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Esther Liu, PharmD, MSIA
Centers for Medicare & Medicaid Services (CMS) has issued a Change Request (CR) 83581 which requires additional claim data reporting for hospices to support hospice payment reform as authorized by the Affordable Care Act, to be effective 2014. Hospices must report line-item visit data dates of service on or after April 1st, 2014, and they may voluntary begin this reporting as of January 1st, 2014. Hospices should make sure that the billing staff is aware of the changes. The additional data requested includes:
1) Visit reporting for general inpatient care (GIP),
2) Reporting of the service facility National Provide Identifier (NPI)
3) Reporting of infusion pumps and prescription drugs
These new requirements from CMS should come as no surprise because the Medicare Payment Advisory Commission (MedPAC), the Government Accountability Office (GAO), and the Office of the Inspector General (OIG) have all recommended over the past several years that CMS collect more comprehensive data in order to better evaluate trends in utilization of the Medicare hospice benefit. On several occasions, industry representatives have communicated to CMS that the required claims information was not comprehensive enough to accurately reflect hospice care. Industry stakeholders also commented that to understand hospice costs, CMS should consider non-labor costs, as these can be significant, and are largely comprised of data on drugs, Durable Medical Equipment (DME), and medical supplies. Finally, the Affordable Care Act gives CMS the authority to collect additional data as needed to revise payments for hospice care. The additional claims data collection is a step forward and will support the hospice payment reform that is coming down the pipeline.
New Reporting Requirement for GIP:
This includes visits reported by hospice nurses, aides, social workers, physical therapists, occupational therapists, and speech-language pathologists, on a line-item basis, with visit and visit length reported as is done for the home levels of care. It also includes certain calls by hospice social workers, with call and call length reported as is done for the home levels of care. CMS is not changing the existing GIP visit reporting requirements when the site of service is a hospice inpatient unit.
New Reporting Requirement for NPI:
This includes the NPI of any nursing facility, hospital, or hospice inpatient facility where the patient is receiving services, regardless of the level of care provided, when the site of service is not the billing hospice. The billing hospice must report the name, address, and NPI of the service facility where the service is being performed when the service is not performed at the same location as the billing hospice's location.
New Reporting Requirement for drugs:
In most hospices, the requested information from CMS should already be recorded somewhere for administrative purposes. The heavy lifting work is about how to make it organized in a format that is ready for CMS claim submission. For some hospices, providing these data might mean additional billing staff to gather information and to file the CMS claim forms, or for the others, a change in IT infrastructure is needed to make sure the data are fed into the right places for billing. There is no unique solution for all hospices to follow; the bottom line is that your hospice needs to find a plan or protocol for your staff that will fit the work flow. And, the plan should also provide better coordination among all vendors involved in the data transmission process, such as your pharmacy benefit management (PBM) company, infusion pharmacy, the electronic medical record system and the Medicare contractor. For example, here at Outcome Resources, we provide invoices that package all the NDC coding for CMS submission and we work with our clients and their vendors to figure out a plan for data transmission if necessary. When your plan is in place, you should also take advantage of the voluntary reporting period and start testing your protocol for glitches on January 1st, 2014. That way, your hospice can resolve any issues now in order to avoid rejected claims later when data submission becomes mandatory on April 1st, 2014.
Do you want to further discuss your hospice's plan for achieving your goals in regards to the new reporting requirements for prescription drugs? Request More Information Today.
1) The official instruction, CR8358 issued to your Medicare contractor regarding this change may be viewed on the CMS website:
< http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2747CP.pdf>
2) To view the Affordable Care Act, See the following:
< http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf>
Viibryd (vilazodone) was approved in 2011 by FDA for the treatment of major depression. The usual dosage is 40mg once daily with a titration schedule of 10mg for 7 days follow with 20mg for 7 days when initiating therapy. The manufacturer recommended titrating vilazodone when initiating therapy in order to reduce incidences of the most common side effects such as nausea, vomiting and insomnia. The efficacy of this product was established in an 8 week trial and the long-term effect of this product remains unknown. The vilazodone compound is structurally similar to trazodone, but its efficacy is thought to be related to its enhancement of serotonergic activity in the CNS through selective serotonin reuptake inhibition similarly to SSRIs (Selective Serotonin Reuptake Inhibitors). Vilazodone is also a partial agonist at serotonergic 5-HT1A receptors like aripiprazole; however, the result of this action on serotonergic transmission and its role in vilazodone's antidepressant effect are unknown. Clinically, vilazodone is believed to share a similar side effect profile to the SSRIs (citalopram, sertraline, etc.), but with a lower incidence of sexual dysfunction. However, there is no head-to-head comparison between vilazodone and other antidepressants so the clinical advantage of vilazodone for patients is unclear. Due to the limited clinical experience with vilazodone, it is not recommended to be used as a first choice to manage depression because there are many similar low-cost alternatives with tremendous clinical experience available on the market. The recommended first choice for treatment of major depression should remain the generic SSRIs, such as citalopram. The application of vilazodone in hospice practice is limited at this time due to higher cost and very limited clinical experience with its use. Unless the patient came to hospice already stabilized on vilazodone, it would not be a likely choice for depression management in this population.
Outcome Resources considered it an honor to recently sponsor the 2013 Hospice Action Network Advocacy Intensive in Washington, D.C. Together with over 200 hospice professionals we had the opportunity to share positive, caring and supportive stories with nearly all of the nation's Senators and State Representatives. In addition, this year, ten advocates whose hospice programs would otherwise be unable to afford it were able to attend the Hospice Action Network's Advocacy Intensive thanks to Outcome Resources scholarships.
The support of our elected officials is crucial to protect and preserve the hospice Medicare Benefit and to support legislation that positively affects those patients and families facing end of life. We are grateful to the Hospice Action Network for providing all of us involved in hospice the forum and opportunity to speak with a unified message in support of our daily efforts. During the meetings on the Hill with Representatives, Senators, and Legislative Assistants, advocates focused on requesting support with the following issues and legislation:
To learn more about these issues or how you can help, please visit Hospice Action Network. Outcome Resources has been involved as hospice advocates for many years and will continue to support these efforts at every opportunity. We are honored to have Angie Truesdale, Vice President, Public Policy, and Tony Kudner, Manager, Grassroots Advocacy, presenting a session at the Outcome Resources Pathways to Success Conference by the Bay this November. To learn more about the Conference, visit the Conference Website or Download the Information Sheet.
View our photos of the HAN Advocacy Intensive on Facebook at http://on.fb.me/13eUw3N. Read more about Outcome Resources participation in the HAN Advocacy Intensive on NHPCO's Blog at http://nhpco.blogspot.com/2013/08/outcome-resources-helps-bring-advocates.html.
Photo: The North Carolina Hospice Delegation with Senator Kay Hagan
The FDA has updated the labeling for oral ketoconazole (Nizoral®), restricting its indications and adding warnings about serious liver injury, adrenal suppression and drug-drug interactions. A Medication Guide, which addresses these safety issues and should be handed out with each ketoconazole prescription, has also been added.
The FDA's actions coincided with a similar announcement in Europe. On July 26, 2013, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) announced their negative risk-benefit assessment for oral ketoconazole-containing medicines used to treat infections caused by Candida and dermatophytes. They recommended suspension of these medicines throughout the European Union, citing a high risk of liver injury associated with ketoconazole and the availability of safer alternative treatments.
In the United States, specific label changes include the following:
• Oral ketoconazole is no longer indicated for treatment of Candida or dermatophyte infections. It should not be used for any type of fungal infection of the skin or nails.
• Ketoconazole tablets are indicated only for the treatment of the following fungal infections: blastomycosis, coccidioidomycosis, histoplasmosis, chromomycosis, and paracoccidioidomycosis, and only when other therapies have failed or the patient does not tolerate other therapies.
• Ketoconazole should not be used for advanced prostate cancer or Cushing's syndrome.
• Oral ketoconazole is now contraindicated in patients with any type of liver disease.
• An updated Boxed Warning with stronger language about hepatoxicity and a new warning about QT prolongation
• A new warning about adrenal suppression. Ketoconazole is unique in the 'azole' class in that it causes adrenal corticosteroid suppression at doses of 400 mg per day and higher. The recommended dose of 200 mg - 400 mg daily should not be exceeded. Adrenal function should be monitored in patients with adrenal insufficiency or with borderline adrenal function and in patients under prolonged periods of stress (major surgery, intensive care, etc.).
