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Clean your soft and hard surfaces better the way professionals do, all with one machine! Use as water filter vacuum cleaner, steam cleaner, or injection & vacuum extraction.
Compact design creates a multi-purpose cleaner combing dry steam - water / detergent - and vacuum action. Dirt is trapped in the recovery tank thanks to the Ventury effect system. Combine the water filtration with HEPA filter trapping 99.9% of particles. Perfect for allergy and asthma sufferers! UL listed
The design and accessories make the Vapor Clean Gaia the first home use vapor cleaner and "true-steam" upholstery and light carpet / spot cleaner in the USA. Utilize the high temperature of steam with 180° heated water to clean carpet and upholsteries. Now you can maintain all of your home with one machine!
Simple one step operation will vacuum and steam clean all hard surface floors including hardwoods, marble, granite, slate, terrazzo, porcelain, vinyl, laminates and more.... leaving no soap residues. Bathroom and kitchen floors have never been so easy!
- 1700 Watts
- 293 F Internal Boiler Temperature
- 1.6 Liter Boiler
- 1.5 Liter Injector Capacity
- Stainless Steel Boiler - AISI 304 18/10
- Up to 60- PSI operating pressure - 4 Bar
- Steam temperature at the exit: 240 - 260°F
- 21 lbs
- High temperature steam with powerful extraction leaving hard surface floors dry in seconds
- Heated water / solution exit temp 180° +
- Extended Warranty
1 Year Parts & Labor
Lifetime Boiler
- 5 Levels of vacuum suction
- Audible beeper notifies when:
Steam boiler running empty
Injector running low
- Hose offers on/off switch for steam on handle
- Separate on/off switch for vacuum on handle
- US Warranty 1 year parts and 1 year labor on defects in materials and workmanship
- Extended US Warranty: Extended Warranty Available
- Non-US Warranty: 30 days parts and labor
- 1 Flexible hose with on/off steam switch & on/off vacuum switch
- 2 Extension Wands
- 1 Multipurpose Floor tool for all hard surface floor cleaning
- 1 Transparent Floor tool for carpet extraction
- 1 Vacuum driven Turbo Brush with "Beater Bar"
- 1 Upholstery Tool
- 3 Incrementally sized squeegees
- 1 Detail nozzle with crevice tool'
- 1 Detail cleaning extension
- 2 Bristle brushes 1 large/1 small
- 1 Atomizer
- 3 Nylon Detail / 1 Stainless Detail cleaning brushes
- 1 Blower attachment
- 1 Filler Bottle
Check the fittings (elbows) inside recovery tank. Also, the recovery tank needs to be seated properly, tight, to the back of the machine. Lastly, make sure there is water in the recovery tank when using and the lid is securely fitted on top of recovery tank when using. Any of all of these things can result in loss of vacuum pressure.
Can the Vapor Clean GAIA be used as a regular vacuum cleaner in the home?
Hello John, The Gaia can be used as a vacuum only, also. It has the water filtration so no bags are needed. Hepa filter should not need to be replaced. It is located on the bottom of machine and should be cleaned after use. Service is naturally done at our location. Accessories can always be purchased, as we carry the complete line for each machine. When customer is using on hard floor surfaces, they will steam and vacuum. When using on carpeting, they can inject/extract. The injection is hot water and the extraction is the vacuum. Hope this helps!
Vernique was very helpful assisting me with my order. I appreciate the ability to purchase an extended warranty. I have purchased from your company before and I feel secure that should something go wrong there will be someone available to assist me in resolving any issues or possible repairs. An item such as the Gaia vapor vacuum is an investment for my household that I research prior to purchase and take care when using. All Brands customer care and extended warranty place me at ease when making such an expensive purchase. Deborah
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Get additional savings when you purchase any of these items along with this product.


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Sunlight readable displays for explosion-protected HMI systems
No more glare….
The PC-based, explosion-protected operating systems from the Open HMI series can now be fitted with the new innovative 15" displays to reduce glare and reflections to a minimum.
The new displays can be read easily, even in bright sunlight, since a filter pack effectively diverts even strong incoming ambient light. The new solution is based on a very effective combination of polarisation filters placed on top of and behind one another in front of the display.
Many important operating and monitoring tasks are carried out at HMI systems installed outdoors. This can only be done safely and easily, if the displays do not reflect ambient light too strongly.
Thanks to the new solution, bulky canopies that were supposed to give shade, but in practice hardly did so, are no longer necessary. High brightness displays, which caused thermal problems in explosion-protected systems in particular, are also no longer necessary, as the new package does not require particularly bright LEDs.
Unlike any standard filters used so far, this filter pack hardly affects the image display for viewers: although the sunlight readable displays can be adjusted to up to 1,000 cd/m², they are already easily readable even in direct sunlight with a luminescence of 700 to 800 cd/m².
Certified for hazardous gas and dust explosion zones 1, 2, 21 and 22, the Open HMIs are fitted with low-energy CPUs from the Intel Atom series and consist of explosion-protected modules. These touch screen systems can be operated in rugged environments and even at continuously extreme ambient temperatures between -30 °C and +50 °C.
Numerous international certifications ensure suitability for various applications in a wide range of industries, such as the oil and gas sector, package units and the chemical and pharmaceutical industries.

subset: commoncrawl


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My mood is continuing to get lower and lower and much as I utterly detest my local psych hospital, I find myself feeling really frightened that the bin is the direction that I'm heading in. Life is becoming more than just a struggle, it's currently at the point of absolutely everything feeling impossible.
The winter seems to be starting early – by 5pm it is already dark outside – and like every year when it gets like this I find myself only taking the dogs out once when it's daylight (their lunch time walk) and the other times I walk them (breakfast, dinner and bedtime) are all in the dark. I feel more comfortable to be outside when people can't see me properly, when I can hide myself under my thick jacket and big furry hood.
Why? Because the dark feels safer for some reason. My thoughts are starting to become really paranoid again. I don't like people being able to see me or look at me properly, it sets my head off thinking all sorts of crazy stuff.
The depression is definitely in full swing and I feel as though I'm sinking lower and lower with every day that passes. And it shouldn't be this way – I have good/happy things going on in my life at the moment (or at least that's how they should feel). But the smiles I put on are so fake I'm sure everyone can tell. I just can't seem to feel happy. I got my essay results from the essay I had to do a few weeks ago and passed with 65%. That's a good grade B. Was I happy? No not really. Just relieved I didn't need to resit. My parents took me for a lovely birthday lunch last Monday… again fake smiles throughout which I felt awful about.
The only person I've been somewhat honest with was the psychiatrist and support worker on Wednesday. That's been the only time I've said the words out loud – I'm self harming again and I keep getting these waves of feeling like I just do not want to be here any more that come over me out of the blue and are so strong they drag me under them.
I have a couple of things happening this coming week that I should be happy about but instead I am miserable. I'm hell bent on hurting myself yet doing my hardest to just cling on a little bit longer… maybe when I get my first appointment with the psychologist through it will help me feel more positive. Who knows. The self destruct button feels like it's getting closer and closer to being pressed.
I guess I've just got to keep going… but in what direction I just do not know.


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The biggest driver of that growth was being introduced into virtually every Bay Area Whole Foods. So far it's been a great partnership, and we're looking forward to expanding even further with them in the New Year. We did tasting demos at numerous locations, and all were met with rave reviews and brisk sales.
By the way, our sources at the North Pole are telling us that jars of SFQ are going to be very popular stocking stuffers this year, so if you're still looking for that certain something to stick in your favorite foodie's Christmas sock, be sure to pick up a few jars. Thank you, and enjoy!
Santa Photo © Fabriche


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Two Elizabethan writers of fiction: Thomas Nashe and Thomas Deloney
Folcroft Library Editions, 1977 - Literary Criticism - 60 pages
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afterwards Archbishop Whitgift Aretino attack ballad Beccles called Chapter character Christ's Tears clothiers Cole courtesan Cutwolfe dead death Deloney's devil Diamante Duke Duke of Saxony Earl Elizabethan England English Erasmus Esdras Euphues fiction Gabriel Harvey Gentle Craft Gillian gossip Green King Greene's Harvey Harvey's hath hear hostess humour husband imitate Isle of Dogs Italian Jack of Newbury Jack Wilton Jack's John Juliana king Leave her company literary live London Lord maids Marlowe Marprelate Controversy married matter McKerrow merry Mistress Farmer Mistress Winchcomb murder Nashe's never novel pamphlet Peachey Pierce Pierce's Supererogation Pietro Aretino play pleasant praise pray prose quoth Richard Casteler Robert Greene satirical servants Shakespeare shoemaker shoemaker's soul story style Surrey Tarlton tell thee Thomas Cole Thomas Deloney Thomas Nashe Thomas of Reading thou town Unfortunate Traveller unto verse Westminster wherein wife wives writing Zadoch


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The aging of the population of the United States is occurring at a time of major economic and social changes. The science of sociology offers an important knowledge base and analytical approach that can help us understand and plan for our changing demographics.
In a new report, The Future of the Sociology of Aging: An Agenda for Action, a panel assembled by the National Research Council evaluates contributions of social demography, social epidemiology and sociology to the study of aging and identifies promising new research directions in these fields.
The report is one of several recent publications from the National Academies dealing with the implications of the aging U.S. population, including:
- Fostering Independence, Participation, and Healthy Aging Through Technology: Workshop Summary (2013)
- Aging and the Macroeconomy: Long-Term Implications of an Older Population (2012)
- Perspectives on the Future of the Sociology of Aging (2012)
Join the Koshland Science Museum for a weekend of special activities celebrating opportunities for healthy aging September 21-22, 2013. See "The Science of Healthy Aging" for more information.


