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Secondary Market
The 'primary market' refers to the sale of a bond directly by government to a buyer, that is, the first-time issue of the bond. The 'secondary market' refers to the subsequent trading in these bonds, after their date of issue but before their maturity date.
A list of institutions authorized to trade in bonds is provided below. You can also read or download more information on the bond trading here, in two parts: Brochure Part 1 Brochure Part 2
Institutions Authorized to Trade Government Bonds (Exchange Members)
- West Indies Stockbrokers Limited MARKET BOND
- Caribbean Stockbrokers Limited
- AIC Securities Limited TRADING
- Republic Securities Limited
- Bourse Securities Limited
- First Citizens Brokerage and Advisory Services Limited
- Scotia Investments Limited
GOVERNMENT SECURITIES INTERMEDIARIES (GSIs)
- ANSA Merchant Bank Limited
- Citicorp Merchant Bank Limited
- First Citizens Bank Limited
- Intercommercial Bank Limited
- Republic Bank Limited
- RBTT Merchant Bank Limited
- Scotiatrust and Merchant Bank Limited
- Trinidad and Tobago Unit Trust Corporation
- FirstCaribbean International Bank Limited
- First Citizens Investment Services Limited
- Bourse Securities Limited


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German economy turns solid growth, finances in 2014
The German economy, Europe's biggest, braved global economic storms to expand by a better-than-expected 1.5 percent in 2014, and turn in a surplus in its public finances, data showed Thursday.
German gross domestic product (GDP) grew by 1.5 percent last year, beating the government's projection of 1.2 percent, and was sharply improved from the 0.1 percent growth in 2013, the federal statistics office Destatis said in a statement.
The country's finances were in order too, with the overall public budget showing a surplus equivalent to 0.4 percent of GDP, the statisticians said.
"On the whole, the German economy turned out to be stable on an annual average in 2014," they said in a statement.
At 1.5 percent, GDP growth was "above the average of the last 10 years of 1.2 percent," it said.
"Obviously, the German economy turned out to be strong in a difficult global economic environment, benefiting especially from a strong domestic demand," Destatis chief Roderich Egeler told a news conference.
Following a dynamic start to the year and a subsequent period of weakness in the summer, "the economic situation had stabilised towards the end of 2014," Egeler said.
GDP expanded by "around a quarter of a percentage point" in the final three months of the year, said Destatis economist Norbert Raeth.
A more detailed estimate of fourth-quarter GDP data is scheduled to be released in mid-February.
Taking the different GDP components, exports increased by 3.7 percent across the whole of 2014, consumer spending was up 1.1 percent and public spending rose 1.0 percent.
Investment, which had declined in both 2012 and 2013, rebounded, increasing by 3.7 percent.
Looking ahead to this year, the government is pencilling in growth of 1.3 percent, but could upgrade its forecast, the weekly newspaper Die Zeit reported.
Economy Minister Sigmar Gabriel is scheduled to reveal his updated forecast at the end of January.
- 'Economic success story continues' -
ING DiBa economist Carsten Brzeski said on the basis of the full-year data, fourth-quarter growth likely stood at 0.3 percent.
"It was a very special year in which the German economy ... proved unusually sensitive to the weather, the timing of vacation and public holidays," the expert said.
It had also been hit by geopolitical conflicts in its backyard and ongoing weakness in other eurozone countries.
"However, under the surface ... the economic success story continued as unemployment remained low, employment reached a new record high and private consumption turned out to be an important growth driver," Brzeski said.
Berenberg Bank economist Christian Schulz agreed.
"After two years of near-stagnation, German GDP recorded a first sizeable increase as the economy shook off the confidence shock of the 2010-2012 euro crisis," he said.
He said the robust labour market "remains the key strength. As a result, consumption is increasingly becoming the key pillar of economic growth."
With more and more people working and paying taxes and social security contributions, and increasingly fewer people unemployed and receiving benefits, tax revenues continued to rise more than expenditure.
As a result, "Germany's fiscal health has not been better in decades," Schulz said.
The strong fiscal position, the buoyant labour market, low inflation, the sharp drop in oil prices, the lower euro and the monetary easing by the European Central Bank "provide plenty of reasons to be optimistic," the expert continued.
"We expect the German economy to gradually pick up speed throughout 2015 and reach trend growth rates of around 2.0 percent annualised in the second half of the year," he concluded.

subset: commoncrawl


text: Los Chicos Altos Vs Palo Q'Sea - Palenque Barcelona by WONDERWHEEL Recordings published on 2012-11-04T22:13:06Z Purchase the CD & Digital http://wonderwheel.11spot.com/various-artists-turntables-on-las-ramblas.html On his instinctive travels & paths of rhythm, Nickodemus comes back from Barcelona with a full compilation of unreleased songs from friends & family affiliated with the monthly Turntables on las RAMBLAS party! Like the Turntables on the Hudson parties & compilations in NYC, latin, funk, house & global grooves mirror the party atmosphere as well as the diversity of Barcelona's constantly changing demographics & soundscape. Highlights include: Colombian funk bomb "Palenque Barcelona" by Los Chicos Altos Vs. Palo Q'Sea, DJ VADIM's very catchy hip hop remix of "Fly Away" by Mariella, Novalima's biggest song off of their new album "Macaco" (ESL Music), Carlos Barbosa & Blasterjaxx catchy & heavy hitting "Toca Flute" song with a DJ Sabo Moombahton Edit, as well as the long awaited Cumbia DUB remix of Flowering Inferno (aka Quantic) with a Nickodemus & Zeb remix. Other songs include, Sid Vaga's Nu-Disco Balkan electronic remix by Oscar Barila, original Turntables on the Hudson collaborators Sujinho (Nossa) remixes Nickodemus' Andalucian gypsy "Los Tarantos", Pablo Sanchez (Lovemonk/ WONDERWHEEL Recordings) Hip House track featuring vocals by iLLspokinN, Brazilian Barcelona local Wagner Pa sends us a classic samba "Na Estrada" (on the road), & a finishing touch by Catalan superstars La Troba Kung Fu with a Toti & AndyLoop Remix of the song "Barcelona." CD compilation design by AndyLoop. Turntables on las RAMBLAS is the 1st of the Turntables on the Hudson "City to City, River to River" series connecting various DJ's, artists, musicians & party people city to city that will soon feature Turntables on the Nile, Turntables in Lima, Turntables on the Caribbean & more… Press contact (Worldwide) - Garrett Baker email@example.com Distribution contact (Worldwide) - Lori Miller firstname.lastname@example.com Label contact - Aaron Schultz firstname.lastname@example.com Press contact (Spain) - "Marc Isern :: Vibra Comunicació" - firstname.lastname@example.com Distribution contact (Spain) - Borja Torres firstname.lastname@example.com Comment by Dj Fred Spider Fresh! 2017/05/12 23:32:56 +0000 Comment by Myrto Giotakou classic and fave..<3 3 3 3 2015/11/05 21:24:58 +0000 Comment by DeelaMusic Dope 2013/12/15 13:31:57 +0000 Comment by LeñahSelektah@Prod gracias por compartir one love!! 2013/12/14 09:53:39 +0000 Comment by Will Magid This is what they call HAPPY MUSIC! 2013/04/03 16:47:16 +0000 Comment by Dr. Best fantastic! 2013/03/20 06:48:20 +0000 Comment by scarola riquísimo ! 2013/02/14 11:47:42 +0000 Comment by Breanna. Love this so much !!! 2013/01/07 10:26:15 +0000 Comment by azdjmelo so good!! 2012/11/16 02:29:27 +0000 Comment by linaluv YEH! <3 <3 <3 2012/11/14 14:57:23 +0000 Comment by DJ AZIBI uuuhmmmm me gusta;) saludos chicos;) 2012/11/14 02:11:35 +0000 Comment by los chicos altos @djstereo77: gracias hermano!! 2012/11/10 22:03:31 +0000 Comment by los chicos altos @nickodemusnyc: let´s drop it at TOTR in december :-) 2012/11/10 22:03:16 +0000 Comment by los chicos altos @john-newell: thanks john <3 2012/11/10 22:01:56 +0000 Comment by Doctor Stereo ((( fiesta ))) 2012/11/10 21:34:59 +0000 Comment by John Ghost Featured on this week's Sexxy Saturday Cumbia!!! http://generationbass.com/2012/11/10/sexxy-saturday-cumbia-live-expansions/ 2012/11/10 19:38:59 +0000 Comment by Stereo 77 "Palenque! Pa, Pa, Palenque!" Fuego mi gente! 2012/11/08 17:03:43 +0000 Comment by Nickodemus (NYC) This makes the dance floor smile every time!!! 2012/11/06 23:38:26 +0000 Comment by los chicos altos @dj-andyloop: t´estimo també amic :-) 2012/11/05 22:47:20 +0000 Comment by los chicos altos @sujinho: suji <3 2012/11/05 21:52:51 +0000 Comment by los chicos altos @uncle-griff: Gracias Señor!! 2012/11/05 20:57:31 +0000 Comment by Señor Griff That is a lovely sound. 2012/11/05 20:48:42 +0000 Comment by Fat Beatz Music Sabroson! 2012/11/05 20:41:42 +0000 Comment by los chicos altos @k-sabroso: thanks bro :-) 2012/11/05 19:51:11 +0000 Comment by los chicos altos @kkostov: EZ thanks kosta! 2012/11/05 19:50:55 +0000 Comment by los chicos altos @voodoofunk: gracias gigi nos vemos pronto en barna! 2012/11/05 19:50:37 +0000 Comment by los chicos altos @ion-din-anina: te <3 tambien :-) 2012/11/05 19:50:13 +0000 Comment by ION din Anina <3 2012/11/05 19:29:58 +0000 Comment by Broso This is massive! Los Chicos Altos never disappoint. 2012/11/05 19:05:05 +0000 Comment by VOODOOCUTS yes! 2012/11/05 11:52:56 +0000