• Updated warnings about drug-drug interactions. Important drug-drug interactions in the hospice population include:
o Certain benzodiazepines. Ketoconazole is contraindicated with triazolam, midazolam and alprazolam because it can increase the activity of these benzodiazepines and result in profound sedation.
o Certain statins. Ketoconazole is contraindicated with lovastatin and simvastatin due to increased risk of myopathy and rhabdomyolysis.
o Fentanyl. Ketoconazole can increase the effects of the fentanyl patch.
o Other meds that may be increased by ketoconazole: calcium channel blockers like amlodipine and nifedipine, buspirone, carbamazepine, digoxin, methylprednisolone, warfarin, verapamil.
These new warnings do not apply to topical ketoconazole formulations, like creams, shampoos, foams and gels.
More information can be found on the FDA's website at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm362672
In hospice, as many of our patients have difficulty swallowing, we are frequently faced with the question of whether or not medications can be crushed or capsules opened for easier administration. The Institute for Safe Medication Practices (ISMP) publishes a very helpful guideline entitled "Oral Dosage Forms That Should Not Be Crushed", or the "Do Not Crush" list.
There are a number of reasons why a medication should not be crushed. By far the most common reason is when a medication has built-in extended-release properties. For these medications, crushing disrupts the extended-release formulation, resulting in a "dose dumping" effect in which the entire dose, meant to be released over a long period of time (like 12 or 24 hours), is released all at once, immediately. This can result in profound side effects and can even be fatal (such as with extended-release opioids).
Less frequently, medications can't be crushed because they are too irritating to the stomach or esophageal lining, or because they are particularly toxic or teratogenic. Sometimes, the medication simply tastes bad.
The recently updated 2013 version of the ISMP's Do Not Crush list can be found here. We recommend consulting this list as a useful reference when determining options for administering medications in a patient with swallowing difficulty.
Dr. Julia Harder, PharmD, CGP
In May of this year, the REDUCE study was published in JAMA (1). This important study provided evidence supporting the use of shorter steroid courses to manage acute COPD exacerbations.
Conventionally, we have recommended 10-14 day oral steroid courses, based on previous studies and international COPD guidelines. (For example, the 2013 GOLD Guidelines recommend 30-40 mg of prednisone for 10-14 days.) (2)
This study, by Leuppi and colleagues, investigated whether a 5-day steroid course was noninferior to a 14-day course. Reducing unnecessary steroid exposure is an important goal in hospice, as steroids lead to many short-term side effects, including steroid-induced psychosis, insomnia, hyperglycemia and fluid retention.
The REDUCE study was a randomized, noninferiority multicenter trial in 5 Swiss teaching hospitals, enrolling 314 patients presenting to the emergency department with acute COPD exacerbation. Patients were randomized to treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled, double-blind fashion. The primary endpoint was time to next exacerbation of COPD.
The cohort primarily included patients with GOLD stage IV disease (very severe) and many of the patients had experienced previous exacerbations.
When the investigators looked at time to reexacerbation (the primary endpoint), they saw no difference in one therapy group versus the other. Time to next COPD exacerbation was 43.5 days in the 5-day steroid group and 29 days in the 14-day steroid group. Furthermore, there was no difference between the two groups in time to death, quality-of-life measurements, rehospitalization rates, the subsequent need for corticosteroids or the subsequent need for mechanical ventilation. In conclusion, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment, and these findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD.
1. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309:2223-2231.
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of COPD. 2013. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html Accessed July 23, 2013.
Dr. Julia Harder, PharmD, CGP
Two years ago, the FDA issued a warning that doses of citalopram (Celexa) exceeding 40 mg per day may cause prolongation of the cardiac QT interval, which can result in potentially fatal cardiac arrhythmias including Torsades de Pointes (please see our previous blog post on the FDA's warning for more information). In addition, the maximum recommended dose of citalopram for patients greater than 60 years of age – most of the patients we treat in hospice – was reduced to 20 mg per day because of further increased risk of adverse cardiac outcomes in the geriatric population.
A recent study (see reference below) published in the American Journal of Psychiatry offers some evidence that contradicts the FDA's warnings. In this study, doses of citalopram greater than 40 mg daily were not associated with increased risk of ventricular arrhythmia or all-cause mortality (cardiac and non-cardiac) as compared to lower doses.
This was a cohort study conducted using Veterans Health Administration data between 2004 and 2009. The study included almost a million depressed patients who were prescribed either citalopram (n = 618,450) or sertraline (n = 365,898). Sertraline was used as a comparison because it is also a selective serotonin reuptake inhibitor (SSRI), like citalopram, but does not have any warnings regarding adverse cardiac effects. Statistical analysis examined the association between antidepressant dosing and adverse outcomes including ventricular arrhythmia and all-cause (cardiac and non-cardiac) mortality.
The results were surprising in that higher doses of both antidepressants were actually associated with fewer adverse outcomes. Citalopram daily doses > 40 mg were associated with lower risks of ventricular arrhythmia (adjusted hazard ratio = 0.68, 95% CI = 0.61–0.76) and all-cause mortality (adjusted hazard ratio = 0.94, 95% CI = 0.90–0.99) compared with daily doses of 1–20 mg. Citalopram daily doses of 21–40 mg were associated with lower risks of ventricular arrhythmia (adjusted hazard ratio = 0.80, 95% CI = 0.74–0.86) compared with dosages of 1–20 mg/day but did not have significantly different risks of mortality. The sertraline cohort revealed similar findings, except there were no significant associations between daily dose and mortality. According to the authors, "these results raise questions regarding the continued merit of the FDA warning."
The FDA's warning was initially prompted by post-marketing reports of QT interval prolongation and Torsades de Pointes associated with citalopram. The FDA evaluated the results of a thorough QT study assessing the effects of 20 mg and 60 mg doses of citalopram on the QT interval in adults. In this randomized, multi-center, double-blind, placebo-controlled trial, 119 subjects received citalopram 20 mg per day, citalopram 60 mg per day, and placebo in a crossover fashion (meaning each individual received all three interventions for comparison).
Compared to placebo, maximum mean prolongations in the individually corrected QT intervals were 8.5 milliseconds (ms) for 20 mg citalopram and 18.5 ms for 60 mg citalopram. For 40 mg citalopram, prolongation of the corrected QT interval was estimated to be 12.6 ms. Let's put these numbers in perspective. In adult males a QT interval greater than 450 ms is considered prolonged and between 430 and 450 ms is considered borderline. For females, a QT interval greater than 470 ms is considered prolonged and between 450 and 470 ms is considered borderline. So, you can see that a QT interval increase of nearly 20 ms (as may potentially be seen with the 60 mg dose) could be clinically significant.
As a result of this QT study, the FDA determined that citalopram causes dose-dependent QT interval prolongation and should no longer be used at doses above 40 mg per day. Safety information about the potential for QT interval prolongation and Torsades de Pointes with drug dosage and usage recommendations were added to the package inserts of Celexa and its generic equivalents.
How can we make sense of this conflicting data? While the recent Veterans Health Administration study looked at an incredibly large number of patients, it's important to keep in mind that, as a cohort study, it can only demonstrate an association, not cause-and-effect. In other words, we cannot determine conclusively whether the antidepressant dose was the direct cause of the varying risks of arrhythmia and mortality, or whether other factors came into play. While the authors did attempt to correct for potentially confounding variables, it is impossible to completely do so with an observational study. Randomized controlled trials (RCTs), which more comprehensively account for confounding variables and are prospective (rather than retrospective) in nature, are considered superior forms of evidence to observational studies like cohort studies. The FDA's study, though it looked at a much smaller number of patients, was an RCT using a crossover design to demonstrate conclusively the dose-dependent QT prolongation caused by citalopram. So, while the Veterans Health Administration data do raise questions, do not dismiss the FDA's warnings about citalopram at this time. Especially in the hospice population, where many of our patients are already at an increased risk of QT prolongation and cardiac arrhythmia, it's important to stick to the dosing limits currently included in citalopram drug labeling. For more comprehensive information about QT prolongation, including risk factors and which other medications may cause it, please see this blog post.