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Moved all messages to the messages/ folder.
This meant changing a lot of includes and things.
Changed motor max speed and added constants in set_motors.msg
The new speed range is -100 to 100, to be consistent with the pwmdriver. They can be accessed with motors::set_motors::MIN_SPEED andmotors::set_motors::MAX_SPEED respectively.
\Fixed teleop to work with behaviors. Teleop currently has priority over behaviors
Added services to set individual control for visualization tools.
However, there is a bug in the sonar viz for multiple scouts, looking into it now.
Merge branch 'master' of ssh://roboclub.org/home/svn/scoutos
Conflicts: scout/scoutsim/src/sim_frame.cpp
Working on turning sonar on and off for robots individually.
Sepearated refresh rate for scouts and for the simulator.
Fixed teleop with new units, and changes the refresh rate to be closer to true m/s.
Conflicts: scout/scoutsim/src/scout_constants.h
Continuing work on standardization of units.
Changes to add ghost scout to sim frame and make it show up on the simulator.Currently the functionality for killing scouts does not kill the ghost scout. That needs to be fixed eventually.
Conflicts: scout/scoutsim/src/scout.cpp scout/scoutsim/src/scout.h
Fixed sonar bug (corrected y direction)Added sonar_toggle and set_scan command and callbacksCleaned up sonar_visual toggle code
Scoutsim now has consistent units of m and m/s.
This will cause some problems.
Loads specific images for each scout if they exist
Otherwise, looks in the images folder for scout.png.Added a few default scouts with numbers, and the xcf files they were created from.
Scoutsim: Added Sonar Toggle
Sonar display can now be toggled via Menu->Sim->Sonar
Added built-in scoutsim teleop!
Edited Sonar to display points on simulator.
Changed rate of sonar scan to 0.5sMade a new wxDC graphics object for sonar
Added walls to the scoutsim visualizer.
Broke the build and then fixed it. Now onto testing!
Added wireless handling to scoutsim. Untested.
Basic line sensor readings!
Added maps and menus in scoutsim.
Menu options for about, quit, clear, and viewing different maps.
Fixed up scoutsim package. Sorry.
Sonar prototypes in scoutsim package.
Fixed the scoutsim node.
Just a couple bugs. All the nodes compile now! You can run "rosmake" from the "scout" directory (compile the whole stack).
Updated the licensing information in many files.
This is a broken commit because I decided to do this at a bad time. Sorry! The build will be working after next commit, I promise (and I won't push till then). This commit reflects the licensing in the files after I used my auto-add/remove script.
Got motor control working with scoutsim
Behaviors can now use the MotorControl class to change the speed of the motors in the simulator. The simulator correctly handles the command.At the moment, the set_motors command is limited to 'scout1'. We should look into prefixes to specify which scout (scout1, scout2, etc) each behavior should command....
Made a lot of changes to the general structure.
Applied object-orienting techniques to the code, cleaning it up considerably. Major design changes are as follows:


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April 11, 2013
Breakfast Cinnamon Pizza | Store-bought Dough
**UPDATE : I found the pizza dough at Trader Joe's, but I think Whole Foods and other grocery stores carry it! Also, I've heard you can go to pizzerias and ask for pre-cooked dough.
Cinnamon Pizza
with store-bought dough
1 store-bought pizza dough
2 tablespoons of butter, softened
brown sugar
Butter Icing
1 tablespoon of butter, melted
1 cup of powdered sugar
Preheat an oven to 425 degrees.
Stretch the dough out onto a greased baking sheet. Spread with softened butter. Sprinkle with brown sugar and cinnamon. Bake for 10 minutes.
Mix together melted butter and powdered sugar. Add small amounts of milk until it is drizzle-able.
Remove from oven and let cool for 5 minutes then drizzle it over the dough.
12 comments:
Mmmm..this was dangerous to share with a pregnant lady! Looks great.ReplyDelete
we made this for breakfast this morning! What a great idea! Thanks!ReplyDelete
I would love to know where you buy your dough from! Thanks!ReplyDelete
- Susan2:24 PM
How long can you keep bread dough in the fridge? I'm with Jennifer. It's a clever idea.ReplyDelete
This comment has been removed by the author.ReplyDelete
Made this Sunday for breakfast. It was fabulous! Love, love, love your blog :)ReplyDelete
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Last Saturday was a good day. For a start I wore a stripey dress and yellow shoes [BTW: these facts are not at all pertinent to the story ... but hey, I'm just setting the scene for you ... ], the sun was shining and James and I went out for lunch [goat's cheese bruschetta - in case you're wondering] in a little local town which has plenty of tea shops ... and almost as many charity shops. One in particular stands out as it sells mainly retro and vintage items rather than the usual tat ornaments made last year and biographies no one ever reads.
So far so good ... but wait ... it gets better. Bearing in mind how much I adore, crave, seek-out and obsess over retro prints .... and keeping in mind too just how much I have always loved stationary ... just imagine how I felt when my eyes alighted on the shelf where these beauties stood:
Two A4 ring-binders with the most incredible textured plastic covers, in amazing designs:
So far so amazing, yes? But then ...
... then, drawn nearer by their sheer magnificence I reached out to touch them and peer inside. Which is when 'amazing' turned into 'amazing-er'.
And here's why:
Stamps! STAMPS!
Lots and lots of them:
Pretty stamps:
Stylish stamps:
Wonderfully illustrated stamps:
Stripey stamps:
Weirdly hot stamps:
And if all this wasn't enough for one woman to take ... alongside the pages of organised stamps were several envelopes stuffed with assorted unsorted extras:


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An apparent attack on a student attending an alternative school that was posted on Facebook has led to an investigation by Dover Police.
Detectives with the Dover Police Department will be requesting arrest warrants in connection with an apparent attack on a student riding a school bus.
The incident came to light through a video posted on social media sites, said department spokesman Cpl. Mark Hoffman.
The attack, which Hoffman called a "brutal assault" took place the afternoon of April 29 aboard the bus, operated by Parkway Academy Central, Hoffman said.
According to its website, the Parkway Academy is an alternative discipline school that provides individualized educational services for students unable to function in a standard school setting. Services include social and psychological services.
The investigation began as soon as police were made aware of the video, Hoffman said.
"We had received a message about the post, and began looking into it. We realized the school is in our jurisdiction and decided to launch an investigation."
The video – which police will not post to their website – shows four students coming up from behind the victim and hitting him in the back of the head, Hoffman said.
"Then they pulled him down and began pummeling him," he said. The footage lasts approximately 25 seconds, Hoffman said.
A Dover officer has gone to the school and identified several suspects as well as the person taking the video, Hoffman said. Police also have contacted the victim's family.
Detectives will be interviewing the victim and, "we expect to start getting warrants for the suspect later today or tomorrow," Hoffman estimated.
One of the suspects posted the video and the victim's uncle spotted it on Facebook, Hoffman said.
Calls made to the school administration to gather additional information were not returned.
Parkway Academy Central is one of four schools operated by Providence of Delaware, of Wilmington, a subsidiary of Providence Service Corporation, which describes itself as "a human services organization" that, according to its website, provides "accessible, effective, high-quality, community-based mental health services, social support, and academic instruction as alternatives to traditional methods."


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BRISTOL — Voters in the Bristol Police District next month will weigh in a proposed budget for the 2011-2012 fiscal year that features a 10.5 percent cut in spending and would require 6.5 percent less money from taxpayers.
The full text of this article is only available to online subscribers.
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text:
NEW YORK — Journalists from CBS News, Buzzfeed and Sky News who were covering the unrest in eastern Ukraine have been freed Friday after being detained by pro-Russia insurgents.
CBS correspondent Clarissa Ward and her crew, and Buzzfeed Mideast correspondent Mike Giglio, were taken into custody after being stopped at a checkpoint outside the city of Slovyansk. Sky News said its four-person crew was similarly detained and released, but offered few details.
Friday's incidents came three days after the Committee to Protect Journalists expressed alarm at how reporters and media organizations were being targeted in the Ukraine.
Ward said she and her crew were bound with tape and transported to another location, and one of her male colleagues was beaten while being held captive. Ward and Giglio said they both heard discussions among their captors about keeping the journalists as hostages.
"Men who were holding us kept telling us not to be frightened and that everything would be OK," Ward said in an interview on "CBS This Morning." ''Then another group of commanders appeared to come in and gave them instructions to release us, ultimately. But all in all, I think it's fair to say that it was an unpleasant and quite frightening experience."
The commanders who released them said the people who had taken them into custody were emotional because the Ukrainian Army had begun an offensive against the insurgents in Slovyansk, Ward said.
"It's fair to say that — when I was listening to the pro-Russian separatists speaking to each other — I can understand Russian and there was a lot of very strong anti-American rhetoric going on," she said. "One guy was shouting at me in Russian, you know, 'If President Obama was smart, he wouldn't be supporting the fascists in Kiev.'"
Giglio said via Twitter that his ordeal lasted about three hours. He said it appeared to be motivated by fear and panic among the militiamen.
"They were very spooked," he said.
He said he was unharmed, although one journalist had been beaten. It was not immediately clear if Giglio and Ward were referring to the same beating.
Giglio was asked to name the U.S. capital and pronounce the word 'garden' to prove he was an American. He said his belongings were taken and returned, except for his flak jacket and helmet.
Once it was decided they would be released "the pro-Russia militiamen politely served us tea," Giglio tweeted.
Late last month, correspondent Simon Ostrovsky from the Canadian-based Vice News was taken into custody and held for three days by pro-Russia insurgents in eastern Ukraine. He said later he was beaten and handcuffed and appeared to have been specifically targeted for his reporting: the men taking him captive in Slovyansk had a picture of him.
"I don't think they wanted to kill me," he said in an interview on NBC's "Today" show after his release. "They just wanted to put a scare in me. It was very scary."
Natalia Ligacheva, head of the Ukrainian media watchdog Telekritika, said as of Thursday, at least four Ukrainian journalists continued to be held hostage by pro-Russian insurgents in eastern Ukraine. She said Ukrainian media groups have recommended that journalists refrain from traveling to insurgency hotspots unless they have undergone security training.
"This situation is completely horrible and absurd because even during open military hostilities, journalists and medics and Red Cross workers are not subjected to violence," Ligacheva said. "And here journalists have become a key target."
Associated Press correspondent Maria Danilova in Kiev contributed to this report. Giglio said via Twitter that his whole ordeal took three hours.


