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The Department of Veterans Affairs (VA) has a system-wide, patient-centric electronic medical record system (EMR) within which the authors developed the Clinical Case Registries (CCR) to support population-centric delivery and evaluation of VA medical care. To date, the authors have applied the CCR to populations with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Local components use diagnosis codes and laboratory test results to identify patients who may have HIV or HCV and support queries on local care delivery with customizable reports. For each patient in a local registry, key EMR data are transferred via HL7 messaging to a single national registry. From 128 local registry systems, over 60,000 and 320,000 veterans in VA care have been identified as having HIV and HCV, respectively, and entered in the national database. Local and national reports covering demographics, resource usage, quality of care metrics and medication safety issues have been generated.
The US Department of Veterans Affairs (VA) operates the largest medical system in the United States with 153 medical centers, 745 community-based outpatient clinics, 135 nursing homes, 43 domiciliaries, and 225 readjustment counseling centers grouped into 21 Veterans Integrated Service Networks (VISNs) around the United States. In Federal Government fiscal year 2008, the VA provided care to 5.5 million veterans. 1
The VA has a long and successful history of using information technology in delivering high-quality health care. In the late 1970s, development started on the VA electronic medical record system (EMR), now known as VistA (Veterans Health Information Systems and Technology Architecture). 2 CPRS (Computerized Patient Record System), the graphical user interface (GUI) component of VistA, was released in the late 1990s. The installation of CPRS was mandated nationally in 1999 and thus, medical documentation and ordering have been fully computerized at all VA facilities for almost a decade.
From its inception, the EMR software relied on flexible local configuration while requiring that code be portable across the entire VA. While a common structure was mandated for data dictionaries, local users were given control over the content. For example, each site has local legacy files for medication and laboratory definitions. While the system has successfully met the needs of local users, the local legacy systems must be mapped to a common set of codes when data aggregation is required, which is often a major undertaking. Furthermore, allowing free-text data entry in most fields, another flexible feature, poses major problems for machine interpretation of the data when portability is required.
Numerous decision-support tools have been developed within VistA/CPRS that prompt the health care provider on a range of issues such as appropriate medication dosing, potential medication interactions, preventative medicine recommendations, and routine clinical condition monitoring. These tools function on a local level once a clinician has accessed an individual patient's medical record.
Despite the availability of these support tools, VistA/CPRS does not provide the local clinician or administrator with ready ability to assess the care of a population of individuals. For example, decision support tools prompt a clinician seeing a diabetic patient regarding delivery of appropriate preventative services, but a clinician or administrator cannot readily assess the frequency with which these same preventative services are provided to a group of diabetic patients. Being able to generate population information for a distinct location and to compare that location to other locations or to the national VA system or external systems is critical to assessing safe, effective, and cost-effective care.
The VA has developed, implemented, and refined a registry system, the Clinical Case Registries (CCR), which uses the established EMR to identify cohorts of veterans with targeted conditions at the local and national level. The CCR incorporated lessons learned from two earlier VA registries: one for human immunodeficiency virus (HIV), known as the Immunology Case Registry (ICR), 3 and one for hepatitis C virus (HCV), known as the Hepatitis C Case Registry (HCCR). These two registries supported only limited local reports and transmitted limited data elements to a national database. In contrast, in the CCR, local clinicians can generate customizable reports on a variety of issues including resource usage, medication safety and quality of care on groups within their local population. On a national level, the CCR collects and aggregates selected clinical and demographic data from the EMR and structures it in a modern relational database system for statistical analysis. This system was designed and implemented in the context of an already well-established EMR. We believe that our experience designing this system of local and national registries and moving data from local legacy medical-records systems into a relational database system, while maintaining data integrity, quality and security, should prove useful to others undertaking similar or related tasks.
The purpose of the CCR is to support accurate identification of a population locally and nationally, provide customizable reporting on the local population, and create a national database to support administrative, clinical and research needs, including quality management.
We identified local clinicians, local and national healthcare administrators, quality management staff, and VA researchers as potential users of the CCR. The VA clinical staff based at the Center for Quality Management in Public Health (CQM) is the primary user of the national database. The CQM staff provided software specifications and conducted extensive alpha and beta testing on both local and national CCR software.
In the design process, we identified several important performance characteristics of a successful population-management system. First, the system should identify a target population with a high degree of sensitivity and specificity. Second, the system should provide local and national report-generation capabilities that can be customized by the end user. Third, the local system should be simple to learn, easy to use, and local reports must be quick to finish. Fourth, because veterans receive care at multiple facilities, data from all medical facilities should be aggregated to the unique-patient level. Fifth, the local and national systems had to operate in a changing clinical environment. Sixth, local, regional and national level data on agreed-upon measures should be available to permit comparisons between local, regional and national performance. Finally, both the local and national systems had to be secure.
The CCR software allows multiple registries, each with registry-specific data elements. The same patient may be included in multiple registries. A patient is entered once in the local CCR when selected for his/her first registry with flags set to identify entry into the first and any subsequent registry.
The CCR has two registries defined: HIV and HCV. These two chronic viral infections share risk factors and about one third of veterans in the HIV registry are also in the HCV registry.
The local CCR software package resides within the VistA environment at 128 VA reporting facilities which encompass data from all VA care sites. To identify patients potentially with HIV or HCV, the CCR software scans VistA records each night for new occurrences of a set of International Classification of Diseases − 9th Revision (ICD-9) codes in inpatient, outpatient visit, and problem-list records. The software also scans the result field of a set of laboratory tests identified by Logical Observation Identifiers Names and Codes (LOINC) for any new occurrences of a "positive" test result. This result field is a free text field. Using data from the ICR, we developed an algorithm to identify positive results as those that equal "P" or contain "POS" "DETEC" or "REACT" and do not contain "NEG" "NO" or "IND." A patient identified as meeting the electronic criteria for a target condition is called a "pending" patient.
At each of the 128 reporting facilities, a local staff member, referred to as a "CCR coordinator," is responsible for a periodic, manual review of the list of pending patients. The coordinator uses a GUI interface in the CCR software, which identifies each pending patient at that facility and displays the initial diagnoses and/or laboratory results indicative of the target condition as well as subsequent information that might help to confirm infection. Patients who have the condition of interest are confirmed manually by the coordinator and added to the list of local registry patients. That night, information on confirmed patients is transmitted and added to the national registry.
Patients who are not confirmed as having the condition of interest are manually deleted from the list of pending patients. After a patient has been deleted from the pending list, date triggers ensure that any new diagnosis or laboratory test result indicative of the target condition results in that patient being added once again to the pending list.
Security of medical health information is a top priority for VA. Since the local CCR contains information protected under federal law, access to it must be restricted. Access to the CCR software package is managed through the VistA software structure of security key and menu assignment. Local facilities are requested to restrict access to the CCR to those who need access for routine medical care, quality and safety initiatives, administrative oversight and, when approved in accordance with regulations, for research. Access is provided at three levels. Office of Information Technology (OIT) staff hold programmer keys which permit full access. Staff with administrator keys can process pending patients, create local customized fields, set up local report parameters, and run local reports. Staff with user keys can only run local reports.
Users with administrative keys can create an unlimited number of local user-definable fields to "flag" subsets of patients in a single registry. For example, local staff might want to identify all veterans in the CCR: HCV who have successfully completed HCV antiviral therapy. A local field can be created and, for each patient to whom it applies, the flag can be set and a user-defined date entered for each patient. Information from local definable fields is not transmitted to the national database.
In addition, the local CCR software supports fields completed by local users that are transmitted to the national database. Currently, such local user-completed fields are required for the CCR: HIV. The local coordinator must manually enter a patient's risk factors for HIV and whether the patient had a prior clinical AIDS diagnosis because this information cannot be obtained from existing VistA data fields.
The local CCR software provides extensive local population-based and patient-based reports on patients confirmed into the local registry. These reports were developed to meet several basic needs of front-line clinicians and local administrators. There are 16 reports available, roughly categorized as (1) registry reports, (2) clinical reports, and (3) usage reports, although the uses overlap. The registry reports concern basic demographics of patients confirmed in the local registry. Usage reports concern inpatient stays, laboratory tests, outpatient prescriptions, outpatient visits, procedures, radiology and summary usage. Clinical reports concern patient follow-up at outpatient clinics, current hospitalization, diagnoses, medication histories, and combinations of medication and laboratory results.
To produce these local reports local VistA data are queried. The reporting software accounts for variability in local dictionaries and the addition of new medications. All local laboratory names ever used for key tests of the conditions of interest are identified by the local coordinator and stored as local report parameters. When new disease-specific medications become available, local report files of National Drug Code (NDC) numbers for registry-related medications are updated via release of a patch. In addition, for all reports, the user is prompted to select the data elements from the local dictionaries. Report-definition selections can be saved in a template format by a user for use in future queries. A report can be scheduled to run at a particular time of day (to limit impact during office hours), on a particular day, or at a user-defined interval. Improvements to the reports are made periodically and additional local reports have been added via the release of patches to the software.
Users can customize local reports in several ways. Users can define the target date range, select aggregate or individual data, and select particular groups of data elements (e.g., diagnoses or medications). The population can be set to include or exclude patients who have a particular diagnosis or who have been identified with a local flag as described above. The population can also be limited to those receiving care in a time period where "care" is defined as having any of the following types of usage: inpatient stay, laboratory test, outpatient prescription fill, outpatient visit or radiology procedure. In addition, users can create groups of medications with "or" logic within groups and "and" logic between groups. Moreover, CCR users with access to multiple registries can limit the report population to patients who are, or are not, in the other registry. Thus, a user of the CCR: HIV can opt to include only those patients also in the local CCR: HCV, effectively creating population reports for the HCV-HIV coinfected population.
The clinical "Combined Meds and Lab Report" permits the query of both pharmacy and laboratory data. The power of this report resides in the logic that can be applied between prescription and laboratory data. The user can qualify a query based on who did or did not receive a group of medications in combination with receiving or not receiving a laboratory test or receiving a test with results in a selected range. Using this report, for example, one can list all HIV patients whose most recent cholesterol level was above a particular threshold and who are not receiving any lipid-lowering medications.
The goal of the national CCR database is to create a concise and timely snapshot of key health care data that maximizes the utility of the information for administrative, quality of care, safety, and research activities. Following consultation with both clinical and administrative end users, we narrowed the data selection for transmission to the national CCR database ().
On a nightly basis, the local CCR software uses standard VistA application programming interfaces (APIs) to extract data from the VistA packages, assemble HL7 messages and transmit them via TCP/IP to the national database. The local CCR software extracts all new relevant data elements for all patients in the registry based on identified date fields in each package. Wherever possible, records include a patient identifier, usage date, record modification date, location, provider information, coding standard where applicable, result, and any qualifiers or comments. For additional data security, the patient identifiers are a locally assigned number and an encoded Social Security Number (SSN) and not a direct patient identifier such as name or the actual SSN. Extraction to the national CCR is lagged 7 days after a record's initial creation to allow for correction or expansion of a record shortly after its creation, which occurs frequently. For example, laboratory tests results are often added to a laboratory record a few days after the specimen was submitted and the initial record created. Since a single veteran may appear in multiple registries, the HL7 message is constructed to allow multiple copies of registry data elements but only one copy of clinical data elements. When a new patient is confirmed into the registry, the CCR software completes a one time "back pull" of all the VistA data elements included in the national database for that patient, thereby capturing his or her historical data. A HL7 message size limit of 5GB was required to accommodate network traffic policy and message processing restrictions in place at CCR launch.
At the national database, e*Gate (SeaBeyond, now Sun Microsystems) is used to receive the HL7 message, acknowledge receipt to the local site, and forward messages to customized parsing software. The acknowledgment receipt also confirms the period for the next nightly extract. The custom-coded parser software performs four key duties. First, after checking that the message structure is valid, the parser initiates message parsing into a staging database (currently Oracle 10 g). Second, because the HL7 messaging format is not space efficient, all valid messages are compressed and saved on a separate server for source data backup. The compressed files require 1/20th of the storage space required by the HL7 messages. Third, a copy of each message is forwarded to the development server where additional work can be conducted on data validation, integrity, and standardization. Finally, the parsing software completes the migration of data from the staging database to the clean database by merging new or revised data with existing data.
The national database structure was optimized over VistA to limit data duplication. Even with the 7-day delay in data extraction from local VistA files, later changes in data that result in retransmission of data could result in duplicate entries. To prevent duplication, record keys (outside of the patient identifier) used in the local VistA files are maintained in the national CCR database. When data are retransmitted, the unique record key identifies the record as pre-existing and overwrites the pre-existing record with the newly transmitted data.
As of January 2008, the production database was approximately 400 GB in size. The largest table is laboratory records with over 450 million rows; it dwarfs the next largest table, outpatient diagnoses with approximately 90 million rows. The amount of data collected per patient varies and depends on the amount of care a patient uses, which in turn depends on the severity of his or her target disease, the existence of other medical conditions and extent of pharmacological treatment.
Because of the nightly addition of data, analyses requiring static data cannot use the production database. On a quarterly basis, static "snapshots" of the production database are created on a separate server for use in a variety of healthcare operations. For each patient, the national CCR receives both a locally assigned patient identifier and an encoded SSN such that all information for a unique patient can be aggregated based on the encoded SSN. If a change is made locally in a patient's SSN, the national database will receive the new encoded SSN without a change in the local patient identifier. Such inconsistencies are flagged and then reviewed for adjudication.
Prior to any analysis of these quarterly snapshots, additional work is required to standardize various data elements. Several data elements in the national database incorporate the standardized coding systems of Current Procedural Terminology (CPT-4) codes for procedures, ICD-9 codes for diagnoses, LOINC codes for laboratories and NDC numbers for medication names. For data fields that rely on local mapping to a coding standard, we have developed national custom-coded mapping tools to identify and repair errors made in the local maps. For example, each site must locally map every local laboratory test name to a LOINC code; inevitably errors are made in the process and these are corrected in the national database. Currently, remapping on the national database exists for laboratory tests and medication names. For many of the large, text only fields (e.g., radiology reports), we do not perform any standardization and must rely on ad hoc free text queries.
Using these snapshots, we conduct scheduled and ad hoc queries related to resource usage, administration, operations, quality and drug safety. Datasets from the static snapshots are provided to VA researchers through a regularly scheduled application process and to other VA program offices for operational activities such as budget planning.
As with any secondary database involving complex data integration, the national CCR may not be fully consistent with the local source data. The size of the database and the nightly addition of data make full validation too costly to complete in a timely manner. Instead, we approach data validation in three ways. First, we conducted an extensive review of initial data received from every facility in every field. Second, on an ongoing basis, we undertake monthly, facility-level data field counts to assess trends for each facility with the goal of quickly identifying missing data. Third, we include validation in all aspects of our quality and safety national initiatives. For example, if we need to investigate a drug safety issue related to Drug X causing abnormal Lab Y, then we will conduct an initial validation analysis on both Drug X and Lab Y to ensure that we are collecting information from each local site at the expected rate.