Zivin K, Pfeiffer PN, Bohnert ASB, et al. Evaluation of the FDA warning against prescribing citalopram at doses exceeding 40 mg. Am J Psychiatry. 2013; 170: 642-650.
Dr. Julia Harder, PharmD CGP
With so many different benzodiazepines available, each with its own distinct pharmacokinetic profile, it can sometimes be difficult to choose an appropriate agent to match a patient's needs. We've developed this Benzodiazepines Chart to help you compare the benzodiazepines, understand their similarities and differences, and make patient-specific selections.
You will notice that the chart places emphasis on the pharmacokinetics of each agent. That's because the pharmacokinetics are the main way in which the benzodiazepines differ from one another. Primarily, we focus on the half-life (which tells you something about the medication's duration of action) and the speed of onset. In hospice patients, we want to avoid the benzodiazepines with very long half-lives, as these agents stick around for days, and many have metabolites that accumulate (especially in the elderly). We may also want to avoid benzodiazepines with very short half-lives (such as midazolam), except in specific circumstances.
Route of administration is frequently important in hospice. Most benzodiazepines can only be given PO, but a select few can be given sublingually or via injection, and diazepam can be given rectally. You will see on the chart which routes of administration, and which dosage forms, are available for each agent.
"Typical and Max Dosing" is there mainly to give you a feel for where most patients should be. But the therapeutic dose and the maximum daily dose sometimes depend on indication (anxiety versus seizure disorder, for example). For more precise dosing you may need to consult a comprehensive dosing reference, and always titrate to your patient's needs.
We've also included a "Comparative Oral Dose" column to help you convert from one agent to another. Please keep in mind that these numbers are only estimates. In some cases, especially for those benzodiazepines that are not as well studied, the numbers vary widely depending on which reference you consult. In other cases (such as converting from lorazepam to alprazolam, for example), the conversion ratios are pretty consistent. But, each patient is unique and we can never completely predict how a specific patient will respond to one medication versus another. So, you will need to use your clinical judgment any time you convert a patient from one benzodiazepine to another, and should always monitor the patient very closely.
The chart does not include pricing information. Pricing is fairly consistent across this medication category, with a few notable exceptions which you will find in the "Comments" column.
We hope you find this chart useful in your hospice practice, and welcome any questions or comments here on the blog.
Dr. Julia Harder, PharmD, CGP
The hospice community is buzzing with the news of the Centers for Medicare & Medicaid Services (CMS)'s Proposed Rule, released on May 10, regarding the use of Debility Unspecified and Adult Failure to Thrive (AFTT) as primary hospice diagnoses. This blog post will update you on what the Proposed Rule is, what it will mean for your hospice if implemented, and what you can do now to prepare for the possible change. To read the complete Proposed Rule, go to: http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10389.pdf.
What is the Proposed Change?
Debility and AFTT would not be allowed as principal hospice diagnoses on the hospice claim form. When reported as a principal diagnosis, these would be considered questionable encounters for hospice care, and the claim would be returned to the provider for a more definitive principal diagnosis.
According to CMS, Debility and AFTT are non-specific, symptom diagnoses, classified under the ICD-9 category of "Symptoms, Signs and Ill-Defined Conditions." Codes under the classification "Symptoms, Signs, and Ill-defined Conditions" are not to be used as the principal diagnosis when a related definitive diagnosis has been established or confirmed by the provider.
The principal diagnosis listed should be the diagnosis which is determined to be most contributory to the terminal condition. Debility and AFTT could be listed on the hospice claim as other, additional, or coexisting diagnoses if needed to support prognosis.
Why is CMS Proposing this Change?
The Proposed Rule gives data showing the changes in diagnosis patterns among Medicare hospice enrollees, with a growing percentage of beneficiaries being admitted under the non-specific diagnoses of Debility and AFTT. In the past 10 years, Debility Unspecified has moved from the 3rd most common hospice diagnosis (6% of all patients) to the #1 most common diagnosis, accounting for 12% of hospice patients. AFTT has moved from #8 (3% of patients) up to #3 (7% of patients). In 2012, Debility and AFTT, the #1 and #3 most common hospice diagnoses, collectively accounted for about one in five hospice patients. See Chart here.
Simultaneously, the average lifetime length of stay for beneficiaries has increased, from 54 days in 2000 to 86 days in 2010, an increase of 59 percent. While this is undoubtedly partially due to the earlier identification of patients who are eligible for hospice services and increased awareness among Medicare beneficiaries of the availability of the hospice benefit, it is probably also due in part to the increased number of patients being admitted with Debility and AFTT, as these patients tend to have longer length of stays in hospice.
Furthermore, CMS expressed concern that if a nonspecific, ill-defined diagnosis is reported as the principal hospice diagnosis, a comprehensive, individualized plan of care may be difficult to accurately develop and implement, and, as a result, the hospice beneficiary may not receive the full benefit of hospice services. The comprehensive hospice plan of care should start with an accurate and thorough assessment and identification of the conditions contributing to the terminal illness and decline so that the patient will receive the best and most patient-specific care.
What Should Our Hospice Do Now?
It is important to understand that this is still a Proposed Rule and is not yet in effect, so you may still submit claims under Debility and AFTT. Because we do not yet know what the Final Rule will be, it may not be necessary to make sweeping changes now. However, many hospices have already reduced, or completely ceased, their use of Debility and AFTT as primary diagnoses, and some are even changing the primary diagnosis for existing beneficiaries currently admitted under Debility or AFTT. Your hospice will need to decide how you want to proceed at present. Consider making some changes now to prepare your hospice and reduce the impact when the Final Rule is released.
Try to reduce or even cease the use of Debility and AFTT as primary hospice diagnoses. Instead, select a primary diagnosis that is most contributory to the patient's terminal disease trajectory. Reviewing the Plan of Care, the patient's medical history, and the patient's drug profile may help you determine which diagnosis is most contributing to the patient's overall decline and will require the greatest amount of palliative interventions. List this medical condition as the primary diagnosis, and include Debility or AFTT as an additional diagnosis if needed to support prognosis.
CMS is accepting comments on the Proposed Rule until June 28, 2013. You may submit a comment:
• Online at http://www.regulations.gov. Follow the "Submit a Comment" instructions and refer to file code CMS–1449–P.
• By mail to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1449–P, P.O. Box 8010, Baltimore, MD 21244–8010.
And please leave us a comment here on the blog… What impact has this Proposed Rule had on your hospice?
The American College of Gastroenterology (ACG) released new treatment guidelines on the diagnosis and management of gastroesophageal reflux disease (GERD) in the March issue of The American Journal of Gastroenterology. This blog post will present highlights from the updated guidelines, particularly those that are most relevant to the management of GERD in the hospice setting. Some of the recommendations may surprise you, as many of these recommendations are not routinely followed in clinical practice.
Management of GERD
Risks Associated with PPIs
Reference: Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroeneterol 2013; 108: 308-328.
Access the complete guidelines here: http://gi.org/wp-content/uploads/2013/03/ACG_Guideline_GERD_March_2013.pdf
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The 8th Annual ARFF Chiefs & Leadership School — January 21-24, 2014
The ARFF Training Alliance, ARFF Chiefs & Leadership School will be held January 21-24, 2014 at the Westin Hotel in Cape Coral, Florida. REGISTRATION is Now Open. For additional information including "Call for Papers, Exhibitor Information, etc., "Click Here" Take a look at this PROMO
SECTION 1 SEMINAR/WORKSHOP – May 6-9, 2014
Join us May 6-9, 2014 for the Section 1 Seminar/Workshop hosted by the ARFF Working Group and the FAA Technical Center. Along with classroom educational sessions, a tour and demonstrations will also be conducted at the FAA Technical Center. Presentations would include the latest research being conducted in New Large Aircraft, Composite Material Firefighting, Cargo Firefighting and issues surrounding the Lithium Ion battery fires. Don't miss this great educational opportunity! Check back for Registration and Hotel information in the very near future.
