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NASRO Member Services is your resource for NASRO information. Our office is staffed by the following individuals, Monday through Friday, 8:30am – 4:30pm CST:
Administrative Assistant, Emily Tarr (email@example.com) If you call the office, Emily is most likely the first person you will get. She can answer general questions or make sure that you are directed to the correct person. She is in charge of our memberships including invoicing, renewals and new memberships. She also works closely with the Training Coordinator with class registrations. She will help with conference registrations, invoicing and account receivables. Please feel free to contact Emily with any questions that you may have.
Executive Assistant, Janet Hyatt (email@example.com) Janet is the office manager for NASRO and maintains the office accounting records. She is in responsible for processing Practitioner applications, receiving and processing Award and Elections documents and anything concerning office procedures. She also works closely with Jennifer Thornton in processing Exhibitor applications as well as JOSS advertising contracts. Please feel free to call or email Janet with any questions that you may have.
Training Director, Kerri Williamson (email@example.com) Kerri works closely with the Executive Director, Host Agencies, and Instructors to ensure that training classes runs smoothly. She is responsible for scheduling trainers for our annual conference and securing writers for the Journal of School Safety. If you are interested in hosting a class, would like information about serving as a trainer at our conference, or are interested in writing for the Journal, Kerri is just a phone call or email away.
Training Assistant, Wodrian Adolphus (firstname.lastname@example.com) Wodrian works closely with the Training Director to ensure that registration for training classes are processed and that all classes receive their required supplies. She also assists with the scheduling of courses. If you have a question about a NASRO training, please give Wodrian a call or send her an email .
Chief Financial Advisor, Debra Stockhill, CPA. Debra prepares our monthly Financial Reports and works closely with the Board of Directors to create our Annual Budget and prepare for our annual Audit.
Please feel free to send us an email or give us a call.
NASRO Member Services
2020 Valleydale Road Suite 207A
Hoover, AL 35244


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Arthritis suffers often immobilize themselves to avoid joint pain and stiffness. What they do not realize is that immobilization can make the pain and stiffness worse. Although moving around may seem painful, as you continue to move your joints improve and the pain decreases. However, if you have immobilized yourself for long periods, it can get hard to get yourself going again. Fortunately, joint therapy can help you get back on the path of mobility. This specific type of therapy is often used to help arthritis sufferers and individuals that experience joint pain due to an accident, injury, or other type of joint trauma.
Joint therapy provides several options for the improvement of joint mobility and the reduction of joint pain. When you go to see a therapist for joint pain, he or she will mobilize your joints through a variety of stretches and exercises. For example, you may have to lay back on a surface while the therapist moves your legs in a bicycle motion. In addition, the therapist may also have you use various exercise equipment such as an elliptical machine. Many therapists now offer gameplay similar to the Nintendo Wii that promotes movement and fun at the same time.
Improving joint pain through joint therapy provides a number of different benefits. Not only is it a natural solution to joint pain, it also allows you to get back into the swing of things so you can take part in activities that you enjoy. Whether you like to ride bikes, walk, run, hike, or dig in your garden, you will certainly feel well enough to perform those activities. There is no reason why anyone should have to give up activities because of joint pain and stiffness. Keep in mind that giving up on those activities may actually increase your joint troubles.
While you will not be able to move around as if you have the body of a sixteen year old again, joint therapy can certainly aid you in movements that make you feel younger and even stronger. Lying around promotes stiffness and stiffness creates more pain. Although it might hurt at first to get moving, movement is definitely the key to recovery. If you feel that joint therapy causes you more pain, express your concerns to the therapist so he or she can change up the routine for something that is more comfortable for you to do.

subset: commoncrawl


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I was traveling with a school group and we took up most of the hotel. The rooms were clean. The dinner and breakfast were well prepared. The staff was accommodating but not what I would call friendly. The biggest issue we had was the heat....More
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Getting you more information on this room
"I was put on the 4th floor, and noticed no noise on a Friday night."


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Enterprise platform for marketers to drive top line revenue. Previously known as Bislr.
Footprint is a free real time website tracking and live traffic monitor.
Autopilot is leading in Top 10K Sites, Top 100K Sites and Top 1M Sites.
Autopilot has better usage coverage in more websites categories. Including Business & Industry, Internet & Telecom, Marketing & Advertising, Computer & Electronics and 69 other categories.
Footprint is leading in Arts & Entertainment, People & Society, Shopping, Music & Audio and 66 other categories.
Autopilot is leading in most countries, including United States, Australia, United Kingdom, India and 67 other countries.
Footprint is leading in Turkey, Romania, Ukraine, Ghana and 16 other countries.


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Tulip Stencil
$5.99 – $14.99
We have the best Tulip stencil template that is re-usable and works with a variety of canvases. Our stencils are produced from Mylar which is a reusable and washable material. You can apply our stencils for walls, fabric, and many different craft projects. Our Tulip stencils are offered in custom sizes if necessary.


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Friendly and kind staff, great location, nice swimming pool and horse riding facilities. The breakfast was delicious and also the food at the restaurant. The lady of the staff helped us in any needs. Highly recommended!
Getting you more information on this room
Getting you more information on this room
"apartments in the villa were the best, then apartments on top of the stables were nice"
"Apartments "Vinci" and " Bolghieri are good for families, big and well fittet."


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Epilepsy treatment needs more research, an expert has stated.
Delphine van der Pauw, a research and information executive at Epilepsy Research UK, said some causes of the condition remain undiscovered and the complex association between genetic disposition and environmental factors needs to be investigated.
Most sufferers take anti-epileptic drugs to control their seizures but resources should be devoted to finding a preventative measure, Ms van der Pauw believes.
"Studies have made promising findings about molecules that, if blocked pharmacologically, could potentially prevent seizure development but more research into these leads is needed before a preventative treatment becomes available," she added.
Her comments came after a report published in Neurology, the medical journal of the American Academy of Neurology, found babies born prematurely were more likely to develop epilepsy in later life.
The research revealed people born between the 32nd and 34th weeks of pregnancy were twice as likely to be admitted to hospital with the condition as those born full-term.


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Note: The Parks and Recreation Master Plan, adopted Nov. 5, 2012, includes plans for all Milton facilities. Click here to view the Executive Summary of the Plan. Click here for the full plan.
Bell Memorial Park
15245 Bell Park Road
An active-use park with four baseball fields, pavilions, picnic areas, parking, concessions and a playground. Hopewell Youth Association maintains the league through a use agreement with the City of Milton. Click here to learn more about the Bell Memorial Park Expansion project. Click here for the Field Rental Agreement.
Providence Park
13440 Providence Park Drive
Providence Park is now open to the public.
Fulton County's Board of Commissioners sold the City of Milton Providence Park for the $4,200 on Tuesday, June 2, 2015.
The park, closed 2004 and re-opened by they City of Milton in 2016, was owned by Fulton County since before the city's formation in December 2006. The 42-acre site includes a lodge, hiking trails, a rock-climbing cliff and a lake. Crews cleaned it for 11 years, finishing in 2015, after testing turned up contaminants in the ground water and soils.
The Georgia Environmental Protection Division now deems the clean-up complete, and Milton is more than happy to take possession of the passive-use park and return it to use for residents.
Milton re-opened the park to the public in November of 2016.
Bethwell Community Center
2695 Hopewell Road
The Bethwell Community Center houses City of Milton Parks and Recreation programs and activities and summer day camp. It is available for individual or group rentals. For more information, call 678-242-2489 or click here.
RENTAL INFORMATION: To rent the Bethwell Community Center, click here.
Broadwell Pavilion
12615 Broadwell Road
The Broadwell Road Pavilion features a 40-foot by 52-foot open pavilion with a large stone fireplace, restrooms and storage facilities.
The pavilion hosts the Milton Market (a weekly summer food trucks and farmer's market), the Milton Hometown Jubilee, Christmas in Crabapple and various other special projects.
RENTAL INFORMATION: To rent the Broadwell Pavilion, click here.
Birmingham Park
750 Hickory Flat Road
This 200-acre site, located behind Fire Station No. 43 at 750 Hickory Flat Road, is currently undeveloped but open for passive use (hiking, dog walking, or horseback riding). This park's master plan is complete and awaiting funding.
Freedom Park
13200 Deerfield Parkway
Freedom Park is an exercise center for the runners, cyclists and walkers on Deerfield Parkway and hosts the city's patriotic events. It features a .15 mile trail and equipment for sit-ups and body curls, a cardio walker, and rowing and elliptical machines.
Friendship Community Park
12785 Birmingham Highway
This 1.81-acre park is a joint venture with the the Fulton County School System. Located between Crabapple Crossing Elementary and Northwestern Middle School, it features a small picnic pavilion, walking path, half-court basketball and a play field.
Please note: The park is closed to the general public during active school hours, generally 7 a.m. to 4 p.m., on days school is in session. The children of the surrounding schools utilize the park during that time. To see days school is in session, click here. For more information, call 678-242-2500.
RENTAL INFORMATION: To rent the Freedom Park picnic pavilion, click here.
Thomas S. Byrd Sr. House
15690 Hopewell Road
The 2.5-acre site, which contains the nearly 4,000-square-foot, two-story home, dates back to at least the mid-1800s according to local historians.
Senior Services North Fulton occupies the home during normal business hours thanks to a 2012 agreement. When not in use by seniors, Milton will utilize the space for city-sponsored events and pursue facility rentals for special occasions.