The CCR software was launched in March 2004 to create a HIV registry. The HIV registry was selected as the initial registry given the experience with the ICR and to permit validation of both local and national registries with a relatively small cohort. The CCR: HIV was auto-populated with the patients in the ICR—a registry for which case identification was completely manual. The auto-populated data consisted of 73,171 local registry patients representing 56,320 unique patients. An historical data query using the diagnosis and laboratory case identification criteria of the CCR: HIV identified another 23,746 patients as pending. These patients had not been in the ICR and hence were not in the CCR: HIV. Of these not-previously identified pending patients, 5,326 (22%) were manually confirmed by local staff into the CCR: HIV after review of local information including text notes and scanned documents not amenable to machine review. Their addition increased the number of local registry patients by 7%, suggestive of the extent of undercounting in a completely manual system relative to an automated system with manual confirmation.
Validation checks identified some errors in data transmission to the national CCR and in local report functions. After three patch releases and additional data validation, a fourth patch was released in April 2005 to perform a one-time back pull of all national registry data elements available from 1/1/85 to the present on all CCR: HIV patients.
In February 2006, an HCV registry was added to the CCR software via a patch. The HCV patient lists were migrated from the HCCR which had automatic addition of patients based on diagnosis codes and laboratory test results. Overall, 380,862 local registry patients representing 366,527 unique patients were migrated from the HCCR to the CCR: HCV. Since the HCCR had on-going automatic addition of patients there was no historical sweep to identify missing cases. At the implementation of the CCR: HCV, a one-time historical back pull of all national registry data elements for HCV-infected veterans was conducted at each of the reporting VA facilities. Each reporting facility continues to transmit 1 or 2 HL7 messages per night with parsing and database load times completed within a few hours.
As detailed above, the local CCR software performs a nightly search to identify potential new cases. Since the initial installation of the CCR, the software has successfully identified thousands of patients who have subsequently been confirmed by local coordinators into the local registries and transmitted to the national CCR. Because we do not currently collect information about individual pending patients, we cannot determine exactly what proportion of pending patients have been confirmed into the registry.
After the installation of the CCR: HIV and the clearing of the initial historical backlog of pending CCR: HIV patients, approximately 3,000 new local registry patients have been added each year to the local CCR: HIV (3,069 in 2004, 3,222 in 2005, 2,965 in 2006 and 3,121 in 2007). These new local registry patients represent 12,298 new unique patients added to the national CCR: HIV. Since the initial installation of the CCR: HCV, 37,169 new local registry patients have been added (10,293 in 2006 and 26,876 in 2007); they represent 37,064 new unique patients added to the national CCR: HCV.
As of Dec 31, 2007, 92,740 local registry patients had been entered in local CCR: HIV registries and transmitted to the national database, representing 63,109 unique patients. The total number of patients in the local CCR: HIV registry lists ranged from 2 to 5,228, median 448 and interquartile range 167–954.
In the CCR: HCV, 424,104 local registry patients had been entered in local CCR: HCV registries and transmitted to the national database as of Dec 31, 2007, representing 324,065 unique patients. The total number of patients in the local CCR: HCV registries ranged from 95 to 10,956, median 2,782 and interquartile range 1523 to 4440.
Some clinical data from the early 1990s is not available in the national CCR due to archiving of local patient records before the one-time historical back pulls. Given these data restrictions, we limited validation to the subset of patients who were in VA care at any time in the 10 years between 1998 and 2007. "In care" is defined as a record in the CCR during those 10 years of an outpatient visit, outpatient prescription fill or inpatient stay. The 10 year in-care populations consist of 36,841 patients in the CCR: HIV and 317,998 patients in the CCR: HCV.
Both HIV and HCV are diagnosed based in part on laboratory testing. To assess the accuracy with which patients are included in the national CCR, we first determined the number of patients who have laboratory data sufficient to inform their inclusion in the registry. For patients without such laboratory data, we analyzed outpatient medication information to identify patients who had received HIV and HCV antiviral medications that would support a diagnosis of HIV or HCV.
The laboratory tests analyzed for HIV infection were HIV antibody, western blot and HIV viral load. Results for antibody and western blot tests that could be categorized as negative or positive were considered informative, and results for viral load tests that could be categorized as detectable or not detectable were considered informative. Patients were categorized as positive (P) for HIV if the most recent informative western blot test had a positive result, or the most recent informative antibody test had a positive result (without a confirmatory western blot test) or the patient had a detectable HIV viral load at any time (without a negative antibody test or negative western blot on the same day or more recently). Patients were categorized as viral load only (VL) if all available results for HIV viral loads were undetectable and the patient had no informative antibody or western blot results. The remaining patients were categorized as indeterminate (I) if all available results were not informative (e.g., "see report" or "indeterminate"), untested (U) if the patient had no HIV tests or negative (N) if the most recent western blot test was negative or the most recent antibody test was negative.
Among patients in the CCR: HIV and in VA care in the 10 years from 1998–2007, 33,040 (89.7%) had CCR: HIV laboratory evidence of HIV infection (). Among the 1,279 patients with laboratory status of VL, 1,124 (87.9%) had received HIV antiviral medication. The latter are likely patients who transfer to VA care already on HIV antiviral medication with undetectable viral loads who do not undergo antibody or western blot testing in VA. Smaller percentages of those categorized as I or U had received HIV antivirals. Patients with status of I may have laboratory test results (e.g., "Call lab for result") that are available to the local coordinator who confirms the patient in the registry and to the local provider who prescribes the HIV antivirals but not to the national CCR. Similarly, patients with status of U may have laboratory tests done outside the VA that are not entered in the VA EMR but are available to the local coordinator and to the VA provider. Two hundred ninety-five (0.8%) of patients in the CCR: HIV in care from 1998–2007 have laboratory and pharmacy evidence that they are in the CCR: HIV registry in error; these veterans were identified as negative by laboratory criteria and had not received HIV antivirals from VA. Overall, of the 36,841 patients in the CCR: HIV in VA care in the past 10 years, 94.2% have laboratory or prescription confirmation of HIV infection, 5.0% have no laboratory or pharmacy confirmation in the national CCR and may be in the CCR: HIV in error and 0.8% definitively appear to be in the CCR: HIV in error.
The target cohort for the CCR: HCV is those veterans with a history of chronic hepatitis C infection. Unlike HIV, infection with HCV spontaneously clears in 20–25% of those infected. 4 Moreover, the available HCV antiviral treatments have a low but significant rate of "virologic cure" in those patients who tolerate and adhere to treatment. 5,6 The HCCR software automatically added a patient with a positive HCV antibody test result regardless of whether the patient had evidence of chronic HCV infection. Chronic HCV infection is defined by a detectable HCV viral load or an identifiable HCV genotype. Our decision to migrate all veterans in the HCCR into the CCR: HCV led to inclusion in the CCR: HCV of thousands of patients who were not chronically infected. At the time, we believed that many VA facilities did not have the resources to implement manual review of all 380,000 cases identified as possible HCV infection from the HCCR. Faced with this situation, our approach is a gradual one. With the implementation of the manual-confirmation process of the CCR: HCV, local coordinators were instructed to confirm only those patients with chronic HCV infection as evidenced by a detectable HCV viral load or an identifiable HCV genotype. In addition, national reports can exclude those patients without evidence of chronic HCV infection.
For HCV validation, we analyzed HCV antibody, recombinant immunoblot assay (RIBA), genotype and HCV viral load tests. Antibody and RIBA test results that could be categorized as negative or positive were considered informative. Viral load results that could be categorized as detectable or not detectable were considered informative. Genotype results that could be assigned to a known genotype were considered informative. CCR: HCV patients were categorized for the validation analysis based on (1) HCV infection status and (2) chronic HCV infection status. For HCV infection, patients were categorized as positive (P) if they had a positive result for an antibody or RIBA test, a detectable viral load at any time or an identifiable genotype at any time; indeterminate (I) if all the available results were not informative; untested (U) if the patient had no HCV tests; or negative (N) if the patient had only negative results for any antibody or RIBA tests or undetectable viral loads.
Among patients in the CCR: HCV and in care in the 10 years from 1998–2007, 292,205 (91.9%) have laboratory evidence of HCV infection (). Of the 25,793 patients who do not have laboratory evidence of HCV infection (laboratory status of I, N or U), only 544 had prescription evidence of HCV infection. Overall, out of the 317,998 patients in the CCR: HCV in care in the 10 years from 1998–2007, 292,749 (92.1%) have laboratory or prescription evidence of past or present HCV infection.
Among patients in the CCR: HCV and in care in the 10 years from 1998–2007, 190,608 (59.9%) have laboratory evidence of chronic HCV infection. Of the remaining 127,390 patients, only 1,434 had received VA prescriptions for HCV antiviral medication. Like HIV, patients who were tested outside the VA may receive HCV antiviral medication without laboratory confirmation in the national database. In addition, patients with laboratory status of N who receive HCV antiviral medications may have started HCV antiviral medication outside VA and achieved an undetectable HCV viral load before receiving such medication from VA. Overall, for the cohort in the CCR: HCV in care in the past 10 years, 60.4% have laboratory or prescription evidence of chronic HCV infection.
In any approach to patient addition, patients may be entered into a local registry in error for a variety of reasons. In the CCR: HIV, the change from the manual mode of the ICR to the automatic pending with manual confirmation mode of the CCR arguably would be expected to identify additional cases. Since both approaches rely on manual review for addition to the registry, the change from the ICR to the CCR would not necessarily be expected to reduce the number of uninfected patients added to the registry in error. Indeed, the rate of inclusion of uninfected patients among patients recently confirmed into the CCR: HIV is almost identical to the rate for all patients on the CCR: HIV in care in the last 10 years, some of whom were added to the CCR: HIV because of their inclusion in the ICR. In 2007, 2,860 unique patients were added to the national CCR: HIV; 93.7% of these had laboratory or medication validation of HIV infection which is comparable to the 10-year cohort rate of 94.2%. Additionally, 0.7% of those added to the national CCR in 2007 have a laboratory status of N and definitively appear to be in the registry in error, almost identical to the definitive error rate of 0.8% in the 10-year cohort.
The change from automatic addition in the HCCR to the CCR mode of automatic pending with manual confirmation would be expected to reduce the rate of inclusion of uninfected patients. We have evidence that is the case. In 2007, 25,561 unique patients were added to the national CCR: HCV, of these 78.4% had laboratory or medication evidence of chronic HCV infection, compared with 60.4% for the 10-year cohort.
As described above, one of the main goals of the CCR was to provide clinicians with local reporting capabilities to foster local assessments of patient care. The local CCR was designed with 16 reports with user-defined parameters. As part of the nightly HL7 extract, we collect the number of reports that were run in each local registry. In 2007, an average of 2,204 reports were run each month in the local CCR: HIV and 639 reports were run each month in the local CCR: HCV. From anecdotal communication with clinicians, we believe that three reports are most frequently used. Several facilities run the Current Inpatient Report every day to identify registry patients who are inpatients. Several facilities run a Patient Medication History Report for each patient seen at a clinic visit, thereby obtaining a complete antiviral medication refill history which provides objective information on a patient's medication adherence. Finally, the Combined Meds and Lab Report is run frequently by numerous facilities to answer a variety of questions about the clinical care or condition of the registry population.
Facility, VISN and national reports concerning the HIV and HCV populations have been made available on the VA intranet for individuals with access to content behind the VA firewall. Over 20 annual reports have been posted which cover demographics, pharmacological treatment rates and rates of selected comorbidities of the populations as well as several of the quality measures proposed by the National Quality Forum. 7 We plan to make national level data available on the Internet.
In the era of migration of paper medical records to various electronic solutions, practitioners are becoming accustomed to managing a broad range of conditions and issues with electronic reminders, prompts, and reports. The vast majority of these tools provide patient-centric information, perhaps used most efficiently when incorporated into a medical visit. At the same time, the desire for evidence-based medicine and rising health care costs have prompted development of population quality measures that relate to the process and costs of care and outcomes. To permit comparisons of population quality measures across facilities within a healthcare system, data must be comparable and in a standardized format amenable to aggregation. Such aggregated data provides a population view where process, cost and outcomes can be measured and compared.
We present here one solution to providing a population measurement tool that meets a variety of local and national healthcare system objectives. The combination of computer generated lists of potential cases with manual review for confirmation has proven to have both a high degree of sensitivity and specificity for identifying the target population. The local CCR has extensive capacity to run reports on a wide variety of usage and quality issues that can be customized by the end user. Local reports are being run as providers take advantage of this capacity. The national database allows data from all VA medical facilities to be aggregated to the unique patient level. Facility, VISN and national results on agreed-upon measures are available on the VA intranet to permit comparisons of local, regional and national performance. Finally, subsets of national CCR data have been provided to 25 researchers and used by CQM staff to address a range of questions in both HIV and HCV. 8–13
The CCR has proven useful in several additional ways beyond the original design objectives, particularly for rapidly addressing patient safety issues. For example, following an FDA alert about the contraindication of proton pump inhibitors and atazanavir, 14 CQM was able to quickly analyze national data to identify patients in the VA receiving the contraindicated combination and to provide individual facilities with lists of patients at their facility who might be receiving the contraindicated combination.
On a national level, the registry data provides information for other VA and non-VA entities to make informed decisions about HCV and HIV care. Aggregate data from the national CCR are used in VA cost modeling. Longitudinal data from the CCR regarding diagnoses and usage are used to anticipate increasing needs for specific types of care. Various ad hoc queries of national data are conducted to meet requests from the VA's pharmacy benefits management group, HIV and HCV advisory panels, Public Health Strategic Healthcare Group (the parent of CQM), and other regional and national advisory and policy offices in VA. Data also assists other Federal agencies including the Department of Human Health Services to which CCR: HIV data in aggregated nonidentifiable format are provided to assist in measuring met and unmet community needs.
Other healthcare organizations have provided varying components of the CCR depending on the existence and extent of the local EMR. In general, very few healthcare systems have an EMR as robust as VA's. 15 In a recent survey, only 1.5% of non-VA United States hospitals have a comprehensive EMR; including VA hospitals doubled the number of such hospitals. 16 For facilities with no or limited EMRs, available population management tools generally rely on databases separate from the EMR. 17–20 Initial case finding for such registries generally relies on ICD-9 codes from billing systems 18 or manual identification by healthcare providers. 19,20 Such systems tend to accrue data through manual data entry given the limitations of the EMR which forces data standardization. 18–20 For sites with EMR functionality that includes electronic laboratory results, applications have been designed to identify cases of reportable diseases using ICD-9 codes and laboratory results and then transmit relevant clinical, laboratory and demographic details to the local health authority. 21–23 These reportable disease are generally acute infections that require laboratory confirmation from the reporting facility and have been able to construct case identification algorithms that do not require local confirmation. These systems, however, provide no local reporting tools for health care providers and do not construct a central database with complete medical information on the identified cases. Intermountain Healthcare (IHC) is one of the few healthcare systems with a comprehensive EMR system comparable to VA's. 24 The IHC has created a centralized patient database, known as the central data repository to make a patient's entire IHC medical record available to clinicians at the point of care. 25 Population based reports can be generated from the inclusive central data repository. The IHC did not allow for the local data dictionary flexibility which has slowed VA efforts to construct a similar central data repository.
In our experience, the combination of computer generated lists of potential cases with manual confirmation has proven to be an excellent way to generate comprehensive yet accurate registry lists. Manual confirmation is particularly necessary for any registry lists created through use of diagnosis codes because of errors in diagnosis coding. However, manual confirmation requires local staff trained to perform the review. Given the inevitable turnover in local staff, on-going training is necessary; we provide monthly support calls, web-based trainings and frequently personal assistance via telephone or e-mail. In addition, CQM monitors the number of pending patients; if a list of pending patients at a facility becomes quite large CQM can assist local personnel with the review of pending patients. Transmission of additional information about the pending patients to the national database would be useful to provide oversight of pending patient processing and may be added in future enhancements. Similarly, transmission of additional information about which local reports were run—not just the total number of reports—would be useful to guide future report development.
Since the CCR software rests on an ever-changing local EMR, the software requires continual updates and maintenance. The CCR extracts data from a variety of clinical packages and any change in those packages potentially impacts the CCR data extraction. Thus, critical data elements have to be monitored repeatedly for missing data. Fortunately, the CCR is now generally recognized within VA as a user of data from multiple clinical packages. As such, CQM staff work with the developers of many of the VistA packages to proactively adapt CCR data extraction in anticipation of VistA package changes. In addition, as new laboratory tests and diagnosis codes relevant to the target conditions are developed, the software must be updated to add new LOINC codes and new diagnosis codes to the search for pending patients.
The CCR provides a major extension to the patient-centric EMR to enable both local and national views of patient populations. Local clinicians can use these tools to manage their local populations. National data can be used to target quality and safety issues at the local level and inform local providers. The CCR provides an extensible platform for a range of registries beyond the current HIV and HCV registries. The software could easily accommodate the creation of registries for any clinical conditions that can be identified through electronically available and well-defined data elements.
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.