HAMBURG GERMANY – June 10-13, 2014 – We are still in the planning stages for this one-of-a-kind conference/workshop in Hamburg, Germany. Highlights of this program will be a field trip to Airbus (Finkenwerder Plant), Hamburg Fire Academy Tour, Airport Fire Department Tour, Live Fire foam application demos along with many classroom sessions on current topics for the aviation firefighting industry worldwide. Don't Miss this event. Registration and hotel information will be available shortly.


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Ask The Devs 7!
Posted 14 June 2012 - 08:28 AM
Posted 14 June 2012 - 08:28 AM
Posted 14 June 2012 - 08:30 AM
Or any other factions?
Posted 14 June 2012 - 08:31 AM
Posted 14 June 2012 - 08:32 AM
Garth Erlam, on 14 June 2012 - 08:28 AM, said:
Will pilots or Mercenary groups be required to 'localize' to one part of the Inner Sphere? Will there be 'travel time' to get from one planet to another?
Posted 14 June 2012 - 08:36 AM
Posted 14 June 2012 - 08:38 AM
- It was said that the first Map type is a combination of Team Deathmatch and Base Capture. How exactly does one capture a base? How many people will play these matches ( so far it looks like Lance vs Lance, but there also was 3 Lances vs 3 Lances to be heard)? What buildings make up a base? Turrets, Satellite Dishes?
- How many Map Type terrains are there so far? (Hills, Greenlands, Urban, Snow?)
Posted 14 June 2012 - 08:39 AM
Q2. Do you plan on supporting Reactor Core Breaches? If so, how often do they happen? How spectacular and damaging are they?
Posted 14 June 2012 - 08:49 AM
Aegis Kleais, on 14 June 2012 - 08:39 AM, said:
Q2. Do you plan on supporting Reactor Core Breaches? If so, how often do they happen? How spectacular and damaging are they?
Ya those 2 questions are good ones please answer those ones. And adding to Q2. what will be the blast radius if they do happen.
Edited by Atayu, 14 June 2012 - 08:50 AM.
Posted 14 June 2012 - 08:51 AM
Some mechs have plenty of variants but the other variants only show up much later than 3049 or they have only primitive outdated technology.
Take the Firebee for example which is a very cool mech indeed. Hint hint. Can i hope on seeing it in MW:O or not despite it's lack of variants?
Q2 - This might be interpreted as not being a proper question but here goes.
In many of the previous MW games urban areas had rather large distances between each building and the total number of buildings was rather low with large open areas surrounding the urban area.
Those types of urban maps don't look realistic compared to how big cities are in real life.
I guess the real question here is- Could you give us an idea of what to expect from an urban map in MW:O?
Map sketches or maybe even a short gameplay video on an urban map. Something along those lines would be great.
The MW 5 video looks very much like a real city for example but that is MW 5 not MW:O.
Posted 14 June 2012 - 08:53 AM
How are Merc Contracts going to work? Will a merc group be able to accept multiple contracts at one time, for the same or different houses, or will the contracts themselves have multiple layers, such as defense of planet X with a required or optional assault on System Y? How long will contracts work? Will larger merc corps be able to "divide" their forces to cover multiple contracts (if it is allowed), such as Battalion A covers Contract 1 for FRR, Battalion B covers contract 2 for Steiner, and Battalion C covers contract 3 for Davion (assuming none of those contracts conflict directly with each other)?
Finally, how will payment work for Merc Corps? Will a contract completed grant the whole corp a c-bill payment, just the individuals who participated, or both?
Posted 14 June 2012 - 08:58 AM
Posted 14 June 2012 - 08:59 AM
Q: For those who'll do a bit of roleplay. Will we get appropiate Numbers/Letters and "military" Symbols to use as Decals ?
Posted 14 June 2012 - 08:59 AM
- From dev comments on the forums and devblogs, I've come to understand that there will be some key differences in the way merc corps will be able to manage themselves as opposed to how house troops will function. Can you elaborate on this a bit? e.g. What sorts of tools will merc commanders have available? How will contracts work (single objection or signing on for a longer duration "campaign" with a house?)
- Will destruction of one or both side torsos result in "coring" of an XL engine?
- Are SRMs going to have guidance as per canon/TT?
- Will Flamers produce more heat in the attacking 'mech than the target as per TT, or the other way around?
- Sensor data for targeting was relayed automatically from the IGN vids. Where does the Battlegrid come into play?
- Will alternate ammunition like Inferno missiles be available? Will LBX be able to use standard and cluster rounds?
- What's your favorite Crusader variant?
Posted 14 June 2012 - 09:00 AM
Q2: Will jump jets use actual physics or simply press button to fly? If they use actual physics, would it be theoretically possible to strip enough weight off a mech to keep it in the air all the time?
Posted 14 June 2012 - 09:00 AM
Will all planned-for-launch mechs be available during July 17th early access?
Posted 14 June 2012 - 09:10 AM
Q2: Is it possible to get into battle unrepaired? Say you lost an arm, decide not to repair, can you go into battle still? (in World of Tanks you can't)
Q3: Is it possible to lose arms and weapons, and still have enough health? Or is it after you lost like, two arms/weapons you are defeated/dead?
Posted 14 June 2012 - 09:24 AM
1 user(s) are reading this topic
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Holly Willoughby Embossed Pencil Dress
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Colour: Navy. Shell 1: 79% polyester, 17% ryon, 4% elastane. Shell 2: 70% cotton, 30% polyester. Machine washable. -
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oh dear you will have to excuse me, i have just cum in my pants!!!!!!!!
You may be a bit premature man… I'm sure my pile is pretty softcore compared to others!!
not compared to mine it isnt!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
any hardware set up gets me all excited - doesnt matter how soft core - whats the overall worth of ur set up if youdont mind me asking????
im on the verge of buying the new access virus - i am selling my grandma to make up the money :s
overall worth? not that much really. everything in the pictures including the crummy laptop is $3000 CAD max. i never buy anything new (except monitors and mixing board) so i just go for bargains
Nobody else has a digital camera? C'mon let's see those gear pics! 8)
This a picture of my old setup is the same now but in a different place.
Trent Reznor's studio (one of them). Your get 5 arbitrary points for identifying every piece of equipment. I recognize about 80% so far.
I am tempted to take out a huge loan and sign a blank invoice with analoguehaven.com - showing them this picture and saying "I want that".
Unfortunately it is all gone now, Flooded during the recent hurricaine in New Orleans. [/img]
Here's my old studio, now being shipped out west and rebuilt in a not-crap room.
The home rig is mainly for editing and mixing, plus some work-related QA stuff. I just started collecting synths - still a work in progress.
Anyway keep the pics coming! Great stuff!
Cheers, -t
Our set up:
56 channel Mackie 8 Bus, 40 tracks of digital audio using Logic on a Mac G4. RME Hammerfall Soundcard (x2), Alesis AI3 (x3), Behringer Ultragain Pro (x2) Dynaudio M1.5 and Yamaha NS10M, TL Audio 3011 (4 band EQ), Line-6 Pod Pro, Zoom 1204, Focusrite Mixmaster, TL Audio 5021 (valve compressor), TL Audio 5013 (valve parametric EQ), Focusrite Trakmaster, Ibanez MSP1000, Behringer Composer Pro (x3), Behringer Multi Gate (x2), Behringer Intelligate (x2), XIX EH1901, Studio Electronics ATC-1, Novation Supernova, Emu Orbit, Roland SH32, Korg TR-Rack, Alesis S4+, Quasimidi Sirius, dbx Quantum, Lexicon MPX 500 (x3), Lexicon MPX 200, SPL Vitaliser (x2), motu midi timepiece
oh my
g*dd*mn.. that is some hot porn indeed!
damn now i have to clean my studio so i can post in this thread :D
why should you? A messy workplace is very human i guess..
in that case i'm VERY human


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The therapy every day, the tutoring, the doctors' office visits, the living and eating in your car, the hours spent preparing special diet food, the hundreds of hours spent researching on the Internet, the time spent dispensing and taking pills, the hostile stares from other people, the whispers behind your back, the old friends that have stopped calling, and new friends that don't quite get it…. Couple all of that with holidays, and sometimes it is just too much! Sometimes we may want to throw our hands up in the air and scream, "Forget it! Life is too short!!!!" Unfortunately, autism doesn't go away when we get overwhelmed, but there are some ways to reduce the stress and make it a little more fun. Here a few suggestions on how to throw caution to the wind and totally rock autism:
Today was the big day. It was Baptism Day at church. I could hardly believe that the little girl standing in the water, publicly professing her love for Jesus, was the same little girl who just a few years ago had no language and would only tolerate church because they had a really cool fake fish tank. God had spoken to her heart, made her one of His own, and we were once again humbled by His mercy and love. Baptism Day didn't come easy though. Just as it takes a long period of rain showers each April to finally produce the beautiful, delightful flowers in May, it took some serious "April showers" to get Lizzie to her baptism.