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Freqently Asked Questions
View Larger Map
All sex offenders that are required by law to register and have never been registered in Nebraska, must do so in person at a Nebraska State Patrol office designated to accept registrations. Any Nebraska registered sex offender needing to update, change, or verify their information must do so in person at the County Sheriff's Office in their jurisdiction. The addresses above apply to any offender who lives (permanently or temporarily for more than three days), works, or attends school in Lancaster County. The Sheriff's Office will accept sex offender registrations between the hours of 8:00am and 4:00pm. Currently registration updates/changes are accepted seven days a week but on October 6, 2012, registration days will be Monday through Friday ONLY.
If you are unsure if you are required to register as a sex offender, please visit the Nebraska State Patrol's website regarding sex offender registry.
Lincoln Police Department
Justice and Law Enforcement Center
575 S. 10th Street, Lincoln, NE
Phone: (402) 441-7210
Hours: Monday through Friday, 1:00 p.m. to 3:00 p.m.
Fee: $5.00 for up to three cards. Additional cards are $5.00 each
Nebraska State Patrol
Criminal Identification Division Office
3800 NW 12th, Lincoln, NE
Phone: (402) 471-4545
Hours: Monday through Friday, 8:00 a.m. to 4:30 p.m.
Fee: No fee
Another resource, the Dru Sjodin National Sex Offender Public Website (NSOPW), coordinated by the U.S. Department of Justice, is a cooperative effort between Jurisdictions hosting public sex offender registries and the federal government.
Click here to download the Lancaster County Junk Vehicle informational brochure.


text: Get your own private BBW porn show on cam. If think you can handle a big beautiful model and her soft curves, be sure to take one private so she can show you her voluptuous booty. If thin hips aren't your thing, check out our bbw chat room. These chubby girls have had to work harder and know how to handle their man; and we love their true naked female shape. Enjoy flirting and chasing our live bbw webcam girls! It's all about tits and ass here - the bigger the better.


text:
CSUN News
30 MW deal in India
CSUN's wholly-owned subsidiary CEEG (Nanjing) Renewable Energy Co., Ltd. has won a 30 MW contract in India using CSUN's polycrystalline modules. Shipment is expected to be completed by the end of the month.
Marketing News
Meet CSUN
PV Expo, Tokyo/Japan – 25-27 February
Intersolar Summit Turkey, Istanbul/Turkey – 18 March
SOLAREX, Istanbul/Turkey – 9-11 April
SNEC, Shanghai/China – 28-30 April
Market News
Italy: Plan to halt all solar incentives
Italy's industry deputy minister Claudio De Vincenti announced at a power conference that the government believes there is no necessity to further promote solar and that the newest decree containing the renewable energy incentives for the next three years will exclude solar.
Only a few days before Italian grid operator Terna had announced that PV had covered a record of 7.53% of the country's power need in 2014.
Source: PV Magazine 26.1.2015
UK: 700 MW of small-scale PV in 2014
700 MW of PV capacity was added in UK's FIT-driven small-scale sector last year. According to the Solar Trade Association (STA) a healthy growth of domestic and commercial rooftop solar systems as well as small solar farms.
UK's residential rooftop PV sector is showing steady and healthy growth: 125,000 homes installed solar systems last year. A growth which for the first time since 2012 triggered a reduction of residential PV FIT (in the UK the FITs are regularly reduced due to volumes being met or a nine-month period being reached). IHS analysts expect an average of 40 MW/month of residential PV in 2015.
Source: PV Magazine, 23.1.2015
Turkey: 3 GW of PV by 2023
Turkish President Erdogan stated at an energy summit that Turkey would double its energy consumption by 2023, making extensive energy investments necessary. The government aims at adding 110 GW to the current 70 GW installed power capacity by 2023. 90% of the country's power shall be provided by gas, coal and renewable energy alike (30% each) and 10% by nuclear energy. The government's aim is to reduce natural gas imports, which currently provide the biggest share of Turkey's power generation (40%). Despite high insolation times, the 2023 target only includes a minimum of 3 GW of solar PV installations. Concerns are voiced in the market that the permitting process for licensed projects is quite slow and inefficient. Currently, the 2013 applications for licensed projects are being evaluated and licenses granted to 600 MW of installed capacity. Submission of applications for new PV licenses will start in April 2015.
In 2014 882 MW of solar and wind capacity were added.
Source: PV Magazine 23.1.2015


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text:
Cast of That 70s Show: Where Are They Now?
Where Is the Cast of That '70s Show Now?
Where Is the Cast of That '70s Show Now?
It's been over seven years since we've seen Topher Grace, Ashton Kutcher, Mila Kunis and Laura Prepon in full '70s garb, but we have been seeing them and hearing from a lot of them lately. We learned the sad news recently that Lisa Robin Kelly, who played Eric's sister Laurie, passed away. Still, it's a good time to catch up with the rest of the cast, given that Prepon recently splashed back into the pop culture stratosphere for her role in the hit Netflix series Orange Is the New Black, while Kutcher has been all over the headlines with the recent release of Jobs. What has the gang from That '70s show been up to? Click through to find out.
—Additional reporting by Maggie Pehanick
0previous images
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text:
Hi out there,
currently, I'm trying around with gpe/familiar 0.8.4 on my sinuspad.
Installation went fine but now, I'm having problems getting a stable wlan connection up and running.
I've been trying some time with a netgear ma401 with the orinoco driver which seems to work from time to time but not very stable: I need to insert the card a couple of times to get it running. So far, I didn't find a pattern behind this so I have to try and try which is very annoying. Once I get the card running, the network works and I can run things like ipkg.
Very unhappy with this situation, I got me another wlan card: Belkin F5D6020 ver.2 which uses an atmel chipset (got it very cheap...). Somewhere on the net, I found a feed that provides a compiled atmelwlandriver (atmelwlandriver.sourceforge.net) for the simpad, but for kernel version 2.4.25. Current kernel version in familiar 0.8.4 is 2.4.27.
I modified /etc/pcmcia/config so that the card is recognized by the cardmanager on insert but I have no success in binding the right driver to it.
Has anybody suceeded in getting an atmel based wlan card running on familiar 0.8.4?
If not, any idea why my ma401 doesn't seem to work stable? Maybe I should use hostap instead of orinoco?
One more question: ma401 should be able to handle WPA encryption after a firmware upgrade (which mine has). Can I use this feature on gpe/familiar/simpad?
Thanks for your help


text:
DENVER (AP) Linebacker D.J. Williams is on track to make his 2012 debut Sunday against San Diego after the Denver Broncos put him on their 53-man roster Saturday.
Williams returned to practice this week after serving two NFL-mandated suspensions that cost him nine games and about $4 million.
On Friday, coach John Fox said Williams had looked good in practice all week ``and he's a guy we would definitely consider to be active for the game.''
If he plays Sunday, he'll likely play in sub packages and on special teams.
Williams was suspended six games for violating the league's policy on performance-enhancing drugs and three games for an alcohol-related arrest. The Broncos had a roster exemption for Williams but already had a spot open after waiving safety Duke Ihenacho on Tuesday.


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Free legal advice clinic for veterans Aug. 24 in Lumberton
The Jefferson County Bar Association (JCBA) will host a free legal advice clinic for area veterans Saturday, Aug. 24, 2013, from 8:30 a.m. – noon at Lumberton Fire & EMS, 228 Country Lane Drive, Lumberton. Appointments are encouraged by calling the bar office at (409) 835-8647, but walk-ins will be welcome. Volunteer attorneys will be available to provide legal advice on issues such as family law, wills and probate, consumer issues, landlord/tenant law, tax issues, bankruptcy, employment, foreclosures, and veterans' benefits and disability claims. For veterans needing legal representation and who financially qualify, pro bono attorneys will be assigned. The guidelines have been adjusted for veterans so that they may have income up to 200 percent above the poverty level and still qualify for services. The free clinic is open to any Jefferson, Hardin, Orange, Liberty or Chambers County veteran or spouse of a deceased veteran.
July 15, 2013, the Texas Access to Justice Foundation (TAJF) has once again awarded JCBA funds to support its efforts to provide basic legal services to area veterans and the spouses of deceased veterans. The JCBA's legal advice clinic is part of the statewide Texas Lawyers for Texas Veterans (TLTV) initiative, a program begun by the State Bar of Texas and funded by TAJF to ensure that organized legal clinics exist throughout the state to specifically assist military veterans who cannot afford or do not have access to basic legal services. TAJF is the leading financial supporter of civil legal aid to the poor in Texas. Created in 1984 by the Supreme Court of Texas, TAJF awards millions of dollars per year that benefits hundreds of thousands of low-income Texans annually including victims of crime, abused and neglected children, veterans, the elderly and the homeless.


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Bespoke Picture Framing
We have a large collection of quality photo frames in stock. Only selected popular ranges are listed here, please quote catalogue numbers when ordering by phone. Walk-in for a wider range of selection of our photo frames.
Bespoke / Tapestry Framing
Professional framing service available for any size / quantity. Selected mouldings and mount colors are listed here, for a wider range of choices please walk-in or call us. Collection and delivery available in selected areas of London.
- Photo framing
- Oil painting / Tapestry Framing
- Canvas stretching and mounting
- T-Shirt, Medal etc framing
- Dry mounting
- ...and much more.