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Maudella 5991; ca. 1970s; Robe. Wrap-over robe in two lengths has tie belt, front bands and patch pockets, extended shoulders, loose fitting three quarter length sleeves with turn back cuffs.
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KENOSHA, Wis., Sept. 27, 2013 /PRNewswire-iReach/ -- The term "used car" defines a huge selection of automobiles on the market. There are all kinds of makes and models, and the range of years can literally be anything. Because of that, it's pretty obvious that consumers have a lot of...
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text:
Watch out. The Gang is out tonight.
I'm pretty sure everyone in this house loves Halloween.
Especially Mathilde.
She's so excited to get to try every American candy ever made.
Ha ha.
I'll mention her probable stomach ache tomorrow.
We went out in our neighborhood.
Then Cookie and I came home.
Followed by the Gang.
Cookie and I raided the first round of the Gang's winnings.
And got pretty sticky.
And I wait for the Gang to return.
So I can get my favorites out of their treat bags.


text:
What is sin? One definition is that sin is anything within me, or an action produced by me, which fails to bring glory to God (Romans 3:23). Whenever the Holy Spirit opens the eyes of your heart to see your … Continue reading
September 20, 2016
by Paul Tautges
Comments Off on 10 Things That Are True When I Confess My Sin


text:
Compact MP4 Player
MP4 player that looks just like a phone but plays your movies and music on the run!
Available branded with your logo in up to 4 colours these promotional MP4 players make the perfect corporate gifts fro both clients and as staff rewards.
Decoration: Pad Printing
Pack Contains: headphones, charger, usb adaptor, manual and gift box.
Min Qty: 25
Select print colours: Click the colour button below
Production time is 7-10 business days
Optional data preloading $1.00 per unit
Up to a 4 color logo imprinting on both sides
Second location imprint with a one color imprint available
Virtual Pre-Production Proof and PMS color matching service are provided at no extra charge for each order
All our products can also be ordered without any customization at our discounted wholesale prices
1. 1.8" CSTN display with slim size
2. Large screen and elegant picture menu
3. MP3/WMA digital play
4. FM radio function
5. FM recording, capable of storing FM radio content
8. Digital recording function, capable of high-quality recording
9. A-B repeat function
10. Adjustable for multiple sound effects
11. Supporting Id3, capable of synchronous display of song name, singer and lyrics
12. Linear control function ; Games Function
13. Built-in lithium battery, capable of being charged when inside this unit