In the first few years of autism, you jump in full force hitting all the therapies, supplements, and latest research out there hard. Then you start to realize that you are in this for the long haul, and you must slow down and pace yourself for the survival of your family. Never have we had to do this more than dealing with Lizzie's eating issues. Lizzie was a problem eater. A problem eater is a child that would rather starve than eat something that they don't want to eat. The texture, consistency or smell is so offensive to them that hunger pains pale in comparison. I know this first-hand because when Lizzie was four-years old, I almost starved her.
I am blessed to have a wonderful mother that is not only supportive in words, but also in her actions. She has made autism more bearable by helping me in exactly the way I need it. When I need her, she comes running.....especially if it has to do with Lizzie. Mom, you really are the "wind beneath my wings".....even if you had to wait almost 38 years to hear it! Thanks Mom. I love you.
See Me Beautiful…..A Grandmother's Journey with Autism By Marilyn Statler The piercing scream had heads turning in the McDonalds play area. The beautiful little girl with the huge brown eyes and brown curls was standing in the middle of the area screaming at the top of her lungs. She didn't appear to be hurt or even unhappy—she was just screaming. My heart stopped. I knew at that moment that something was terribly wrong with my precious granddaughter, Lizzie.
Do you remember that TV show "Kids Say the Darndest Things?" It was a show, hosted by Bill Cosby, that ran over a decade ago in which the host would ask kids questions in hopes of getting them to say something funny or inappropriate. Well, you don't have to put my daughter, Lizzie, on a TV show to get her to say something inappropriate. Inappropriate comments flow so freely out of her sweet little mouth that I sometimes find myself thinking, "We worked so, so hard to get you to talk, and seriously, is this what you are going to say?!!!!" Having a child with autism causes every subject to be laid out on the table for discussion. There is no ability to dance around a topic or keep hush-hush on any subject. Every topic, regardless of how socially inappropriate, is thrust out in the open to be discussed with no filter on what might be said. For Lizzie, her thoughts and her words are one and the same, and sometimes her words can catch me completely off guard.
A recent series of conflicts left me seriously doubting humanity. With each twist and turn of kindness and flexibly I tried to show, I was slapped in the face with an attitude of entitlement and more demands made in an ugly and hurtful way. Because I am still pretty irritated with the whole situation, it would give me great satisfaction to list my every right and her every wrong just to make you see how hard I tried to do the right thing. I would also love to share the list of funny (and not so funny) ways I have creatively crafted in my mind to get back at her. But at some point, I need to consciously stop thinking about it and choose to focus my energy on the good I can do in the world instead. Sometimes I think autism helps me quickly get to bottom of a person's true character. If someone is kind and welcoming to Lizzie, then I know they have a good heart and can likely be trusted. But if they show irritation or choose to talk down to her, then I know pretty quickly that I need to be on guard with them in other areas of life as well.
In honor of Father's Day, I bring to you a guest blog from the Greatest Father on the Planet: my husband, Greg. I will admit there have been times of frustration when I felt that I was doing "it all" for autism. I researched, I scheduled, I lived and breathed autism 24/7. Then I realized Greg was doing "his all" to provide for autism, and that in itself is enough to send most guys packing.
Here is Greg's very real account of how autism has affected him: LOOK WHAT LOVE WILL DO by Greg Hornok I will never be nominated for Father of the Year by any autism association. In fact, by most measures, I am a completely inadequate father for the special needs that my wonderful daughter, Lizzie, requires. I am not naturally prone to have patience, understanding, or even a great deal of sympathy. I come home from work tired and little bit irritable. I have worried about the money we have spent on therapy over the last several years. I have worried that the decisions of which therapies to use were the right ones. I have worried way too much about the toll that autism has taken on my marriage and the relationship with our other kids.
Because I tend to want to look good myself, I often find myself expecting my kids to do what makes me look good to others. Sit still, be quiet, don't talk too loud, smile nicely, fold you napkin in your lap, get good grades in school, and excel in your sport. This list goes on and on and on. When my second child was born, I quickly realized that it was going to be impossible for me to continue parenting in this way. Lizzie was diagnosed with autism shortly after her second birthday. At this time, I had begun learning what made her different and what her needs were. The only problem was that this often conflicted with the social norm. One day I decided to meet my husband for lunch with Lizzie. We ordered at the counter and then quickly sat at an open table as we waited for our food. Lizzie hadn't been out of the house in weeks. Between her rigid therapy schedule and the fact that it was difficult to keep her from wandering, it was easier to just stay home. Shortly after we got to our table, Lizzie stood up in the booth, gripped the edge and started jumping. At first it was just harmless little bounces. Then it turned into huge jumps where she appeared to be using all her strength to slam her feet as hard as she could down on that booth.
"When God closes a door, He opens a window." (Author unknown) As I stood in front of 80 moms at the National Autism Association of North Texas Autism Moms' Evening Out on May 4th, I was in awe of all the hard work, determination and love that was packed into one room. The inner strength of this group of women was truly inspiring. As my eyes scanned the room, bouncing from face to face in the crowd, I was humbled by the fact the each of these women had traveled the same road I had...and all had become stronger, braver and more compassionate than they once were. Some were familiar faces that brought back memories from a specific struggle in my autism journey. Others were new faces. But it didn't matter, we already knew each other. For each of us had heard those dreaded words, "Your child has autism." Each of us has stumbled trying to put our child back together again piece-by- piece. And each of us has our own book-worthy story. The stories my differ in the details, but in the end we all want the same thing….healing for our child.
As Autism Awareness Month wraps up, I feel a bit guilty about the bah humbug attitude I have had this year. Maybe it is because I have been at dealing with autism for over seven years, and I just don't feel like getting in the "spirit of autism" this year. In the beginning, I remember the rush each April would bring. I had never had a cause before, and it felt good to give back and to do something that mattered. I was going change the world, and I was going to do it all in one month! I helped at a booth at the mall, I gave a huge autism awareness cake to the school, I wrote articles for the school newsletters, wore my "Green Our Vaccines" shirt everywhere, posted all kinds of stuff on Facebook and even stood with a sign in an autism-related protest. Now seven years later, quite frankly, I am tired of autism. I am tired of the fact that there are endless treatments to try for my daughter, and the guilt that goes along with picking and choosing which to try. If I try one new treatment, what if the other one was the one that was going to work for her? Usually we are doing so many treatments at the same time, how do I know which, if any, are really making the difference? When can I ever rest with the peace-of-mind that I have done everything I can do and just accept who she is?


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Date: Friday 06 Jul 2012
- US non-farm payrolls disappoint
- Miners drag the Footsie lower
- IMF to cut global GDP forecast
After treading water for the morning session, the Footsie dropped in afternoon trade after a disappointing employment report from the US dampened the outlook for the global economy.
The US Labor Department revealed that 80,000 non-farm payrolls were added in June, less than the 100,000 expected by analysts. The jobless rate was unchanged at 8.2%.
We continue to believe that higher uncertainty from events in Europe and, to a lesser degree, the potential for significant fiscal tightening in the US early next year are causing firms to postpone investment and hiring decisions, said analyst Michael Gapen from Barclays Capital.
Investors were still digesting yesterdays news that the Bank of England (BoE) ramped up its asset purchase programme and the European Central Bank (ECB) and the People's Bank of China (PBoC) both slashed their benchmark interest rates.
Critics to the BoE move said that the £50bn increase in quantitative easing will only have a marginal effect on the real economy. ECB governing council member Erkki Liikanen said that the European rate cut should not be expected to save the day. Meanwhile, some say that the Chinese decision reflects policymakers' concerns about a 'hard-landing'.