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|Reviews for b:Em
| Guest chapter 1 . 3/4/2012
| just for the future chapter 1 . 12/30/2010
i think next time you do a rape story, mention in the summary that it's raped. you never know who might come upon it and the past they might have. warnings would be nice...
| Chloe Reilly chapter 1 . 10/31/2010
So basically is this rape?:L
| Oriane88 chapter 1 . 9/26/2010
Ermm the sex was a bit weird...
& I believe if you're as scared as she i supposed to be, you don't get off like she does!
Not much structure, links are a bit weak, but you can always make it better, as A pairing B/Em is always worth it! :)
Hope you don't take it the wrong way! :s
| genisus chapter 1 . 9/3/2010
I was waiting for Edward to come in and kick his ass lol good story
| rubell chapter 1 . 7/8/2010
i like the blood play as well, and the fact that he didnt change her...
| Hanna Kallin chapter 1 . 5/9/2010
| ReadingIsSexy15 chapter 1 . 2/13/2010
| invisible-to-all chapter 1 . 2/1/2010
that wa like rape
| Tarkonta chapter 1 . 8/19/2009
this isnt smut...smut is forplay Lemon is sex Lime is hardcore. nice story. 1 question wouldnt Emmett's tongue have Venom thus putting it into Bella's bloodstream when he licked the wounds?
| Danielique chapter 1 . 7/15/2009
Oh, it was .. really good. I hope it was a dream :D I hate Bella with Emmett together. :D:D But pretty good.
| brit chapter 1 . 7/10/2009
that was really good u should have finished tho it wouldve been even better finishd
| K.K. Fush chapter 1 . 6/17/2009
Never thought Em would be the rapist sort
| lovethemall chapter 1 . 6/15/2009
this is really good can you do more like this?
| emmettismymonkeyman chapter 1 . 6/10/2009
was it all a dream? or did that actually happen to bella, and why is it a rape-turned-pure lust story?