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Basic Strong Heel Socks by Gerdine Crawford-Strong
Welcome! You are browsing as a guestWould you like to see 154 projects made from this pattern and much more? create a free account What am I missing?
Basic Strong Heel Socks
Errata available: knittinguniverse.com
This technique is ideal for self-patterning Fair Isle or striped yarn. You can continue with one skein of yarn without creating any distortion of the yarn pattern at the ankle or heel without switching to another skein. A free PDF variation of this pattern is available on the Knitting Universe website.
For more information, see: http://www.knittinguniverse.com/downloads/


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Denso plans to launch its answer to Ford's Sync voice-activated infotainment system in 2011.
Called Blue Harmony, the system allows drivers to manage music, directions, e-mail, Internet radio, news headlines and other infotainment options through voice commands. It is displayed on a touch-screen mounted in the center of the dashboard, according to Craig Matichuk, Denso telematics systems engineer.
Matichuk led the development of Blue Harmony from Denso's North American headquarters in Southfield.
The Blue Harmony system also allows users to customize the touch-screen layout, and download Denso-developed applications to run services like Pandora Internet radio, social networking Web site Facebook and photo sharing Web site Flickr.
Unlike some voice-activated infotainment systems on the market now, Blue Harmony does not require several specific prompts to play a particular song over the vehicle's sound system.
Instead, a Blue Harmony prototype demo at the 2010 North American International Auto Show allowed Matichuk to create a new station on customizable Internet radio station Pandora by saying "I want to make a new Pandora station."
The system is still under development and Denso is demonstrating prototypes to potential customers, which Denso senior public relations specialist Bridgette Gollinger declined to name.
The system is expected to go to production in 2011.
Visteon Corp. and Delphi Automotive L.L.P. are also developing competing technologies.
Courtesy: Crains Detroit.


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Need a Fertility Test in Camden, AR? Simply order online 24/7 and get a fast, affordable Fertility Test at a lab near you (Find More Locations):
Why would I get a Fertility Test?
A Fertility Test can help people in Camden, AR check for fertility through various blood and urine markers. A Fertility Test is part of a standard evaluation or as a precursor to in-vitro fertilization.
How much does a Fertility Test cost?
Our Fertility Test prices include the doctor's order that you need to get tested in Camden, AR, all lab fees and taxes, and a pdf copy of your results. For current prices, please CLICK HERE.
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Le Méridien Oran Hotel & Convention Centre
Les Genets, Chemin de Wilaya, Route 75, Oran, Algeria
Phone: (213)(41) 984000
4.0/5 33 reviews
Unexpected horizons of North Africa
Strategically placed between the Mountain of Lions and the Santa Cruz fort, Le Méridien Oran sets itself apart by its contemporary design, chic interiors and curated approach to arts, all intended to attract curious and open-minded guests.The Hub at Le Méridien Oran, which is the reinterpretation of the traditional lobby concept, creates a space that welcomes social interaction with inspirations of the brand's award-winning arrival experience and coffee culture.
Get these exclusive SPG® member benefits:
- Best Rates
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Explore the Middle East & Africa from May to September and save more when you book on SPG.com! Adventure or relaxation, cities or beaches, shopping or culture – choose your own experience.
- 20% off your room; SPG® members get 30% off!
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Lock in our lowest rates with up to 5% off, enjoy free Wi-Fi and earn Starpoints® on your next hotel stay at over 1,300 hotels and resorts worldwide.
Must be a SPG Member to qualify. Not a member? Join now!
Terms & Conditions
© 2017 Starwood Hotels & Resorts Worldwide, Inc
Rooms & Suites
Hotel Information
- Check in: 3:00 PM Check out: 12:00 PM
- Complimentary Parking For Guests
- Conveniently Located For Orans Attractions And The Business Area
- Largest Convention Centre In North Africa
- SPG Category 4
Hotel Features
- Seasonal Outdoor Pool
- Business Centre
- Choice Of Restaurants And Bars
- 35 Meeting Rooms
Restaurants & Bars
Enjoy Oran through the finest cuisine
Unlock flavors at wide choice of cuisines. We offer Italian, Mediterranean, regional and many more possibilities to enjoy dining with us.
All discounts are available at the outlets for SPG members® only. Please review full terms & conditions
- Favola
- Latest Recipe
- Chai Tea Room
- Royal Lounge
Latest Recipe
- Cost: $$
- Cuisine Type: International
- SPG Discount: 20%
- Hours Of Operation
Hours Of Operation
Meetings & Events
Your meetings in Oran
With 23 meeting rooms and the largest convention centre in North Africa, this is the right place to host your events
- 23 Conference Rooms Allowing Up To 35 Meeting Spaces
- From 2 to 3,000 Guests
- Dedicated Team Of Meeting Specialists
- Latest Conference Technologies
- Wide Range Of Catering Food And Coffee Breaks
- Join SPG Pro
Discover Oran
How to find us
Located between the Mountain of Lions and the Santa Cruz fort.


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Fashion Friday: Brands and their favorite apps l Digiday
With so many apps these days, brands can spread themselves far and wide. Which are best suited for ads that feel native to that platform? Here are three brands that made it work seamlessly on their platform of choosing. VISIT us: http://www.digiday.com LIKE us on FACEBOOK: https://www.facebook.com/digiday FOLLOW us on TWITTER: https://twitter.com/Digiday FOLLOW our INSTAGRAM: https://instagram.com/digiday/


text: Photos (1) Map and Directions Street View Commute Time Walk Score Driving Walking Transit Get Directions Close No driving directions were found. Please adjust your search. To: From: Via: Directions turn left on street 4 minutes 2.5 miles Driving Directions - View this Property Today - Well established 1073 sq ft Commercial space Massage studio. Prime Location - Condominiums, schools, transportation, High-traffic Kingsway Exposure! Hundreds of existing & upcoming residential units within a couple of blocks. 4 clean working rooms with sink. One shower room and one laundry room. Monthly rent fee $3,500 plus GST. Please call listing agent for more details, showing by appointments only! Please do not disturb staffs. Property Details ID: C8008212 Storeys: 0 Style: Other New Construction: No Status: Active Living Area: 1,073 Features Lease Per Unit square feet Other Fireplace Present - False Transaction Type For sale Listed By Sutton Grp-West Coast (Van49)