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About Me
- Biggie Fudgecakes
- I'm a spoilt bratty boy Chihuahua with cashmere blonde fur and a penchant for fake fur. I love dressing up and have quite an extensive wardrobe. I'm very sociable and quite cocky, I love nothing more than a girly shopping trip to the West End or Manchester where people look and admire me. I have a big selection of teddies and toys and I like sitting up high so I can feel superior and I adore the feel of fake fur under my paws.
Thursday, 3 May 2012
Dog In Poloneck .......
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Traditional values with modern thinking - loyalty, flexibility, reliability, foresight and readiness are our bywords. Read more
Serving international shipping - Liner, chemical tanker and dry cargo services across Europe and Africa. View video
Success based on tradition - The group of companies has a long, proud history going back over
120 years. Read more
Consulate - The company headquarters is home to the Honorary Consulate of the Republic of South Africa.Read more
The Deutsche Afrika-Linien/John T. Essberger Group of Companies dates back to the
year 1924 when the former Imperial Navy Officer, Commander John Theodor Essberger
established himself as a tanker ship owner in Hamburg.
Today the group consists of the Deutsche Afrika-Linien operating traditional
liner services to Southern Africa, East Africa and the Islands of the Indian
Ocean, and John T.Essberger with its chemical tanker, dry cargo and ship
management divisions. Read more


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BBC News
- Heathrow reveals expansion 'masterplan'
- MPs' maternity rights: Labour's Stella Creasy speaks out
- Instagram boss Adam Mosseri: 'We can't solve bullying on our own'
- 'Money mules': Rising numbers are in middle age
- Lives 'destroyed by NHS eating disorder failures'
- Tory leadership hopefuls to face second vote
- ITV bans all-male comedy writing teams
- Dogs' eyes evolve to appeal to humans
- South Western Railway workers begin five-day strike
- Leicester temple wheelchair row taxi driver 'suspended'
- 'I lost £50 when diners left without paying'
- The gay men breaking blood donation rules
- Beechwood: 'I can't believe the evil that happened there'
- How to answer 'What's your biggest weakness?'
- The 'brutal reality' for alcohol-damaged children
- KFC's vegan burger: Could it wean you off chicken?
- London stabbing: 'He was my amazing brother'
- Inside Heathrow's high-tech baggage system
- Lenny Kravitz jams with nine-year-old drummer
- Danniella Westbrook: Drug-free EastEnders star 'to train as therapist'
- Andy Murray's 'life-changing' hip surgery has left him pain-free
- Newspaper headlines: Rory Stewart's PM bid on front pages
- HMP Birmingham: Scanner funding failure 'inexplicable'
- Prison to pilot scheme: The rehabilitation project lowering reoffending
- Swansea crash death victim's mum calls for A4067 speed cameras
- Scotland's papers: Protest 'shut down' and HIV data leaked
- Parish council tax bills rise 'to save services from cuts'
Picture Gallery
Please submit your pictures of Anderby here
scarecrow at anderby july 2012
By: Peter Varney
scarecrow at anderby july 2012
By: Peter Varney


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Pierre Bank Theft Suspects Scheduled to Plead Guilty
PIERRE - Two people accused of stealing money from a Pierre bank are scheduled to enter guilty pleas next week.
Ismael Ortiz and Alejandra Madrid initially pleaded not guilty to taking about $2,000 from a BankWest branch last November. KCCR radio reports they are scheduled to change their pleas Wednesday in federal court.
The suspects are accused of stealing money from a teller's station while she was distracted. Both are scheduled to plead guilty to bank larceny, and Ortiz also is scheduled to plead guilty to illegally entering the country after being deported. Other charges are to be dismissed.
Copyright 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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Rocky RIDE Steel Toe Western Boot
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Rocky RIDE Steel Toe Western Boot
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Additional Information
Rocky designed these men's RIDE boots with all of the makings of a traditional Western. It has exceptionally hardy full-grain leather, detailed stitching (the use of neutral colors prevents the footwear from ever going out of style and won't clash with any apparel you throw on), a square toe, sturdy pull straps and it has been assembled with Goodyear welt construction, which gives the footwear great durability, makes it sturdier and allows you to have outsole resoled. Yet, what makes it a dependable work boot is its protective features; this steel-toe boot has met the ASTM F2413 I/75 C/75 Protective Toe Classification (can endure up to 75 lbs. of impact and compression) as well as the ASTM F2413 Electrical Hazard Standard.
You will be able to get these Western boots on smoothly, because an Expansion Fit SeamÃ"ž has been constructed into the footwear; it's convenient because the seam expands, allowing you to slide your foot down into and out of these boots with ease, but then closes back so it will not alter the look or interfere with the great fit.
The interior has been made with a very strong yet incredibly soft tricot lining; it does an excellent job at protecting the interior from wear and keeps your legs comfortable. For the bottoms of your feet to be supremely comforted and receive ideal support, this Western has been equipped with: a RIDE footbed (cooling ventilation with amazing cushioning) with arch stabilizer, a steel shank (stability, arch support) and there are two layers of amazingly-soft EVA that have been built into the footwear.
The slip and oil-resistant RIDE outsole gets its great durability and traction from the rubber that was used to make it, as well as the Dura-Red layer that holds up through extreme wear. The rocker heel is the perfect accompaniment to the outsole; it allows your footing to be steady and also aids in providing grip.
Considering its unbelievable durability, phenomenal comfort and support, incredibly protective safety features and strong base, there's no reason why you shouldn't want to pull on this pair of Rocky RIDE Steel Toe Western Work Boots (#6185).
- Square toe
- Steel Toe
- ASTM F2413 protective toe classification
- ASTM F2413 electrical hazard standard
- Expansion Fit Seam for easy on and off
- Rocky Ride Outsole
- 11 Inches in height


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The Secretary of State for Health, Andrew Lansley CBE, is supported by four health ministers. and is Chair of the Departmental Board.
Una O'Brien CB is Permanent Secretary at the Department of Health.
Sir David Nicholson KCB, CBE, is Chief Executive of the National Health Service in England.
Of the Department's 14 directors, 8 are currently at director general level.
The Department currently has 6 chief professional officers, who are leaders in their professions and provide the Department with expert knowledge about health and social care disciplines. They are headed up by the Chief Medical Officer, Professor Dame Sally Davies.
The National Clinical Directors – the health Tsars – represent the NHS in the Department of Health.
You can see the Department's organogram on data.gov.uk. This reflects all posts and senior salaries paid as at 31 March 2011. Or you can view the supporting information which is available here.


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United Kingdom: Rise of Sexually Transmitted Infections on Gay Scene Linked to Crystal Meth
Researchers report that increased use of crystal methamphetamine is driving up incidence of HIV among men who have sex with men (MSM) in London. Ecstasy, cocaine, ketamine, y-butyrolactone, and speed are also widely available among MSM in London, according to Tony Kirby and Michelle Thornber-Dunwell, authors of the Lancet article.
There were 3,010 new cases of HIV in the United Kingdom in 2011, and 1,296 of these infections were diagnosed in London. Thornber-Dunwell and Kirby stated that use of crystal meth increases the risk of HIV, hepatitis C, and other STDs.
Increased incidence was noted at two London locations, the 56 Dean Street Clinic and the CODE clinic. Of the 511 new cases of HIV diagnosed at the Dean Street Clinic, 482 infections occurred among MSM. The CODE clinic is home to Antidote, which provides drug and alcohol services for LGBT people. UK drug clinics are struggling to meet the demand for services, reported David Stuart of Antidote. Stuart said 75 percent of the MSM using CODE's services are HIV-infected. Most of these men -- 60 percent -- say they do not take antiretroviral (ARV) medicines when they are using drugs. Not taking ARVs makes transmission of the virus more likely. Stuart said the availability of drugs and ease of finding sex parties and drug dens via the Internet compound the problem.
Kirby and Thornber-Dunwell reported that the practice of slamming -- dissolving crystal meth or mephedrone in water or blood and injecting them -- creates a "perfect storm" for the transmission of HIV and hepatitis C. Slammers sometimes stay high for days, having unprotected sex with multiple partners.
The full report, "High-Risk Drug Practices Tighten Grip on London Gay Scene," was published in the journal The Lancet (2013; 381(9861):101-102).


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By Britta O'Boyle | Pocket-lint –
Motorola has officially announced the much-rumoured Moto G smartphone at a launch event in Sao Paulo, Brazil, and a parellel events in London, Mexico City and Toronto.
Introduced on stage by Dennis Woodside, CEO of Motorola, the Moto G looks to solve a problem that Motorola's Woodside says affects hundreds of millions of people globally. The Moto G is pitched at those looking for something affordable, without having to sacrifice the experience that it offers.
The design of the Moto G brings design elements seen in the Moto X, like a edge-to-edge display, nice curved back, and a nano-coating designed repel water.
The Moto G also comes with a removable back, so you can change the colour to suit your style, as we as accessories, all colour matched, so go with the phone. You can get speakers, headphones, power packs and covers, all made to suit.
The 4.5-inch handset sports a 1280 x 720 LCD display with a pixel density of 329ppi. The display is finished with the latest Corning Gorilla Glass 3, with Motorola claiming that it's the sharpest screen in its class.
The Moto G comes wth the Qualcomm Snapdragon 400 chipset, clocked at 1.2GHz, promising power and battery life. Motorola says that all day battery life is guaranteed, with 33 per cent more talk time compared to rival handsets on 3G.
The Moto G will ship with Android 4.3 Jelly Bean with a guarantee of an update to Android 4.4 KitKat by January 2014. "Android is the best mobile operating system in the world bar none," said Motorola at the launch event, while taking a swipe at companies like HTC and Samsung, saying that Motorola wasn't interested in duplicating services and adding clutter, and claiming that the result means it will out-perform the Samsung Galaxy S4 in some areas.
There will be a migration service to help you move your old phone into your new, as well as a morphing application to help your Moto G adapt to how you use it, and a simplified camera app to help you get better pictures. There will be a special deal for Moto G owners, as you'll get an additional 50GB of Google Drive space to store your docs in the cloud.
There will be dula SIM models in appropriate markets.
The Moto G will be available for $ 179 for 8GB of storage, unlocked. The 16GB will be $ 199. UK prices are £135 or €169 in Europe.
Moto G goes on sale today in Brazil and some parts of Europe and will be coming to the US in January 2014. It will be available in over 30 countries globally.
© copyright Pocket-lint 2013