subset: commoncrawl


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Clear Voice, Full Heart
In La Traviata, Arizona Opera's latest offering, it's hard to believe that Alfredo Germont, the young nobleman in Giuseppe Verdi's 1853 opera, didn't inspire the sad-sackery in Young MC's "Bust-A-Move." The dude's heart gets dragged around like a rag doll.
That's not to say that Violetta Valéry, the central figure of La Traviata, isn't put through the wringer. We open on a lavish party at Violetta's pad, where eventually Alfredo declares his initially rebuffed love for the lady. Alas, she's engaged to another and prone to illness. Conductor Steven White and stage director John Hoomes helm this rollercoaster of a classic opera with Ambur Braid and Patrick O'Halloran and Caitlin Lynch and Adriano Graziani taking turns playing the lead roles.
Arizona Opera presents La Traviata at Phoenix Symphony Hall through Sunday, March 2. Friday, February 28's curtain is 7:30 p.m., and tickets range from $25 to $135. For more information, visit www.azopera.org or call 602-266-7464.
Fri., Feb. 28, 7:30 p.m.; Sat., March 1, 7:30 p.m.; Sun., March 2, 2 p.m., 2014
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Alchemy of Animation Book - Making an Animated Film in the Modern Age
Animation exploration
Explore the role of the directors, story artists, songwriters, and animators - with a special focus on the digital techniques - in this step-by-step introduction to animated filmmaking. See more
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Magic in the details...
- By Don Hahn
- 144 pages
- Paperback
- Ages 8 and older
The bare necessities
- Hyperion
- Paper
- 11'' H x 8 1/4'' W x x 1/2'' D
- Printed in U.S.A.
Express shipping not available for this item. This item cannot be shipped internationally or outside the contiguous United States. It can only be shipped to a physical address, not to a P.O. Box, APO or FPO address. Please allow 2-3 weeks for delivery.


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Now Closed: Taberna Mexicana
Uh-oh. Looks like summer is starting to take its toll.
The Houston-based restaurant group Legacy's Taberna Mexicana closed its doors last week with a sign on the door stating that it's the economy's fault.
Pesky economy, that guy is always shutting things down.
The Modern Mexican food joint was open for a mere eight months. Its sister restaurant Ninfa's in Glendale closed its doors in April, after its own eight months. To blame: the economy.
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Need Allergy Testing in Hunting Valley, OH? Simply order online 24/7 and get fast, affordable Allergy Testing at a lab near you (Find More Locations):
33790 Bainbridge RdP: (440) 542-9869
Solon OH 44139
M-F, 8:00am - 4:00pm
Why would I get Allergy Testing?
Allergy Testing measures antibodies related to allergy in the blood. People in Hunting Valley, OH order Allergy Testing for general screening or to guide therapy.
How much does Allergy Testing cost?
Our Allergy Testing prices include the doctor's order that you need to get tested in Hunting Valley, OH, all lab fees and taxes, and a pdf copy of your results. For current prices, please CLICK HERE.
We are pleased to offer Allergy Testing in Hunting Valley, OH.