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BRAZIL: Biodiesel production capacity increases
Brazil will be able to produce enough biodiesel to meet requirements for a 2% compulsory blend with regular diesel from 2008, according to Reuters.
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Robert was born on November 15, 1941 in McVille, North Dakota.
He lived from 1945 to 1955 in Stoughton, Wisconsin.
From 1955 to 1962 he lived in Phoenix, Arizona.
Since then he has also lived in Minneapolis, Minnesota; San Francisco, California; New York City; Hartford, Connecticut; and Saint Paul, Minnesota;
He married and fathered the following daughters and sons.
- Daughter Christina Thais Tolo
- Son John Robert Tolo
- Son David Michael Tolo
- Son Mark Daniel Tolo
- Son Benjamin King Tolo
- Daughter Yesha Shalom Proctor
- Son Christopher Denis Tolo
- Daughter Maria Teresa Petric


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comfortable and neutral enough Alya Chrome Bar Stcombines class, style and a touch of modern lines for a very clean look.is a stylish bar stool with a comfortable upholstered seat and backrest on chromed steel legs which are plastic tipped. Aseat is upholstered with a removable velcro enclosed leatherette, (5 Year warranty).
- Suitable for both residential and commercial use.
- Available with strengthened side stretchers
- Steel frame molded by injecting polyurethane foam
- Seat has a steel structure with
- Shape springs for extra flexibility and strength
- Upholstered with a removable velcro enclosed leatherette, PPM, leather
- Colors:Black,White,Blue,Red,Cream, Brown
Bar chair: 16" w | 21" d | 41" h | Seat h 29"
MobiliModern was founded in 2005 with the idea that furniture should be inspiring, exciting and durable. All of the furniture is designed and manufactured with unique commercial grade designs. The main goal of MobiliModern is to provide high quality modern furniture that is both inspirational and exciting. The company is specialized in hospitality projects, however we also provide all seating in general. We promise to always perform best we can to ensure that our integrity will not be compromised.
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Bar & Counter Stools
An extensive selection of bar stools will fit not only your home, but office or restaurant as well. Browse from number of styles and options to equip your bar area or kitchen with barstools and counter height chairs. Our online store proffers stainless steel, wood, plastic, adjustable height, backless, mid century or modern bar and counter stools. Create the bar area of your dreams with our high quality stools.
We can provide even the hard-to-please shopper with so many options for bar area as possible here, at ModernManhattan.com. Thus we offer a vast selection of pub and bar tables at affordable prices from reliable brands. Find the exactly one right for your kitchen or dining room, whether it's counter height chair, backless or uniquely shaped stool.


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ack and Caroline are a couple making a decent living When Jack suddenly loses his job. They agree that he should stay at home and look after the house while Caroline works. It's just that he's never done it before, and really doesn't have a clue...Overview from themoviedb.org
<> Free subtitles & video converter from freemake company


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Preparing for the workforce is essential for people of all ages, and for a successful future. These programs are aimed at increasing employability of participants, especially young adults, by teaching them important skills to succeed in the workforce and to find permanent or temporary employment.
Workforce Development Skills At United Way
Click the links to learn more about Workforce Development Skills programs funded by United Way, and to see the Stories of Change made possible by the generosity of so many in our community. Thanks to you, we are Community Strong.


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This summer we introduced a new fine art weekly camp theme: mural making. We selected a variety of projects that let the kids work with many different mediums, as well as projects that offered the opportunity to work together as well as on their own.
Here are some of the individual landscape murals that were done early in the week.
The culmination of the session was this collaborative mural, done on the last day of camp. Our 1st-2nd grade section kids all worked on it as a team.
First they had to brainstorm to come up with a theme. Outer space won out, and the challenge was on.
This project was a great lesson in procedural thinking, with the kids needing to figure out how to build the image from the background out.
They decided to paint the background first, and then glue on images they created and cut from colorful construction paper.
Once again they brainstormed, coming up with images that would work for the mural's theme.
The kids had to determine what colors and designs would be used to give the mural a cohesive outer-spacey look. A big discussion centered on how many rocket ships would be appropriate to have. Answer: 2.
This mural will remain at The Messy Artist until we need the wall space, a lasting reminder of summer, and kids creating art together!


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Is there any way to combine flat rate and UPS shipping? I would like the customer to be able to select the speed of the shipping, but to skip the whole quote-getting process. So the customer would always see:
UPS Ground: $5 (or maybe even Free shipping!)
UPS 2nd Day: $10
UPS Next Day: $20
This would then link to the appropriate back-end systems where we can print the right labels and arrange the right speed shipping, etc.
I think that for smaller sized purchases this could be the simplest way to handle shipping, both for us and our customers.
Let me know if this is already possible or would be easy to accomplish...


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Way of the Cross in Stone cross shaped by Bethleem. 15 stations made of stone dust and resin, each station measure 63x39 cm. These stations of the Cross are finely hand crafted by the nuns of the Bethlehem monastery in France. This great artwork of the Bethlehem monastic family is crafted in their unique style combined with simplicity and spirituality.
- Model: VS000063
- Shipping Weight: 2Kg
- Materials: stone, resin
- Origin: France
- MEASURESUnits:
- Height: 27 cm
- MEASURESUnits:
- Height: 10.63 in


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What advice can you give me?
I had 2 dates with a guy named Evan from Taiwan. We met on POF. I allowed him to fall in love with me. I kissed him both dates but knew he wasn't right for me. So after date 2 I ended it before it got too deep. He's kinda devestated and has never had a broken heart like this. He kept asking me for reasons, for his own peace of mind. The reasons I gave don't work for him and he now hates me, wishes I get heart broken like him, and thinks I am pathetic. Mostly because the reasons I gave were superficial and had to do with looks or culture and me not liking him as much as he likes me.. And yearning for the brazillian ex of mine who I can't stop thinking about. i feel shitty I just crushed another human heart for selfish reasons... But would it have been more wrong to stay with him for petty? I am confused on how to walk alway from this without feeling like a ruined someone's life.
Most Helpful Guy
Well u actually did the right thing from walking away early so as to no let him fall deeper in love with you. Feeling bad about it is natural, maybe you could get him hooked up with a friend of yours ti make him feel better?
As for wrecking his heart, he just has to gradually come to accept it on his own terms. What u did, you did it for his own good.00|00|0
Most Helpful Girl
You didn't ruin his life, he'll find someone else. Though you should feel guilty since you basically led someone on. Yes it would have been worse to stay with him out of pity, but you shouldn't have dated him at all since you didn't feel a spark and you're not over an ex yet. So pointing out an even worse option doesn't justify the path you chose.
Learn from this experience.00|00|0