text:
Promoting networks between evidence-based medicine and values-based medicine in continuing medical education
In recent years, medical practice has followed two different paradigms: evidence-based medicine (EBM) and values-based medicine (VBM). There is an urgent need to promote medical education that strengthens the relationship between these two paradigms. This work is designed to establish the foundations for a continuing medical education (CME) program aimed at encouraging the dialogue between EBM and VBM by determining the values relevant to everyday medical activities.
A quasi-experimental, observational, comparative, prospective and qualitative study was conducted by analyzing through a concurrent triangulation strategy the correlation between healthcare personnel-patient relationship, healthcare personnel's life history, and ethical judgments regarding dilemmas that arise in daily clinical practice.
In 2009, healthcare personnel working in Mexico were invited to participate in a free, online clinical ethics course. Each participant responded to a set of online survey instruments before and after the CME program. Face-to-face semi-structured interviews were conducted with healthcare personnel, focusing on their views and representations of clinical practice.
The healthcare personnel's core values were honesty and respect. There were significant differences in the clinical practice axiology before and after the course (
The healthcare personnel participating in a CME intervention in clinical ethics improved high-order values: Openness to change (OC) and Self Transcendence (ST), which are essential to fulfilling the healing ends of medicine. The CME intervention strengthened the role of educators and advisors with respect to healthcare personnel. The ethical values developed by healthcare professionals arise from their life history and their professional formation.
In the 21st century, medicine tends to be dominated by two paradigms, evidence-based medicine and values-based medicine (EBM-VBM), which directly impact clinical decision-making processes in daily healthcare practicea
Modern biomedical science faces the challenge of reinforcing the pairing of EBM-VBM and constructing links and networks between them
Values are normative guidelines that allow us to consider actions, objects or situations as good, desirable, pleasant, convenient or useful towards certain aims
The healthcare sector is currently facing a crisis of knowledge, compassion, care, cost and values in general; however, few programs have addressed values among healthcare personnel, and little data exist concerning the effectiveness of such programs
Values are favorable dispositions towards aims that are sought. A physician is willing to act in accordance with the ends of medicine (healing, curing and caring) because they guide and give sense to his/her practice. These ends in medicine have traditionally been traced by clinical ethics in the form of principles and virtues. Principles state the deontological obligations of healthcare personnel and aim to offer an answer to ethical dilemmas. Principles will always be grounded on values. Principles explicitly state the values that we consider important
Figure 1
A Venn-Euler diagram of values
A Venn-Euler diagram of values. Values are the universe, while virtues and principles are subsets. The subset of virtue considers those values that refer directly to the healthcare personnel, their traits of character and decision-making. The subset of Principles expresses a normative procedure according to which actions can be guided to reach certain values
Life preservation is a value that, in order to be upheld, is supported by several epistemic and ethical virtues and principles. Virtues such as wisdom, temperance and compassion aim at life preservation. In addition, principles such as beneficence are important in preserving life because they specify the obligations and provide explicit guidance to the agents' actions. However, in this paper, we maintain a broad perspective regarding values that allows us to move between virtues and principles and to consider the personal and social dimensions of patients and healthcare personnel in addition to the states of affairs that are valuable in strengthening the convergence of EBM-VBM (Figure
As stated earlier, one of the ways to create a novel ethical environment is through education in clinical ethics. The first step is to carry out a situational diagnosis of what the ends of healthcare are considered to be, along with the values linked to these ends
The study's central hypothesis is that a cross-functional clinical ethics course is able to amalgamate EBM and VBM. Therefore, we seek to address the following questions: (1) What are the values of a group of healthcare professionals participating in CME in clinical ethics? (2) Why and how do participants respond to values in their clinical practice? (3) How does CME in clinical ethics impact the pairing of EBM-VBM? Here, we describe the successful use of CME to engineer networks between EBM and VBM.
Study design
A concurrent triangulation design of mixed methods' strategies to analyze both quantitative and qualitative data was used to empirically explore the axiology in the clinical practice of Mexican healthcare professionals
Figure 2
Framework of the analytic methodology
Framework of the analytic methodology. In step 1, we used statistical analyses to examine the axiology of clinical practice (values in healthcare, work values, virtues in medical practice and three clinical vignettes posing ethical dilemmas) and the characteristics of participants prior to conducting the CME in clinical ethics. In step 2, we used qualitative content analysis of semi-structured interviews (SSIs) to examine reasons for values usage in clinical practice and axiology in the ethical discernment process prior to conducting the CME in clinical ethics. After quantitative and qualitative research questions were examined, these results were integrated based on the mutual validation model, which regards the search for convergent findings as validity indicators as the most important purpose of triangulation. We explored potentially strong connections between EBM and VBM using qualitative results, while we inferred the extent of the benefits of novel networks using quantitative results. After conducting the CME in clinical ethics intervention, we repeated the analyses (steps 3 and 4), and the full results were integrated.
Study population
Mexican healthcare personnel with current active practices in several clinical medical areas were invited to participate in an online course in clinical ethics, at no cost, from September 2009 to February 2010. Registration was conducted during a two-month period prior to the CME program (N = 2,891). During registration, each participant provided his/her demographic data and responded to an online survey (Table
Table 1
Sociodemographic characteristics at two stages
Registration (n = 2,891)
Final (n = 973)
Mean ± (SD)
39.38 (±9.9)
38.2 (±9.7)
Level of
Healthcare professionals who enrolled in the online course represented every Mexican state and organizational level of healthcare. The primary healthcare level is preventive and family medicine. The secondary level comprises different medical specialties and general surgery. The tertiary level includes highly specialized medical attention.
The research ethics committee of the Mexican Institute of Social Security (IMSS) approved the study. All participants received written and oral study information and signed a letter of informed consent granting the authors permission to use and publish the data and results of this study.
CME in clinical ethics Intervention
The course was designed by a cross-functional group (including medical doctors, teachers, anthropologists, sociologists, philosophers and bioethicists), and it included five modules: the person and human dignity, medical ethics, healthcare professional/patient relationship, clinical ethics committees, and methodologies for ethical discernment.
The Anahuac University and the IMSS awarded those who completed the course with a 60-hour CME certification. This on-line course provided information to healthcare personnel about ethical terms, concepts and theories. Additionally, the course reviewed guidelines for ethical decision-making, which included exploration of personal values in addition to problem-solving exercises (patient simulation, motivational videos and online discussion forum) regarding how to apply ethical concepts and theories to ethical dilemmas (Figure
Quantitative study
Instrument design (survey)
Although numerous survey instruments measuring values are used worldwide
Figure 3
Hierarchy of values in clinical practice in Mexico
Hierarchy of values in clinical practice in Mexico. Each of the charts shows the state of values before the intervention (
Work values
To assess work values before and after the CME intervention, we used an instrument proposed by Schwartz that operationalizes four high-order values
Ethical discernment instrument
The survey included three clinical vignettes that were used to assess discernment in some of the common ethical dilemmas encountered in medical practice: patient confidentiality, informed consent (autonomy) and withdrawal of care (beneficence). The clinical vignettes revealed differences in discernment before and after the CME
Statistical analysis
Distribution of participants according to gender, age, profession/discipline and healthcare level is described for each of the two phases (Table
Qualitative study (interview)
The aim of the qualitative component of the study was to explore the self-representations of the healthcare professionals. Purposive sampling was undertaken
Face-to-face semi-structured interviews were conducted with healthcare personnel by anthropologists. The interviews focused on the personnel's views and representations of clinical practice. The interviews took place between September 2009 and February 2010, before the CME intervention (78 interviews) and after the CME intervention (42 interviews). Interviews lasted approximately 80 minutes and were recorded and later transcribed.
The transcriptions of interviews were analyzed using the content and thematic analysis method described by De Hoyos
For both sets of interviews, Atlas.ti 6.0 softwared was used to identify emergent themes in addition to the views of the participants. Each interview ended with the presentation of short vignettes concerning clinical cases. The use of vignettes with open-ended questions in qualitative research attempts to determine perceptions, attitudes and moral values, all of which are particularly pertinent for this study
Data analysis for ethics
We used an inductive, ethics-based process of analysis, following Josep Lozano's classification of ethical theories founded on three major approaches
These approaches allow the specification of which values are in conflict for a given ethical dilemma: the confrontation between virtue and duty, virtue and efficiency, or duty and efficiency. The cross-functional research team identified codes for units of meaning in the survey.
Quantitative analyses
Study population
Axiological situational diagnostic data were obtained for 2,891 healthcare professionals who were initially enrolled in the course (registration). The final sample included 973 healthcare professionals who successfully completed the course and who had also completed the before-and-after survey instruments as well as the clinical vignettes. Table
We confirmed that the 973 participants of this study represented the initial participants in the course, using demographic and professional survey information. No differences were found with respect to factors such as professional distribution, gender, age, organizational level of healthcare or geographic distribution.
Most of the participants were female (62%). The predominant profession was physician (57%), followed by nurse (20%). Participants' ages ranged from 17 to 82 years, with 43.5% of the participants being between 36 and 50 years of age (median age of 44 years). The healthcare personnel represented different regions of Mexico. The sample included the four organizational levels of Mexican healthcare: first level, 41%; second level, 32%; third level, 22%; and central level, 5%.
Of the participants, 40% had prior training in bioethics through courses taken during their higher education. Participants' primary motivation to enroll in the course was to improve their professional performance (54.6%), followed by the desire to increase their knowledge of clinical ethics (36.3%).
Axiology in clinical practice
The values of clinical practice refer to favorable attitudes, actions and situations that will help to achieve patients' wellbeing. The priorities and value rankings of 2,891 participants are shown in Figure
Figure 4
Hierarchy of values in clinical practice before and after CME intervention
Hierarchy of values in clinical practice before and after CME intervention. All the values presented statistically significant change before and after the intervention (Wilcoxon Signed Rank Test with Bonferroni's correction).
Healthcare professionals in Mexico assigned great importance to the values of 'honesty' and 'respect' by placing them first and second, respectively, in their hierarchy of values, whereas a low level of importance was given to values such as 'fidelity', 'purity' and 'beauty'. Notably, the two highest and the three lowest values in the ranking remained unchanged after the clinical ethics course (Figure
The value of 'autonomy' was ranked high (third) by the participants after completing the course, whereas prior to the course, it was ranked 10th (mean position shift from 8.00 to 5.86, a statistically significant difference) (Figure
Figure 5
Ethical clusters found among Mexican healthcare personnel
Ethical clusters found among Mexican healthcare personnel. Aretological values are A; deontological values are D; utilitarian values are U. Before (1) and after (2) the educational intervention.
Ethical dilemmas and values
A dilemma is a situation in which a person may choose only one of two courses of action, each of which seems to be well supported by certain values. The survey encompassed three clinical vignettes
The value of 'autonomy' was labelled as 'utilitarian autonomy' when healthcare personnel attempted to obtain informed consent or voluntary discharge, and 'deontological relationship-based autonomy' was a situation in which "the health personnel attempted to obtain informed consent from the patient or surrogate by explaining common risks, benefits, and alternatives (including no intervention), while querying for and answering patient questions in an unbiased fashion"
Work values
According to Schwartz
Table 2
Work values
Mean ± S.D.
Openness to change-B
5.69 ± 0.89
Openness to change-A
5.77 ± 0.87
5.99 ± 0.94
6.05 ± 0.89
2.71 ± 1.10
2.75 ± 1.11
3.50 ± 0.89
0.01; 0.05
3.48 ± 0.90
B = before, A = after, c With significant differences, d Without significant differences.
Figure 6
Four high order values (Schwartz's theory) before and after CME intervention
Four high order values (Schwartz's theory) before and after CME intervention. Each row includes N = Nurses, M = Medical Doctors, HP = Others Healthcare Professionals. A = Administrative personnel. Spheres in red are females. 1 = Before and 2 = After educational intervention. A: Scatter plot in 3D. Openness to Change. Spheres representing post-CME intervention appear compacted. B: Scatter plot in 3D. Self-transcendence. Spheres representing post-CME intervention appear compacted. C: Scatter plot in 3D. Self-Enhancement. D: Scatter plot in 3D. Conservation.
Qualitative content analysis
To strengthen the knowledge claims of the study, the declared values considered in the quantitative analysis were paired with a qualitative analysis that aimed to gain insights into the representations of the actors and their beliefs. A well-validated study on a subject such as clinical ethics and values would be incomplete without both quantitative and qualitative perspectives.