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Residence Inn By Marriott Cortland properties are listed below. Search for cheap and discount Residence Inn By Marriott hotel rates in Cortland, NY for your business gathering or personal travels. We list the best Residence Inn By Marriott Cortland hotels/lodging so you can review the Cortland Residence Inn By Marriott hotel list below to find the perfect place.
This website will also list discounted Cortland, NY hotels + motels that have similar star quality of Residence Inn By Marriott.Need a weekly rate? Get long term quotes from hotels in Cortland NY
How should we direct your call?
With a stay at Residence Inn Syracuse Downtown At Armory Square, you'll be centrally located in Syracuse, steps from Museum of Science and Technology and Armory Square.


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ED Magedson – Founder
Ripoff Report
evaluatelifeinsurance.org8 Tahanto St Internet United States of America
Does your business have a bad reputation?
Fix it the right way.
Corporate Advocacy Program™
This report was posted on Ripoff Report on 12/03/2012 09:23 AM and is a permanent record located here: http://www.ripoffreport.com/reports/evaluatelifeinsuranceorg/internet/evaluatelifeinsuranceorg-james-h-hunt-the-website-indicates-that-he-gives-third-party-ad-977195. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.
Ripoff Report has an exclusive license to this report. It may not be copied without the written permission of Ripoff Report. READ: Foreign websites steal our content
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#1 Consumer Comment
Expert Advice
SUBMITTED: Tuesday, March 17, 2015POSTED: Tuesday, March 17, 2015
Created a ripoffreport account for the sole purpose of responding to the ridiculousness of the claims below. James Hunt is the CLEAR expert in the field of life insurance and has deep experience spanning over 40 years. James provides his services at SIGNIFICANT discounts to what comparable advisors would charge simply becuase he loves what he does.
I have used James's services and have been thoroughly impressed with the level of detail in his analysis. I work in the field of finance and was overwhelmed with the options as it related to "rescuing" policies that had been accumulated in my fathers estate. Typical advisors did not even understand the tax implications of their recommendation (e.g. deemed "boot" vis a vis the loan balance on a 1035 exchange). James was the only one who truly understand all of the options available. Not once did he "pitch" me on new product.
Google James Hunt insurance and read all of the literature he has published on the topic and then try and find someone more knowledgeable than him.
Are you an owner, employee or ex-employee with either negative or positive information about the company or individual, or can you provide "insider information" on this company?
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*Best Before Date: June 2017*
The Aduna Cacao Raw Energy Bar is the perfect healthy snack for chocaholics.
Made from cold-pressed fruit & nuts, each energy-boosting snack bar is packed with antioxidant-rich cacao powder, a full teaspoon of crunchy cacao nibs, mineral-rich walnuts and tangy hibiscus. Delicious and nutritious, each bar is a source of fibre, supporting digestive health and helping you feel fuller for longer.
Add a single bar to your basket or why not treat yourself to a box of 16 bars. Snack time sorted!
Ingredients: Dates, Almonds, Walnuts (11%), Cacao Nibs (7%), Cacao Powder (6%), Water, Hibiscus (1%)
All UK orders over £20 are shipped free of charge. For orders under £20 there will be a standard delivery fee of £2.50. We also offer First Class & Second Class Signed delivery options.
International orders over £50 are eligible for free International Standard Delivery. All other orders will be sent out via a Non-Tracked or Tracked delivery service. Costs will vary depending on the country.
If you need your parcel to arrive by a certain date or would like it to be sent by an alternative service, please call us on 020 7100 4329.
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If for any reason you are unhappy with your purchase and would like to exchange the product or receive a refund, please email us at email@example.com stating the reason for return.
Please note that to qualify for an exchange or refund it is important that all goods must be unopened and in their original packaging with all seals intact.
To exchange or refund your order, we must be notified within fourteen days of you receiving your products.
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Music is a direct reflection of our individual style and personality. Endeavor has always used music as a muse and a source of inspiration. This limited edition collection of snowboards celebrates one of our generations most iconic musicians in collaboration with New York photographer Jesse Frohman.
Kurt Cobain formed Nirvana alongside of Krist Novoselic in 1987. He was the band's songwriter, vocalist and guitarist. Following the release of 'Smells Like Teen Spirit' from the 'Nevermind' album in 1991, Nirvana became over night rock stars.
'Nevermind' brought alternative rock into mainstream. It is representative of a generation and its culture. Through this record, Cobain became the spokesperson of Generation X. He captures feelings and emotions through his lyrics; and presents them through his poetically ferocious rasp.
Kurt Cobain died at the age of 27—a death that music fans still contemplate 20 years later. The photograph pictured captures Cobain's provocative side that is representative of himself, Nirvana and Generation X.
Jesse Frohman's insightful portraiture transcends the nature of celebrity photography. Shot in New York City, this photoshoot was the last time Nirvana was photographed together.


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The Rossoneri president's son stated that he is a big fan of the English striker, while praising the club's decision to keep Thiago Silva and Zlatan Ibrahimovic at San Siro
The Rossoneri are currently in the process of revamping their squad, having parted company with veterans Gennaro Gattuso, Clarence Seedorf, Filippo Inzaghi, Alessandro Nesta, Gianluca Zambrotta and Mark van Bommel so far this summer.
And Pier Silvio Berlusconi shared his excitement over Milan's new project before revealing the names of some players he would like to see at San Siro.
"This is a new Milan, a younger Milan, and it is only right to start a new project every few years," he told Corriere dello Sport.
"Who I would like to see at Milan? Andres Iniesta, obviously. I was also impressed with the physicality of England striker Andy Carroll."
Berlusconi Jr then hailed Milan's signing of Riccardo Montolivo and the club's decision to retain the services of star duo Thiago Silva and Zlatan Ibrahimovic.
"I really like Montolivo, he is a player with a great personality," he added. "Thiago Silva? Keeping him at this point shows an incredible passion for football.
"Ibrahimovic? Champions, like artists, must be accepted for who they are. He is still a great player."


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Mark Twain once said, "Clothes make the man. Naked people have little or no influence in society" and when it comes to the potent power of apparel, the men on our list have enjoyed mighty and stylish reigns as all-round fashion kings. From 50s movie stars to 21st century supermodels, we take a look at some of the century's best-dressed gents and pay homage to their supreme style.
Steve McQueen
Topping every style icon list, it may be predictable to include Steve McQueen in this line-up, but to leave him out would be nonsensical and frankly blasphemous. The anti-hero of American film has become immortalised as one of the big screen's best-dressed stars thanks to his rugged and masculine style. A keen motorbike racer, McQueen was at his best in a sports jacket, a classic white t-shirt and denims, paired with aviator shades, but effortlessly made the transition into a slim-fit tailored suit when the occasion called for it. For "The King of Cool", style was all about purpose, masculinity and the right amount of nonchalance.
David Gandy
Unquestionably, David Gandy is the world's most influential male model and most likely, he is the best-dressed of the sculpted bunch. Far be it for me to dish out the imperatives, but dare I say; this is how a man should dress! Gandy's style is utterly timeless. With the cursive masculinity of the old Hollywood greats, combined with his own modern attention to detail, David Gandy is an all-encompassing style aficionado, who couldn't put a foot wrong if he tried.
Nick Wooster
Nick Wooster is an internet sensation and probably one of the first original street-style icons. The Fashion Advisor for Gilt and Park & Bond favours brands with a heritage or lineage and the idea of the uniform is central to Wooster's look. For this style king, his Zippo lighter is just as important as a tailored jacket and as the 'bad ass' of men's fashion, Nick Wooster is an undisputed 21st century style icon. He combines classic tailoring with militarism and that impressive moustache to create a distinctly personal and innovative look.
Tom Ford
Tom Ford is one of those annoyingly talented guys. Not only did he save Gucci from bankruptcy, serve as the Creative Director of Yves Saint Laurent, and create a successful eponymous clothing line, but he also directed the stunningly-beautiful, Oscar-nominated movie, A Single Man. Oh and along the way, he cemented his own status as a style icon. Tom has said that he favours classic simplicity and when it comes to his beloved suit, he always wears one that gives him broad shoulders, a fitted waist and long legs. A sartorial success if ever there was one.
James Dean
Striving for originality, just like with Steve McQueen, I tried my best to ignore James Dean, but let's face it, when something's good, it's good and there's no denying or ignoring it. And James Dean, in all is rebellious goodness is certainly an unavoidable tour-de-force. The impossibly handsome star achieved fame in his short lifetime, but it was only posthumously that Dean was fully recognised as a style sage. The original Rebel Without a Cause epitomised effortless dressing – shedding any superfluous items and keeping his aesthetic minimalist, original and impossibly cool.