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A subsidiary of Nabors Industries Ltd. (NBR) pumped a mixture of chemicals identified only as "EXP- F0173-11" into a half-dozen oil wells in rural Karnes County, Texas, in July.
Few people outside Nabors, the largest onshore drilling contractor by revenue, know exactly what's in that blend. This much is clear: One ingredient, an unidentified solvent, can cause damage to the kidney and liver, according to safety information about the product that Michigan state regulators have on file.
A year-old Texas law that requires drillers to disclose chemicals they pump underground during hydraulic fracturing, or "fracking," was powerless to compel transparency for EXP- F0173-11. The solvent and several other ingredients in the product are considered a trade secret by Superior Well Services, the Nabors subsidiary. That means they're exempt from disclosure.
Drilling companies in Texas, the biggest oil-and-natural gas producing state, claimed similar exemptions about 19,000 times this year through August, according to their chemical- disclosure reports. Data from the documents were compiled by Pivot Upstream Group, a Houston-based firm that studies the energy industry, and analyzed by Bloomberg News. Nationwide, companies withheld one out of every five chemicals they used in fracking, a separate examination of a broader database shows.
Trade-secret exemptions block information on more than five ingredients for every well in Texas, undermining the statute's purpose of informing people about chemicals that are hauled through their communities and injected thousands of feet beneath their homes and farms, said Lon Burnam, a Democratic state representative and a co-author of the law.
Truck-Sized Hole
"This disclosure bill has a hole big enough to drive a Mack truck through," Burnam says of the law, which he called "much compromised legislation."
"Is it meaningless because there are so many exemptions?" he asked. "I'm afraid it may be."
The Texas disclosure bill marks a growing effort by the oil and gas industry to address public concerns about fracking, a drilling technique in which millions of gallons of water, sand and chemicals are pumped underground to free up more hydrocarbons. While the method has unlocked vast new sources of energy, safety questions center on the hundreds of chemicals used — many of them known carcinogens. The federal Environmental Protection Agency has little authority to regulate fracking; Congress decided in 2005 that the bureau wouldn't oversee the practice.
Flaming Faucets
The 2010 documentary film "Gasland" showed homeowners near fracked wells igniting the water that flowed from their faucets. A year later, the EPA linked fracking to contaminated drinking water in Pavillion, Wyoming. The agency is retesting the Wyoming wells. A separate report from the U.S. Geological Survey this year confirmed the environmental agency's initial finding; it detected levels of methane, ethane, diesel compounds and phenol, which the EPA had identified in 2011.
Companies including Houston-based Halliburton Co. (HAL) have embraced the Texas law as a model that "provides an enormous amount of information to the general public" while protecting trade secrets from competitors, said Susie McMichael, a company spokeswoman.
"Without such protection, companies would have no incentive to develop and put into use new technologies that are both environmentally beneficial and more effective," McMichael said in an e-mail.
Largest Withholders
In August, the largest well-servicing companies that worked in Texas withheld the most information about frack jobs. Wells serviced by Halliburton and Houston-based Baker Hughes Inc., the second- and third-largest oilfield services companies respectively, contained more than nine secrets per well according to reports filed by the companies. Frack jobs by Superior Well Services, the Nabors subsidiary, omitted the most information with more than 32 secrets per well.
For neighbors of fracked wells, the omissions mean they can't use the disclosures to watch for frack fluids migrating into creeks, rivers and aquifers, because they don't know what to look for, says Adam Briggle, who is chairman of a citizen's group in Denton, Texas, called the Denton Stakeholder Drilling Advisory Group.
"We can't test to see what is coming into the environment," says Briggle, 35, who also works as an assistant professor of philosophy at the University of North Texas in Denton. "If frack fluids are so harmless, why do they hold onto these trade secrets so strongly?"
Property Rights
Dennis Smith, a Nabors spokesman, didn't reply to several e- mails and phone messages requesting comment. Baker Hughes provides information on its fracking fluids "in a format that minimizes intellectual-property-rights risks to our products," according to a statement e-mailed by company spokeswoman Pamela Easton.
Halliburton's McMichael noted that the Texas rules were written with input from environmental groups, including Environmental Defense Fund, a New York-based environmental group whose president, Fred Krupp, has called the supply of natural gas that may be liberated by fracking "a potential game changer."
The Texas rules could "help industry do something that industry has trouble doing for itself — gain the public's trust," wrote Scott Anderson, a senior policy adviser to EDF, in an October 2011 letter to the Texas Railroad Commission, which regulates oil and gas drilling in the state.
Watered Down
Yet the regulations "could wind up hurting public confidence rather than helping," particularly if companies report fewer chemicals than the public expects, Anderson wrote. In an interview this week, Anderson said that while EDF considers the Texas rule "landmark legislation" that won industry support for disclosing chemicals, the group doesn't support the final version because it was watered down.
Industry lobbyists made it clear that they wanted strong trade-secret protections, "but they didn't say it would be this heavily utilized," said Cyrus Reed, acting director of the Sierra Club's Lone Star chapter, who worked with companies to develop the rule. "It is disappointing to see this many trade secrets being claimed."
The law, signed by Governor Rick Perry, a Republican, in June 2011, requires companies to disclose their fracking chemicals on FracFocus, a national website that the energy industry helped create in 2011 to allow for voluntary disclosure. Bloomberg News reported in August that more than 40 percent of wells fracked in eight major drilling states last year had been omitted from the voluntary site.
Permitted Secrets
Oil and gas companies are permitted to withhold disclosure of chemicals and their concentrations in any product that they claim to be a trade secret under the Texas law. Such claims can be challenged by state regulators and landowners of well sites or adjacent parcels.
Several other states that require disclosure of fracking chemicals, including Louisiana, Montana, New Mexico and North Dakota, also leave it up to energy companies to determine what chemicals can be labeled secrets. North Dakota's rule requires companies to report fracking chemicals to FracFocus, beginning last April.
"We require whatever FracFocus requires," said Alison Ritter, a spokeswoman for the state Department of Mineral Resources' Oil and Gas Division.
The FracFocus website states that chemicals should be disclosed unless they're a trade secret, as defined by the U.S. Occupational Safety and Health Administration. The operators of FracFocus, which is supported by funds from the industry, don't check trade-secret claims or offer a way to challenge an exemption.
Every Ingredient
Mike Paque, the executive director of the Groundwater Protection Council, a group of state water officials that's one of the operators of FracFocus, didn't respond to requests for an interview.
"We have successfully fulfilled our commitment … to ensure that Texans know every single ingredient used in the hydraulic fracturing process," said Elizabeth Ames Jones, then-chairwoman of the Texas Railroad Commission, when the law was signed last year. "Texans can be assured they will know more about what is going into the ground for fracturing than what goes into a can of soda," she said.
Jones said this month that she's proud of what Texas did. "There are people who want to use scare tactics to drive an agenda that is not good for America," she said in an e-mail.
Descriptions Withheld
The 19,000 trade-secret claims made in Texas this year through August hid information that included descriptions of ingredients as well as identification numbers and concentrations of the chemicals used. Overall, oil and gas companies withheld information on about one out of every seven ingredients they pumped into 3,639 wells.
In 5,000 other instances, Texas well operators failed to disclose information without saying why, filling in boxes on forms with "N/A" or "mixture," for example, or leaving them blank. Such omissions raised the total to almost seven secrets per well from about five.
Nationally, companies claimed trade secrets or otherwise failed to identify the chemicals they used about 22 percent of the time, according to a Bloomberg News analysis of FracFocus data for 18 states. The data were compiled and released this month by SkyTruth.org, a website that uses data and digital mapping to investigate environmental issues.
Among states with at least 250 fracked wells, Oklahoma had the most unknown components; almost a third were listed as trade secrets or had no valid identification numbers attached to them.
August Sample
A smaller sample from Texas, the 370 wells that were reported in August 2012, showed that the number of secrets per well increased to almost eight when small frack jobs — those using less than 100,000 gallons of water — were excluded.
Although oil and gas companies submit the disclosures, the well-servicing companies they hire decide which chemicals will be disclosed or kept secret, said Halliburton's McMichael and others. The number of ingredients they withhold from disclosure can vary widely, based on the August data.
Wells serviced by Geneva-based Weatherford International Ltd. (WFT) averaged 0.1 secrets per well, while Baker Hughes (BHI) averaged 9.1; Halliburton, 9.3; and Superior Well Services, 32.5.
Melanie Kania, a spokeswoman for Weatherford, declined to comment.
Most of the secret chemicals are described only in general terms, such as "polymer" or "surfactant," leaving little clue about their contents, said Theo Colborn, president of The Endocrine Disruption Exchange. The Paonia, Colorado-based nonprofit, which is staffed by scientists, studies chemicals that interfere with human development and has criticized regulatory approaches to fracking.
Wyoming Approvals
Texas wasn't the first state to require disclosure of frack ingredients. In September 2010, Wyoming enacted a similar law, which requires an extra step to claim a trade secret. Companies need to apply with state regulators to explain why they need trade-secret protection for specific ingredients.
Since that rule went into effect, the Wyoming Oil and Gas Conservation Commission has approved 78 additives as trade secrets and rejected six such requests, according to Lori McCoy, a support specialist for the state agency.
Recently, more states are following the Texas model — with an assist from industry. In December 2011, the American Legislative Exchange Council (ALEC), a Washington-based public policy organization that brings together corporations and legislators to craft bills for states, adopted model legislation that is almost identical to the Texas rule.
Exxon Sponsorship
The model bill was sponsored inside ALEC by Exxon Mobil Corp. (XOM), which also advises the council from a seat on its "private enterprise board," according to ALEC documents obtained by Common Cause, a nonprofit group in Washington.
So far, legislators in eight states have proposed bills based at least in part on the ALEC model, according to Todd Wynn, the director of the organization's task force on energy, environment and agriculture.
The main author of the Texas bill said other states will tailor the language to their needs.
"Can it be better and should it be better?" asked state Representative Jim Keffer, a Republican. "Yes, and I think it will be better. People are going to use this bill as a base and then make it fit their state's attitude or their industry."
His Democratic co-author disagreed. It would be "a horrible mistake" for other states to use the Texas bill as a blueprint, Burnam said.
"Texas state government has been a wholly owned subsidiary of national oil and gas interests for a century," he says. "Do not look at it for guidance on anything related to protecting public health and safety."


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TOPEKA, KS -- An officer with the Topeka Police Department was patrolling an area after reports of an altercation took place.
Officer Aaron Bulmer was looking for anyone who may have been involved in the incident but while he was looking, he saw a small child walking towards a pond.
The child appeared to be four years old and he was inside the Central Park Community Center. Officer Bulmer got out of his cruiser to speak with him when the child fell into the pond.
Officer Bulmer jumped in after him and was able to pull the child to safety. Video from his body camera captured the entire incident.
Medical services were called to the scene and the child was transported to a local hospital to be evaluated.
The parent was already out searching for him and was located and reunited with the child. It was also later discovered that the child had Autism.
Officer Bulmer was commended for his fast reaction and his dedication to protect and serve his community.