In other news, the International Monetary Fund (IMF) has warned that it is planning to lower its global growth forecast of 3.5% this year in light of the economic situation becoming "more worrisome".
The gloomy figures from the Labor Department dented stocks in London with the mining sector bearing the brunt of the risk aversion. Yesterdays surprise interest rate cut by the Peoples Bank of China has also scared the industry that Chinese policymakers are worried about a hard-landing for the worlds second-largest economy. Kazakhmys, Evraz, Vedanta and Polymetal were suffering heavy losses this afternoon while luxury brand Burberry, a business heavily exposed and heavily dependent on growth in China, also slumped.
With relatively riskier assets out of favour, electricity, telecoms and utilities stocks were among the best performers: Pennon, SSE, Severn Trent, Centrica and BT were making gains late on.
Having promised on Thursday that it would raise money from disposals, insurance giant Aviva moved quickly to act on that pledge by saying it will sell more of its stake in Delta Lloyd than originally intended, prompting a rise in its share price. Providing a lift was Societe Generale which upgraded the stock from 'sell' to 'hold'.
Food, ingredients and retail firm Associated British Foods rose after saying that it is to buy ethnic flour brand Elephant Atta from Premier Foods for £34m. Analysts at Panmure Gordon said this morning that the acquisition is a "perfect fit" for AB Foods.
Pharmaceuticals giant AstraZeneca was in the red after Jefferies downgraded its rating on the stock from 'buy' to 'hold', following the recent strong performance in the shares. Jefferies says that it sees "major fundamental challenges" for the group, including its clinical and business development capabilities/decision making.
Engineering software firm AVEVA was a high riser after Berenberg upgraded the stock to 'buy' and lifted its target price from 1,660p to 1,927p. Also benefiting from broker commentary was homewares retailer Dunelm after Nomura said that given the groups strong cash generation, a cash return to shareholders is appearing more likely.
In contrast, support services firm Carillion was a heavy faller after UBS downgraded the stock from 'neutral' to 'sell' and cut its target price from 285p to 230p. UBS said that the firm's first-half trading update showed a "deterioration in growth prospects" and that UK construction margins are "clearly not sustainable".
FTSE 100 - Risers
International Consolidated Airlines Group SA (CDI) (IAG) 159.20p +2.25%
SSE (SSE) 1,416.00p +1.58%
Imperial Tobacco Group (IMT) 2,579.00p +1.58%
Pennon Group (PNN) 770.00p +1.45%
G4S (GFS) 290.30p +1.33%
Severn Trent (SVT) 1,689.00p +1.32%
Aviva (AV.) 288.00p +1.19%
Centrica (CNA) 319.10p +1.17%
Shire Plc (SHP) 1,820.00p +1.00%
BT Group (BT.A) 215.20p +0.99%
FTSE 100 - Fallers
CRH (CRH) 1,151.00p -5.19%
Evraz (EVR) 246.20p -4.50%
Kazakhmys (KAZ) 725.00p -4.35%
Weir Group (WEIR) 1,547.00p -4.21%
ICAP (IAP) 313.60p -3.77%
Burberry Group (BRBY) 1,289.00p -3.73%
Marks & Spencer Group (MKS) 318.00p -3.40%
Polymetal International (POLY) 864.50p -3.30%
Vedanta Resources (VED) 914.50p -3.18%
Rio Tinto (RIO) 3,069.00p -2.76%
FTSE 250 - Risers
Dunelm Group (DNLM) 550.00p +3.58%
Aveva Group (AVV) 1,745.00p +2.83%
Rank Group (RNK) 119.00p +2.15%
Micro Focus International (MCRO) 549.00p +2.14%
Spirent Communications (SPT) 170.00p +2.10%
Kier Group (KIE) 1,216.00p +1.84%
JD Sports Fashion (JD.) 740.00p +1.79%
Chemring Group (CHG) 283.50p +1.72%
Soco International (SIA) 331.60p +1.69%
Go-Ahead Group (GOG) 1,247.00p +1.63%
FTSE 250 - Fallers
Carillion (CLLN) 251.40p -6.16%
Talvivaara Mining Company (TALV) 141.20p -4.79%
Petropavlovsk (POG) 458.80p -3.94%
Ocado Group (OCDO) 70.40p -3.89%
Jupiter Fund Management (JUP) 211.00p -3.61%
Imagination Technologies Group (IMG) 466.80p -3.37%
SIG (SHI) 98.30p -2.96%
Ashtead Group (AHT) 262.40p -2.92%
Afren (AFR) 106.60p -2.91%
Aquarius Platinum Ltd. (AQP) 46.11p -2.80%
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$24 for a Powerslider Lightening iPhone 5 Rechargeable External Battery Case - Shipping Included ($49.95 Value)
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Next Windows release could be more desktop-friendly Rumors about the next major Windows release are starting to crop up. Earlier today, Paul Thurrott of the eponymous Supersite for Windows posted a... Type: News story Tags: Operating systems Windows |
172 |
Asus teases custom Radeon R9 290X with DirectCU II cooler The Radeon R9 290X is a beast—and a toasty one at that. Cards based on AMD's reference design appear to be thermally limited, especially... Type: News story Tags: Graphics Cooling |
71 |
Deal of the week: Black Friday edition Amazon has a massive collection of PC games on sale, including a stack of very recent titles: If you don't have Battlefield... Type: News story Tags: CPUs Cases Storage Mobile computing Gaming |
29 |
Microsoft's Larson-Green hints at Windows consolidation Julie Larson-Green, the newly minted head of Microsoft's Devices and Studios engineering group, had some interesting things to say about the future of Windows... Type: News story Tags: Operating systems Windows |
65 |
Deal of the week: Cheap storage, a Bay Trail discount, and more Even with Black Friday discounts not due for another week, there are plenty of bargain-priced SSDs out there today. The most appealing one may... Type: News story Tags: Cases Storage Input devices Mobile computing |
29 |
Deal of the week: bargains on SSDs, graphics, and water cooling Man, it's been a long week. So here I am, mailing in the deals post with another bulleted list. Oh, look, cheap... Type: News story Tags: Graphics Cooling Storage |
25 |
Hotfix for Windows 8.1 mouse accuracy issues now available As expected, Microsoft has released a fix for the mouse movement issues that have affected some users of Windows 8.1. The hotfix, available here,... Type: News story Tags: Input devices Gaming Software Operating systems Windows |
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Report: As Microsoft CEO, Elop could kill Bing, sell Xbox business The search for a new Microsoft CEO is still underway. According to Reuters, the top five candidates include current Ford CEO Alan Mulally and... Type: News story Tags: Game consoles Software Windows |
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Only a few days remain to enter our Dear Diary contest There are only a couple of days left to enter our Dear Diary contest. We're giving away $2,300 in prizes, including gear from... Type: News story Tags: CPUs Graphics Motherboards Multimedia Cases Power Cooling Input devices Mobile computing |
11 |
Windows 8.1 causes mousing issues; fix incoming Still on the fence about upgrading to Windows 8.1? If you're a gamer,... Type: News story Tags: Input devices Windows |
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Deal of the week: Discounted memory, cheap graphics, and more It's finally happened. I've succumbed to the scourge of bulleted lists. They kinda make sense for our weekly deals post, where there's little potential... Type: News story Tags: Graphics Cases Memory Software |
36 |
Our Dear Diary contest now has $2,300 worth of hardware We're giving away roughly $2,300 in hardware as part of our Dear Diary contest. To enter, all you have to do is write... Type: News story Tags: CPUs Graphics Motherboards Multimedia Cases Power Cooling Mobile computing |
17 |
Deal of the week: Cheap convertibles and discounted components We had hoped to fill this week's deal post with links to AMD's Radeon R9 290X graphics card, but it's out of stock... Type: News story Tags: Cases Cooling Storage Memory Mobile computing |
23 |
Microsoft beats Street forecast with 'record' quarterly revenue The PC market suffered in the last calendar quarter, but you wouldn't know it by looking at Microsoft's latest financial results. The company Type: News story Tags: Software Windows |
33 |
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23 |
Microsoft: Surface 2 name chosen to avoid consumer confusion The first Windows RT tablet from Microsoft was called the Surface for Windows RT. The second-gen version of that device, on the other hand, has... Type: News story Tags: Mobile computing Windows Personal tech |
70 |
Release roundup: External storage and windowed cases The release roundup is where we talk about product announcements that didn't make it into our regularly scheduled coverage. This week, we have news from... Type: News story Tags: Cases Storage |
10 |
Microsoft preps native Remote Desktop apps for Android, iOS There's already a wealth of a Remote Desktop clients out for iOS and Android. But later this month, Microsoft will introduce official Remote Desktop clients... Type: News story Tags: Software Windows Personal tech |
42 |
Oculus gets $75 million to produce VR headset for consumers | 15 |


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Jessica is a reporter and the weekend meteorologist.