text: IDH-mutant glioma specific association of rs55705857 located at 8q24.21 involves MYC deregulationYavuz Oktay, Ege Ülgen, +22 authors Koray ÖzdumanScientific reports2016The single nucleotide polymorphism rs55705857, located in a non-coding but evolutionarily conserved region at 8q24.21, is strongly associated with IDH-mutant glioma development and was suggested to be a causal variant. However, the molecular mechanism underlying this association has remained unknown. With a case control study in 285 gliomas, 316 healthy… (More)


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Based in Cranleigh, Surrey we provide IT and computer support services to small and medium sized businesses and home users across Surrey, Sussex and Hampshire.
OrbitTech is a Surrey based company serving the south east of England. We provide computer and network support for Business, Education and Home Users. Our engineers are Microsoft certified & have DBS police clearance
Computer, Networking, Aerial, Satellite, Alarm, CCTV, Sound & Vision Specialists! Open from 8am-8pm 7 Days a week! FREE Estimates & Advice call today: 0800 043 0479
Surrey ITSM offer many services, from Virus removal to full network installs. We are fully insured and have all the tools we need to complete any job that is required of us.
Micro Pro Ltd provides professional computer, network, IT support and solutions for Businesses and Residential clients. We offer everything from Fully Managed IT support to Perfect Wireless Networks and much more.
We offer IT support, consultancy and web-design for business, education and home customers.
Based in Epsom, Surrey
Camberley based IT company providing Computer repair, Laptop repair, PC repair & IT support for Home & Business customers alike. We are a team of 2 engineers with combined experience in excess of 30 years
GFC Technology specialises in providing unrivalled Computer and Information Technology (I.T.) services for variety of businesses and home users across Surrey and the south east.
A family owned business with two branches (Surbiton in Surrey and a new branch in Chelsea, London) We been established for over 15 years with a marvellous team of engineers who can solve about any problems
A family run business, operating 12 years in this area, offering a professional computer repair service at affordable prices with a reputation for fast response times.
Fusionsoft is a UK eCommerce, Web Design and Social Media Marketing company. We also provide domain names, hosting and web maintenance. Click our name in Blue above to see our full profile and view our customer feedback.
Tailor made Website designs and e-marketing services for insurance brokers, financial advisers and other professional firms to deliver eye-catching designs, striking content and first page Google rankings
Aranea Creations is based in the Broadwater area of Worthing, West Sussex and was setup in 2007 to provide customers with cost effective computer repairs, upgrades and support.
Mays Web Design is a friendly, professional team based in the UK working together to create professional, stylish bespoke and functional websites from scratch for small and large businesses.
Doctor Tech offer a full spectrum of services, ranging from PC and laptop sales and repairs, Apple iDevice repairs, home cinema design and installation, CCTV, business & home support and have a highly rated service level
Tri-Synergy, is a full service digital marketing agency in Hampshire. Our expertise covers marketing strategy, digital, technical and creative skills to build sales for your business with a results-driven approach.
Geeks on Wheels - We Fix Computers.Geeks on Wheels was founded in 2004. Our team of qualified trustworthy engineers provide computer support to business and domestic users. We can visit you at your home or business...
ComputerKo is an online Computer repair, retail and IT services vendor that supports home and Business Customers in East London. We do not charge a Call out fee.Call 02082815037 or 07833291373 or email email@example.com
Our family-run business has a reputation of excellent and reliable service, which we have proudly developed to a large expanse of East Sussex and Kent.
Marketing 4 Tradesmen are based in Maidstone and specialise in website design for Tradesmen. We offer a personal friendly service to our clients and will happily come to visit you to go through your website requirements.


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Providing and enhancing leadership capacity and resources that promote the activities of women of color advocates and activists to address the elimination of violence against women and families.
1. We examine within a global context various forms of oppression such as capitalism, racism, sexism, heterosexism and ways they intersect with violence.
2. We welcome all women of Asian/Pacific Islander, Arab/Middle-Eastern, Black/African, Native/Indigenous, and Hispanic/Latin descent to join this cause.
3. We also welcome aspiring allies who are addressing their 'isms on a daily basis as supporters of this cause.
Women of Color Network is a project of the National Resource Center on Domestic Violence and Pennsylvania Coalition Against Domestic Violence.


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We all have our pointless obsessions. Perhaps yours is crochet, heroin or caring about the environment. But let's say it's knitting. You may have a couple of friends who knit, with whom you discuss the subject once in a while. And there's probably a magazine which keeps you up to speed on the comings and goings of the knitting world on a bi-monthly basis. Is this enough to fulfil your incessant hunger for all things knitting-related? Unlikely. But suppose there was a TV channel devoted to knitting, that broadcasted live news, analysis, opinion, statistics and footage surrounding the subject round the clock, seven days a week. Sounds brilliant, right? Well, it is. I know because my pointless obsession really is serviced by such a channel. It's called Sky Sports News and it's the televisual methadone which feeds Britain's rampant epidemic of football news addiction.
Is there enough genuine football related news to fill such a schedule? Not really. Does that matter to the channel's hordes of devoted viewers? Not in the least. When it was launched in 1999, naysayers said such a one-dimensional station couldn't work but the audience has grown by 256% over the past six years. It started as a guilty pleasure for a few football addicts, became cult viewing and is now a full-blown televisual phenomenon. In pubs across Britain, SSN blares incessantly from the TV set while fans debate the latest breaking news stories and engage in furious debates on the relative attractiveness of its female presenters. Beyond the pub, those hooked on its mixture of rigorous high-tech reporting and strangely compelling non-stories include Ant and Dec, Robbie Williams and Alastair Campbell.
The evil genius who conceived of Sky Sports News wanted it to be the first station you could watch with the sound down. When you flick to channel 408 on your Sky remote you're confronted by an avalanche of information. The presenter sits in a box surrounded by graphical news updates, fixture lists, league tables and scoring charts. It's very popular in gyms where people pound the treadmill while simultaneously watching SSN and listening to high-energy disco music on their iPods. Then they leave with a sense of endorphin-fuelled euphoria, increased cardiovascular capacity and an in-depth knowledge of the Bundesliga title race.
Watch it with the sound up and you'll invariably be the first to hear breaking news from the football world. When there's a big story SSN covers it faster and better than any other source. But, on an average day, there's usually only one or two big stories. Space in between is filled with essentially trivial stuff covered with all the drama of a major global conflict. With its galloping soundtrack and melodramatic headlines, SNN always manages to make you feel as if you're watching history unfold. More often than not, you're just witnessing a report about Stockport County's groundsman.
"Coming up," an earnest-faced presenter bellows to the strains of Wagner-esque violins and thundering drum rolls on a Wednesday afternoon. "Breaking news from St James' Park, where Laurent Robert has said he would consider a new contract offer from Newcastle!" This is followed by a three-minute story on a psychologist from Wolverhampton University who says he can strengthen the mental durability of top-flight referees. Then there's a report about the spending habits of Premiership fans, in which we learn that Bolton supporters spend more money on caravans than any of their rivals. In a priceless piece of contrived scripting, a preview of Hartlepool's cup tie with Boston United runs out of relevant footage and suddenly cuts to some random shots of a quayside, the voiceover concluding: "Hartlepool will be hoping to sail past Boston into the next round!"
At potentially cringeworthy moments such as this, SSN's credibility is salvaged by its hosts, perhaps the most talented presenting team on British TV. These are the people who manage to lend an air of importance and integrity to a show sometimes consisting of non-stories, lame puns and constant repetition. They also find time to throw in enough cheeky ad libs and knockabout banter for you to feel a certain warmth towards them. It's consummate newscasting. Husky-voiced Georgie Thompson, sultry Kelly (daughter of Kenny) Dalglish, excitable Dave Clarke and man-mountain Mike Wedderburn: watch it for long enough and they soon feel like family. You find yourself speculating wildly about their off-screen relationships. Does Dave Jones realise that Georgie is just leading him on? Is that a lonely yearning I detect behind Kelly's gorgeous eyes? These considerations are almost as fascinating as the news itself. In his biography, Robbie Williams credits these humble broadcasters with getting him through depression: "The people that read the news on that, I loved them," he says. "They nursed me through the bad time. That was my family for a while."
Occasionally, amid the long day of slow-moving news, the presenters find themselves with something genuinely exciting on their hands. I recently saw Dave Clarke gleefully announce that he had Alastair Campbell on a live video linkup from Westminster to talk about his team Burnley's defeat of Liverpool in the FA Cup. Clarkey was beside himself. After a few minutes discussing the game, he began to stretch the interview out for as long as possible (what else were they going to do? Go back to the Hartlepool v Boston report?) and eventually resorted to guffawing non-sequiturs: "It's great football, isn't it?" he mused to Campbell. "Even if you're at the sharp end of politics you can go to the ground, have a bit of banter, have a cup of beef tea and forget about everything." The ex-spin doctor nodded a baffled smile of agreement down the line.
"Yes, it [the interview] did seem to go on for quite a while, didn't it?" Campbell says when I speak to him about SSN later that day. "I suppose they don't have much else to fill time with on an average day. But personally I like the repetition. It means that if there's something you want to know about you can tune in for just 10 minutes and it will eventually come up. After going to the Burnley Liverpool game I got back to London at about three in the morning and put it straight on. I knew they'd be repeating the goals even at that time of night."
Campbell says he uses the channel sparingly (averaging 10 minutes a day) and is disapproving of my obsessive viewing habits: "It sounds to me as if you lead a very sad life," he says, with some justification. I use SNN to fill a gaping void in my existence, Alastair uses it on a strictly utilitarian basis and Robbie uses it to stop him going bananas. Hundreds of thousands of others have their own reasons. Sky Sports News is a broad church with many different functions. Even if you're not interested in football it's better than watching the proper news. For a start it doesn't contain anything that can be counted as genuinely saddening. Unless you're a Leeds supporter.