The rise of vocation and its consolidation
When qualitatively tracing the most salient values in the life history of the individuals interviewed, we found that healthcare personnel referred to a core of values, where beneficence is dominant together with tradition, incentivizing, achievement and conformity, and that those traits led them to choose a career in the medical field (Figure
Figure 7
Semantic networks
Semantic networks. Keywords were identified with Atlas.ti 6.0 software. Words were sorted according to the frequency of their appearance in the interviews. The cut-off point, which divides the set of words into a high-frequency and low-frequency groups, was identified. Radial graphs explaining the frequency of appearance were created with MS Excel 2007. Red indicates before CME, and blue indicates after CME. A: Semantic Networks for Life History. B: Semantic Networks for Ethical Discernment. C: Semantic Networks for Healthcare Personnel-Patient Relationship.
The configuration of beneficence as a guiding value for the vocation of these professionals is associated with two different and sometimes conflicting sources. In one, social relations are protected through conformity with established values and traditions; in the other, innovations in these values are made when incentives encourage new achievements in the medical field (Figure
The educational intervention permitted the rediscovery of certain values that would consolidate the vocation of the healthcare personnel; even if the participant's perspective shifted, the centrality of beneficence remained. Self-direction and incentivizing came to play an important role once the professionals acquired greater experience, and this experience supported improved knowledge and performance. While self-direction and incentivizing demonstrate an openness to change, they are still well balanced with the protection of social relationships through adherence to prevailing values (Figure
Table 3
Values and healthcare personnel roles
Values and Healthcare Personnel Roles
Professional Humility
Compliance with standards
Capacity to appraise situations and consequences
Medical Attention
For each value and role, the boxes on top correspond to the interviews before CME intervention. The boxes at the bottom correspond to the interviews after CME.
Ethical discernment
Daily medical practice encounters ethical dilemmas when treatment efficiency and other related values must be taken into account to help the physician make a wise decision. The basal values that are most often cited in healthcare professionals' representations are justice, respect, medical attention, an ability to appraise situations and their consequences, compassion and beneficence, followed by compliance with norms and autonomy (Figure
Autonomy, beneficence, justice and non-maleficence are the values suggested by Beauchamp and Childress' principlism for ethical discernment. As stated in the background section, principles express normatively a procedure to uphold a value (Figure
In the analysis, with the exception of justice, values such as respect and compassion were considered more relevant to ethical judgment than the remainder of the values related to principlism (Figure
Additionally, we investigated the interviewees' representations of how medical attention should have an impact. Generally, the medical practitioner described not making decisions based on the notion of an ultimate end of the practice but rather on the ability to appraise specific situations. The ability to appraise situations is, of course, useful in maintaining life and avoiding risks, but it also helps to clarify courses of action in ethically complex cases (Table
The educational intervention modified participants' configuration and hierarchy of values. After the CME intervention, values such as respect, compassion and justice were predominant over the others. Autonomy moved from the eighth position to the fourth position according to importance (Figure
Healthcare personnel-patient relationship
Different kinds of relationships between patients and healthcare personnel
We were able to discern a bundle of values in the specific relationships that we studied. The initial values that prevailed in this relationship were self-direction, justice, medical attention, compassion and beneficence. Again, we noticed that the values related to virtue ethics are stronger than those related to principlism (Figure
Medical attention, the main role played by healthcare professionals
In describing their functions, all interviewees quickly noted that their job was to provide medical attention; they were all immediate and precise in their description. The medical practitioners eloquently spoke about the different types of patient they meet; they recognized in advance the types of persons and diseases they would encounter (Table
In relation to the particular situations in medical attention in which the link with the patient is the common denominator, we found that values such as compassion, justice and beneficence, self-effacement and trust are salient (Table
The health professionals showed great patience when working with patients after the CME intervention. Issues that would normally act as a barrier between the health professional and the patient became an opportunity for the health professional to provide the patient with comprehensive medical care. The healthcare personnel stated that when patients abandon their treatment against medical advice, reactions such anger, disappointment or discomfort are not uncommon. Following the CME intervention, they resolve these issues by informing patients about the treatments and their benefits. Educating patients implies transmitting scientific information that provides them with some certitude regarding their treatment in general. This information must be provided in an understandable and non-condescending way (Table
Virtues in clinical practice
One way of creating a novel ethical environment and improving the quality of medical care is fostering new values to face the challenges of clinical practice. Among the different values that are important for medicine, we find several virtues. Virtues are values that refer directly to the healthcare personnel, their traits of character and decision-making (Figure
Figure 8
Virtues of medical practice
Virtues of medical practice. *Denotes a statistically significant difference before and after the intervention (Wilcoxon Signed Rank Test with Bonferroni correction). Vertical lines tie the pair of values between which no statistically significant difference was found (Steel-Dwass All Pairs Comparison).
We have thus shown experimentally that the two paradigms, EBM and VBM, can be converted into an EBM-VBM binomial through CME intervention. (Figures
Our results demonstrate that the healthcare personnel participating in a CME intervention in clinical ethics improved high-order values Openness to Change and Self-Transcendence, as observed through a concurrent triangulation approach (Figures
Ethical discernment is a daunting task from the perspective of integral ethics, which seeks the good of the patient by integrating the three characteristics of action: as a moral agent, as a process to be evaluated from the perspective of rights and duties, and with respect to the consequences of the action. This approach ensures that healthcare professionals exercise their hierarchy of values (Figure
Following Lozano, dilemmas can arise from different areas; different values and different kinds of ethics take precedence. Values consider the good that is to be achieved through a practice. However, when several of these values are in conflict and a decision cannot be reached, virtue becomes central in solving an ethical problem; the character, practical wisdom and experience of the practitioner are important resources for ethical deliberation (Figure
CME must focus on four areas to strengthen the EBM-VBM binomial: The first area is extensive knowledge of the pathophysiology of disease and availability of real therapeutic alternatives (EBM). The second area is knowledge and awareness of values (VBM). The third one is development of an ability to analyze and discern ethical dilemmas (VBM), and the fourth area is communication skills (VBM)
In this study, we validated our instrument (a value hierarchy in clinical practice) and identified the opportunity for CME intervention. Figure
A notable outcome of our CME clinical ethics course is that it created awareness among physicians and healthcare professionals of how their decisions are made and the values that are at stake (Figures
We propose that an integral approach to ethics similar to the one described by Polo
2) These criteria emphasize different issues involved in an ethical dilemma. A deontological criterion focuses on the fulfilment of general and comprehensive rules. A focus on virtue is more capable of addressing the immediate context. Moreover, a value such as efficiency should not be neglected in the healthcare professions. However, the specific configuration of the dilemma and the moral character of those involved will reveal which criteria should be prioritized in a process of wide reflexive equilibrium
3) The most important criterion for decision making is the respect for the universal trait of human dignity, even if those who address this dilemma conceive of it in different manners. Dignity supports the individual in acting conscientiously and making his/her own life choices
It is of the utmost importance to keep in mind the primacy of those affected by the decisions, ethical values and discernment of healthcare personnel. However, the decisions made by healthcare personnel not only affect patients but also the decision-makers themselves. These decisions determine what kind of person and professional one becomes, how sensitive one is towards others, and how attentive one is towards one's own needs. The best decisions justifiably solve a dilemma by integrating different ethical theories related to human actions. An integrated ethics approach is essential in medicine because medicine is concerned with the person and his/her interests, needs, vocation, virtues and transcendence.
In a nutshell, we can say that the CME intervention favors the creation of networks between EBM and VBM from a philosophical, epistemic, axiological and practical point of view. From the philosophical point of view, we were able to recover the ends of medical practice, namely: healing, curing and caring, the recognition of the person as central to healthcare. This is evident in Table
In ethical discernment, the use of clinical vignettes to picture situations with moral dilemmas proved useful. In these exercises autonomy stands out, it was a value previously overlooked and it became relevant for the healthcare personnel after the CME intervention. Additionally, ethical committees as guarantors of the humanization of healthcare were consolidated, while the promotion of a professional environment directed by academic, ethical and social excellence was encouraged. Strengthening values-based medicine automatically strengthens the EBM-VBM binomial given that they become more balanced. This is clearly shown in the present study. We are looking forward to continuing with the next phase of this project, which involves carrying out participant observation of the active healthcare personnel in medical units, in order to follow up on these results in the long term. This study is one of the first to explore the axiology of clinical practice. Different values and representations may be found depending on the studied population; however, we consider that the empirical method used to explore the representations of these professionals opens a window of opportunity for CME insofar as it strengthens the already-existing values among healthcare personnel; and at the same time, it promotes values that are missing but essential to an effective patient-healthcare personnel relationship. One dimension of medical responsibility involves being attentive to the values that need to be exercised. López Quintás
This is the first endeavor to empirically investigate the axiological foundations of healthcare professionals working in Mexico. It has long been known that values education is one of the most effective methods to meet the challenge of providing high-quality care to populations and improving the patient-healthcare professional relationship
For CME design purposes, we successfully engineered networks between EBM and VBM. Using the combined approach of cross-functional design, online technology, motivational videos, pictures and real-time decision-making, these networks identified the advantages of both paradigms. Perhaps the CME methods used in this study will encourage the humanization of medicine through routes not open to traditional CME methods, thus potentially allowing access to more efficient CME solutions, as in the example presented here.
It has long been speculated that CME in clinical ethics in real time may be a useful platform for engineering novel networks between EBM and VBM. Our strategy of cross-functional CME in clinical ethics may be of broad application in achieving high-quality care.
CASC: capacity to appraise situations and consequences; CME: continuing medical education; C/N: compliance with the norm; CO: conservation; CVs: clinical vignettes; EBM: evidence-based medicine; EVAT: Escala de Valores hacia el Trabajo, Spanish for work values scale; IMSS: Mexican Institute of Social Security; OC: openness to change; OM: order mean; SE: self-enhancement; SSIs: semi-structured interviews; ST: self-transcendence; VBM: values-based medicine
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MMAB and NFAB conceived and designed the present study, while MMAB, MTAO, SQV, JM, RND and ACD collected and assembled the data. MMAB, NFAB, AL, IMM, AdH, CM, SQV, JM, RND, FVG, RV, EC, PS and JMMA contributed to analyzing and interpreting the data. MMAB, NFAB, AL, IMM and AdH drafted the article. MMAB, NFAB, AL, AdH, FS, PS, CM, JMMA, FVG, JG, SIA, MTAO, JAA, OMG, ARF and JKR revised the article for important intellectual content. All authors gave their final approval.
End notes
aOf these two paradigms, EBM appears to predominate: Medline displays 49,491 EBM articles versus 1,701 articles addressing Humanistic Medicine, Patient-Centered Medicine or VBM. bAxiology is the philosophical discipline that studies values and the phenomena surrounding them. cDe Hoyos A, Nava-Diosdado M, Mendez J, Ricco S, Serrano C, Macias-Ojeda C, Cisneros H, Bialostozky D, Altamirano-Bustamante N, Altamirano-Bustamante MM: Cardiovascular medicine at face value: a pilot qualitative study on clinical axiology.
We are indebted to all of the professors and participants who were involved in the on-line clinical ethics course. We are also grateful to the staff of the Direction of Innovation and Technology of the IMSS and ISAPEG for helping us to reach our goal. We greatly appreciate the work of Ana Serrano, Carlos Macías, Uria Guevara and Sandra Lizarraga for their help in data coding and for their participation in fruitful discussions. We appreciate the help of Juan Jimenez in designing the Figures for this paper. Adalberto de Hoyos would like to acknowledge the support provided by the postdoctoral fellowship program at UNAM. The authors are also indebted to the healthcare personnel who generously shared their experiences in the interviews. We also wish to thank Dr. Israel Grijalva Otero for his support. We want to thank Isaac Fernández, our computer guru, for all his support.
Funding for this study was provided by Mexico's Council of Science and Technology (CONACYT) 068673 and the General Direction of Academic Personnel Affairs of UNAM (DGAPA) for the Papiit project ID 400112.
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Pre-publication history
The pre-publication history for this paper can be accessed here:


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The sky was just beginning to lighten, as the bus rattled along the highway. They had been on the road all night long, as Jeremy stared out the window. It was the first time he had managed to snag a window seat. Maybe it was a sign that the others had finally given up on making him the target of their jokes, of their nastiness.
They would be at the ferry terminal in another couple of hours, then off to the Island on the 7am run. According to the band director, they'd check into the hotel and have the whole day off. Tomorrow and Sunday would be practice days, then the parade on Monday. It would be their 5th parade in as many weeks, and he was a bit weary of it all.
At eighteen, a senior, this was supposed to be the culmination of his high school years. Next year he'd be off to college, if accepted, and would be starting all over. He hoped the stories were true, though, that at least in college it was easier to be queer. High School certainly hadn't been fun for those who were, and he could testify to that.
Not that anyone knew, until they were on the road. Somehow he had managed to keep it secret, until that fateful night on their first day out. He could still hear the jeers, feel the sudden anger and hatred around him. It wasn't fair, and maybe he should have denied it, or tried to bluff his way through it, but he hadn't. Now he had spent nearly five weeks in pure purgatory, thanks to one simple mistake.
Leaning back in the seat, he turned to face the window, to just stare out at the passing scenery. He still couldn't believe how those who he had known for years, could turn on him so suddenly. People like Roger, Mark, and Cory, all of whom he had known since grade school. They had joined Band together back then, when the drums they played were bigger than they were.
Yet one simple goof, and now they were the leaders of his torment, always jeering, always with the sissy boy, the fag jokes. It wasn't any open attack, except when on the bus, or in the hotel rooms. He had looked forward to exploring the different cities with his friends, but instead he was left to wander the streets, the shops, alone. No one was willing to have him along, not even the girls.
In some respects they were meaner than him. The way some had come to him, showing off their lipsticks or make up purchases, loudly asking if like the color, given it wasn't pink. That always got the guys snickering, and how some would seek his advice, in front of the others, aboutĀ what under garments to wear. They wanted to know if it would get the guy's hot, seeing as how he was an expert on what got guys turned on.
That had been the hardest part, and it wasn't like the chaperons were any help. For the most part they snickered, or ignored it. To them it was harmless teasing, but it didn't feel like that to him. Even the band leader turned a blind eye to the crap. Like at the first stop, when they had hidden his drum, or painted the words 'faggot' on the drum skin.
They even ignored it when they had replaced his harness with one made with frills, and colored a bright pink, and hid any of the others so he had to use it. Not one word of admonishment from the adults of the group, just the shake of a head, telling him he'd have to use it. That had to be one of the worst parades of his life. To go marching with the others, standing out from the entire group, in front of all those strangers. It even was picked up by the local television station, calling him some sort of activist, guessing at what he was trying to protest.
In some ways, he knew he had been stupid. The weekend before they were to leave, he had gone camping with Neil, and had taken some of his boy magazines with him. It was something he could share with Neil, a guy he had met at summer camp the previous year. They had found that they had more in common than being in the band of their respective schools.
He liked Neil, who was in the wind section of his high school band, a bit thin but man, he had been something that summer. They had kept up their friendship, and when Neil had a chance to come to Jeremy's city, well they made plans to meet. Going camping before Neil left to go back had been his father's idea, and well, it was a perfect way to end Neil's visit.
The sex had been great, even better than at camp, as both had a bit more experience now, so he had taken some skin magazines with him. It had been fun to talk about which one's were hot, which weren't. To simply share an appreciation that other's wouldn't understand. And like an idiot, he had forgotten to empty his duffel bag before packing for the band trip.
Stopping at the campsite, that first night, he had forgotten about the magazines, Hell he'd forgotten about it before packing, so when he dumped his bag out, and the magazines came flying out, he had been as surprised as everyone else. Unfortunately they had moved faster, and it was around the whole campsite in seconds, or so it seemed.
He should have denied they were his, should have figured out some snappy lie, or better yet, taken a page from the Politicians and blamed them, saying that one of them must have put them there, to get at him. That is what he should have done, instead he had just stammered, just stood there pale as a ghost. And ever since he had been the butt of their so called sense of humor.
Staring out the window, he felt rather sad. He didn't understand how guys like Mark or Ron could switch from being a friend, to being the enemy. It really didn't make much sense, except maybe that they were trying to cover their own asses. The way some of the other's had looked at them, wondering. He wondered if he would have acted that way too, if the situation had been reversed?
Looking out, he saw the darkness evaporating, saw the shapes becoming more defined as the bus rolled along. He was tired, but it wasn't a good tired. Not like it had been on that last morning with Neil, at the camping spot they had found. No campgrounds for them, as they had trekked into the woods, off the beaten path, so that no one could intrude. It had been a week of nothing but sex, and he smiled as his body settled deep into the bus seat.
So what if they wanted to harass him? They couldn't take away what he had, and soon he'd be away from them. Soon he'd be off making new friends, and like Neil had said, colleges had a more 'gay friendly' lifestyle. Sure, he would still need to be careful, but incidents like skin mags falling wouldn't do more than raise an eyebrow.
They hadn't done much exploring, other than the odd journey down to the river. There they had found a nice spot, shaded and not quite so open so that they could be seen. It had been fun, to lay on the ground, staring out at the sun shining down on the water. How it had glittered, but not as much as Neil's eyes had, when he would get horny, which seemed to be all the time.
For a skinny kid, Neil did have a rather attractive body, when naked. The ribs didn't really stick out that much, and his stomach was flat. It was fun to run his hand over it, because he could feel each muscle under the skin. Not like there was a lot of fat to cover it. His hips were a bit bony, but then Neil was what one would call your typical eighteen year old high school nerd or geek.
He liked computer sciences, and was nuts about astrology too. The way his face would light up when he was talking about some ram this or quad processors, or when he talked about the worlds beyond. Neil was one of those who liked to dream, but he was all guy too. He loved sex, talking about penises, cut or not, seemed to make his face glow as much as talking about the stars did.
While he didn't think of himself as having a great body, he knew it was more muscular, more filled out than Neil's was, but the sex had been so good, it really didn't matter all that much. He might have outweighed Neil by 30 or so pounds, and he had a lot more hair on his legs than Neil, but when it came to comparing dicks, well Neil won that one hands down.
Who would have thought some skinny runt like Neil would have a dick the size of a torpedo? Back at summer camp it hadn't been that big, least he hadn't thought it had, but in a year, it was like some growth hormone had kicked in, or something. He even asked Neil if he had been using some of those 'penis pills' that inundated his email.
Neil had laughed, and said no, but the way he had laughed, grinned, had only made Jeremy stare at Neil more. They had been out at the river, laying there watching the sun come up. It was their first night, and already he had shot two loads and Neil had only shot once.
It wasn't cold either, and they were stretched out on a pair of blankets, stark naked, just enjoying the warm air, the stars, and each other. He wished it didn't have to be hidden, even then, but stupid he wasn't. Least until the magazines had come out of his duffle bag. Now that was stupid, but thinking back to that first night, it seemed like no one should object to him or Neil.
Looking out, the whole night seemed to be just like that first night, at how Neil had lay next to him, his body just touching him in certain spots, and how good it had felt. The press of someone's legs against his, of feeling his presence. It had given him some good feelings, and when they had turned their heads to look at each other, to talk or say something, it had felt so comfortable, that he wished he could do that with others.
He and Neil were typical eighteen year olds, least he thought so. Yet maybe they weren't, because in all the locker room talk he had heard, no one ever talked about how it felt to lay next to the person they were boinking. No one talked about how it felt, just about how much cum they had shot, or how long they had been banging.
Maybe instead of hounding him, they could take a lesson in what real sex was like, from him and Neil. Man, he still could remember how good it had felt, when Neil had let his hand rest on Jeremy's chest. How his heart had begun to beat a bit faster, as Neil caressed his chest, how the fingers would play the few chest hairs he had. How they felt, tingled as his fingers twisted them a bit, then flattened them out.
How his nipples seemed to stiffen as the tips of Neil's fingers would gently circle them, then rub over the tip. How it made him tremble, how he would bite his teeth, as the hand moved slowly over his body. It was hard to put into words, but damn it had felt good, something he could still feel, if he thought about it real hard.
How his whole body shuddered, when Neil leaned over and lightly pressed his lips against the side of his chest, just beside a nipple. Man, he almost creamed right then and there, as the soft press of those moist lips touched his skin. It had been a perfect night, and the dawn was on track for being even more spectacular.
Strange, but thinking about that camping trip, he couldn't remember when he hadn't been hard, nor if Neil had ever been soft. It was like they were always stiff, always wanting to get it on, yet the sex wasn't just about a quick suck or fuck. Okay, the first afternoon it had been, but only then.
It was more about how they seemed to just enjoy each other, to take their time, to savour it all. Maybe they weren't typical, but damn the sex had been amazing. They had gone through a few boxes of condoms on that trip. Thinking about it now, he realized too that it was more about the way they did things, than the mechanics of it. After all a fuck was a fuck, but it was how they led up to it, how they enjoyed the touch of each other, the closeness, that made it worth remembering.
Like that first morning, how Neil spent so much time just leaning on his side, while he explored all of Jeremy's body. How good it had felt, the way his hand seemed to be all over him, touching, pressing. It was sort of like Neil was trying to memorize every part of him, where every dimple was, every ridge of skin was. How his finger would moved down the centre of his chest, towards his belly.
How it traced around his belly button, making him giggle a little, and how they laughed as suddenly they were tickling each other, hands flying to various body spots, to tickle, to touch. Their peals of laughter only seemed to make them want each other more. Strange that, but one second they were frolicking around, laughing and then the next, they were locked in a passionate kiss.
Neil tasted so good, but the sound of him laughing, the way he would squirm, to reach around and tickle him, or to just hold him, was an unbelievable experience. Everything felt so natural, so unrehearsed. It was as if they could read each other's minds, know what the other wanted.
Why was that so wrong? So many seemed to think it was, but as he thought about it, he couldn't understand it. He was happy when he could feel Neil's arms around him, holding him. How good it had felt to feel his hot breath on his cheeks, while his hand was touching him. Nothing that felt that good, could be wrong.
His eyes closed as his head settled further into the seat, thinking of Neil, of that first morning. How Neil had moved around, how they had kissed, then how Neil was suddenly on top of him, his body pressing down. He could feel the press of his big dick, wedged up into the soft part of his groin, his own dick wedged upwards, against Neil's belly.
Jeremy could feel the heart beating, feel the chest heaving as Neil kissed him hard. How his tongue had pushed past his teeth, had licked him deep inside, then pulled out, while his tongue returned the favour. It felt so good, to feel the Neil's fingers digging into his upper arms, as he moved his hips from side to side, rubbing his hard cock against his crotch.
The way his body moved, to push at his own dick, to make it rub between them, then how he had sat up, his knees on either side of Jeremy. How he had looked down at him, his eyes looking so alive, so filled with fire. It had made his body shake a bit, made his heart skip a beat. Even now he could feel how good it had felt, to be looked at that way.
Nothing dirty about that, nothing unseemly. It just felt so natural, so good. How the eyes seemed to pierce his deep inside, touching him within. The way he had moaned softly, as Neil had looked at him, at how it felt to have his bony knees pushing against the outside of his thighs. Looking up, he knew what Neil wanted, knew it without having to ask.
He had smiled back, and had reached for his pants, to pull out a condom. Jeremy had felt the eyes following his movement, could feel the excitement building in the body on top of his, as he picked up the condom and turned to stare at Neil.
Handing it to him, he saw the eyes widen, saw the desire too. Hell, he could feel it. Until now, he had always been the top, the one to penetrate. Even back at summer camp, he had been the one to do it. Looking up at Neil, he felt the ache inside, knowing that this time, he wanted it as much as Neil had all those other times.
It wasn't like he had never bottomed before, but for some reason, he really wanted it this time. He had this strange ache in his ass, that made him squirm, as he watched Neil tear the condom package, and take out the thin plastic. How it seemed to sort of shine, in his hand, as he grabbed the tip and looked down at Jeremy. It was so different than any of the other times. Something about it had made him lick his lips, made his eyes widen, as Neil stared down at him, as he adjusted himself to sit between Jeremy's legs.
Everything felt suddenly quiet, still even. His heart seemed to be holding itself in check, as he glanced down his body, to see that large dick, to see the tiny white at the slit, as Neil reached down to grab hold of it. How big it looked, yet how much he wanted it. It didn't make sense, as he watched Neil unroll the condom slowly down the cock shaft. Least to him it seemed slow, and almost, sensual. To think, that was soon going to be inside of him, made him tremble a bit, made him a bit anxious too.
He had dicks before, but nothing like Neil's. Still he wanted it, could feel the desire in his body, as he spread his legs a bit, as his own cock was solid, like a rock, sticking up. They didn't say a word to each other, as Neil finished unrolling the condom, then looked up at Jeremy.
It was as if he was asking if Jeremy was certain, and his reply had been a soft whimper, as if, he couldn't wait. His body was trembling, as he lifted up his legs, pushing them apart, and reaching to hold them up high in the air, lifting his rear upwards, to give Neil a good view.
The sudden touch of Neil's fingers around his balls, the way they moved down from the top, between his cheeks, made him shiver. His thighs quivered, the muscles tightening, as he clenched his legs. The pain of being in that position ignored, as his eyes became a bit glazed over. His chest hurt too, as he held his breath, as he licked his lips for the umpteenth time.
The touch was soft as the fingers moved down and circled his hole, then disappeared. He heard Neil slurping, as if he was sucking on something, then he felt the fingers back at his hole, felt their moist tips, knowing that the sound had been Neil sucking on his own fingers.
The tip of the finger circled his hole, then it rested briefly over his hole, before he felt the soft press, the gradual increase of pressure, as Neil let his finger push inwards. He felt the muscles around his hole, felt them tighten, then suddenly he felt the finger sliding into him. He moaned, and shook a bit, as Neil continued to slowly push his finger in, until Jeremy could feel the press of Neil's hands between his cheeks.
He sighed, as the finger began to pump him, to go in and out, then twist around. His body continued to squirm, as Neil added a second finger to the first, stretching his insides a bit more. It felt snug, felt full, as he moaned a bit, as the fingers moved in and out. They didn't go fast, but in a steady in and out motion, that made him quiver a bit more.
His chest began to heave, as the fingers worked deep into his body, then out, then in. They moved from side to side, making him moan his pleasure as he felt the steady motion. Then it was suddenly over, as he felt Neil pressing up against his legs. He felt the hot breath across his face, and opened his eyes to see his face looming over his chest.
The way his short hair looked so damp, as if he had been in the river. How the eyes had a strange glint he had never seen before, that made him catch his own breath. How adorable he looked, really. The way his jaw was held so tight, the thin lines around it more pronounced. His nostrils were flaring as Jeremy felt Neil's cock sliding between his upraised buttocks.
It felt so hot, like a hot poker. He groaned as the huge cock was suddenly being pressed up into his hole. Jeremy could feel the muscles protesting, feel his nerves tingling, as Neil glanced down at Jeremy. How his eyes took on a totally different look, almost feverish. The way his cheeks were pulled inwards, as his small bony chest heaved with the effort.
Then he felt the pain, the sharp jabbing jolt that seemed to suddenly race up and down his spine. God how it hurt, yet didn't. It was all through his body, making his legs quiver, making his arms tighten their grip on his legs. How his own body suddenly became tense, wired with nervous energy.
The pain in his rectum made him groan loudly, made him bite his lower lip as Neil's dick pressed inwards, the head stretching him so much, he was certain his tiny little pink hole would be ripped apart, that it would need stitches or something to be put back together. He cried out, as tears welled up at the corners of his eyes, as the hard cock continued to press inwards.
He heard Neil grunt, heard his breath come rushing past, as a giant wave of pain came rushing into his body. He cried out louder, his body coiled tightly, as the cock head made its way past his tiny hole. He could feel it, feel the sudden tightening of it around the shaft, as Neil pressed inwards, driving his cock into Jeremy.
Slowly he felt his whole insides being filled, as the cock seemed endless. His body shook, his legs quivered, but he didn't want it to stop. The pain was harsh, more than he had ever experienced, yet as he squirmed, he couldn't help but feel the pleasure too. The way his body shuddered as sweat dropped from Neil's looming body onto Jeremy. It all made him feel it even more, as his eyes closed, as he let the moment take hold of him.
He had no idea how long it was, nor did he care. Each hard thrust into his body made him jump, made his body try to burrow into the soft ground beneath him. His legs ached, his arms were numb, as Neil seemed to be pounding him faster and faster. Each crushing blow, driving that thick long pole deeper and deeper.
Jeremy swore he could feel the pulsing vein under the shaft, as it dug deep into him. He could feel the head banging up against his insides, feel it reaching for his throat even, as he tossed his head from side to side, enjoying the pain that was now pure joy. How good it felt, as the hard pole continued to drive in and out of his body.
How good it all felt, as he heard his own cries mingle with Neil's. There was a strange thundering echo in his ears, which he knew had to be the wild beat of his heart, but there were other sounds too. The sounds of the river lapping onto the shore, the sound of the warm wind blowing through the trees above. There were the sounds of Neil's labored breathing, of his own.
They all joined together in one single chorus of noise, that echoed in his ears, that penetrated his mind, as the hard dick kept thrusting into his body. His whole body was shaking, and then he felt his cock being grabbed, felt the hand circle it and began to pump it, to stroke it.
Opening his eyes, he saw the wild look in Neil's face. How he was staring at Jeremy's cock, as he rocked in and out, as his whole body shook. His hand moved as fast as his hips did, in time with the deep thrusts of his cock. Jeremy couldn't believe the image, of how the hand was nothing but a blur, as his legs kept bucking. How the pleasure he was feeling inside, kept on growing, with each hard thrust.
His chest ached, his mind was in a fog, as his eyes opened wider, as the hand stroked his dick, as the cock inside pressed up into his body. Jeremy felt it coming, could feel how his balls were so full that he though they would burst. How hard they hurt as he heard the slapping sounds of Neil's bony groin slamming into him.
It was totally unreal, as their hot flesh met each other. How it felt like he was melting, as if his skin was becoming a pool of molten liquid. The way his whole body shook, as if in the middle of a giant earthquake. How the skin shook, from the wild force of Neil's crashing blows into him.
He cried out, as the pain in his groin matched that in his rectum. His balls seemed like giant balloons, as they were crushed by Neil's inwards thrusts. Then suddenly he felt it, crying out as he did. The rush of release was fantastic. It was like nothing he had ever felt before, as the hot cream left his balls, his cock shaft suddenly becoming even thicker. The blood was suddenly rushing from everywhere, to his dick. His eyes fluttered, the sudden sharp explosion of lights across them made him suddenly arch his whole body up, just as Neil crashed down into it.
The hand around his cock grew even tighter, as the head reared back, then shot forward. Jeremy felt the hot splash across his chin, then across his neck and down on his upper chest. He felt his mouth open, felt himself screaming, but heard nothing but a roaring crashing sound of thunder. His body shook, as if every single muscle had suddenly uncoiled, has sprung.
Just as he thought it was all over, he heard a distant cry, a distant scream. The fullness inside was suddenly gone, and as he felt his chest heave, he felt more splashes of hot liquid across his belly. He felt the muscles inside rumble, felt the nerves scream as the hot liquid burned his flesh. His whole body was once more convulsing, as the streams of hot cream splashed across his rolling stomach.
As the shaking slowly subsided, he managed to open his eyes, to see a blurred shape above him, slowly fall forward. He felt the weight on his whole body, felt the cooling liquid become squished between the falling body, and his own, felt the sudden beat of another drum near his heart. His eyes flickered, as the stars shone above the damp head that was resting on his own heaving chest.
Looking out at the growing light, Jeremy wished he was back at the river, that Neil hadn't gone back home. Maybe he could phone him, or something. He would know what to say, how to make him forget these last five weeks, as he remembered how good it had felt, to have his naked body on top of his. How good it had felt, as his softened cock finally was eased out from his own body.
Turning away from the window, he glanced around at the darkened bus. Everyone was in various positions of rest. Some had their mouths open, a few were even snoring as he looked at his classmates. They simply didn't get it, and he doubted if any ever would. Neil had gotten it, and so what if they teased him. He would always have that, which most of them never would.
He sighed, as his eyes met those of his ex friend, Roger. Jeremy could see how he wasn't asleep, how he was staring at him. Unlike the other times, he didn't lower his eyes, nor did he turn away, he stared back at Roger, daring him to make a comment.
Strange, but somehow thinking of Neil, remembering how it had felt, he didn't fear Roger or the others anymore. He felt different, as if he had something they just never would. Let Roger stare, let the others stare or make their comments. He was who he was, and if they didn't like it, tough shit. Neil had liked it, and he was certain others would too. The Roger's of the world suddenly, no longer mattered to him, or scared him.
Jeremy watched as Roger turned his eyes away, almost as if he had read Jeremy's mind, and Jeremy turned back to look out the window. It felt good, as he watched the sun beginning to rise up on the horizon. He no longer felt ashamed or afraid.