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HMRC poo-poos tax on BlackBerries
Her Majesty's Revenue and Customs (HMRC) today dismissed claims in The Sun and The Times that changes to employee benefit rules mean BlackBerries are likely to be taxed as a personal benefit.
A spokesman for HMRC was blunt: "It's garbage."
He explained: "If an employer loans a BlackBerry to an employee so they can do their job there is no tax implication. And the suggestion that we are going to go around counting people's emails is ludicrous - we've got bigger and more important things to do."
The spokesman said he was loaned a CrackBerry by his employer to do his job as a press officer, but didn't use it for personal emails because: "It's my work email address and they're too awkward to use..."
The actual advice from August's revised rules reads:
Employers are not expected to keep detailed records of every instance of actual private use in order to substantiate a claim for exemption. The "not significant" condition should not be decided purely on the absolute time spent on different uses of the equipment or services provided.
It should be considered in the context of the employee's duties and the necessity for the employee to have the equipment or services provided in order to carry out the duties of the employment.
So there you have it. Using your CrackBerry might still lose you friends, but it won't cost you any more tax. ®


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Standing almost lost amongst high rise constructions in the Green Central City superblock along Jalan Gajah Mada in Jakarta's China Town, is a fine example of Chinese architecture of Old Batavia, known as : Candra Naya.
Because of its historic significance relating to the presence of the Chinese in Batavia during the colonial era, moreover, the land on which it stands is believed to be a "land of prosperity", sure to bring luck to its owners, the present developers have saved this building from the bulldozers.
Instead, Candra Naya Building has now been restored and refurbished to serve as a place for social gatherings for the present Indonesian Chinese community, to revive forgotten traditions, hold seminars, festivals and exhibitions and become the icon for the Green Central City development.
While most Chinese houses in Batavia that were owned by traders used to have simple structures, the Candra Naya, on the other hand, was distinctive for its massive structure and spacious rooms, with the interior of the house decorated with intricate ornaments while its roof top has a tou-kung crown which is also fully ornamented.
The original layout of the Candra Naya compound covered two buildings which flanked the main buildings on the right and the left sides. Both have been dismantled but developers have promised to rebuild these once the construction of all buildings is completed.
Estimated to have been originally built in the early 19th century, nonetheless, the exact date when it was actually constructed remains unclear. The only indication is a painting in the old house which gives the date of the year of the fire rabbit, which should be either 1807 or 1867, said Naniek Widayati, senior architect in the Centre of Architecture Conservation.
The last known owner of the house was a prominent and presumably wealthy Chinese businessman, by the name of Khouw Kim An, who was entrusted by the Dutch government to take care of the Chinese community in Old Batavia. He was also shareholder of the Bataviaasche Bank. Khouw died in a Japanese concentration camp in 1945.
At the end of World War II, the Sin Ming Hui social organization made the home of Khouw Kim An on Jalan Gajah Mada 188 its center. The organization helped and gave information to the war-stricken Chinese community. Sin Ming Hui conducted many works for social purposes. They established health clinics, sports clubs as well as arranged educational activities and organized a club in photography.
In 1962 the Sin Ming Hui social organization changed its name to the Tjandra Naja. Then, adjusting to the new Bahasa Indonesia spelling, the organization's name changed again from Tjandra Naja to Candra Naya. The house of the late Khouw Kim An became the home of the social organization for quite some time and today 'Candra Naya' remains the building's official name.
Already, among others a seminar on the Chinese cultural heritage in Sumatra was recently organized in the Candra Naya as well as the Peh Cun festivities.
Get There
Jalan Gajah Mada is the main road that leads from Harmoni, near the Presidential Palace to the Old Batavia or Jakarta Kota. Jalan Gajah Mada and its counterpart street across the canal, Jalan Hayam Wuruk, that has the opposite going traffic into the city, are normally crammed with traffic.
So, to get there it is best to travel by car or taxi. The Trans Jakarta Busway also passes this way on its route to Jakarta Kota station.


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No Evidence of Foul Play in Rapid City Motel Deaths
RAPID CITY - Rapid City police say they have found no evidence of foul play in the deaths of two people whose bodies were found in a motel room a week ago.
Police spokeswoman Tara Heupel tells the Rapid City Journal that authorities are treating the incident as an unattended death investigation.
Gold Star Motel manager Tony Janis found the bodies of the man and woman on the floor of their room on Feb. 21. Janis said police told him the deaths appear to be a double suicide.
Copyright 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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A New Word-Guessing Game Is Topping the App Store
There's a new king of the Apple App Store.
As happens fairly often, a word-guessing game has jumped to the top of the U.S. list. This one, called 94 Seconds, is a game built by a seven-person team in France that, with a little clever planning, has managed to capture some serious buzz.
Here's how it works: The player has 94 seconds to furiously type out words that start with a given letter and are in a certain category, such as music or countries. Words that fit earn a point, and complicated or less-used words get two points. The goal is to rack up as many points as possible.
Users connect the app to Facebook, where you can see where you stand among your friends. And like other apps, this one has a premium version and gives you ways to get a slight edge in the game by paying money for things called "Jokers."
The game has been the top free app in the Apple App Store for the past three days after and is rapidly rising in the ranks of Apple's top money-makers in the store, according to AppData.
The team attributes the success to a mix of using third-party app promoters, some juice from Apple, and... the nice weather in Southern France, marketing director Benjamin Faure said.
We caught up with Mr. Faure and CEO Gael Bonnafous to find out more about the app. Here's a recap:
WSJ: Has Apple featured 94 Seconds?
Benjamin Faure: Yes, Apple featured the iPhone and iPad apps in every European country. But the launch of 94 Seconds was done in three steps:
First we launched in France and Germany. Those are our core markets, as we have native speakers for these countries in our company. The app has been #1 on iPhone and #2 on Android in France (self promotion with our active user database, no marketing budget). In France, we have also partnered with a famous radio station, which organized 94 Seconds competitions live with their listeners and they really enjoyed it!
Step two was European expansion. We have been featured by Apple and it helped us considerably. The app climbed to the #2 position in UK "only" with the feature. We needed to test the app on an English-speaking market before targeting the US: with a 4.6 rating in UK, it sounded good.
Then came the U.S. and Canada -- for these competitive markets we used third parties, such as App Gratis, our French colleague, or the Chartboost network.
WSJ: Can you give me some background on the company and the founders? Where are you located?
BF: Founded in 2008, it remained a 1 person company for one year. We're still self funded, located in Montpellier, south of France. That's the native country of Gaël Bonnafous, and probably one of the nicest places in France. Another thing is that when you are self founded, you don't have money to attract talents and therefore you need something else. The weather in Montpellier and the south-French way of life helped.
Last year was key period: we took a huge strategic shift stopping all B to B activities in order to focus on B to C development and casual games. The 2012 Gamescom in Germany was the revelation: The game industry is where our skills are and what we like to do. It was an incredible bet as we started from scratch (turnover 0).
We're now at 7 people. We are small which is why we are able to move really fast. What we are going to do in the upcoming month is amazing . However all is "homemade", from translation to developments.
The average age is 26 years (Gael is the oldest at 31), but everybody has worked in mobile for two years minimum (Gael Bonnafous, CEO, for nine years, I have for five years).
WSJ: What is it about this app that's taking off? How does it compare to apps like Draw Something or that What's The Word game?
BF: Each part of the app was developed thinking about the users' experience: simple, fast, smart -- and no crashing.
Then we realized that people love to play with friends or family, either to challenge each other or to try to reach a higher score. We also noticed on Twitter that many players are playing in class, sometimes even with their teacher! There is much virality: 60% of players said they discovered the application by a friend!
I also think that people like to have fun while learning: in 94 Seconds, they often learn new words, states, capitals, vegetables...
WSJ: How is the game monetized?
BF: Several ways. We have in-app purchases with a Premium mode or to add features as additional categories, for example. There are free actions like watching videos to earn Jokers (the game's currency). We also have classic advertising, like splash and banner, on key points.
WSJ: This seems like a radical departure from your company's usual apps -- what prompted it?
BF: As mentioned before, the game has been developed thinking first about the mobile experience: It is not just a mobile adaptation of a Web game. This is a key point and we saw too many people failing in this work.
Another point was making it appeal to the mainstream: 94 Seconds can be played by everybody -- from 94 months to 94 years.
Finally, it's addictive: We really discovered it when we tested it. We really enjoyed playing, not only because it's our game. Being available on the main platforms at the launch also helped -- iPhone, iPad and Android. And, not then. You must be everywhere at the beginning. At the moment we are even working on developing the game on other platforms.
WSJ: What's it like being an app developer internationally?
BF: Working internationally is important and mandatory. We knew from the beginning that the success is outside of France. That is why we continue to expand the app, particularly to Asia and South America.