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"The idea came about when I realised that all the products that my girlfriend - now wife - used were natural, with no nasty chemicals, but when I went to find some for myself, there was nothing on the shelves," explains Duffy, who is 35 and from Queen's Park. "When I asked a shop assistant, she told me to use women's skincare products instead. I was shocked. And since I'd always wanted to start my own business, I thought this could be the gap in the market I needed."
At the time, Duffy was working on product development for corporates such as Starbucks and Samsung. But he soon arranged to meet his friend Rhodri Ferrier, then an investment banker at UBS, to talk about his business idea. "I thought he was very shrewd and would be great to have on board - but he told me my idea was stupid. So I bought him a few more beers. He was soon convinced," laughs Duffy. "By the end of the evening, we'd agreed to become business partners."
The pair had no experience of the beauty industry, but spent all of their evenings and weekends researching natural ingredients, writing a business plan, and talking to retailers. "Then Rhodri grew more frustrated with investment banking, and quit his job," says Duffy. "Two weeks later, I joined him. Then we had to get serious."
The next six months involved juggling product development - "finding the best alternatives to chemicals like parabens, working with an aromatherapist, making 40 iterations of various products until we liked them, and finding a UK factory" - and fundraising. "We combined our life savings and maxed out our credit cards to scrape together £37,000," says Duffy. "But when we started speaking to experts in skincare, safety, warehousing and getting interest from large retailers like Sainsbury's, we realised we were going to need more money."
Fundraising was difficult. "We exhausted a list of about 90 people we knew pretty quickly, then started cold-calling angel investors. We had more than 80 meetings, and eventually secured 18 shareholders, who together put in £1.2 million. Some are friends, others passionately believe in the business idea of natural skincare for men."
With money in the bank and unctions ready for the production line, Duffy and Ferrier succeeded in winning over big buyers - but their business almost went down the tubes early on. "Sainsbury's asked us to formally submit our products for review," says Duffy. "So we needed to create packaging mock-ups. We spent days creating the artwork and hand-applying it to tubes at a workshop in East End, and were bringing them back to Rhodri's flat - our old headquarters - in Notting Hill. But when we got to his front door, we realised he'd left the bag on the Tube."
Happily for Bulldog, "some kind soul handed it in to lost property," reports Duffy. "But it was incredibly stressful at the time - we knew there was no way we could create a new set in time for Sainsbury's deadlines."
As it was, Bulldog's moisturisers, gels and aftershave balm began to be stocked in Sainsbury's in July 2007. The duo moved into "a proper office" in Ladbroke Grove, and first-year turnover hit £500,000. Nowadays, Sainsbury's alone sells £1 million Bulldog products a year. Other stockists of the £5.99 moisturiser and other bathroom creams include Tesco, Waitrose, Boots, Ocado, Planet Organic and Whole Foods.
Bulldog had to make itself known imaginatively. "We compete with multinationals who spend tens of millions of pounds on marketing. But they all use very similar formulations, market their products in the same way and really just repackage traditionally-female products for men. Bulldog competes by being different, with stand-out black and blue packaging and viral marketing." A online ad campaign using comedian David Mitchell scored 12 million views.
Distribution has grown every year: Bulldog in now on the shelves of 2000 stores in the UK, and another 5000 overseas. It secured an export deal to Sweden last February, and is now in Germany, the US, Sweden, Norway and Finland.
Duffy has more international appetite and big plans to crack the US. But he's glad that Bulldog is based in London. "The capital has access to all the best people and companies to collaborate with, and it's so accessible to get around," he says. "It's an amazing place to be an entrepreneur."
Bulldog Natural Skincare
Founded: 2006
Staff: 5
Turnover: More than quadrupled from £500,000 at start-up to around £3 million this year.
Business idol: Ole Kirk Christiansen, the inventor of Lego. "He first inspired me to be creative."
- More about:
- P Funk


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The official Arsenal Supporters Club in Kuwait.
The Arsenal Kuwait Supporters Club founded in 2013.
The group meets at Al Qadsiya Youth Sports Centre for live screenings where there are two screen, free snacks, coffee and tea.
We encourage parents to bring their children to build a new generation of Arsenal supporters. We arrange sport and social activites for our members.
For more information, contact Tariq Hilal at email@example.com or visit our Twitter pageCopyright 2017 The Arsenal Football Club plc. Permission to use quotations from this article is granted subject to appropriate credit being given to www.arsenal.com as the source


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HAVERGAL COLLEGE Toronto Havergal College has been preparing young women to make a difference since 1894. Founded on Anglican values and traditions, the school community gathers with the Chaplain for Morning Prayers three times weekly. A special high light is our traditional Carol Service held at St. Paul's Anglican Church, the school's original parish. Today Havergal girls develop into extraordinary young women with inquiring minds, global capability and self-awareness. They are encouraged to investigate and explore the world around them while discovering their own unique capabilities. As Old Girls, they will join our proud continuum of 8,000 alumnae who are networked to each other and the world. To learn more about the Havergal difference, visit www.havergal.on.ca or contact the Admission Office at (416) 482.4724 or email@example.com.
TRINITY COLLEGE SCHOOL, Port Hope Established in 1865, TCS is one of Canada's oldest and most respected educational institutions. The School places a balanced emphasis on academics, service learning, athletics and the arts--as both a long-held TCS tradition and a rethought, reinvigorated approach to 21st century education. TCS, a caring and supportive educational community, exists to prepare young men and womnen to thrive in university and beyond. This community values developing habits of the heart and mind and continues the tradition of beginning each day with a chapel service before heading off to classes. Our supportive and close-knit community of students, parents, alumni, staff and friends make the School on the Hill a truly special place. To set up a visit or obtain more information, please contact the Admissions Office at (905) 885-3209 or Email: firstname.lastname@example.com Website: www.tcs.on.ca
THE CENTRE FOR CHRISTIAN STUDIE is a national theological school of the Anglican and United Churches offering community based education. CCS offers two-week Leadership Development Modules. and year-long certificate programs in Pastoral Care. Education and Social Justice Ministry, preparing people for lay, diaconal and related ministries. CCS is committed to a theology of justice and to contextual education. Students at CCS learn through integration of experience and academics, intentional community building and personal growth and transformation. For more information about the Centre for Christfan Studies please visit our website at www.ccsonline.ca or call us at (204) 783-4490.
ATLANTIC SCHOOL OF THEOLOGY, an ecumenical...


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Days Inn & Suites Pocahontas
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- Suites
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- Fitness/Health center
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Eastern Arkansas...is flat
... and is quite pretty. There's a hiking trail of about a mile, but it was partly flooded and very mosquito-y, plus it was 90 degrees out, with rank humidity, so I turned around after a few minutes.
Back at the hotel, I enjoyed a little drinkie in the lounge (ducks had already returned home), where there was live piano music (mostly playing showtunes). It was pleasant.
Where I came from
... to be careful, and the trout below the fish hatchery are abundant. Hunting is also good--deer in the fall and turkey in the spring--whichever you prefer you are liable to get your fill.
Probably the most exciting news in the last few years is the legalization of alcohol sales in the county. Big, big news for an area predominantly stuck in the prohibition era. After having lived in Europe for ...
I Can't Find A Tuk Tuk
... other travelers and their assessment of the travel experience.
Seeing other parts of the world and meeting the people allows you to see the "real" world as it is, and not just the way your local news and politicians want to portray it.
The people I met everywhere were basically just like Americans. They want to work and raise their families in peace and have a good life. It's the governments there, just like in the U.S., that determines both their quality ...
Back to the States Reflection
After three weeks of travel, I am home for two weeks. The first leg of the trip is complete. Not wanting to be cliche or over enthusiastic, but this trip has been life changing, in more than one way. One of the biggest things that I learned is the complexity of this small-big world. While that sounds contradictory, I mean it. The industry is not yet too big, thus it seems like everyone is connected in one way or another. We live in a ...
The day before take off...
I could not be more excited to take off tomorrow morning for Dubai, UAE. It is hard to think that around two months ago, I was interviewing for one of the spots to be in the Management Associate Program at BCD Travel. The weeks have gone by incredibly fast. Just a week ago, I was getting ready for my college graduation... and now I am headed for the most incredible adventure that I have ever been on.
Getting ready over the past 2 weeks has ...