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Basically the question. Does the girl always have to make the first move here. Why don't you guys do it?
Most Helpful Guy
In this day and age, I always let the girl make the first move. I myself am nervous to make the first move because A.) What if she isn't ready for it, B.) If she isn't ready, how will she react, and C.) How will a negative reaction affect the both of us. I would much rather a girl tells me when she's ready and make the first move, instead of being rejected, and this is where being open and not playing games is strongly suggested. I wouldn't want to have sex with a girl whose not into it, and then have her feel upset or sad that she did something she was really on the fence about, that falls into the very grey area between consensual and rape. It's neither the Woman's or the Man's responsibility to make the first move, out dated and cliche ways say that the man should take the lead, but it's 2014, Women have a voice, as do men, so if you want something ask permission. Men aren't entitled to Women, and vice versa.10|10|0


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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
Notification sender displays : =?UTF-8?B??=Asked by charitychallenge on April 12, 2015 at 09:43 PM
Please see this form:
For form completed notification emails received from Jotform, the following shows up for the email sender:
=?UTF-8?B??= <firstname.lastname@example.com>
I have searched previous references to this problem and my situation is different.
I have checked and actually chosen a field for the Sender, but the above still displays.
Please advise.
JotForm Support
Hello charitychallenge,
I'm sorry for the trouble caused to you.
This is actually caused when you do not set the "Sender Email" address in the email alert. I did check your form's notification email alert and did not find any issue with that. Have you solved this issue already?
I did test your form by sending a test submission. The autoresponder email I received does display the sender details correctly. The submission emaisl sent to your email address also seems to display it correctly. Please check the screenshot below:
Can you please check the submission email you must have received and get back to us if the issue persists.
We will wait for your response.
Thank you!
Problem is still not solved. It is not the registrant email with the problem, but the Notification email to administrators. Notification emails from your registrations still show up with that prefix.
Please put your email address in as a recipient of notifications and then you will see the problem too.
Ashwin - the problem is the Sender name
JotForm Support
Hello charitychallenge,
I did few changes in your form's notification email alert. I also added my own email address in the conditions as well. When I tested your form, the sender name was sent correctly. Please check the screenshot below:
Can you test your form again and see if the issue persists.
Thank you!
Note: I have deleted my email address which was added in the condition.
Thank you
I'd like to know what you ended up doing to fix this.
The attached screen settings look no different.
JotForm Support
Hello charitychallenge,
I replaced the radio button question with a text box filed which you have set in your form to set teh Sender Name. Please check the screenshot below:
Thank you!
"I replaced the radio button question with a text box filed"
Okay - actually it was a check box (not radio button) that you replaced, but I see what you did.
I'm glad you told me - I use this approach on all other forms (without a problem), so I will change to text box fields for those forms as well in the future.
I am just interested to know why this suddenly caused a problem when it hasn't before. The inconsistency of why this suddenly caused a problem worries me.
JotForm Support
Hello charitychallenge,
Okay - actually it was a check box (not radio button) that you replaced, but I see what you did.
Sorry about that. I should have updated you on this in my initial response.
Though it should work fine with the check box question as well but I am glad that the text box option has worked for you. I am not sure why it was not working with the check box option earlier.
Thank you!