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Figure 1. Calibration curve for the modified TMPM mortality model. Vertical bars represent 95% confidence intervals.
Figure 2. Calibration curve for the modified TMPM death or major complications model. Vertical bars represent 95% confidence intervals.
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Glance LG, Dick AW, Mukamel DB, Osler TM. Association Between Trauma Quality Indicators and Outcomes for Injured Patients. Arch Surg. 2012;147(4):308–315. doi:10.1001/archsurg.2011.1327
© 2019
Author Affiliations: Departments of Anesthesiology and Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, New York (Dr Glance); RAND Health, RAND, Santa Monica (Dr Dick), and Center for Health Policy Research, Department of Medicine, University of California, Irvine (Dr Mukamel); and Department of Surgery, University of Vermont Medical College, Burlington (Dr Osler).
Objective To examine the association between the American College of Surgeons Committee on Trauma (ACSCOT) quality indicators and outcomes.
Design Cross-sectional study.
Setting Data from the Pennsylvania Trauma Outcome Study.
Patients We studied data from 210 942 patients admitted to 35 trauma centers in Pennsylvania between 2000 and 2009.
Main Outcome Measures Regression analyses were performed to examine the association between ACSCOT quality indicators and in-hospital mortality and death or major complications.
Results Seven of the ACSCOT quality indicators were associated with either increased (1) in-hospital mortality or (2) death or major complications. No head computed tomography scan in patients with a Glasgow Coma Scale score less than 13 was associated with a 4-fold increase in mortality (adjusted odds ratio [AOR], 4.39; 95% confidence interval [CI], 3.18-6.07) and a nearly 3-fold increased risk of death or major complications (AOR, 2.76; 95% CI 2.05-3.72). Gunshot wounds to the abdomen managed nonoperatively were associated with a nearly 5-fold increase in mortality (AOR, 4.80; 95% CI, 2.95-7.81). Femoral fractures treated with nonfixation were also strongly associated with mortality (AOR, 4.08; 95% CI, 2.50-6.66) and death or major complications (AOR, 2.54; 95% CI, 1.96-3.31).
Conclusion Several current ACSCOT quality indicators have a strong association with clinical outcomes. These findings should be interpreted with caution because some measures may lack face validity for identifying poor-quality care in complex patients with multiple injuries.
Traumatic injuries are the leading cause of death in patients younger than 45 years and are the fifth most common cause of mortality overall in the United States.1 In 2000, 10% of hospital discharges were owing to injuries, and the direct cost of treating 50 million injury cases was $80.2 billion, with an estimated additional $326 billion in indirect costs.2 In light of the substantial mortality, morbidity, and cost of caring for injured patients, improving the care of trauma patients is an important national priority.3
The release of the landmark Institute of Medicine report on medical errors4 has resulted in public and private initiatives to improve health care quality through performance measurement and promoting adherence to evidence-based practices.5,6 The wide variability in clinical outcomes across hospitals treating trauma patients,7,8 even among designated level I trauma centers,9 is evidence of large gaps in trauma care quality across hospitals. It is unknown to what extent this variability is caused by differences in clinical practice across trauma centers. More than 10 years before the release of the Institute of Medicine report, the American College of Surgeons Committee on Trauma (ACSCOT) created a set of quality indicators (audit filters), based on expert consensus,10,11 to measure adherence to best practices and facilitate quality improvement.12 In 2006, ACSCOT created the Trauma Quality Improvement Program (TQIP) to develop a national reporting and quality improvement program for trauma patients.3 As part of its mandate, TQIP will seek to identify and validate best practices in trauma care13 and has proposed several candidate process measures for evaluation and inclusion in TQIP.3
Because process measures directly measure clinical practice, they are actionable; poorly performing hospitals can focus on improving compliance with a specific measure (eg, timely administration of antibiotics). Process measures are also an effective mechanism for achieving rapid adoption of new evidence into clinical practice and promoting standardization.14 However, process measures must first be validated to ensure that improved adherence to a recommended practice standard is associated with optimal patient outcomes. Recent negative findings from studies examining the results of 2 national patient safety projects, Leapfrog Safe Practices Scores6 and the Surgical Care Improvement Project,15 highlight the need to establish a strong evidence-based link between practice standards and clinical outcomes before adopting them as performance measures.
In addition to the process measures proposed by the American College of Surgeons TQIP, recent comprehensive reviews of existing trauma quality indicators have also identified candidate process measures for evaluating trauma center quality.16,17 Many of the proposed candidate measures are similar to existing ACSCOT audit filters. The 2 largest previous studies investigating trauma audit filters are based on data nearly 20 years old and may not reflect contemporary clinical practice.18,19Quiz Ref IDAs part of an Agency for Healthcare Research and Quality–funded study to help develop the national infrastructure for trauma quality reporting,7 the current study examined the association between existing quality indicators and clinical outcomes using a large population-based trauma outcomes registry. We used data from Pennsylvania trauma centers to examine whether ACSCOT audit filters are associated with mortality and morbidity. Data on the validity of these expert-based performance measures may help inform the development of future trauma performance measures.
This study was based on data from the Pennsylvania Trauma Outcome Study (PTOS), obtained from the Pennsylvania Trauma Systems Foundation, on patients with traumatic injuries admitted to Pennsylvania trauma centers between 2000 and 2009. The Pennsylvania population, which makes up 4.2% of the US total population and includes rural and urban areas, provides a representative case mix of injured patients.20Quiz Ref IDThe PTOS database is a statewide trauma registry that includes data on all trauma admissions at accredited trauma centers meeting PTOS inclusion criteria: admission to the intensive care unit or step-down unit, hospital length of stay greater than 48 hours, hospital admissions transferred from another hospital, and transfers to an accredited trauma center.21 The PTOS database includes deidentified data on patient demographics, Abbreviated Injury Score codes and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, mechanism of injury (based on ICD-9-CM E codes), comorbidities, physiology information, mechanisms of injury, in-hospital mortality and complications, transfer status, processes of care, and encrypted hospital identifiers.
The study population consisted of trauma patients older than 16 years in the PTOS database, after excluding patients with burns, hypothermia, isolated hip fractures, superficial injuries, unspecified injuries, and nontraumatic mechanism of injury. From this initial cohort of 228 851 patient observations, we excluded patients with missing information on transfer status (291), demographics (174); invalid Abbreviated Injury Score codes (12 732); and patients transferred out to another hospital (4712). The final study cohort consisted of 210 942 patients in 35 trauma centers. This study was approved by the institutional review board at the University of Rochester School of Medicine.
The goal of this study was to estimate the association between the ACSCOT audit filters (Table 1) and (1) in-hospital mortality and (2) death or major complication. The unit of analysis was the patient. Initial exploratory analyses were conducted using univariate logistic regression.
In the first set of analyses, separate logistic regression models were estimated to test the independent effect of each of the ACSCOT audit filters on in-hospital mortality. We used the previously validated Trauma Mortality Probability Model (TMPM-AIS)22 modified by the addition of age, sex, comorbidities, mechanism of injury (based on E codes), transfer status, the Glasgow Coma Scale (GCS) motor component score, systolic blood pressure, and year of admission to control for confounding. Backward stepwise selection was used to determine which of the comorbidities to include. Fractional polynomial analysis was used to determine the optimal specification for continuous predictor variables.23 The STATA implementation of the MICE method of multiple imputation described by van Buuren et al24 was used to impute missing values of the motor component of the GCS and systolic blood pressure. Model parameters estimated in the 5 imputed data sets were combined using Rubin's rule.25 Each analysis was based on the applicable trauma patient population eligible for a particular audit filter (Table 2).
In the second set of analyses, we tested the independent association between each of the ACSCOT audit filters and death or major complications. We defined this composite complication outcome if any of the following occurred after hospital admission: death, acute respiratory distress syndrome, acute myocardial infarction, acute respiratory failure requiring more than 48 hours of ventilatory support, aspiration pneumonia, pneumonia, pulmonary embolism, fat embolism syndrome, acute renal failure, central nervous system infection, progression of original neurological insult, liver failure, sepsis, septicemia, empyema, dehiscence, gastrointestinal bleeding, small-bowel obstruction, compartment syndrome, arterial occlusion, and postoperative hemorrhage. We controlled for age, sex, injury severity, mechanism of injury, the motor component score of the GCS, systolic blood pressure, comorbidities, transfer status, and year of admission, using the modified TMPM-AIS, as described earlier.
Data management and statistical analyses were performed using STATA SE/MP version 11.0 (StataCorp). Robust variance estimators were used to account for the nonindependence of observations within hospitals. All statistical tests were 2-tailed and P values less than .05 were considered significant. The performance of the logistic regression models (for mortality) was assessed using measures of discrimination (C statistic) and calibration (calibration curves).
The study sample consisted of 210 942 patients admitted to 35 trauma centers in Pennsylvania between 2000 and 2009. Population characteristics are displayed in Table 3. The median age of patients in the study sample was 47 years and 63% were male. Twenty-seven percent of the patients were transferred from another hospital. The 3 leading causes of injury were blunt trauma (41.4%), motor vehicle collisions (26.4%), and low falls (13.7%). Quiz Ref IDThe overall mortality rate for this population was 6.3% and the rate of major complications was 7.2%. The median length of stay was 4 days. Gunshot wounds were associated with the highest overall mortality rates (24%) and the highest rate of death or major complications (34%). Patients with GCS motor component scores between 1 and 4 had mortality rates ranging from 22% to 46%. Patients with significant hypotension (systolic blood pressure <90 mm Hg) had mortality rates between 21% and 95%.
The number of patients eligible for each of the audit filters and proportion of patients flagged for nonadherence are listed in Table 2. The rate of missing data exceeded 10% for 5 of the audit filters, primarily because of missing time elements. The results of the analyses for these audit filters are presented in the Tables but will not be discussed further.
Unadjusted and adjusted outcomes for patients flagged by the ACSCOT audit filters compared with unflagged patients are displayed in Table 2 and Table 4. The statistical performance of the mortality and major complication or death models used to adjust for confounding were examined. Both models exhibited excellent calibration, as shown in Figure 1 and Figure 2. Both the TMPM mortality model and the TMPM death or major complication model had excellent discrimination, with C statistics of 0.96 and 0.89, respectively.
Twenty percent of patients with an admission GCS score less than 13 did not receive a head computed tomography (CT) scan. This filter was associated with large increases in mortality (adjusted odds ratio [AOR], 4.39; 95% confidence interval [CI], 3.18-6.07) and death or major complications (AOR, 2.76; 95% CI, 2.05-3.72).
Of those patients admitted with a gunshot wound to the abdomen, 8% were flagged because they were managed nonoperatively. These patients had a nearly 5-fold increase in their risk of mortality (AOR, 4.80; 95% CI, 2.95-7.81).
Fifteen percent of trauma patients with femoral diaphyseal fractures were treated with nonfixation. These patients had a 4-fold increased risk of mortality (AOR, 4.08; 95% CI, 2.50-6.66) and greater than 2-fold greater risk of death or major complication (AOR, 2.54; 95% CI, 1.96-3.31).