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Natural Gas Daily North America Policy & Regulation
Oil and gas production lowering US emissions – Moniz16 August 2016
Increased oil and gas production in the United States is helping reduce carbon emissions, Energy Secretary Ernest Moniz said on Monday.
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Nippon Telegraph and Telephone Corporation (NYSE: NTT), is firmly in the large market cap category with market cap of 92433.76. To be considered a large market cap stock companies have to be valued at more than $10 billion. The current price for Nippon Telegraph and Telephone Corporation is 44.88 (with a change from open of 0.13%), this in conjunction with a target price of 57.25. Volume today has so far reached 183248, with an average volume of about 321.19. The GAP for this stock, is 0.74%.
The P/E ratio is 12.09, bringing the forward P/E to a value of 11.18. The current EPS for Nippon Telegraph and Telephone Corporation, is 3.68, with a EPS growth for this year coming to a value of 47.90%. Performance has been interesting with performance year to date coming to 11.95%.
Looking further into the growth statistics for Nippon Telegraph and Telephone Corporation, EPS is looking like it will grow 12.27% in the next year. Looking even further it is projected to be 9.50%. Quarter over quarter is 27.90% for EPS growth and for sales growth quarter over quarter it is 0.40%. Looking at past EPS growth statistics we see that for the past five years it has been 12.70%. Sales growth for the past five years has in fact been 2.30%.
Looking at the ownership, we see that the insider ownership is at 41.00% and institutional ownership is 1.40%. Shares outstanding is 2077.63, while shares float is at a value of 837.69. Float short for Nippon Telegraph and Telephone Corporation is 0.05% and the short ratio is 1.37.
In terms of debt, long term debt/equity is 0.4, while the total debt/equity comes to 0.51. The ability to meet these debts, means that the current ratio is 1.4, and the quick ratio is 1.3. The most recent gross margin is 51.30% and their operating margin is 12.80%. The profit margin is 6.80%.
Nippon Telegraph and Telephone Corporation has seen returns on assets of 3.80%, and on investment, 7.60%. Return on equity is 9.00%. Price/Earnings to growth ratio is 1.27. Price/Sales ratio is at a value of 0.82, with Price/book ratio coming to 1.1 and Price/cash is 10.84, and finally Price/Free cash Flow is 10.85.
The simple moving averages are -3.74% and 2.43% for 20 day and 200 day simple moving average respectively. For the 52 week high and low the 52 week high is -9.64% and the 52 week low is 32.66%.
Nippon Telegraph and Telephone Corporation has a dividend yield of 2.65%, with a current price of 44.88. The ability to pay this means the payout ratio is 29.30%. This is in an industry, Telecom Services – Foreign, with equally high dividends from other companies in this sector, which it is Technology. Nippon Telegraph and Telephone Corporation is based in Japan.
Performance in the Telecom Services – Foreign industry means that Nippon Telegraph and Telephone Corporation has seen performance for the past week of -0.36%, with performance for the month coming to -7.31%. Looking at the data for the quarter it is at a value of 4.90%, and for the half year the performance is 22.02%. Volatility for this week is 1.14% and for the month this is 0.93%.
Disclaimer: Remember there is a risk to your investment, this is not a recommendation, nor personal advice, never invest more than you are able too loose.


text: 2. As of noon trading, Gap ( GPS) is down $0.76 (-2.3%) to $32.12 on average volume Thus far, 2.7 million shares of Gap exchanged hands as compared to its average daily volume of 6.0 million shares. The stock has ranged in price between $32.04-$32.90 after having opened the day at $32.83 as compared to the previous trading day's close of $32.88. The Gap, Inc. operates as a specialty retailer. The company offers apparel, accessories, and personal care products for men, women, children, and babies under the Gap, Old Navy, Banana Republic, Piperlime, and Athleta brand names. Gap has a market cap of $15.8 billion and is part of the retail industry. The company has a P/E ratio of 16.1, below the S&P 500 P/E ratio of 17.7. Shares are up 5.9% year to date as of the close of trading on Friday. Currently there are 9 analysts that rate Gap a buy, 2 analysts rate it a sell, and 11 rate it a hold. TheStreet Ratings rates Gap as a buy. The company's strengths can be seen in multiple areas, such as its increase in net income, revenue growth, solid stock price performance, expanding profit margins and good cash flow from operations. Although the company may harbor some minor weaknesses, we feel they are unlikely to have a significant impact on results. Get the full Gap Ratings Report now. It's Official: Action Alerts PLUS beats the S&P 500 with Dividends Reinvested! Cramer and Link were up 16.72% in 2012. Were you? See what they are trading for 14-days FREE


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How to Boost the value of your home in Boonville MO
Boonville is a wonderful community and the team at Mastertech Plumbing Heating and Cooling is proud to be a part of such a wonderful community. We're more than the local plumber – we're active neighbors that both promote and participate in all the area has to offer. The commercial hub and center for government in Cooper County, Boonville has an active tourism trade, as well as thriving agriculture and manufacturing activity. This safe, friendly city has a wonderful small town vibe that makes its real estate a sound investment.
Boonville MO has a history dating back to the times of the American Civil War. These roots have made the area a buzzing center for cultural events and festivals that bring the community together. Anyone looking to experience the Frontier lifestyle will enjoy some of the activities and experiences offered in the area. Besides this, Boonville by virtue of its enviable location near Katy Trail, is a popular destination for cyclists and serious hikers alike.
Boonville has a sound education system with top-notch elementary, middle and high schools to serve the community. Residents also engage actively in activities of the many churches that knit the region together.
To make your home stand out from the others in the area, like other savvy homeowners, you may want to consider giving it some smart makeovers in areas that matter. Boosting the value of your home may be simpler than you think.
Our Plumbing Heating and Cooling services can simplify your home makeover
Mastertech offers Air Conditioning repair, as well as Plumbing and Heating related services. Our quality of work is relied upon by many long standing members of the community. While a buyer frequently plans on some renovation expenses for personalizing the interiors and making it look more like they want it to, they expect the basics to be in place. By ensuring your home's plumbing and heating is in working order, you are likely to be able to command a higher asking price and win the confidence of the buyer. A hassle-free option is to utilize the services of a professional air conditioning, heating and plumbing services firm like ours. We, at Mastertech can take on your home renovation needs in these areas and ensure your home draws the buyers it deserves.
Call us for air conditioning, heating and plumbing renovations in Boonville MO
Get in touch with us to schedule a consultation for your AC repair, plumbing and heating renovation jobs. Call our customer service team at and allows us to help you boost the value of your home.


