Research and Education of AHIMA with co-recipient Anne Casto, October 2007
Dean's Award for Outstanding Research, School of Allied Health Sciences, East Carolina University, August 2007
Drs. Rick Bamberg, Elizabeth Layman, and Harold Jones were recipients of the 2001 J. Warren Perry Distinguished Author Award for their article "Leadership Progression in Schools of Allied Health." The Author Award honors the best article of the year in the Journal of Allied Health.
Layman has been appointed to the Fellowship Review Committee of the American Health Information Management Association. This distinguished group is responsible for making recommendations for fellowship and candidacy.
Fellow of the American Health Information Management Association (FAHIMA), February 2001
Spotlight Award, North Carolina Health Information Management Association, May 2001
J. Warren Perry Distinguished Author Award, Journal of Allied Health, Nov. 1996
Outstanding Poster Presentation in Health Care Reform, Association of Schools of Allied Health Professions, 29th Annual Conference, Charleston, SC, November 1996
Outstanding Dissertation 1995-1996, College of Education, Department of Educational Policy Studies, Georgia State University, Atlanta, May 1996
Aspen Systems Graduate Scholarship, Foundation of Record Education, American Health Information Management Association, 1993
Outstanding Member, Augusta Area Health Information Management Association, 1993
Alpha Eta Society, Georgia Chapter, June 1993
Certificate of Achievement for Superior Achievement and Excellence, Minnesota Medical Record Association, 1986
Myers-Briggs Type Indicator, Association of Psychological Type, June 1994
Certified Coding Specialist, C05514, June 1992
Registered Record Administrator, 17041, October 1989
Accredited Record Technician, 26751, September 1986
Research Interest
Leadership and Management
Professional Burnout
Governance in Higher Education
Professional Organizations
American Health Information Management Association
North Carolina Health Information Management Association
National Association for Health Care Quality
Assembly on Education of the American Health Information Management Association
American Educational Research Association


text:
Tiffany Van Soest and Lion Fight's Crumbling Walls of Perception
- Published in Muay Thai
If you were to observe Lion Fight Promotions from the outside, it would look like a healthy promotion that's on the up-and-up. Lion Fight airs on AXS TV, has aired some tremendous fights over that span of time including some of the biggest names in American muay thai as well as big, international names. Over the last few months they've picked up even more steam when UFC and comedy personality Joe Rogan started to get excited about Lion Fight and talking about it on the Joe Rogan Experience.
Suddenly Lion Fight went from this thing that hardcore fight fans maybe kinda sorta knew about to the mecca of "high level striking" in the United States. That's the kind of pull and influence someone like Rogan has. While I can't fault him for his own tastes and opinions, nor the pull that he has with a good portion of social media fight fans, the hyperbole has been palpable since then, leaving Lion Fight in the position of untouchable darling of the fight scene.
Cracks started to form on the veneer of Lion Fight in January, though, when word broke that the United States Muay Thai Association, the organization that had provided oversight for a total of three Lion Fight events, declared itself "done" with Lion Fight. The claim? Lack of payment as well as cooperation from the promotion. Lion Fight was quick to declare that the switch to IKF for Lion Fight 27 was decided in advance, but the story sort of tapered off into the ether as stories like this tend to do for promotions that aren't huge and in the national spotlight.
Word was after the event that there were some outstanding payment issues that were bound to surface, only it took nearly two months for anything to bubble up and pour into the public eye. In a now-redacted tweet and corresponding Instagram post from newly-crowned champion Tiffany Van Soest, she claimed to still be owed money for her Lion Fight 27 performance, which the company hadn't made good on. So she was auctioning off her Lion Fight championship for $500 to pay some bills -- or so was the implication -- and people seemed shocked. The USMTA/IKF bait-and-switch was quick and happened without much visibility, but non-payment for one of their world champions? That was something that would catch some eyes. And it did.
Along with the recent, quiet departure of longtime posterboy for the promotion in Kevin Ross, things might seem a bit off within the realm of Lion Fight. Joe Schilling has gone on record publicly talking down the home of some of his most notable fights before he signed with GLORY and Bellator, going as far as to dub the promotion "Lion Fart" and within some of the more hardcore muay thai circles there are a lot of "I told you so's" floating around. Needless to say, while the promotion might be picking up steam and exposure, with that exposure has come an increased focus on every aspect of the promotion. There has been talk of a "uniform deal" that sounds a lot like UFC and Reebok's much-maligned deal, but there have only been whispers of complaints thus far.
Van Soest's decision to come forward and call out the promotion was a power play, if anything. A fan-backed GoFundMe was launched almost immediately and far surpassed the goal of $500, with many within the community quick to rally behind her to help cover any costs she needed help with an wanted her to keep the belt. Van Soest is a popular fighter who by all reports seems to be done with Lion Fight and should be heading off to greener pastures in the near future, so there shouldn't be any doubts as to if she'll be fighting again any time soon thanks to how marketable she is. If she needed to borrow some money she clearly could have, although that isn't the point. The point here is that the only way that she saw that money was by going public and taking scrapes at Lion Fight's public perception, which at this point is one of their most treasured assets.
It worked.
This afternoon they were quick to offer up an official statement claiming that there was an issue when the check was deposited, but that they have wired her the money this afternoon to clear up any sort of outstanding payment. But, the issue here feels more complicated than that. Lion Fight owed Van Soest money and the only way for Van Soest and her team to see that money was to make a statement on social media. The IKF, who sanctioned the event after USMTA dropped off, even has rules in place that are meant to avoid situations like this:
Promoter is required to pay to the IKF Representative or Associate directly after the event weigh-ins and before the Official event Rules meeting in CASH or CERTIFIED Checks ALL PRO Fighter Purses made out to each PRO Fighter.
The Official IKF Event representative shall hold all fight purses and distribute them to all pro fighters AFTER the event.
Lion Fight is, for many young fighters and fans, something to aspire to, the place where muay thai fighters in the United States can strive to fight and earn their fame in. Legends and heroes like Kevin Ross, Tiffany Van Soest, Joe Schilling, John Wayne Parr, Cris Cyborg Santos, Malaipet, Cosmo Alexandre, Artem Levin, Simon Marcus and many more have fought within Lion Fight's ring and while there have been more options for those inclined towards kickboxing, the same can't be said for muay thai. Lion Fight is pretty much the only game in town on a quasi-national level when it comes to clinching, elbows and knees, utilizing the full thai rules and this is a major blow to that perception that they are the best stand up striking organization in America.
For now they still are, the only problem is that not all fighters have the same sort of voice or platforms available to them like Van Soest does. For the good of the sport here's to hoping that stuff like this doesn't pop up again any time soon, or if it does that it's taken care of behind closed doors, not in the public view.


text:
Hydrometers & Refractometers
Hydrometers and refractometers are instruments used to measure the specific gravity of your saltwater or the ratio of the density of the liquid to the density of the water. Bulk Reef Supply carries the Red Sea Hydrometer with Integrated Thermometer and the Milwaukee Digital Seawater Refractometer.
Aqua Craft Refractometer Calibration Fluid$6.99
Out of stock
PINPOINT Salinity Calibration Fluid$7.99
Milwaukee Protective Hardshell Case for Refractometer$22.99
Refractometer for Reading Salinity with Calibration Fluid$39.99
Out of stock