Strong storms bring damaging winds, heavy rain, and moderately sized hail
Strong to severe thunderstorms are moving through mid-Missouri this afternoon, producing locally heavy rainfall amounts, moderately sized hail, and strong winds gusting over 60 miles per hour.
The main squall line is pushing through Jefferson City and the U.S. 54 corridor right now, and there have been reports of power lines and trees down in Cole County.
The main threats with today's weather will be primariliy focused on strong, damaging winds and localized flooding. Some areas may recieve 2 inches or more of rain by the end of the day. Brief areas of circulation may be possible on the leading edge of the line of cells.
A tornado watch is in effect until 8:00 p.m. for Audrain, Boone, Callaway, Camden, Cole, Gasconade, Maries, Miller, Moniteau, Morgan, Montgomery, Osage, Phelps, and Pulaski counties.
Stay tuned to KRCG 13 for coverage of today's severe weather, and follow us on twitter @KRCG13 and on Facebook.


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Thailand holidays often centre around cosmopolitan Bangkok, but Thailand's beautiful islands, like Phuket and Koh Samui, definitely merit some exploration as well. Holiday around northern Chiang Mai for trekking and rafting with Thailand's hill tribes. Culture vultures on holiday in Thailand will love the UNESCO-listed ancient capital, Ayutthaya. Plenty of spicy local cuisine tops the holiday off a treat.
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Among the works at this year's local artist show at the Godfrey Dean Gallery are a series turning a few heads, with the works relegated to a back room because of their content.
In terms of content artist Jennifer DeGroot is drawn to the human form, although almost exclusively a woman's form.
"I don't usually do men," she said.
In the case of the animal-headed women, they started from a dream.
"I had a dream about a snapping turtle woman," said DeGroot, adding her boyfriend had been playing a video game with various monsters, "so I probably had that in my head when I went to sleep."
From there the series grew, which was a surprise for DeGroot.
"I don't usually work with animals," she said, adding in some respects they are easier since people notice small imperfections in an animal than a human face simply because we are all more familiar with the human form.
As it did the scant clothing of snapping turtle woman were left behind and the women's body were drawn naked.
"Honestly I don't like drawing clothes. Usually I do nudes," said DeGroot.
While nude, DeGroot said that is not done as a way to shock or titillate.
"They're not supposed to be sexual," she offered, adding "not that there's anything wrong with that in art."
The pieces do convey feeling though.
"I was just trying to get over different emotions," she said, adding that realization came after. Initially she said she drew the pieces "for my own selfish pleasure of working on art."
DeGroot said consciously trying to create works with specific meanings are constrictive.
"Putting messages into my work I end up thinking about it too much to have the fun (of doing it)," she said. "I like to sit down and just think about what I would like to see, what would look cool."
And, some pieces though do end up telling a story.
One of the women has a third eye on its chest.
"I see the world with my heart more than my head," said DeGroot.
And there may be a subconscious message in DeGroot's favourite piece, a deer-headed woman nursing a deer-headed baby. She said as a mother she appreciates the stigmatism some women face for breast feeding in public, and also the reverse where some that do breast feed look down on those choosing to feed formula.
"I like the deer. I just had so much fun working on it. It was more the experience working on it than the finished product," she said.
As for art in general DeGroot said it is in her blood.
"There are a lot of artists in my family. Everybody is into something, music, visual arts, my little sister is big into film editing," she said.
And at a young age DeGroot found comic books.
"They were a big thing when I was young, and still are," she said, noting comics such as Allan Moore's Watchmen, and characters such as Venom and Carnage, and Spawn by Canadian creator Todd McFarlane were inspirations. "… I love comic book art."
DeGroot also loved art in school, although she admitted she may not have been her instructor's favourite student.
"I frustrated my art teacher a lot," she said, explaining she took forever to complete projects. "If I'm going to do something it has to be done properly."
However, being a perfectionist often meant late assignments.
That said DeGroot was happy her high school art teacher Diane Koch attended the recent opening at the Godfrey Dean Gallery.
"I love her, but I think she was usually frustrated with me," she said, adding her admiration for Koch came as a result of her approach to instructing. "She was really good at letting me really stretch the boundaries of what I wanted to put in my art."
At times pushing boundaries does draw attention to DeGroot's art related to its content.
In fact the pieces in the Yorkton show at the Godfrey Dean Gallery raised a few eyebrows.
"I was surprised by the controversy over the pieces I have up here," she said.
The pieces, each depicting a woman, many of them naked, and all having animal heads, are certainly different than what most artists take on, although DeGroot said she never thought of them as that daring. "I just don't see them the same."
However, DeGroot does admit science fiction and fantasy art does catch her own eye, and those influences can be seen in the animal-headed women. She said Brian Froud ,well-known for his take on fairies "is a huge "influence on me.
"I think I draw a lot from his work in sketching especially."
For DeGroot art is escapism.
"You know how some people sit and knit and watch TV?" she asked. "I sit down and draw."
In those times DeGroot said she just falls into her work letting whatever comes into her mind transfer to the sketch pad.
"That's my problem doing commissioned work, I like to do things my own way," she said.
As for people's reactions to the works, DeGroot said while it does have people talking, for the most part it has been well-received.
Initially she posted a couple of works to her Facebook page.
"The reaction has been really, really good," she said, adding "My mom loves them," which was not expected.
DeGroot said she is not really worried how people view the works.
"I'm not big into telling people how to see my art," she said.
But DeGroot did suggest it was time to share her efforts.
"I'm a stay at home mom now and I have a lot of time to sit and think about what I want out of my life," she said, adding in "a moment of clarity" she realized it was time "people should see what I've been working on my whole life."
DeGroot said she would like to begin selling her work, letting her at present hobby grow into something more, but added that will take time.
"I'd like to build up my portfolio of work a little bit more," she said, adding she also needs to become more attuned with what works will sell. That said DeGroot isn't about to do landscapes just to sell her art. "I don't want to compromise what I do either."
As for the series, there are more to come.
"I'm thinking about doing a moth next," she said, adding that could lead to doing a series of insect-women as a sort of self-therapy.
"They (insects) scare me. I'd like to overcome that."


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Hip Injuries, Age 12 and Older
Topic Overview
A hip injury and pain can make it hard to walk, go up and down stairs, squat, or sleep on the side that hurts. A clicking or snapping feeling or sound around your hip joint (snapping hip) may bother you or cause you to worry. But if your hip is not painful, in many cases the click or snap is nothing to worry about. Home treatment may be all that is needed for minor hip symptoms.
To better understand hip injuries, it may be helpful to know how the hip works. It is the largest ball-and-socket joint in the body. The thighbone (femur) fits tightly into a cup-shaped socket (acetabulum) in the pelvis. The hip joint is tighter and more stable than the shoulder joint but it does not move as freely. The hip joint is held together by muscles in the buttock, groin, and spine; tendons; ligaments; and a joint capsule. Several fluid-filled sacs (bursae) cushion and lubricate the hip joint and let the tendons and muscles glide and move smoothly. The largest nerve in the body (sciatic nerve) passes through the pelvis into the leg.
Hip injuries
Injuries are a common cause of hip problems. You may not remember a specific injury, especially if your symptoms began slowly or during everyday activities.
- Overuse injuries occur from repeating the same activity. The repeated activity, such as running or bicycling long distances, stresses the hip joint and may cause irritation and inflammation. Examples of overuse injuries include irritation of the large sac (bursae) that cushions the bones of the hip joint (trochanteric bursitis), irritation of the tendons in the hip ( tendinitis ), muscle strain , and hairline cracks ( stress fracture ) in the neck of the thighbone (femur).