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Endicott - Kid Creole and the Coconuts MP3
Original video from Kid Creole and the Coconuts for Endicott. Not sure why this wasn't on Youtube so I posted it.
Day in the Life Endicott Men's Lacrosse MP3
Kid Creole & the Coconuts - Endicott 1985 MP3
Kid Creole & the Coconuts - Endicott 1985 Endicott's up by five o'clock, Endicott's givin' all he got Endicott's job is six to nine but Endicott's home by nine o'five ...
Endicott Admission Video MP3
Discover Endicott, a four year, co-educational, independent college located in Beverly, Massachusetts, 20 miles north of Boston, the college 'capital' of the world.
Lynchburg vs Endicott | 2015 College Lacrosse Highlights MP3
www.lax.com - In a match up featuring two of the top ten teams in Division Three college lacrosse, the Endicott Gulls hosted the Lynchburg Hornets at Endicott ...
Kid Creole & The Coconuts - Endicott MP3
Endicott, from The Leisure Tour. Recorded in 1985.
Tufts Lacrosse vs Endicott [ 2015 Highlights ] MP3
Tufts Lacrosse vs Endicott College [ 2015 Highlight ] Discover more unique NCAA college lacrosse highlights and lacrosse films here: http://jumboslax.tv Music: ...
Kinser Endicott at Fingerlake MX | Soul id MP3
Check out Motocross on Soul id: https://soulid.me/id/Motocross Team Soul id visited pro motocross rider Kinser Endicott at his home track Finger Lake MX.
Endicott Kid Creole & The Coconuts MP3
Kid Creole & The Coconuts. Live in 2009.
Endicott College Men's Soccer 2014 ECAC Champions MP3
Endicott College defeated Colby-Sawyer College in the ECAC Division III Mens Soccer Championship.
Tufts Lacrosse vs. Endicott [2014 Highlights] MP3
Tufts Lacrosse vs Endicott [2014 Highlights]. Discover more college lacrosse highlights and films: http://jumboslaxtv.com/ Music: "Lost and Found" by Pretty ...
Professor Timothy Endicott, "Interpretation and the Rule of Law" MP3
The Coxford Lecture series presents Professor Timothy Endicott, Dean of Oxford Law. March 28, 2013.
Quincy Endicott I Over The Garden Wall I Cartoon Network MP3
Is millionaire Quincy Endicott?s sprawling mansion haunted by a beautiful ghost, or is the tea baron going mad? Greg and Fred the Horse are on the case!
14 Year Old Calvin Endicott Dirt Late Model MP3
The 14 year old Calvin Endicott, wheeling the #7 Dirt Late Model for his very first time at practice. At Beckley Motor Speedway in Wv.
Endicott College Baseball MP3
Endicott College Baseball Promotional Video 2014 (2014 CCC Championship) A big thanks to the Endicott Baseball players and coaches for cooperating in the ...
MLAX: Endicott Men's Lacrosse Webrecruiter MP3
The sights and sounds of the Endicott men's lacrosse experience.
Les novices de Pina Bausch : rencontre avec Jo-ann Endicott MP3
En 2008, quelques mois avant sa mort, Pina Bausch propose à Jo-Ann Endicott, l'une des plus anciennes danseuses de sa troupe, de reprendre avec ...
Endicott Gulls Football Pump-Up Video 2014 "Jungle" MP3
I do not own the rights to the song "Jungle"
Endicott College Drive Through 2013 MP3
Endicott College Cheerleading Blast Off 2014 MP3
Basketball Blastoff Performance 2014.
2015 Endicott Football Season Preview MP3
Endicott Dance Team Open Jazz UDA Regionals 2015 MP3
via YouTube Capture.
14 Year Old Calvin Endicott Dirt Late Model MP3
The 14 year old Calvin Endicott, wheeling the #7 Dirt Late Model for his very first time at practice. At Beckley Motor Speedway.
Gary Wilson - She Makes Me Think Of Endicott MP3
LP: Mary Had Brown Hair (2004, Stones Throw) http://www.stonesthrow.com/garywilson ...
Endicott Men's Volleyball 2015 MP3
Video for the Endicott Men's Volleyball Team 2015! Good Luck at NCAA's boys! For a Sports Media assignment Made by Lauren Sheehan.
Endicott Men's Ice Hockey 2015-16 Season Preview MP3
Endicott men's ice hockey head coach RJ Tolan previews the upcoming 2015-16 season for the first-year NCAA varsity program.
UMass Boston Baseball vs Endicott College Highlights (4/27/15) MP3
After falling behind 6-1 in the top of the fourth, UMass Boston baseball came back to earn an 8-7 walk-off victory over regionally-ranked Endicott College.
2015 Endicott Men's Soccer Season Preview MP3
Uncle Monk "Mr. Endicott" MP3
Uncle Monk performing "Mr. Endicott" at Music City Roots live from the Loveless Cafe on 6.15.2011.


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text:
Audubon Zoo
Audubon Zoo is home to three endangered Sumatran orangutans. The youngest member of the troop, Menari, was born at the Zoo in June 2009. While Menari is a New Orleans native her mother, Feliz, came from Brownsville, Texas, and Berani, her father, came from the Miami Zoo. The last orangutan birth at the Zoo (before Menari) was Blaze, who arrived in 1996.
Menari's birth was a heralded event because Sumatran orangutans are a critically endangered species. Their wild population has been reduced by 50% since 1993 but there is hope. To help this species, Audubon participates with AZA's Wildlife Conservation and Management Committee (WCMC) that manages over 500 cooperative Animal Programs, including Taxon Advisory Groups, Species Survival Plan® Programs (SSP) and Studbook Programs. These Animal Programs, in coordination with significant contributions from AZA Scientific Advisory Groups, Institutional Liaisons and Institutional Representatives are responsible for the extraordinary leadership, development, oversight, promotion, evaluation and support of AZA's cooperative animal management, conservation and scientific initiatives.
Audubon Zoo's involvement with these initiatives covers 110 species including Menari and her orangutan family. Menari is growing into a healthy, active youth and can be seen playing with her parents in the Asia exhibit.


text:
It seems all is well for Anushka Sharma's 'NH 10', which has reportedly been passed with an 'A' certificate.
According to a report in a leading daily, the Examining Committee of the Central Board of Film Certification (CBFC), who had split over the certification of Anushka Sharma starrer 'NH10', has now passed the film with an adult certificate after a Revising Committee gave them the green signal.
'NH 10' was denied certification earlier due to plenty of violence and abusive language.
However, when the film was screened to the Revising Committee they passed the film without much edit. Producer Anurag Kashyap confirmed the same to the leading daily. "NH10 has been passed with a few audio cuts and a video cut that does not damage the film at all. They saw it completely in context and even appreciated it. It was a very reassuring revising committee," quoted Kashyap, the co-producer of the film.
Added his business partner, Vikas Bahl, "The RC's decision was unanimous. They understood what we were talking about and saw the larger picture. Even the visual cut was minimal. The scene was retained, we were just told to edit it a bit. And many of the cuss words too have been retained."
Directed by Navdeep Singh and produced by Eros International, Anushka Sharma and Phantom Productions, 'NH 10' also stars Neil Bhoopalam and Darshan Kumar in the lead.
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text:
What Is The Name Of The Prophets (pbuh) Cat?
Posted 21 October 2010 - 08:11 PM
There is a hadith that one day the Prophet (saws) heard the Adhan and was preparing to go to masjid when he noticed his cat sleeping on the sleeve of his shirt. So he cut off the sleve and left the cat alone to not wake it. He went to the masjid and did his prayers. When he came back the cat was so grateful that it bowed and the Prophet (saws) pet him on the head three times.
It goes something like that. Well, do you know the answer?
Salaam alykum
Posted 02 December 2010 - 01:03 AM
wow i didnt know the Prophet kept cats though i had read that Fatima (R.A) used to have cats.
tell us the answer
Posted 03 December 2010 - 05:16 PM
I googled it and found it to be Muezza. But I did not find any reference in those articles or blog posts.
May be someone here can consult a reliable source and inform us.
Edited by In War with me, 03 December 2010 - 05:18 PM.
Posted 03 December 2010 - 11:08 PM
Yes that is it!! DING DING DING!! His (or her) name is Meuzza Sorry IDK if it was male or female hahaha
Walaykumussalam warahmathullahi wabrakathuhu.
I googled it and found it to be Muezza. But I did not find any reference in those articles or blog posts.
May be someone here can consult a reliable source and inform us.
Hmmm I can not recall where I got that hadith from. But it is one of my favorite hadiths hahaha
I am pretty sure it is authentic but as always we should make sure.
Posted 09 December 2010 - 12:14 PM
Posted 03 February 2011 - 08:02 AM
Posted 26 February 2011 - 02:13 AM
Posted 11 April 2011 - 07:18 AM
Posted 02 June 2011 - 05:37 PM
Posted 02 June 2011 - 06:18 PM
Posted 02 June 2011 - 06:23 PM
Posted 03 June 2011 - 05:24 PM
Posted 04 June 2011 - 11:35 AM
Edited by In War with me, 04 June 2011 - 11:36 AM.