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|Page (1) of 1 - 11/04/04
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InDis Baltic Announces Online Image Editor (OIE) 2.0Release signals next generation online image editing (November 04, 2004)
InDis Baltic announces the release of Online Image Editor (OIE) 2.0. It enables content managers and editors to add and maintain photos, images or other graphical material directly from within their browser. The new version introduces significant new functionality, many changes, enhanced user interface and numerous new possibilities.
"This release makes OIE a powerful, versatile component and unique enhancement for any Content or Website Management System or actually even every internet user," says Peter Quintus, InDis Baltic General Manager. "The new features are especially exciting as it enables not only to simply edit an existing photo on a website but lets the user perform all possible activities with images, graphics or photos. It is like having an online version of Adobe Photoshop. The fact that we have been able to do this in a thin client and webserver independent solution is revolutionary."
OIE provides an easy-to-use user interface which enables users to quickly and painlessly edit or create images, photos or graphics. It also enables designers to create more complex graphics in a drag-and-drop environment. It dramatically reduces the time and development effort required for users to customize graphical content over traditional approaches.
Previously people needed to use either expensive graphical programs or slow, limited or clumsy, java or flash based online image editors to do some editing. With OIE all this can be avoided as the actual editing takes place on the user's own PC. This versatile solution enables people to quickly edit or create any graphical file with vastly improved performance and usability compared to traditional online editors.
Besides all the common functions graphical programs have, this release introduces new functionality including:
Layers - unlimited use of layers for text placement or inserting additional images or geometrical symbols.
Zoom - full support for zooming images.
Transparency - support for transparent gif and (even partial) transparent png formats.
Enhancements - properties bars allows quick and easy modification of options. Optional grid.
User interface - multilingual and changeable (size, available options to users, colours and fonts) to fit any CMS or website.
Faster performance - new optimizations greatly improve both load-time and runtime performance
An evaluation version of OIE 2.0 is available via http://www.indis.lt/OnlineImageEditor.asp
The license for OIE 2.0 is Euro 99,95 (excl. VAT) for an unlimited amount of users, CMS or websites.
About InDis Baltic
InDis Baltic is a daughter company of dutch-based InDis (http://www.indis.nl). Active since 1998 both provide the international and national market with optimised eSolutions.
InDis Baltic Pylimo g. 11-7 LT-01118 Vilnius Lithuania Tel +370 5 2395022 Fax +370 5 2395023
For more information: http://www.indis.lt.
Page: 1
Related Keywords:InDis Baltic, Online Image Editor, OIE, image editing, Peter Quintus,