Less than 1% of patients with an emergency department (ED) discharge GCS score of 8 or less left the ED without a definitive airway. Flagged patients were at higher risk of death (AOR, 1.33; 95% CI, 0.97-1.82) but were less likely to experience the composite outcome of death or major complication (AOR, 0.63; 95% CI, 0.47-0.85).
Only 6% of trauma patients were admitted by nonsurgeons. This audit filter was an independent predictor of a lower risk of death or major complication (AOR, 0.75; 95% CI, 0.65-0.86).
The percentage of patients requiring a laparotomy that was not performed within 2 hours of ED arrival was 19%. Delayed laparotomy was associated with reduced risk of mortality (AOR, 0.74; 95% CI, 0.60-0.91) but a higher risk of death or major complication (AOR, 1.42; 95% CI, 1.19-1.69).
Nearly 40% of patients transported to the hospital from the hospital scene by ambulance or helicopter were missing an ambulance record in the medical record. Patients flagged with missing ambulance records had a lower in-hospital mortality rate (AOR, 0.79; 95% CI, 0.72-0.88).
Hourly documentation of vital signs in the ED was absent in almost 4% of the patients. Missing ED documentation was associated with lower mortality (AOR, 0.75; 95% CI, 0.69-0.82) and a lower rate of death or major complications (AOR, 0.76; 95% CI, 0.69-0.83).
Approximately 7% of patients experienced a major complication. There was a nonsignificant trend toward a higher mortality rate in this patient group (AOR, 1.18; 95% CI, 0.98-1.42).
Patients who were flagged because they required reintubation within 48 hours of extubation (8%) were less likely to die (AOR, 0.45; 95% CI, 0.37-0.54) but experienced a nearly 5-fold increase in the risk of the composite outcome of death or major complication (AOR, 4.46; 95% CI, 3.47-5.75).
Less than 1% of patients were flagged because of a discharge diagnosis of cervical spine injury that was not diagnosed on admission. These patients had a 2-fold higher risk of death or major complications (AOR, 1.96; 95% CI, 1.41-2.74).
Quiz Ref IDIn this large population-based observational study of the association between the ACSCOT audit filters and clinical outcomes, we find evidence that 6 of the audit filters are predictive of increased mortality or the composite outcome death or major complications. For some of the filters, the clinical impact appears to be very strong. For example, trauma patients with an admission GCS score less than 13 who did not receive a head CT scan had a 4-fold increased risk of mortality and a nearly 3-fold higher risk of death or major complications. Similarly, patients admitted with a gunshot wound to the abdomen who were managed nonoperatively experienced a 5-fold higher odds of mortality compared with those undergoing surgery. In comparison, there is no evidence that incomplete documentation is associated with worse outcomes.
The ACSCOT audit filters, first introduced in 1987 and then subsequently revised in 1990 and 1993, are based on expert consensus.11,18 In comparison with many of the process measures developed by the American College of Cardiology, trauma process measures are not based on data from large multicenter randomized controlled trials.16 Process measures can be an effective means of promoting best practices26 and improving quality27,28 and have been adopted by several large national initiatives to improve quality of care across a wide spectrum of medical and surgical conditions.15,28 However, in some cases, the absence of a strong evidence base linking specific processes of care and clinical outcomes limits the value of performance measures as a tool to improve the quality of health care.15,29,30 Viewed in this light, ongoing efforts by the ACSCOT to evaluate process measures for inclusion in TQIP may benefit from the findings of our exploratory analysis examining the association between existing ACSCOT trauma audit filters and outcome.
To our knowledge, there are only 2 other large-scale observational studies that have investigated the link between the ACSCOT audit filters and outcomes.18,19 Both of these studies were conducted more than 15 years ago, and one did not adjust for differences in case mix.18 The other study, by Copes and colleagues,19 was also based on the PTOS database and used a case-control design to control for case mix differences. However, 80% of the audit filters examined by Copes et al did not have matches for 20% or more of the patients flagged by the audit filter. Ignoring these observations in the case-control study may have introduced significant bias.31 The lack of risk adjustment in one study, and the large amount of missing matches in the second, makes it difficult to compare our study findings with those of these prior studies. In addition, the period separating our study from prior studies limits the utility of such a comparison.
Process measures can be used to improve quality and clinical outcomes by promoting adherence to best practices.26 Unlike outcome measures, which can identify a quality problem but not its root cause, process measures are directly actionable because they quantify adherence to a practice guideline based on best practices.32 However, the Achilles' heel of process measures is the lack of strong evidence supporting large areas of clinical practice.32 Even in the field of cardiology, which has a very strong evidence base grounded in many large experimental trials, nearly 50% of the practice guidelines developed by the American College of Cardiology are based on the lowest quality of evidence.33 The increasing pressure to create process measures for hospitals and physicians and link these to financial incentives through pay for performance and Centers for Medicare & Medicaid Services value-based purchasing34 may have important unintended consequences.35 Recent research findings on the effectiveness of measures designed to reduce the incidence of surgical infections,15 control blood glucose levels, and improve perioperative cardiac outcomes through the use of β-blockers36 highlight the potential downside of creating performance measures based on incomplete evidence. The challenge facing the ACSCOT in creating process measures for TQIP is to move beyond expert consensus. To do so, the National Trauma Databank should be expanded to include more information on processes of care to facilitate comparative effectiveness research. Beyond this, trauma surgeons may need to consider testing the efficacy of best practices, based on the initial results of comparative effectiveness research, using large multicenter randomized controlled trials. Results of these trials may help provide the evidence base for creating the next generation of ACSCOT quality measures.
Quiz Ref IDThe implications of our findings with respect to the future development of process measures for trauma care are not straightforward. Although some of the American College of Surgeons audit filters are strongly associated with increased mortality, these same audit filters may not be suitable as performance measures. For example, despite the finding that there is a strong association between mortality and no head CT scan, it is likely that in many cases CT scanning was not performed because other aspects of care were assigned a higher clinical priority. In particular, patients requiring emergent laparotomy to control hemorrhage may not have time for a head CT scan on admission. Nonfixation of femur fractures may also reflect the need to prioritize clinical care in complex patients with multiple injuries. These issues will need to be addressed by TQIP as they evaluate several proposed measures such as the use of intracranial pressure monitoring in patients with severe traumatic brain injury, time to operative fixation in patients with long bone fractures, and time to hemorrhage control.37 Failure to carry out specific best practices in individual patients may reflect appropriate clinical decision making in complex patients with multiple injuries as opposed to substandard care.
This study has several limitations. First, this study is based on data from Pennsylvania and may not be generalizable to the rest of the United States. Alternative data sources such as the National Trauma Databank and the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, however, do not include the necessary patient-level information on the ACSCOT audit filters. Second, this study, like other observational studies, is potentially biased owing to unmeasured confounders. For example, the findings that patients with an abnormal GCS score who do not receive a head CT scan are more likely to die may reflect confounding by indication; patients with abnormal neurological examination findings who did not undergo CT scanning may have been too unstable to spend time in the radiology suite as opposed to dying because they did not receive indicated care. It is unlikely that a propensity-based analysis would eliminate this potential source of bias, since propensity scoring can only balance groups using available data and cannot adjust for unmeasured risk factors. Although it is impossible to rule out bias as a threat to the internal validity of this study, the excellent statistical performance of our risk adjustment model reduces the likelihood of this type of bias.
Third, we did not explore the association between the ACSCOT audit filters and functional outcomes. As captured by the Institute of Medicine definition of quality, the goal of health care is to "increase the likelihood of desired health outcomes."38 Future work to validate revised trauma performance measures should include functional outcomes as one of the quality domains.
Fourth, the ACSCOT audit filters were first designed as quality indicators to identify patients for peer review, as opposed to performance measures to use for hospital benchmarking. However, as is the case with the Agency for Healthcare Research and Quality Patient Safety Indicators, quality indicators originally intended to facilitate peer review are now routinely used for performance measurement.39 Thus, from a practical standpoint, assessing the validity of the ACSCOT audit filters as performance measures is reasonable. Finally, we examined the association between audit filters that were developed more than 20 years ago and whose relevance to modern trauma management may be challenged. However, some of the process measures currently under review by TQIP overlap with existing ACSCOT measures (eg, deep venous thrombosis prophylaxis and time to operative fixation for fractures). Since TQIP intends to incorporate process measures as part of its reporting system, our exploratory analysis to examine the validity of the ACSCOT audit filters using a contemporary data set should help facilitate the development of an updated set of trauma performance measures. The primary challenge to the construction of process measures for TQIP is the same today as it was 20 years ago: identifying best practices in trauma care using the best available evidence, which unfortunately remains quite limited.
Despite its limitations, we believe that this study will help inform efforts by the American College of Surgeons to develop new performance measures for trauma care. The large variability in outcomes across specialized trauma centers challenges the trauma community to develop standardized treatment approaches, based on best practices, to improve the overall quality of trauma care in the United States. Although performance measurement is an integral part of efforts to improve trauma outcomes, it is imperative that we focus our measurement and standardization efforts on clinical practices that have been demonstrated to lead to better outcomes. The next version of ACSCOT process measures should be based on the best available evidence and should be carefully validated before accepting them as the basis for trauma center evaluation and quality improvement. Because of the complexity of trauma care, the goal of creating evidence-based and clinically valid process measures is likely to prove very challenging.
Correspondence: Laurent G. Glance, MD, University of Rochester Medical Center, 601 Elmwood Ave, Box 604, Rochester, NY 14642 (firstname.lastname@example.com).
Accepted for Publication: September 8, 2011.
Published Online: December 19, 2011. doi:10.1001/archsurg.2011.1327. Corrected on March 13, 2012.
Author Contributions:Study concept and design: Glance, Dick, Mukamel, and Osler. Acquisition of data: Glance. Analysis and interpretation of data: Glance, Dick, Mukamel, and Osler. Drafting of the manuscript: Glance and Dick. Critical revision of the manuscript for important intellectual content: Glance, Dick, Mukamel, and Osler. Statistical analysis: Glance, Dick, Mukamel, and Osler. Obtained funding: Glance, Dick, and Mukamel. Administrative, technical, and material support: Glance.
Financial Disclosure: None reported.
Funding/Support: This project was supported by grant RO1 HS 16737 from the Agency for Healthcare and Quality Research.
Additional Information: These data were provided by the Pennsylvania Trauma Systems Foundation, Mechanicsburg. The foundation specifically disclaims responsibility for any analyses, interpretations, or conclusions.
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