text:
- Gulf of Siam
- geographical name see Thailand, Gulf of
New Collegiate Dictionary. 2001.
New Collegiate Dictionary. 2001.
Gulf of Siam — noun an arm of the South China Sea between Indochina and the Malay Peninsula • Syn: ↑Gulf of Thailand • Instance Hypernyms: ↑gulf • Part Holonyms: ↑South China Sea … Useful english dictionary
Gulf of Thailand — The Gulf of Thailand (or Gulf of Siam) is a gulf that borders, but is not part of the South China Sea (Pacific Ocean). The gulf is bordered by Cambodia, Thailand and Vietnam. The northern tip of the gulf is the Bay of Bangkok at the mouth of the… … Wikipedia
Gulf of Thailand — noun an arm of the South China Sea between Indochina and the Malay Peninsula • Syn: ↑Gulf of Siam • Instance Hypernyms: ↑gulf • Part Holonyms: ↑South China Sea … Useful english dictionary
Siam, Gulf of — geographical name see Thailand (Gulf of) … New Collegiate Dictionary
Siam, Gulf of — part of the South China Sea betw. the Malay Peninsula and Indochina … Webster's Gazetteer
Siam, Gulf of — … Useful english dictionary
Thailand, Gulf of — formerly Gulf of Siam Inlet of the South China Sea. Mostly bordering Thailand, though Cambodia and Vietnam form its southeastern shore, it is 300–350 mi (500–560 km) wide and 450 mi (725 km) long. Thailand s main harbours lie along its shores,… … Universalium
Thailand, Gulf of — or formerly Gulf of Siam geographical name arm of S China Sea between Indochina & Malay Peninsula … New Collegiate Dictionary
Siam (Thailand) — Siam † Catholic Encyclopedia ► Siam Siam, the land of the White Elephant or the country of the Muang Thai (the Free), is situated in the south eastern corner of Asia, lying between 4° and 21° north lat. and 97° and 106° east long. It… … Catholic encyclopedia
gulf — gulflike, adj. gulfy, adj. /gulf/, n. 1. a portion of an ocean or sea partly enclosed by land. 2. a deep hollow; chasm or abyss. 3. any wide separation, as in position, status, or education. 4. something that engulfs or swallows up. v.t. 5. to… … Universalium


text: Today I paid $1.28/gal. for diesel. My price has dropped dramatically over the past month. Are any of you seeing the price of fuel go down. Also the price for 87 octane was $1.32. These are the lowest prices I have seen since last spring. Are any of you experiencing lower fuel cost?


text:
Staff was very courteous and the location was perfect.
Great host,s comfy room thank you for the upgrade , and very pleasant lovely breakfast thanks will stay again . What isn't there to like great host great location parking a bit of a bug bear but hey you can't have everything


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Coconut Creamed Corn
Creamed corn goes tropical with coconut milk, cilantro and lime juice. We love this with the kick of crushed red pepper, but it's great without it if you don't enjoy spicy food. Try it with garlic-rubbed grilled flank steak and a vinegary Asian slaw.
TOTAL TIME: 20 min
- 4 ear(s) corn kernels cut from cob
- 1 cup(s) coconut milk, light
- 1/4 teaspoon salt
- 2 tablespoon cilantro, fresh chopped
- 1 tablespoon lime juice
- 1/4 teaspoon pepper, red, crushed (optional)
1. Combine corn kernels, coconut milk and salt in a medium saucepan.
2. Bring to a boil, then adjust the heat to maintain an active simmer.
3. Cook, stirring occasionally, until most of the coconut milk has evaporated, 12 to 15 minutes.
4. Stir in cilantro, lime juice and crushed red pepper, if using.
Nutrition Detailsper serving
Calories 148, Fat 5g, Cholesterol -, Sodium 178mg, Saturated Fat 3g, Protein 5g, Fiber 3g, Carbohydrates 24g