- A sudden (acute) injury may occur from a fall on the hip,
a direct blow to the hip or knee, or abnormal twisting or bending of the leg. Examples of acute injuries that may cause hip pain include:
- A broken hip ( hip fracture ) or pelvis ( pelvic fracture ), such as an avulsion fracture
- A dislocated hip or sprained hip .
- Muscle strain in the groin or buttock.
- Severe bruising ( contusion) .
Treatment for a hip injury depends on the location, type, and severity of the injury as well as your age, general health, and activities (such as work, sports, hobbies). Treatment may include first aid measures; application of a brace, cast, harness, or traction; physical therapy; medicines; or surgery.
Check your symptoms to decide if and when you should see a doctor.
Home Treatment
Home treatment may help relieve hip pain, swelling, and stiffness.
- Rest. Try to rest and protect an injured or sore area. Stop, change, or take a break from any activity that may be causing your pain or soreness.
- Ice will reduce your pain and swelling. Put ice or cold packs on the injured area immediately. Put ice on for 20 minutes out of every hour and do this 4 or more times in the first 1 to 2 days. Wrap the ice in a wet towel. Do not put the ice right on the skin. Do not fall asleep with an ice pack on your skin.
- Sleep on your uninjured hip with a pillow between your knees, or sleep on your back with pillows beneath your knees.
- Gently massage or rub your hip to relieve pain and help blood flow.
- For the first 1 to 2 days after an injury, do not do things that might increase swelling, such as taking hot showers or use hot tubs, hot packs, or alcohol beverages.
- Do not use aspirin for the first 24 hours after an injury. Aspirin may cause more bruising under the skin.
- After 2 to 3 days, if you
do not have swelling or the swelling is gone, you can put
heat on the area. Moist heat with a hot
water bottle, warm towel, or a heating pad set on low may feel good on your
hip. You can carefully begin normal activities and gentle stretching.
- Prone buttocks squeeze, to strengthen the buttocks muscles. These muscles support your back and help you lift with your legs.
- Pelvic tilts , to stretch the lower back
- Hamstring stretch , to stretch the muscles in the back of the thigh
- Hip flexor stretch , to stretch the muscles in the hip that help the hip glide and work smoothly
Try a nonprescription medicine to help treat your fever or pain: |
Be sure to follow these safety tips when you use a nonprescription medicine: |
Do not smoke. Smoking may delay healing because it interferes with blood supply and tissue healing. For more information, see the topic Quitting Smoking.
Cast care tips
If you have a cast, see cast care tips.
Symptoms to watch for during home treatment
Call your doctor if any of the following occur during home treatment:
- Pain or swelling develops.
- Signs of infection develop.
- Numbness, tingling, or weakness develops.
- Pale, white, blue, or cold skin develops.
- Symptoms do not get better with home treatment.
- Symptoms become more severe or more frequent.
The following tips may prevent hip injuries.
Keep bones strong
- Eat foods rich in calcium , like yogurt, cheese, milk, and dark green vegetables. Eat foods rich in vitamin D , like eggs, fatty fish, cereal, and fortified milk.
- Exercise and stay active. It is best to do weight-bearing exercise, such as walking, jogging, stair climbing, dancing, or lifting weights, for 2½ hours a week. One way to do this is to be active 30 minutes a day, at least 5 days a week. In addition to weight-bearing exercise, experts recommend that you do resistance exercises at least 2 days a week. Talk to your doctor about an exercise program that is right for you. Begin slowly, especially if you have not been active. For more information, see the topic Fitness.
- Don't drink more than 2 alcohol drinks a day if you are a man, or 1 alcohol drink a day if you are a woman. People who drink more than this may have a higher chance for developing osteoporosis . Alcohol use also increases your chance of falling and breaking a bone.
- Stop or do not begin smoking. Smoking also increases your chance for developing osteoporosis. It also interferes with blood supply and healing. For more information, see the topic Quitting Smoking.
Prevent hip injuries
- Wear your seat belt in a car.
- Do not carry objects that are too heavy.
- Use a step stool. Do not stand on chairs or other unsteady objects.
- Wear protective gear during sports or recreational activities, such as roller-skating or soccer. Supportive splints, such as wrist guards, may lower your chance for injury.
- Do not do activities that make one side of the pelvis higher than the other, such as running in only one direction on a track or working sideways on a slope. Keep your hips level.
Reduce falls
Hip injuries can happen from falls. Do all you can to prevent falls.
- Remove any obstacles from your walking path and fix anything in your house that may cause you to fall. Household hazards that can cause falls include slippery floors, poor lighting, cluttered walkways, throw rugs, raised doorway thresholds, and electrical cords.
- Keep furniture or other items that have sharp edges away from normal walking pathways in your house.
- Use nonskid floor wax, and wipe up spills immediately.
- Have your vision and hearing checked regularly. If you have poor vision or hearing, you may have a harder time keeping your balance.
- Know the side effects of any medicines you are taking. Ask your doctor or pharmacist whether the medicines you are taking can change your balance. For example, sleeping pills or sedatives can change your balance.
- Check the condition of your shoes on a regular basis. Wear low-heeled shoes that fit well and give your feet good support.
- Have a lot of lights in your house, especially on stairways, porches, and outside walkways. Use night-lights in areas such as hallways and bathrooms. Add extra light switches or use remote switches, such as switches that go on or off when you clap your hands, to make it easier to turn lights on if you have to get up during the night.
- Have sturdy handrails on stairways.
- Put grab bars and nonskid mats inside and outside your shower or tub and near the toilet and sinks. Use shower chairs and bath benches.
- Be safe when you go outdoors. Use a cane or walker if you need to. If you live in an area that gets snow and ice in the winter, have a family member or friend sprinkle salt or sand on slippery steps and sidewalks.
If you live alone, you may want to get an emergency contact bracelet or necklace. If you fall and can't get to the phone, you can press the button on your bracelet or necklace. This calls 911 or an emergency number for you so that help can be sent.
Exercises to stretch and strengthen your hip and back area
Warm up and stretch before exercising to prevent muscle strains and injury.
- Prone buttocks squeeze, to strengthen the buttocks muscles. These muscles support your back and help you lift with your legs.
- Pelvic tilts to stretch the lower back
- Hamstring stretch to stretch the muscles in the back of the thigh
- Hip flexor stretch to stretch the muscles in the hip that help the hip glide and work smoothly
Preparing For Your Appointment
To prepare for your appointment, see the topic Making the Most of Your Appointment.
You can help your doctor diagnose and treat your condition by being prepared to answer the following questions:
- What are your main symptoms? How long have you had your symptoms?
- How and when did an injury occur?
- Have you had any injuries in the past to the same area? Do you have any continuing problems because of the previous injury?
- Do you have hip pain when you walk? How far can you walk without discomfort? Does the pain get better or worse as you continue to walk?
- What activities make your symptoms better or worse?
- What sports activities are you involved in? Have you recently started a new activity?
- Do you think that activities related to your job or hobbies caused your symptoms?
- What home treatment measures have you tried? Did they help?
- What nonprescription medicines have you tried? Did they help?
- What prescription and nonprescription medicines do you take?
- Do you have any health risks that may increase the seriousness of your symptoms?
Related Information
By | Healthwise Staff |
Primary Medical Reviewer | William H. Blahd, Jr., MD, FACEP - Emergency Medicine |
Specialist Medical Reviewer | H. Michael O'Connor, MD - Emergency Medicine |
Last Revised | July 30, 2012 |
- Top of Page
Next Section:
Check Your Symptoms
Previous Section:
Topic Overview - Top of Page
Next Section:
Home Treatment
Previous Section:
Check Your Symptoms - Top of Page
Next Section:
Previous Section:
Home Treatment - Top of Page
Next Section:
Preparing For Your Appointment
Previous Section:
Prevention - Top of Page
Next Section:
Related Information
Previous Section:
Preparing For Your Appointment - Top of Page
Next Section:
Previous Section:
Related Information - Top of Page
Last Revised: July 30, 2012
This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.
To learn more visit Healthwise.org
© 1995-2013 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.


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