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Motel 6 Lakeland
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Walkin' in Memphis
... brought music to all.
Additional galleries look at the history of Sun Records founded by Sam Phillips. This label recorded such musical greats as B.B. King, Roy Orbison, and Elvis, among countless others. Others focus on the development of soul music through Stax, HI, and Satellite Records which recruited artists from the black community. The Memphis music scene was marked by a time of collaboration in times that were filled with ...
Day Seven Monday 1st September 2014 Memphis
... we rocked up to Union avenue and to a tiny museum/recording studio Sun records in which a young Elvis Presley walked through the studio doors requested the receptionist Marion to record a song for his mum for her birthday many moons ago the rest is what they say history. As you walked into the studio a sudden throwback to the 1950s greets you in the shape of a diner style area, a wurlzer juke box and a bar that sells milkshakes and smoothies donned with candy and snacks ...
One for the money...
... to enjoy one more live music venue before bed. However, we did not expect to run into the entire biking contingent of Tennessee. Apparently, on a Wednesday night, Beale Street plays host to Biker night. Here hundreds of bikers were converged on either side of the street, their engines roaring and spluttering as they waited to roar off into the darkness. The neon lights were reflecting off the bright paintwork of the bikes and music was blaring from the ...
Elvis and Civil Rights
... fountains inside. They had set up most of the exhibits in a building on the property. You could see how a few decades ago it would have been such a peaceful area. Rolling grounds, trees, horses still on the property. Now there is a main highway in front and neighbours' backyards bordering.
We had a platinum pass so we could see a few other smaller exhibits and see his planes. We boarded the larger plane, the 'Lisa Marie'. You can see ...
Saturday, October 5
We were up at 7:00AM. This is the first morning we were able to get the stove out, heat up some water and have coffee and hot chocolate...AND drink it with a morning camp fire. It was nice. We left camp at about 8:30AM. It was sunny and 66 degrees. We breakfasted at Subway. It was another morning of going North, South , East and West before we got our bearings and found our way to ...


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Do you think they had Christmas in Rapture?
Hello my friends so glad you could join me, anyway do you think they had Christmas in Rapture
Now this is a question I've had in my head ever since the very first snow flake I saw touch the ground.
So what do you think did they have Christmas in Rapture?


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Date of Stay: May, 2016
The park staff who check us in was friendly. We were unable to get satellite signal due to the trees. The over the air stations were limited and had significant interference on some of the channels. A decent stop for a night or two, but for a very basic park, the price was a bit high. Space was reasonably level and large.
Date of Stay: September, 2015
Staff was friendly and the check in was quick. The space was long and level concrete. The problem is the spaces are fairly narrow, 11 ft, and there is no curving of the entry and exit points to allow for the turning radius of a 5th wheel making it difficult to avoid going on to the soft grass. The pad was surrounded by grass that did not drain well and with the heavy summer rains it was a bit of a quagmire. The patio extension was basically standing water. Heavy summer rains are normal so the owner's should have taken this into consideration and created better drainage for the sites. They do have a separate water source at the sites to wash your RV or vehicle, which is nice. The park is convenient to the freeway but far enough so it was quiet.
Date of Stay: September, 2015
Check in was quick, staff was friendly was escorted us to our site. Sites were we were was a grass field. Spaces were very large and fairly level. WIFI worked well and getting our sattelite signal was easy. Overall a good place for an overnight stay.
Date of Stay: September, 2015
Check in was fast and the staff was friendly and helpful. We escorted to our site which was very long and reasonably level. There was a small amount of freeway noise. Site and interior roads are gravel with many mature tree providing shade. Price was the biggest negative, but your paying for proximity to Richmond and other attractions.
Date of Stay: August, 2015
Person who checked me in was friendly. Spaces are fairly well separated from your neighbors, but the actual pad is relatively small. You won't be able to remain hooked up if your total length is over 45 ft. There is no addition parking. The price obviously reflects being in Amish country and is still high in my opinion. The price reflects a $3 surcharge for 50 amp service. WIFI was pretty good.
Date of Stay: August, 2015
Rate is for weekly rate, electricity was extra. The site we had was one of four towards the front was deep and fairly level, a little off side-to-side. The hookups were good, and the cable had a good selection of channels. If you have satellite you'll need one of these front sites due to the trees, our site was open, but those towards the back are heavily forested. The owner is very friendly and very easy going. Plenty of area to walk a dog. The pool was older, but decent. Half of the pool was very shallow, 2ft, which was great for young kids. They have two play areas with swings and other features which were nice. We stayed here to visit our daughter's family who live near Philadelphia, and this was the closest and nicest place we could find for this rate. We would definitely stay here again.
Date of Stay: October, 2014
The only two negatives with our site was that the sewer hookup was set at the back of the site, which required us to park as far back as possible to get close enough to hookup and to have a downward flow. Unfortunately, this put us very close to our neighbor's fire pit. If someone was inclined to have a large fire it could cause damage to the back of our rig. Other than that the park is great, friendly staff, and well worth the price. Wi-Fi was excellent.
Date of Stay: October, 2014
Friendly staff, as is usual with most KOAs, and as with most KOAs the price is high. The spaces were very long with sufficient space for any size rig. This sites are cement with a small area with a picnic table on it. There is a hedge that divides the spaces, which is nice to define the spots, but they make it difficult to access some of the hookups. Wi-Fi was good and cable channels were extensive, but we use satellite. For dinner we tried the Main Street BBQ and were very happy with the portions and the quality of the food. The biggest drawback was the price as we've stayed at comparable parks with significantly lower prices, otherwise I'd rate this park as a 10.
Date of Stay: April, 2012
Check in was fast and friendly. Site was gravel, as is most of the park. At little grass towards the front for walking the dog. Cable was excellent and the Wi-Fi was better than most. Definitely will stay here again if we stop in Deming. Good for an overnighter or to stay for checking out the area. If there was more grassy area for the pets it would get a 9.
Date of Stay: April, 2012
Dirt and gravel lot, but the sites are very level and getting cable for the rate is unusual. Owner was friendly. As stated in other reviews the cable was a bit snowy. We were probably the only non long term RV at the park. Some road noise, but it eased up later in the night. Descent place for an overnight stop and you can't beat the rate for a 50 amp, full hook-up. Since Fort Stockton is a logical stop for traveling through Texas, we will probably stop here again.
Date of Stay: April, 2012
Owner and camp host were very helpful and friendly. The camp host met us at the entrance and escorted us to our site. The site was reasonably level, gravel and grass. Park is basically an open field, which would get pretty muddy if it rained any appreciable amount. While a little way off the main road, it actually is adjacent to the freeway, so there is road noise. It's good for an overnight stay.
Date of Stay: August, 2011
Fast and friendly check in with escort to your site. Sites are gravel and fairly level. Small grass areas for pets, but some larger areas at the lower level and near the entry road if your pet needs a longer walk. Good Wi-Fi and TV channel selection with good reception. Note: only cash or checks are accepted. We had a severe rainstorm our first afternoon and the area drained well.
Date of Stay: August, 2011
Staff member who checked us in was friendly and guided to our site. Roads are a little tight and you have to be aware of the trees. Site was not real level, looking around most could use some attention. Good selection of TV channels, but the signal was grainy. Decent Wi-Fi, slow at times. There was good shade from the previously mentioned trees. Good for an overnight or a few days stay. Typical of KOA's, though, a bit overpriced.
Date of Stay: July, 2011
Excellent location for visiting KC and the surrounding area. Adjacent to the Worlds of fun/Oceans of Fun amusement park (campground users get a $10 per person discount on tickets). Sites are large with lots of space between each site. Good amenities, but TV channel selection on their cable is a bit unusual as they do not have a CBS channel (you can get it on the antenna). Wi-Fi is fair, when it's crowded on the weekends it's difficult to get through to websites. Nice pool and they have a lifeguard that helps keep the unruly kids under control, as many parents don't seem to be able to do it.
Date of Stay: July, 2011
Fairly typical KOA. Nice staff, they escorted us to our site. Easy on and off to the freeway. Level, long pull through. The campground is basically all gravel, 6 concrete pads, so it's a bit dusty. Good cable and descent WI-FI. A bit of an irritant was that someone, possibly our neighbor, shut off our water sometime during the night, it wasn't leaking or creating a problem. I have no idea why they would do this, but it seems some here feel they can tamper with other people's equipment.


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Solange - Musician Solange Knowles poses for Elle Muliarchyk's lens in the latest issue of Rika Magazine. Solange models at her home, wearing funky looks courtesy of stylist Jenke-Ahmed Tailly with hair and makeup by Nikki Helms and Munemi Imai. … [Read more...]
Amanda Booth by Steven Lyon for Remix #69
Journey Home - Amanda Booth packs all of her most elegant and striking outfits for a difficult trip home in the latest edition of Remix Magazine. Captured by Steven Lyon and styled by Jenke-ahmed Tailly, the blonde model wears the designs of Azzedine Alaia as she travels from the cozy indoors to a Mexican beach. … [Read more...]
Lurve Magazine #3 | Stairway to Heaven by Alexandra Catiere
Photographer Alexandra Catiere and art director Shala Monroque create a story that is part eerie and part beautiful for the latest edition of Lurve Magazine. The haunting editorial entitled, Stairway to Heaven, features models Aminata Niaria, Sessilee Lopez, Lyndsey Scott and Adama Diallo as goddesses of another world. Styled by Jenke -Ahmed Tailly in draping dresses and … [Read more...]