text:
Ageing in general practice (AGP) trial: a cluster randomised trial to examine the effectiveness of peer education on GP diagnostic assessment and management of dementia
Dementia is increasing in prevalence as the population ages. An earlier rather than later diagnosis allows persons with dementia and their families to plan ahead and access appropriate management. However, most diagnoses are made by general practitioners (GPs) later in the course of the disease and are associated with management that is poorly adherent to recommended guidelines. This trial examines the effectiveness of a peer led dementia educational intervention for GPs.
The study is a cluster randomised trial, conducted across three states and five sites. All GPs will complete an audit of their consenting patients aged 75 years or more at three time points - baseline, 12 and 24 months. GPs allocated to the intervention group will receive two educational sessions from a peer GP or nurse, and will administer the GPCOG to consenting patients at baseline and 12 months. The first education session will provide information about dementia and the second will provide individualised feedback on audit results. GPs in the waitlist group will receive the RACGP Guidelines by post following the 12 month audit
Outcomes: Primary outcomes are carer and consumer quality of life and depression. Secondary outcomes include: rates of GP identification of dementia compared to a more detailed gold standard assessment conducted in the patient's home; GP identification of differential diagnoses including reversible causes of cognitive impairment; and GP referral to specialists, Alzheimers' Australia and support services. A "case finding" and a "screening" group will be compared and the psychometrics of the GPCOG will be examined.
Sample size: Approximately 2,000 subjects aged 75 years and over will be recruited through approximately 160 GPs, to yield approximately 200 subjects with dementia (reducing to 168 by 24 months).
The trial outlined in this paper has been peer reviewed and supported by the Australian National Health and Medical Research Council. At the time of submission of this paper 2,034 subjects have been recruited and the intervention delivered to 114 GPs.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12607000117415.
Importance of dementia as an issue
Dementia is an increasingly common condition largely due to increasing longevity of the population in Australia, and other countries. Approximately 1 in 5 Australians over the age of 80 have some form of dementia
Dementia is associated with substantial economic, social and emotional burden. The disease is costly in terms of the need for support services whether sufferers live at home or in residential aged care, as well as in terms of lost productivity for carers and people living with dementia
The role of the GP in identifying and managing dementia
General practitioners (GPs) appear well positioned as the first point of contact for older persons seeking health care, including those living with dementia. In the decade between the 2000 and 2010, the number of patients aged under 45 years seen annually by GPs increased by 190,000, whereas the number of patients aged 45 years and over increased by 16 million
General practitioners often make the diagnosis of dementia some considerable time into the course of the disease
General practitioners often fail to identify dementia early in the course of the disease and also adhere poorly to published dementia guidelines
Addressing barriers to diagnosis and guideline adherence
Both qualitative and quantitative research suggests a range of reasons for late diagnosis and otherwise poor adherence to guidelines by GPs
Screening vs case finding as a means of identifying dementia
In general, medical advisory groups and policy makers recommend case finding (further testing only for those who are perceived by the GP as having symptoms suggesting possible dementia) rather than broadly screening persons over a certain age for dementia
Rationale for the educational intervention
This trial addresses the problems outlined above with an interactive educational intervention for GPs, which is described in detail below. The education includes visits by a peer health professional educator and an audit with feedback. The small positive effects of educational meetings
Aims of the study
1. Compared to a GP group which does not receive peer delivered education, to examine whether training in and use of a dementia screening instrument and relevant information (see
i. GP identification (diagnosis) of dementia
ii. Distinction by GPs between dementia and other diseases, including depression (hereafter termed "differential diagnosis")
iii. GP elimination of reversible causes of cognitive impairment
iv. Active management of dementia by GPs as evidenced by increased referral to appropriate services, to Alzheimer's Australia and/or to medical specialists for memory problems where indicated.
Outcomes for consumers and their support people in terms of quality of life (primary outcome), depression (primary outcome), satisfaction with care, and access to Alzheimer's Australia, appropriate services or specialists when indicated.
2. To determine whether a screening or a case finding approach to dementia results in:
i. better outcomes for people with dementia and their carers
ii. a more acceptable process for consumers, support people and GPs
3. o test the psychometric properties of the GPCOG including inter-rater reliability, test-retest reliability and comparison with the MMSE..
Study Design
The trial is a cluster randomised study (summarised in Figure
Figure 1
Summary of recruitment, randomization and study design
Summary of recruitment, randomization and study design.
Recruitment will occur across 5 sites: Newcastle (NSW), Sydney (NSW), Melbourne (Victoria), Adelaide (South Australia) and Bendigo (Victoria). Sydney, Melbourne and Adelaide are state capital cities of more than a million people each, Newcastle is a regional centre of around 300,000 people and Bendigo is a smaller centre of just under 100,000 people with some smaller surrounding towns.
Recruitment of participants
With the exception of Bendigo (which will also include nearby towns as noted above) each site will generate a list of possible GP practices within 30 km of the site headquarters based on lists provided by the local Division of General Practice. Practices will be allocated a random approach order, and will be contacted via phone initially. GPs who express an interest in participation will be visited in order for the study to be explained. Basic demographics will be collected at this visit, from those GPs that agree to participate. It is not expected that all the GPs in a practice will participate. When one or more GPs in a practice consent, the practice as a whole will be allocated to either the intervention or waitlist group. Randomisation will occur at a practice level in order to avoid contamination from patients visiting several GPs who had been randomised to different arms within a single practice.
Randomisation will follow procedures outlined in the CONSORT statement
Inclusion criteria for GPs/practices
• Located within 30 kilometres of recruitment centre (with the exception of Bendigo, a rural town)
• Consent to participate in study
• Have patients on a computerised database
• Have patients aged 75 years and over and living in the community
• Consent to being randomised to either intervention waitlist group.
Exclusion criteria for GPs/practices
• Involved in project development
• Does not meet inclusion criteria
Patients and support persons
Patients will be recruited by a mail out from each consenting GP to all eligible patients on their database. Patient participants will return their consent in reply paid envelopes to the study centre. Patients will be interviewed by study personnel blind to the group allocation of the patient and their GP. For patients scoring in the dementia range on the CAMCOG instrument (described below), the interviewer will request that they nominate a support person, if available, to take part in the study. Nominated support people will be given a consent form and information sheet for recruitment into the study.
Inclusion criteria for patients:
• Aged 75 years or over
• Listed on participating GPs' databases
• Visited recruited GPs within the last 24 months
• Consent to a home visit or surgery visit by project staff
• Speak and understand English
Inclusion criteria for support persons:
• Identified as a carer or support person by a patient scoring in dementia range on CAMCOG instrument
• Prior consent from the person with dementia for his/her carer to participate in the study
• Speak and understand English
• Consent to a home visit or surgery visit by the project staff.
Exclusion criteria for patients:
• Parkinson's disease, multiple sclerosis, motor neuron disease or central nervous system inflammation
• Psychotic symptoms prior to recruitment
• Developmental disability
• Insufficient English to complete a psychometric assessment (judged by interviewer)
• Progressive malignancy
• Substance abuse
• Deemed too sick to complete study by the GP
• Lives in a residential aged care facility at entry to the study
• Does not meet inclusion criteria
• Valid and informed consent cannot be obtained from the person involved and they do not have a person responsible for them.
Exclusion criteria for support persons:
• Insufficient English to complete testing (judged by the interviewer)
• Non-consenting patient-participant
• Does not consent to a home visit or surgery visit by the project staff.
• Too unwell to participate
• De not meet inclusion criteria.
Case finding and screening
"Case finding" patients will be identified during the patient interview using the following 4 questions:
1. Do you have any complaints about your memory?
2. Have you mentioned these to you GP?
3. If not, have you been intending to tell your GP?
4. Have you sought treatment or taken any remedies such as herbal medications or vitamins specifically for you memory? Please give details.
If questions 2, 3 or 4 are answered in the affirmative, the patient will be considered as a "case finding" patient. Patients identified as having possible or probable dementia on the GP baseline audit will also be considered as a "case finding" patient. All other patients will be identified as "screening" patients - that is, patients who would not receive a cognitive function test unless the GP decided to screen all patients aged over a certain age.
The intervention
All GPs will audit their consenting patients for dementia, and complete a supplementary audit indicating diagnostic evaluation and management for patients they consider to have dementia. This will occur at three time points during the study: baseline, 12 months and 24 months. Intervention GPs will receive education as described below. The rationale for the educational intervention is described in the
Intervention GPs
Intervention GPs will participate in two visits at their surgery with a peer medical or nurse educator. At the first visit (after completion of the baseline audit), GPs will be taught how to use the GPCOG screening instrument (described below), and will be given information about dementia diagnosis, diagnostic workup and management according to strategies incorporated in the RACGP Consensus Guidelines for the care of Patients with Early Dementia (hereafter called the RACGP Dementia Guidelines)
As the study is being conducted across five sites, a number of different peer educators will be used. All educators will undergo a training program either face-to-face or via teleconference to familiarise them with the educational package developed for intervention GPs. The package consists of a slide presentation that will be delivered by educators via laptop computer, and hard-copy support materials that will be supplied to the GPs.
Waitlist GPs
Waitlist GPs will complete the audits as per Figure
Research instruments
The following instruments will be used be used as part of the patient and/or carer assessments:
The GPCOG
The GPCOG
The CAMCOG
The CAMCOG is a subsection of the CAMDEX instrument, which has been validated in the UK
The Geriatric Depression Scale
The Geriatric Depression Scale (GDS) has been well validated and widely used in Primary Health Care research
The WHOQOL-BREF
The WHOQOL-BREF is a widely used quality of life instrument
The Beck Depression Inventory
The Beck Depression Inventory
The General Practice Assessment Questionnaire
The General Practice Assessment Questionnaire (GPAQ) will be used to ascertain the patients' support persons' satisfaction with their care from their GP over the previous 12 months. The GPAQ is very widely used in the UK as part of the GP quality outcomes framework, and has been shown to be acceptable, reliable and have an interpretable factor structure
Activities of Daily Living (ADL)
The Lawton and Brody ADL Questionnaire
Data collection
Patient assessment