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It has been a challenging year for Megyn Kelly. She has quickly lost the support of Fox News fans in her many desperate attempts to appeal to the mainstream media.
Her troubles began when she targeted Donald Trump during the Republican presidential debates. She has spent the majority of her air time since then trying to derail his campaign, but her efforts clearly failed.
Now, rumors are circulating that Fox News plans to fire Kelly and replace her with Judge Jeanine Pirro. The network is not willing to let her ratings drop further than they already have, especially after her recent altercation with New Gingrich.
Watch the video below and tell us what you think. Is Fox News making the right move in getting rid of Fox?


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Painted Plumage Set by Circle of Jan van Kessel from Tattly Temporary Tattoos
Wings down, these marvelous birds are bound to quill your friends with envy! Just add water to bring the Circle of Jan van Kessel's artwork to life.
Working with the National Gallery of Art in Washington, D.C., the Painted Plumage Set is our first set produced as part of a licensing partnership with an art institution. These stunning birds have been extracted from the intricately painted Study of Birds and Monkey (1660/1670) by the Circle of Jan van Kessel. Rendered in oil on copper, the rich autumnal colors and precise brushstrokes of this Old Master's artwork translate beautifully onto the skin. Learn more about our partnership in our interview with Gregory Jecmen, an Associate Curator of Old Master Prints and Drawings at the National Gallery of Art here.
The Painted Plumage Set contains two each of Birds in Flight (Detail), Bird of Paradise (Detail), Heron (Detail), Painted Peacock (Detail), a Tattly Sponge, and a card insert illustrating the paintings showcasing the natural environments in which the birds were depicted.
Tattlys are safe and non-toxic, lasting on average 2-4 days. We suggest placing on oil-free areas where skin does not stretch and keep them clean! Watch our Application Video to become a pro.
Designed by
Circle of Jan van Kessel
Antwerp, Belgium
Born into a family of painters and artists, Jan van Kessel (Flemish, 1626–1679) is most well-known for his small-scale depictions of flora and fauna. Inspired by Joris Hoefnagel's (1542-1600) scientific naturalism, van Kessel's paintings, and those produced by The Circle of Jan van Kessel, are recognizably by their bright colors and intricate detailing.
This Tattly is:
- • Safe & non-toxic
- • Printed with vegetable-based ink
- • Made in the USA
- • FDA-compliant and fun for all ages
More from Circle of Jan van Kessel
You might also love
- Pig Sold Out
- by Julia Rothman
- Premier Set
- by Tattly
- Tattone Sold Out
- by Josh Smith


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In seeing some of the comments and questions, I just realized something else that was wrong with the Series Finale and Season.
In the beginning, the following are on a plane together 1. Jack 2. Kate 3. Charlie 4. Claire 5. Sayid 6. Rose 7. Bernard 8. Desmond 9. Cindy 10. Sawyer 11. Artz (was he on there) 12. Frank (was he on there too) 13. John 14. US Marshall 15. Christian Shepard - in casket
These folks all were flying on a plane together. The island is sunk (which would have happened according the the final episode if the MIB got off the island). They talk to each other, they touch each other, they interact.
But then we go to the end of the season and they are all going to a church. That we have never seen before, that has no relevance to the story or the peoples experiences. But somehow they have built it as a place they would join together and go on to the new life.
HUH?????? That makes no sense at all.
If the island is sunk, they should be infected with evil, if we go by the importance of the island and what was happening when it was "uncorked". But somehow in never, never land, everything is fine.
They don't see each other on a plane that they are all together on AND was the catalyst for all of this, but they build a church. On the island, Eko and Charlie tried to build a church, but it was abandoned.
Oh, Writers, why did you have to ruin the show.


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Each month, Rated People connects over 50,000 homeowners with quality tradesmen - simply enter your job details in the form above to get started.
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Managing your job is easier with the Rated People Homes App, download it today.


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Texas Thoroughbred Association to host yearling sale in August
The Texas Thoroughbred Association will host a yearling sale at Lone Star Park in late August on a date to be announced.
The breed organization made the announcement Monday during its inaugural 2-year-olds in training sale.
It will be the first renewal of the auction put on by the TTA after Fasig-Tipton ended its partnership with the group following last year's juvenile sale. The auction was canceled in 2015.
The auction will be managed by Tim Boyce, who led the recent 2-year-old sale, and was previously the Texas sales director for Fasig-Tipton. Information on consigning to the sale will be announced at a later date.
"The TTA is committed to advancing the Texas racing and breeding industry, and part of that commitment includes giving horsemen a venue to buy and sell horses in this state," said Mary Ruyle, executive director of the TTA. "In advance of this decision, we found significant interest from Texas breeders with yearlings to consign, and with the central location and quality facility at Lone Star we also expect to attract quality consignments from around the region."


text: Janitor Adjust content blocking xxxlkxxx Channel: fmlposts next random Comment Top NextComment Tia Harribel is best waifu next Tags: FML Today, at lunch I was running tty my grawp' s table with my friend. She accidentally tripped me, and I slid across the cafe Fleur face first an my belly. The whale silent. They then brake put in hysteria when the head Janitor ran up tty me and yelled SAFER' like ll baseball umpire. PML 877965 1258) it definitely does! {SSH B) - you deserved it () . On / OB/ NOS' at 9: 42 pm - misc - by em (worn an) - Canada Ontario) Like yesh' . ... +1694 Views: 48484 Submitted: 12/07/2012 Facebook Twitter Google+ Tumblr Pinterest


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Looking at traveling to Santa Teresa the begining of December, and would like some knowledgable info on the weather at that time.
Looking at traveling to Santa Teresa the begining of December, and would like some knowledgable info on the weather at that time.
By the beginning of December it should normally be sunny and nice as it is part of our Summer season, however now a days it is very hard to tell about weather. Have a great trip!
Agree with Mike, should be fine. Weather in general is tricky here, but so far been a pretty dry year. Early December is one of the best times of year to come IMO. nice and green, good weather overall, and still before any rate hikes for Christmas. Have a blast.
I agree as well it should be nice and sunny. Have a great trip
In the last few years we have had some rains even late decembers...but this year with El Niño weather fact...maybe good cahnces to have dryer weather...around the end of November early Deecember...
The end of November and beginning of December is one of my favorite times because the dust has not started to blow around and the landscape is still very green and lush. If it does rain, it will be in the afternoon or evening. The mornings and early afternoon is usually very nice.
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text:
- Fanon: Many people believe that the father of Sonia's child was supposed to be Alucard. While there's no hard proof in-game, the two seem to be close and speak to each other affectionately, and in the best ending Sonia's child is stated to "carry on the fate and tragedy of the Belmont family, and the bloodline of dark ways." As for the dialogue:
Alucard: "Please understand. I am the only one who can make amends for the sins committed by my father, and there is no reason for you to get involved in this battle. Sonia, I could not bear to lose you, too. Now, turn back!"
(They fight, and then later...)
Sonia: "Alucard. I'm so sorry."
Alucard: "Do not trouble yourself about it, Sonia. Now, I must sleep. I fear we shall not meet again. Farewell, my beloved, my beautiful vampire hunter."
Sonia: "Alucard! Alucard, I will never forget you. Farewell, dear Alucard."
- Apparently confirmed by the game developers in a magazine feature.
- Life Isn't Fair: The general stance nowadays is that Legends was unfairly Vindicated by History thanks to the fact that this game came out months after Symphony of the Night and its status as a medium transfer to a portable console kinda destroyed the chances of people liking this game back then. Present day, the story is considered pretty good, the gameplay is at least passable, and the music is different but still good. Even if a player does not like the game, they will at least admit it does not deserve the hate it originally got.