The research nurse will use a laptop computer to collect demographic data from all consenting patients and to administer the GPGOG, CAMCOG, GDS, WHOQOL-BREF, GPAQ and ADL (for patients in CAMCOG dementia range only). Patients will be asked about any memory-related services accessed, referral to Alzheimer's Australia, and referral to a specialist for memory problems. The research nurse will compile a list of all prescription and over the counter medications currently used by the patient, so that medication can be excluded as a cause of cognitive impairment. Complementary and alternative medicines will be included. In addition the nurse will perform a "75 + Health Assessment" rebateable under the Australian Medicare system on eligible patients where this has been requested by the GP. These data will not be used by the study, but are returned to the GP for his or her use. This part of the assessment is a provided as a service to the GP. Brief questions used in our previous research will be used to measure the acceptability of the interview process. We will ask patients to send answers back in a reply-paid envelope, to avoid bias due to the presence of the nurse. At the completion of the assessment the nurse will hand the patient a sealed envelope. In the case of patients in the intervention group, it will direct the patient to obtain an appointment with his/her GP as soon as possible to follow up on the 75+ Health Assessment and to have the GPCOG re-administered. In the case of patients in the waitlist group, it will suggest a follow up for the 75 Plus Health Assessment only. Patients will be reassessed using the same instruments at 12 and 24 months after baseline interviews.
Support person assessment
The research nurse will use a laptop computer to collect demographic data from consenting support persons and to administer the WHOQOL-BREF, BDI and GPAQ.
Information regarding services accessed and acceptability of the interview process will be collected as described above for patients. Patients will be reassessed using the same instruments at 12 and 24 months after baseline interviews.
GP audit
GPs will be sent a list of their participating patients by fax or email. They will be asked to confirm each patient's eligibility for the study and to provide their clinical judgement in relation to each patient's dementia status using one of four options: No Dementia, Possible Dementia, Probable Dementia or Definite Dementia. GPs will be asked to complete a supplementary audit for any patients with possible, probable or definite dementia to gather data on differential diagnosis (e.g depression), memory-related tests and investigations performed (i.e. paper and pencil test; pathology; radiology) and referrals to services and specialists. GPs will return their completed audit forms to local project officer via mail, fax or email. GPs will complete audits at baseline, 12 and 24 months.
Outcome measures
Primary outcome measures related to the first aim (collected at baseline, 12 months and 24 months) are:
1. World Health Organization Quality of Life-Bref Scale (WHOQOL-BREF) score for patients
2. Geriatric Depression Scale score for patients
Secondary outcome measures related to the first aim (collected at baseline, 12 months and 24 months) are:
1. World Health Organization Quality of Life-Bref Scale (WHOQOL BREF) for carers
2. Beck Depression Inventory score for carers
3. Agreement of GP audit for dementia with CAMCOG instrument
4. GP differential diagnosis for dementia
5. GP identification and treatment of reversible causes of dementia 6.GP dementia related referrals made
7. General Practice Assessment Questionnaire score
8. Acceptability of the process scale score
9. Services accessed
To meet the second aim of the study, screening and case finding groups (as defined above) will be compared on primary and secondary outcome measures 1 and 2 as listed above. The GPCOG score will be compared with the gold standard of the CAMCOG score to address the third aim of the study. The performance of the GPCOG against the CAMCOG will also be compared with that of the MMSE against the CAMCOG, as the MMSE is widely used to screen for dementia.
Adverse events
Research nurses will report any subjects that they are concerned about to their local academic GP associated with the project. The GP will decide upon a course of action, up to and including reporting the matter to the subject's own GP (with subject permission). Nurses will cease interviewing subjects who report feeling tired or uncomfortable during the interview. The subject will be given the option of completing the interview at a later time, using only the data collected to that point, or withdrawing from the study.
Sample size
It was calculated that 45 patients with dementia in each group (Waitlist and Intervention) would give a power of 0.9 to detect a 7% difference between the change in pre and post scores on any of the four domain scales of the WHOQOL-BREF with a type 1 error of .05. The population standard deviation used is 18.5
The hierarchical nature of the study design will probably lead to some within cluster correlations and the greatest impact of this is likely to be associated with patients clustered within a GP practice. Clustering within each GP may be discounted, as it is anticipated that most GPs will have less than five patients with dementia in this study. Assuming an intra-class correlation coefficient of 0.05 and an average cluster size of 5 patients with dementia in a practice, this gives a design effect of 1.45 and a total sample size of 54 patients per group. We will therefore allow for 56 patients with dementia in the waitlist group and 112 in the intervention group to allow for comparison of outcomes between the waitlist and intervention groups overall. This sample size also allows comparison of "case finding" and "screening" patients and their support persons within the group. It is assumed that about 50% of participants will be screening and 50% case finding. Thus, we aim to recruit 168 participants with dementia overall. Based on a dementia prevalence of approximately 10% in over 75 year old Australians
For the GDS, following the same set of assumptions and approach as for the WHO QOL-BREF (power, type 1 error and correlations), 45 patients in both the Intervention and Waitlist groups would allow detection of an average difference in the change in pre and post scores of 0.9 points on the 15 point GDS, using a standard deviation of 2.39
For an estimate of test re-test reliability on the GPCOG a sample size of 100 will be used to ensure the correlation is estimated to a reasonable precision. The 95% confidence interval for a Pearson correlation of 0.9 would be [0.86, 0.93] and for a correlation of 0.80 [0.73, 0.85].
Study drop outs/withdrawals
We aim to recruit 2000 subjects, based on a dementia prevalence rate of 10% in the Australian population aged 75 years and over
We do not anticipate a high drop-out rate of GPs, as the demands on GPs are not onerous. As patients are consented separately to GPs, patients can continue even if their GPs withdraw from the study.
Statistical analyses
All surveys collected on laptop computers will be downloaded to a central database. Where necessary in the analysis, the longitudinal and hierarchical/cluster nature of the study design will be taken into account using mixed effects models and other appropriate methods (see below). The primary analysis will be by intention to treat. Analyses will address the following questions:
Do GPs trained in the use of a screening instrument detect dementia better?
Detection rates of GPs trained in using the GPCOG (the Intervention group) will be compared with detection rates of Waitlist GPs against the 'gold standard' of the CAMCOG.
Do GPs trained in screening and management distinguish dementia from other conditions, particularly depression, compared with a waitlist group?
Differential diagnoses (particularly of depression), of the Intervention group will be compared with those of the Waitlist group. Misclassification rates of the GPs in the Intervention group will be compared with those in the waitlist group.
Do GPs trained in screening and management adhere to the guidelines?
Outcomes measured will include identification of reversible causes of dementia, tests ordered and referral patterns to specialists, support services and Alzheimer's Australia, as suggested in the guidelines.
Do GPs trained in screening and management provide better health outcomes?
Outcomes of Intervention and Waitlist groups will be compared at twelve months, for both patients and their carers (quality of life, depression, satisfaction with care, services accessed)
Do subjects with and without dementia and support persons find the screening acceptable?
All subjects and support persons will be asked to rate the acceptability of the screening instrument and procedures. Descriptive analysis will be performed. Case finding and screening groups will be compared.
Do GPs find the process acceptable?
GPs will be asked to rate the acceptability of the GPCOG and the Management Guidelines. Descriptive data will be reported.
Does case finding or screening produce better results?
Within the Intervention group, the patient outcomes for the group with memory complaints or identified by the GP as having possible or probable dementia (case finding group) will be compared with outcomes for the group without memory complaints or identified memory problems (screening group). Acceptability of the process and satisfaction with care will be particularly examined, both from a quantitative and a qualitative point of view. The performance of the GPCOG in the case finding and screening groups will be compared. In particular positive predictive value, negative predictive value and misclassification rates will be compared. GP audits will be examined to determine how many patients in each group would have a missed diagnosis of dementia if the GPCOG had not been administered.
Test parameters of the GPCOG
The GPCOG will be compared with the DSM diagnosis derived from the CAMCOG as a 'gold standard', and sensitivity, specificity, positive predictive value, negative predictive value and misclassification rate will be calculated. ROC curve analysis will be employed to examine the discrimination ability of the GPCOG test (i.e. ability to detect dementia) relative to MMSE. This is important as the MMSE is now commonly used in General Practice. GPCOG test-re-test and inter-rater reliability (between the nurse and the GP) will be calculated, using the kappa coefficient and intra-class correlation coefficient.
Missing data
In the case of data missing from the study questionnaires, the questionnaires will be handled as suggested in the literature for that questionnaire. This varies from questionnaire to questionnaire.
Steering group
The project is being overseen by a group consisting of the chief investigators, associate investigators and the project manager. This group will meet two to three times a year by teleconference and face to face. Day to day management will be undertaken by monthly project officer teleconferences.
Ethics approval was sought and granted initially from the Newcastle University Human Research Ethics Committee (Approval No. H-151-1205), and following this, from the appropriate Ethics Committees at each site.
Competing interests
CDP and HB have sat on advisory boards for Pfizer, Novartis, Janssen and Lundbeck, and been speakers sponsored by Pfizer, Novartis (HB only) and Janssen (HB only). HB has been an investigator on projects funded by Pfizer, Novartis, Janssen, Lundbeck, Lilly and Sanofi, and acted as a consultant for Merck and Baxter. Other authors have no competing interests to declare.
Authors' contributions
CDP conceived and developed this study, drafted the manuscript and has overall management of the project. HB assisted in study design and manages operations at the Sydney site. NS assisted in study design, and manages operations at the Adelaide site. JG assisted in study design, and manages operations at the Melbourne site. JM assisted in study design. PD assisted in study design, and manages operations at the Bendigo site. PM assisted in study design and drafted the manuscript. NP developed the educational intervention, assisted in study design. GH developed the educational intervention, assisted in study design. SG assisted in study design, provided project management and drafted the manuscript. BP collected data and provided project management. KM assisted in study design, collates data, will assist with statistical analysis and drafted the manuscript. All authors read and approved the final manuscript.
The authors acknowledge the invaluable contributions of Professor Charles Bridges-Webb. This study is supported by the Australian Government's National Health and Medical Research Council (Grant ID #351220 and #510745).
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Pre-publication history
The pre-publication history for this paper can be accessed here: