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Nearly 20,000 workers across Pa. haven't been paid since mid-December
Health care workers paying for payroll blunder
Thousands of health care workers across the state are in a state of financial limbo. They have not been paid since the middle of December and they have no idea when their next paycheck may arrive.
Landa Turner is a home health care worker because she loves to take care of people. These days she's still coming to work, even though she hasn't been paid in a month.
"I fear what's going to happen in the next couple of weeks if they don't get this together," Turner said.
Turner is one of about 20,000 health care workers across the state who has not been paid. Last year the state welfare department made a decision to take 37 different payroll agencies that were paying all the health care workers and consolidate them into one.
The welfare department tells News 8 it made the decision to save taxpayers and distribute payroll in a consistent fashion. Public Partnerships Limited, also known as PPL, is the company that took over and is responsible for the new paychecks, which have yet to go out.
"They're telling us that their systems were not matching up, their data bases were not matching up," said Donna Morgan at the Department of Public Welfare.
Connie Bolen, of Palmyra, contacted 8 On Your Side because the health care workers that help take care of her elderly mother have not been paid.
"If you knew this process was coming, make the transition more effective and that is not," Bolen said.
All of the women have called the new payroll company repeatedly. One of them told News 8 she has left more than 60 messages.
After News 8 On Your Side contacted the welfare department on behalf of Bolen and the women who care for her mom, Bolen was finally contacted about two hours later.
She got a few answers, but the caregivers like Landa Turner and Tammy Eash still don't have their money.
"It's frustrating. I mean you put the time in and you depend on the paycheck," Eash said.
Bolen says she can depend on the women who care for her mom to stay on the job, but she worries about other patients who may be abandoned.
"The workers are not going to come to work because they are not getting paid. They have to go somewhere else to get paid. And that person is alone with nowhere to go and nothing, and don't know what to do," said Bolen.
News 8 attempted to contact the new payroll service, Public Partnerships Limited, but we have not received a response.
The welfare department tells News 8 that the company has added more phone lines to handle more calls.
8 On Your Side will continue to follow this story.


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Certification Exam Details
Exam Study Guides
NewTek Certified Operator Exams are timed multiple choice and multiple response exams. Exams are proctored at numerous testing centers around the US. The test items are drawn randomly from a large bank of questions which are divided into skills and knowledge areas. For some questions, a description of the initial conditions for the question, and often an image, appears above the question. Read each question carefully, then pick the best response from those given. None of these are trick questions, but the available responses are not meant to describe the complete behavior of the product, only to test your knowledge of how the machine and a qualified operator work together to produce the best live production. To get the highest possible score, pick the best available answer.
A Practice Exam is provided to give you an idea of what the format of the actual exam is like, along with a sampling of the types of questions asked. The Practice Exam is not intended to assess your ability to pass the actual Certification Exam, only to give you a sense of the format and questions provided. Numerous industry acronyms are used in the exam. Read the list of acronyms.
Cost, scheduling, and rules
NewTek Certification exams cost $150. Collecting the exam fee and scheduling are done by the individual testing centers, not by NewTek. Contact a testing center near you to schedule an exam, or if you should need to cancel or re-schedule your exam. Candidates must bring a valid picture ID with them to the testing center and must have an email account that can be accessed via a Web browser.
You may not bring any personal materials with you into the testing area, and are required to leave cell phones, Blackberries, laptops, backpacks, iPads, etc. outside the testing room. You may not talk with anyone or get any help with the exam during testing. The contents of the exam remain NewTek property, and you may not divulge the questions or answer choices to anyone. Before taking an exam, you are required to agree to the terms of the Certified Operator Agreement.
How to prepare for the exam
A number of resources are available to help you get ready. Of course, operating a TriCaster or 3Play in a real-world setting is the best training of all, but other resources exist. Visit the Learning Resources page to find links to training curricula and videos, product User Guides, frequently asked questions files, and the busy Discussion Forums.
Exam outcomes
The passing score for the exams range from 70% to 75%. If you pass, you join the ranks of an elite force of live event producers. Within a few days, you'll get a congratulations email with an official, personalized, printable certificate as a PDF attachment. This certificate is suitable for framing and displaying proudly, and it attests to your knowledge and experience with NewTek product operation.
Additionally, if you choose, your name and contact information will be added to the searchable Certified Operator Directory on the NewTek website so potential employers can find you easily and verify your certification. All certifications expire after two years. The Certification Exams are periodically updated to reflect the latest shipping version of the software and hardware.
Often, this indicates a need for further study and practice with product operation in order to attain a level of proficiency required to pass the exam. Don't be discouraged; some operators do not pass the test the first time. Instead, use this as motivation for further study and practice. Refer to the Learning Resources page for study materials.
You must wait one week before attempting a retest. The retest is the same price as taking the exam the first time.

subset: commoncrawl


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There have been increasing concerns regarding the safety and efficacy of neuroleptics in people with dementia, but there are very few long-term trials to inform clinical practice. The aim of this study was to determine the impact of long-term treatment with neuroleptic agents upon global cognitive decline and neuropsychiatric symptoms in patients with Alzheimer disease.
Methods and Findings
Design: Randomised, blinded, placebo-controlled parallel two-group treatment discontinuation trial.
Setting: Oxfordshire, Newcastle and Gateshead, London and Edinburgh, United Kingdom.
Participants: Patients currently prescribed the neuroleptics thioridazine, chlorpromazine, haloperidol trifluoperazine or risperidone for behavioural or psychiatric disturbance in dementia for at least 3 mo.
Interventions: Continue neuroleptic treatment for 12 mo or switch to an identical placebo.
Outcome measures: Primary outcome was total Severe Impairment Battery (SIB) score. Neuropsychiatric symptoms were evaluated with the Neuropsychiatric Inventory (NPI).
Results: 165 patients were randomised (83 to continue treatment and 82 to placebo, i.e., discontinue treatment), of whom 128 (78%) commenced treatment (64 continue/64 placebo). Of those, 26 were lost to follow-up (13 per arm), resulting in 51 patients per arm analysed for the primary outcome. There was no significant difference between the continue treatment and placebo groups in the estimated mean change in SIB scores between baseline and 6 mo; estimated mean difference in deterioration (favouring placebo) −0.4 (95% confidence interval [CI] −6.4 to 5.5), adjusted for baseline value (p = 0.9). For neuropsychiatric symptoms, there was no significant difference between the continue treatment and placebo groups (n = 56 and 53, respectively) in the estimated mean change in NPI scores between baseline and 6 mo; estimated mean difference in deterioration (favouring continue treatment) −2.4 (95% CI −8.2 to 3.5), adjusted for baseline value (p = 0.4). Both results became more pronounced at 12 mo. There was some evidence to suggest that those patients with initial NPI ≥ 15 benefited on neuropsychiatric symptoms from continuing treatment.
For most patients with AD, withdrawal of neuroleptics had no overall detrimental effect on functional and cognitive status. Neuroleptics may have some value in the maintenance treatment of more severe neuropsychiatric symptoms, but this benefit must be weighed against the side effects of therapy.
Trial registration: Cochrane Central Registry of Controlled Trials/National Research Register (#ISRCTN33368770).
Citation: Ballard C, Lana MM, Theodoulou M, Douglas S, McShane R, Jacoby R, et al. (2008) A Randomised, Blinded, Placebo-Controlled Trial in Dementia Patients Continuing or Stopping Neuroleptics (The DART-AD Trial). PLoS Med 5(4): e76. https://doi.org/10.1371/journal.pmed.0050076
Academic Editor: Carol Brayne, University of Cambridge, United Kingdom
Received: May 31, 2007; Accepted: February 15, 2008; Published: April 1, 2008
Copyright: © 2008 Ballard et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The DART-AD project was made possible by a grant from The Alzheimer's Research Trust, Cambridge, UK (http://www.alzheimers-research.org.uk) to Profs Ballard and Jacoby and to RM. The peer review process undertaken by the funder did result in some modifications to the study design. The funder has no other role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: CB has received honoraria from Novartis, Pfizer, Shire, Lundbeck, Myriad, Janssen, Astra Zeneca, and Servier pharmaceutical companies and research grants from Novartis, Lundbeck, Astra-Zeneca, and Janssen pharmaceuticals. The remaining authors have declared that they have no competing interests.
Abbreviations: AD, Alzheimer disease; ANCOVA, analysis of covariance; BADLS, Bristol Activities of Daily Living Scale; CGIC, Clinician's Global Impression of Change; CI, confidence interval; DMC, data-monitoring committee; EPS, extrapyramidal signs and symptoms; FAS, Verbal Fluency Task; FAST, Functional Assessment Staging; IQR, interquartile range; NPI, Neuropsychiatric Inventory; SD, standard deviation; SIB, Severe Impairment Battery; (S)MMSE, (Standardised) Mini Mental State Examination; STALD, Sheffield Test for Acquired Language Disorders; UPDRS, Unified Parkinson's Disease Rating Scale
Editors' Summary
The number of people with dementia (currently 25 million worldwide) is expected to increase by 5 million each year. The risk of dementia, including Alzheimer disease, increases sharply with age: Alzheimer's Disease International estimates that 1.4% of people 65–69 have dementia, whereas almost a full quarter of those over the age of 85 years are affected. Almost all older dementia patients will experience, along with the cognitive and functional decline typical of the illness, some neuropsychiatric symptoms. These symptoms can include agitation, aggression, and psychosis, and are often devastating for the older patient and his or her family and caregiver. Managing these symptoms is often a prime concern for health-care providers and families. Neuroleptics (sometimes called antipsychotics) are the class of drugs often used to manage or control neuropsychiatric problems, but there have been questions about their safety and appropriateness. Safety concerns involve risk of stroke, parkinsonism, sedation, edema, and chest infections but also include a worsening of cognitive decline with prolonged use of neuroleptics.
Why Was the Study Done?
Previous studies on the effectiveness and safety of neuroleptics in older people have been short term. Ballard and colleagues wanted to study over a longer period of time the impact of neuroleptic drugs on elderly patients with dementia. Specifically, they wanted to know if being on a neuroleptic was associated with more cognitive decline than coming off the drug. They also wanted to investigate whether discontinuing the drug exacerbated any neuropsychiatric symptoms, Parkinson disease-like symptoms, or other functional, language, and cognition difficulties frequently associated with dementia.
What Did the Researchers Do and Find?
The researchers recruited older patients with Alzheimer disease from across England who had been on neuroleptics for at least three months. They randomised patients to one of two groups: the first group continued taking the same neuroleptic at the same dosage level while the second group was switched to an identical-looking placebo. The researchers assessed the patients' cognitive status and neuropsychiatric symptoms upon their entry into the study. Six and 12 months later the researchers assessed any cognitive decline and the level of neuropsychiatric and other problems that patients were experiencing.
At both 6 and 12 months, the researchers found that there were no differences between the two groups (continued treatment and placebo) in terms of cognitive decline. The placebo group may have had less cognitive decline, but this was not statistically significant. They also found no overall differences between the two groups in the change in the number of neuropsychiatric symptoms over these time periods. Patients with severe neuropsychiatric problems at the outset of the trial did better on continued neuroleptic therapy, but this advantage was not statistically significant. There was a significant decline on the verbal fluency language tests among the patients who continued on their neuroleptic.
What Do these Findings Mean?
The researchers report perhaps the first trial of this duration on continued versus withdrawn neuroleptic treatment among older dementia patients. The findings do not indicate any benefit of continuing neuroleptic therapies in older patients on either cognitive or neuropsychiatric outcomes. The researchers conclude that neuroleptics, with their known safety issues, should not be used as first-line treatment to manage problems such as agitation or aggression. For older dementia patients whose neuropsychiatric symptoms are not remedied by nonpharmaceutical treatments, the researchers advise caution. More studies are urgently needed to find better solutions to help older patients with dementia who have agitation, aggression, and psychosis.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050076.
- Alzheimer's Disease International is an umbrella organisation of organisations worldwide
- The Alzheimer's Research Trust in the UK is a charity funding research to cure or prevent dementias
- The US National Institutes of Aging has information on Alzheimer Disease in English and Spanish
- Two governmental regulatory agencies—the Medicines and Healthcare Products Regulatory Agency in the UK and the Food and Drug Administration in the US—offer information about antipsychotics in people with dementia
Worldwide, there are 25 million people with dementia [1], the majority of whom have Alzheimer disease (AD). It is a devastating illness that results in a progressive decline in cognitive ability and functional capacity, causes immense distress to patients, their carers, and families, and has an enormous societal impact. Currently the most frequent treatment issue for people with AD presenting to clinical services remains the management of neuropsychiatric symptoms, such as aggression, agitation, and psychosis. Over 90% of people with dementia develop these symptoms at some point during their illness [2]. The symptoms are frequently distressing for the patients who experience them [3] and problematic for their caregivers [4], in whom they are associated with clinically significant depression [5]. In addition, they are often the precipitant for institutional care [6].
Neuroleptics are widely used as the first-line pharmacological approach to treat these neuropsychiatric symptoms. Efficacy has been examined in eight randomized, placebo-controlled trials with typical neuroleptics [7,8] and 18 placebo-controlled trials with atypical neuroleptics [9–11]. The strongest evidence of efficacy is for risperidone, for which there are five published trials indicating a modest but significant diminution in aggression compared to placebo, but limited evidence of benefit for other neuropsychiatric symptoms [9–11]. However, given that in the US and Europe, up to 60% of people with dementia residing in care facilities are prescribed neuroleptics (e.g., [12,13]) for median periods of greater than a year [14,15], the pivotal question is whether longer-term therapy with atypical neuroleptics confers any treatment benefit. There are only two placebo-controlled trials of a neuroleptic for more than 14 wk, and neither showed significant efficacy of neuroleptic treatment for neuropsychiatric symptoms [16,17]. Similarly, longitudinal cohort studies [18] and placebo-controlled neuroleptic withdrawal studies [14,15,19] do not indicate benefit from neuroleptic therapy. However, all of the withdrawal studies continued for 3 mo or less, leaving some uncertainty regarding long-term symptom outcome. In addition, the largest study did suggest a benefit for treatment with atypical neuroleptics in people with scores greater than 14 on the Neuropsychiatric Inventory (NPI) [15].
Any beneficial effects of neuroleptics in people with AD must be weighed against the short- and long-term adverse effects which, according to meta-analyses, include parkinsonism, sedation, oedema, chest infections, stroke (odds ratio 2.5–3) and mortality (odds ratio 1.5–1.7) [7–11,20–22]. Additional evidence has also highlighted accelerated cognitive decline as an important potential negative consequence of prolonged use of neuroleptics [16,23]. A meta-analysis [17] has confirmed this observation, indicating 0.7 of a Mini Mental State Examination (MMSE) point (95% confidence interval [CI] 0.38 to 1.09) greater decline over 6–12 wk in neuroleptic-treated patients compared to those treated with placebo, which appears modest but represents a doubling in the expected rate of cognitive deterioration over this period.
In the US the Food and Drug Administration [22] has warned about the risk of increased mortality and stroke with neuroleptics in people with dementia, and most practice guidelines recommend nonpharmacological approaches as the first-line treatment for agitation and other neuropsychiatric symptoms (e.g., [24]). However, there is still considerable debate as to the place of neuroleptics in the management of severe and distressing symptoms that are intractable to other treatment approaches, especially when there is potential risk to the patient or to others.
The main aim of the trial was to determine whether ongoing treatment with neuroleptics accelerates cognitive decline in people with AD. We additionally sought to determine whether ongoing treatment with neuroleptics confers any benefit for the long-term maintenance treatment of neuropsychiatric symptoms in people with AD.
Participants were patients in Oxfordshire, South Birmingham, Newcastle and Gateshead, London and Edinburgh prescribed the neuroleptics thioridazine, chlorpromazine, haloperidol, trifluoperazine or risperidone for behavioural or psychiatric disturbance in dementia for at least 3 months.
Participants had to meet all inclusion criteria. The inclusion criteria were (a) patient lived in a nursing or residential home; (b) patient fulfilled the NINCDS/ADRDA criteria for possible or probable AD [25]; (c) patient had either a MMSE [26] score > 6 or a Severe Battery Impairment [27] score > 30; and (d) patient was taking at least 10 mg chlorpromazine equivalents (CPZe) of a typical neuroleptic or at least 0.5 mg daily of risperidone.
The exclusion criteria were (a) patient was unable to complete primary outcome measures at baseline assessment; (b) clinician responsible for care or study clinician considered that the patient suffered from any physical condition—including marked extrapyramidal disorder—that would have made participation in the trial distressing or likely to increase suffering; (c) patient was currently taking thioridazine and showing a prolonged QTc on electrocardiogram [28,29]; (d) the patient was likely to be unable to take capsules.
Two caregivers of people with Alzheimer's disease were closely involved in the development of the protocol, which was peer reviewed through the auspices of the Alzheimer's Research Trust (Cambridge, UK). As this was a multicentre trial, the study was in the first instance reviewed and approved by a properly constituted Multi-Centre Research Ethics Committee (the North of England MREC). Subsequent site-specific approval was then granted by properly constituted Local Research Ethics Committees at each of the participating centres. All Ethics Committees were conducted under the auspices of the Central Organization of Research Ethics Committees (COREC, now the National Research Ethics Service UK, http://www.nres.npsa.nhs.uk/).
Potentially suitable individuals residing in care facilities, their next of kin, and staff within the care facilities were provided with comprehensive information about the study. Those wishing to take part were invited to participate. If the potential participant had adequate capacity, the individual him- or herself was asked to complete the written study consent procedures. In these circumstances, the next of kin (or if no family members were in contact, an appropriate guardian, usually the manager of the care facility) was also asked to provide written assent to participation. If participants did not have adequate capacity, then written assent from the next of kin and agreement as far as could be ascertained from the potential participant were obtained and considered appropriate to enable participation. This procedure was fully approved by the MREC, and was standard procedure in clinical trials involving vulnerable adults in the UK, until subsequent legislative changes (Mental Capacity Act 2005), introduced after the current study, enabled consent to be provided by a caregiver.
Participants were randomised in equal numbers either to continue neuroleptic treatment for 12 mo or to switch to placebo. Three fixed dosages, named respectively (a) very low; (b) low; and (c) high, were chosen for each of the permitted neuroleptic drugs to correspond as near as possible to the dose the patient was being prescribed prior to trial entry (Table 1).
Fixed Dosage Regimens for the Respective Neuroleptics
Each of the neuroleptics was overencapsulated to conceal the identity of the contents. Placebo capsules were identical to the overencapsulated neuroleptics, but contained only inert filler. The respective treatments were maintained at the same fixed dose throughout the 12 mo treatment period of the trial.
The primary aim of this study was to determine whether treatment with neuroleptic agents is associated with an accelerated rate of cognitive decline in dementia. Secondary objectives were: (a) to examine the impact of neuroleptics on function and other cognitive outcomes; (b) to determine whether discontinuing neuroleptics was associated with an exacerbation of neuropsychiatric symptoms, both overall and in people with NPI scores above and below 14 [15]; (c) to examine the impact on parkinsonism; and (d) to determine the impact on global clinician rated outcome.
Primary outcomes.
The primary outcome was the total SIB score [27] (change from baseline to 6 mo). This is a well-validated instrument designed to evaluate global cognitive functioning in individuals who are too impaired to complete standard neuropsychological tests. There are 40 questions in the SIB, assessing social interaction, memory, orientation, language, attention, praxis, visuospatial ability, construction, and orienting to name. A total score is obtained by summing all questions and ranged from 0 to 100. A higher score indicates higher cognitive ability.
Secondary outcomes.
1. Standardised Mini Mental State Examination (SMMSE) [26]: A widely used instrument for assessing cognitive mental status. It assesses orientation, attention, immediate and short-term recall, language, and the ability to follow simple verbal and written commands. The maximum total score is 30. A higher total score indicates higher cognitive function. A standardized approach to the administration has been published and was adopted in the current study [26].
2. FAS test of Verbal Fluency [30]: A verbal fluency test for which the total score is presented as the sum of all acceptable words generated.
3. Bristol Activities of Daily Living Scale (BADLS) [31]: A 20-item questionnaire to measure daily living abilities, specifically in patients with dementia. The maximum score is 60.
4. Sheffield Test for Acquired Language Disorders (STALD) [32]: Developed as a nonspecialist clinical aid to help identify dysphasia. The test assesses receptive and expressive skills. It gives a total score ranging from 0 to 26.
5. NPI [33]: A caregiver-administered questionnaire that assesses 12 behaviours of patients on the basis of frequency and severity: delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritability, aberrant motor behaviour, night-time behaviours, and appetite/eating behaviours. Each behaviour is scored by multiplying the frequency and severity (i.e., frequency × severity); the higher the score, the greater the neuropsychiatric impairment. A total score can be calculated by summing the scores of all behaviours (range 1 to 144). Lower scores indicate less frequent/severe.
6. Functional Assessment Staging (FAST) [34]: Has seven main stages that consist of physical and instrumental active daily living, which are intended to project the progression of loss of function in patients with dementia.
7. Modified Unified Parkinson's Disease Rating Scale (M-UPDRS): A modification of the full UPDRS, to focus only the items that were independent of cognitive function [35]. A score of 8 or more indicates significant parkinsonism [35].
8. Clinician's Global Impression of Change (CGIC): A widely used and validated rating scale [36] based on the health-care provider's "general clinical impressions" with or without the informant input (i.e., family members). It evaluates global function and is scored from 1 (very much improved) to 7 (very much worsened).
For scales requiring an informant, the information was provided by a nurse or professional caregiver who had regular contact with the individual, usually the key worker. As far as possible, the same informant provided information for subsequent assessments. The outcome assessment schedule is summarised in Table 2.
Outcome Assessment Schedule
Although the study was of 12 mo treatment (or discontinuation), our primary focus was the progression of cognitive impairment at the 6 mo assessment. This schedule was predetermined in view of the frailty and predicted high mortality of this patient population.
Sample Size
The planned sample size of this trial was 110 patients per treatment group. In the absence of data from randomized clinical trials to inform power calculations at the time the protocol was developed, this calculation was undertaken using two different approaches. First, based upon the occurrence of clinically significant cognitive decline (defined as decline greater than the mean expected cognitive decline of four points per year on the MMSE), in 50% of patients continuing on neuroleptics versus 30% on placebo, allowing for a dropout rate of 15%–20%. Second, using a generic approach [37], the same sample size gives 80% power to the 5% level of significance to detect an effect size of 0.43 (regarded conservatively as a medium effect size). As we expected the SIB to be a more sensitive measure than MMSE, it was anticipated that the sample size would have more than sufficient power to detect a clinically important difference.
Randomisation was performed centrally at the Centre for Statistics in Medicine in Oxford (CSMO), using dedicated computer software (MINIM). The clinician responsible for randomisation of a patient faxed a randomisation form to the CSMO (or sent e-mail in exceptional circumstances) and provided details appropriate and sufficient for establishing eligibility. If a patient was eligible and informed consent/assent had been obtained and baseline assessments had been completed, the patient was randomised by the statistician either to continue taking medication or to discontinue (placebo group). The statistician directly communicated the allocation to the relevant trial pharmacy, ensuring concealment. The randomisation programme included a minimisation algorithm to ensure balanced allocation of participants across the intervention groups for the following important prognostic factors: presence or absence of extrapyramidal signs (EPS); visual hallucinations and delusions; use of cholinesterase inhibitors (y/n); SMMSE score (<6/≥6); and current neuroleptic medication (atypical/typical). The first 22 patients (10% of the target sample size) were allocated randomly to avoid predictability at the outset. These allocations were computer generated using block randomisation (block sizes of two and four) using Stata version 7 software (ralloc.ado v3.2.3 subroutine) [38]. Subsequently, the minimisation algorithm was applied with an allocation ratio that was not fully deterministic. The statistician carrying out the randomisation had no direct contact with patients and allocation was, therefore, totally independent of patient recruitment.
The clinicians, those administering the trial medication, the caregivers, the relatives, the patients themselves, and those assessing the outcomes were all blinded to treatment allocation.
Statistical Methods
We used SPSS (release 12.0.1) to enter and manage data, and Stata (release 9.2) for analysis. Demographic factors and clinical characteristics were summarised with counts (percentages) for categorical variables, mean (standard deviation [SD]) for normally distributed continuous variables, or median (interquartile [IQR] or entire range) for other continuous variables. We restricted comparative analysis to those patients who started allocated treatment and had at least one assessment after randomisation, and participants were analysed in the groups to which they were allocated. Primary analysis was performed on patients with complete data at both baseline and week 26, including those who did not adhere to the protocol (e.g., those who never started treatment but for whom we had complete data). As the trial was conducted with masking of treatments, knowledge of allocation could not have contributed to drop-outs before or after treatment, so that exclusion of such patients did not impart bias. For the primary analysis, we summarised the change in the severe impairment battery (i.e., SIB at 6 mo − SIB at baseline) score from baseline to 6 mo using the mean and SD. To establish the magnitude and direction of the treatment effect, we used analysis of covariance (ANCOVA) to compare the two groups, giving the mean difference (in change in SIB from baseline to 6 mo) between groups (plus 95% CIs and p-values) with adjustment for baseline value. An additional ANCOVA was performed with adjustment for the minimisation factors, as well as geographical centre, in addition to the treatment contrast and baseline values. Changes in secondary outcomes were summarised and compared similarly.
For non-normally distributed continuous outcomes, we performed nonparametric Wilcoxon rank-sum tests to investigate differences between the treatment groups.
Prespecified sensitivity analyses were carried out to examine the robustness of conclusions to different assumptions about departures from randomised policies, dependent on the availability of data and the particular set of circumstances, namely:
1. Imputation is a method of "filling in" missing data with plausible values to give a completed dataset. Multiple imputation replaces each missing value with a set of plausible values that represent the uncertainty about the right value to impute. The procedure involves filling in missing data m times to generate m complete datasets. Then the m complete datasets are analysed by using standard statistical analyses, and finally, the results from the m complete datasets are combined to produce inferential results. Variables that were included in the imputation model were all assessments of SIB, NPI, FAS, SMMSE, BADLS, STALD-receptive, STALD-expressive, FAST, and CGIC collected at baseline, 6, and 12 mo. Other baseline covariates that were also included in the imputation model were allocated treatment group, sex, centre, presence of significant EPS, visual hallucinations or delusions, age at randomisation, type of neuroleptic drug at baseline, and whether the participant was taking cholinesterase inhibitors at trial entry.
2. In order to test the robustness of the SIB result, we limited a sensitivity analysis to those patients for whom the risk of possible floor and ceiling effects was smallest, i.e., SIB baseline cut-off values ≥ 40 but ≤ 90. Prespecified subgroup analyses were carried out on change in SIB and change in NPI. We performed the test of interaction, i.e., examined whether the treatment effects were consistent across subgroups. The subgroups investigated were (a) type of neuroleptic (atypical versus typical)—it made clinical sense to examine whether the type of neuroleptic (atypical versus typical) at baseline made a difference since, if one type was more harmful than the other, then discontinuation would benefit those patients more; (b) baseline NPI (≤ 14 versus ≥ 15)—we intended to look at consistency of treatment effect in relation to baseline NPI (≤ 14 versus 15 or more) in an attempt to replicate Ballard et al. 2004 [15]; and (c) centre effects (Newcastle versus Oxford versus London/Edinburgh). London and Edinburgh were grouped together because only a small number of participants were recruited from Edinburgh, and all were assessed by the London-based researchers.
Study Governance
A three-person independent data-monitoring committee (DMC) was charged with overseeing patient safety. Its remit included prompt review of serious adverse events and a comprehensive review of all adverse events based upon interim data reports. The remit also required advice regarding any new or emerging information on the safety of the study treatments. If required, the DMC would make recommendations to the trial steering group and the sponsor about the safe continuation of the trial and any issues of concern. These decisions relied upon the independence and expertise of the DMC members and did not follow any strict "stopping rules."
Participant Flow
The first patient was randomised in October 2001 and the last in December 2004. 165 patients were randomised (83 to continue treatment and 82 to placebo, i.e., discontinue treatment), of whom 128 (78%) commenced treatment (64 continue/64 placebo) (Figure 1). Of those, 26 were lost to follow-up (13 per arm), resulting in 51 patients per arm analysed for the primary outcome. Of those (102 total), 77 remained on allocated treatment at 6 mo follow-up (40 continue/37 placebo). A further 22 participants withdrew between 6 and 12 mo follow-up (Figure 1). Over the full 12 mo of the study 47 people did not complete follow-up. Of these individuals 21 died and a further 26 (55%) stopped the allocated treatment. Baseline demographic and clinical characteristics were evenly balanced across the two groups (Tables 3 and 4). The majority of the participants were taking risperidone/placebo risperidone (n = 101) or haloperidol/placebo haloperidol (n = 43) at baseline. A full breakdown of the neuroleptic drugs used in the study is given in Table 5.
Demographic and Clinical Characteristics and Assessments at Baseline (All Patients Randomized)
Demographic and Clinical Characteristics and Assessments at Baseline (Analysis Population)
Details of Type and Dose of Treatment before Randomisation by Allocated Treatment Group
Primary Outcome—Severe Impairment Battery
There was no significant difference between the continue treatment and placebo groups (n = 51 in both arms) in the estimated mean change in SIB scores between baseline and 6 mo (Figure 2; Table 6), 5.7 points (SD 14.2) deterioration for the placebo group, and a 6.2 (SD 16.0) deterioration for the continue treatment group; estimated mean difference in deterioration (favouring placebo) −0.4 (95% CI −6.4 to 5.5), adjusted for baseline value (p = 0.9).
Summary of Change from Baseline to 6 Months for Main Outcomes plus Comparative Statistics
Secondary Outcomes
Neuropsychiatric symptoms.
For the NPI, there was no significant difference between the continue treatment and placebo groups (n = 56 and 53, respectively) in the estimated mean change in NPI scores between baseline and 6 mo, 4.5 points (SD 17.6) deterioration for the placebo group compared to a 1.3 (SD 15.5) deterioration for the continue treatment group; estimated mean difference in deterioration (favouring continue treatment) −2.4 (95% CI −8.2 to 3.5), adjusted for baseline value (p = 0.4). In patients with NPI scores ≤ 14 (Figure 3) the change in NPI over 6 mo was very similar in the neuroleptic and placebo groups (estimated difference 0.49, 95% CI −5.63 to 6.60), whereas in the people with NPI scores > 14 there was a five-point, albeit nonsignificant, advantage for people continuing to receive neuroleptics (estimated difference −5.33, 95% CI −15.82 to 5.17).
Cognition, language, and function.
For the SMMSE, there was no significant difference between the continue treatment and placebo groups (n = 44 and 40, respectively) in the estimated mean change in SMMSE scores between baseline and 6 mo (Table 6), 1.0 points (SD 4.2) deterioration for the placebo group, and a 1.8 (SD 3.6) deterioration for the continue treatment group; estimated mean difference in deterioration (favouring placebo) −1.0 (95% CI −2.7 to 0.7), adjusted for baseline value (p = 0.2). For the BADLS, likewise there was no significant difference between the continue treatment and placebo groups (n = 54 and 52, respectively) in the estimated mean change in BADLS scores between baseline and 6 mo, 0.2 points (SD 7.2) worsening for the placebo group, and a 1.8 (SD 8.9) worsening for the continue treatment group; estimated mean difference in improvement (favouring placebo) 1.7 (95% CI −1.2 to 4.6), adjusted for baseline value (p = 0.2).
For the STALD (receptive skills), once again there was no significant difference between the continue treatment and placebo groups (n = 34 and 39 respectively) in the estimated mean change in STALD (receptive skills) scores between baseline and 6 mo, 0.3 points (SD 2.1) deterioration for the placebo group, and a 0.5 (SD 1.7) deterioration for the continue treatment group; estimated mean difference in deterioration (favouring placebo) −0.2 (95% CI −1.1 to 0.6), adjusted for baseline value (p = 0.6). For the STALD there was no significant difference between the continue treatment and placebo groups (n = 34 and 39, respectively) in the estimated mean change in receptive language scores between baseline and 6 mo. For expressive language there was no significant difference of placebo compared to the treatment group; estimated mean difference (favouring placebo) −1.0 (95% CI −2.0 to 0.04), adjusted for baseline value (p = 0.06).
However, for the FAS, there was strong evidence, i.e., a highly significant difference between the continue treatment and placebo groups (n = 34 and 31, respectively) in the estimated mean change in FAS totals between baseline and 6 mo. There was 0.6 points (SD 6.2) improvement for the placebo group compared to a 3.2 (SD 6.6) deterioration for the continue treatment group; estimated mean difference (favouring placebo) −4.5 (95% CI −7.3 to −1.7), adjusted for baseline value (p = 0.002).
For the M-UPDRS, there was a slight but nonsignificant difference between the continue treatment and placebo groups (n = 41 and 43, respectively) in the estimated mean change in M-UPDRS scores between baseline and 6 mo, 0.4 points (SD 3.2) improvement for the placebo group compared to a 0.8 (SD 4.1) deterioration for the continue treatment group; estimated mean difference (favouring placebo) 1.1 (95% CI −0.4 to 2.6), adjusted for baseline value (p = 0.1).
Global Outcome
For the change in FAST and CGIC, there was no evidence whatsoever of any differences between the continue treatment and placebo groups (Wilcoxon rank-sum test p = 0.9 for both).
Prespecified Sensitivity Analyses
Imputed values were included for 12 participants, six in each treatment arm. These individuals had similar characteristics to the overall trial population, but as would be expected for participants unable to complete the trial, at baseline they were more cognitively impaired (SIB ± SD, 68.1 ± 22.3 versus 74.4 ± 21.9) and had higher levels of neuropsychiatric symptoms (NPI ± SD, 22.2 ± 14.8 versus 16.0 ± 13.9) than patients who subsequently completed the 6 month assessments. The results for SIB (mean difference −2.1, 95% CI −8.8 to 4.6, p = 0.5), NPI, SMMSE, UPDRS, BADLS, STALD, and FAS all remained consistent when missing data were replaced using multiple imputation techniques. In addition, the result for sensitivity analysis of SIB excluding participants whose baseline SIB was < 40 or > 90, i.e., excluding patients unlikely to benefit from treatment (mean difference −0.2, 95% CI −9.2 to 8.9, p = 0.9) was again consistent with the primary result.
Prespecified subgroup analysis.
There was no evidence of any interaction between treatment group and the various subgroups (Figures 3 and 4).
Post-Hoc Additional Exploratory Sensitivity Analysis
Given that a substantial proportion of patients did not actually start allocated treatment (∼22%), we decided to examine the robustness of results by performing an analysis with all data available. In addition, according to the protocol, all patients with SMMSE < 6 at pretrial screening were not required to complete SMMSE and FAS at any subsequent assessments; however, some measures were collected during the follow-up. Therefore, additional sensitivity analysis was performed on SMMSE and FAS to assess if results remained consistent when these measures were included. Once again, there were no substantive differences between the primary and sensitivity analyses, i.e., the results are very robust.
Although not specified in the original analysis plan, to avoid omitting potentially important clinical differences, additional descriptive data were also obtained regarding emergent delusions and agitation in participants who did not have these symptoms at baseline. The pattern of emergent symptoms appeared similar in the two treatment arms at 1, 3, and 6 mo assessments, respectively, for both delusions (neuroleptics 14%, 16%, 5% versus placebo 5%, 8%, 13%) and agitation (neuroleptics 17%, 23%, 32% versus placebo 23%, 26%, 34%).
12 Month Assessment Data
Analysis at 12 mo was limited to the two main outcomes, cognitive function and neuropsychiatric features, given the large amount of missing data. There was no significant difference between the continue treatment and placebo groups (n = 28 and 27, respectively) in the estimated mean change in SIB scores between baseline and 12 mo, although there was a clinically important but not statistically significant numerical advantage of 8 points for the placebo group—8.5 points (SD 13.4) deterioration in the placebo group, and a 16.5 (SD 23.1) deterioration in the continue treatment group; estimated mean difference in deterioration (favouring placebo) −8.4 (95% CI −18.6 to 1.7), adjusted for baseline value (p = 0.1).
For the NPI, there was, however, a significant difference between the continue treatment and placebo groups (n = 28 and 31 respectively) in the estimated mean change in NPI scores between baseline and 12 mo, with 11.4 points (SD 17.7) deterioration for the placebo group compared to a 1.4 (SD 22.1) deterioration for the continue treatment group; estimated mean difference in deterioration (favouring continue treatment) −10.9 (95% CI −20.1 to −1.7), adjusted for baseline value (p = 0.02). A cut-off ≤ 14 on the NPI was again helpful in interpreting the results. For participants with baseline NPI scores below this threshold, there was no significant difference between treatment groups; estimated mean difference in deterioration (favouring continue treatment) −5.2 (95% CI −15.8 to 5.4), whereas for individuals with higher NPI scores there was a significant −16.9 point "advantage" for the group who continued neuroleptics (95% CI −32.5 to −1.2). However, the test of interaction, although underpowered, was not significant (p = 0.2); therefore there is no evidence of a statistical interaction.
Because of difficulties in identifying people with Alzheimer disease in nursing homes who were taking neuroleptics and were able to complete the rigorous cognitive assessments, the recruitment target sample size based on the power calculation was not attained. However, despite this drawback, we report the largest and longest-duration randomized placebo controlled trial of neuroleptic discontinuation. To our knowledge this is the first study of this type to evaluate outcome over 6 mo and beyond.
Treatment with neuroleptics was not associated with significantly greater decline in global cognitive function than placebo, although there were numerical advantages for the placebo-treated group on the SIB and the SMMSE (1 point decrease on SMMSE, 0.4 point decrease on SIB overall, ∼3 point decrease on SIB in people with NPI scores ≤ 14) at 6 mo, which became more pronounced by month 12, at which point there was an 8 point advantage on the SIB for the placebo-treated group, equivalent to approximately 6 mo of average expected cognitive decline. The failure of these differences to attain statistical significance may be because of limited statistical power (a type II error), as the magnitude of difference in change in global cognition between neuroleptics and placebo at 6 mo was consistent with the effect size identified in a recent meta-analysis [11], and became more substantial over further follow-up. It would be more usual in a study of this type to hypothesise equivalence or the absence of an advantage to the treatment that is being removed, and there is certainly no evidence at all from these results suggesting any cognitive advantage favouring antipsychotics.
On secondary cognitive outcomes, there was a significant deterioration in verbal fluency for patients taking neuroleptics compared to people receiving placebo, and there was a nonsignificant numerical advantage for the placebo-treated group on the BADLS. There were nonsignificant numerical advantages for the placebo group with respect to the severity of parkinsonism.
There was a marginal nonsignificant 2.4 point advantage on the total NPI score for continuing neuroleptic treatment over the first 6 mo of treatment. Using a baseline NPI threshold ≤14, previously reported to be predictive of outcome in a 3 mo neuroleptic withdrawal trial [15], the change in NPI did not differ between the treatment groups. Participants with baseline NPI scores > 14 had an almost 5 point advantage (albeit nonsignificant) if they remained on neuroleptics, whereas there was no benefit for people with NPI scores below this threshold. For patients with more severe neuropsychiatric symptoms, there were modest benefits at 6 mo and more substantial advantages at 12 mo, which have to be weighed against the potential for serious adverse events. Some of the changes in NPI score are likely to be related to natural symptom course, or a Hawthorne effect, or regression to the mean, although there should be no imbalance in these factors between groups. There were no differences between groups for global clinician-rated outcome, and in an additional descriptive evaluation there appeared to be no difference in emergent delusions or agitation between groups.
In the post-hoc analysis there was no indication of a difference between people taking typical or atypical neuroleptics. The majority of individuals were taking risperidone or haloperidol, and the number of people taking other drugs was too small to enable any meaningful comparison. In particular, it will be important in further work to determine whether neuroleptics with more prominent antimuscarinic properties have a more potent impact on cognition in patients with dementia.
Several studies have demonstrated that psychological management approaches can replace neuroleptic therapy without any significant worsening of neuropsychiatric symptoms [14,39]; and evidence is emerging that cholinesterase inhibitors [40] or memantine [41] may be safer, effective alternatives for some symptoms. The authors of the recent CATIE study [17], a large, pragmatic, 36-wk placebo-controlled trial of atypical neuroleptics in AD, concluded that the modest benefits were not sufficient to justify therapy in the presence of the increased risk of serious adverse events. Clinicians should certainly try to replace atypical neuroleptics with safer management approaches. Taking into consideration CATIE, the results of 6- to 12-wk placebo-controlled trials, and our own data, we would suggest that there is, however, a limited place for atypical neuroleptics in the maintenance treatment of severe neuropsychiatric manifestations (particularly aggression) in AD when there is tangible risk or severe distress, and the symptoms have been refractory to other treatment approaches.
The magnitude of the impact of neuroleptics upon cognition, although consistent with a recent meta-analysis, was considerably less marked than reported in a recent 6 mo placebo-controlled trial of quetiapine [16]. There are numerous possible explanations for this difference, although it may be noted that unlike quetiapine, none of the atypical antipsychotics used in the current study had substantial antimuscarinic properties, and it is possible that antimuscarinic properties may exacerbate the impact of neuroleptics upon cognition. Although this is speculative, it is consistent with a study comparing cognition in patients with AD treated with either risperidone or olanzapine, where olanzapine treatment was associated with greater impairment of attentional and executive performance related to anticholinergic activity [42]. Within the current study there was a significant detrimental impact upon expressive language function, an important skill to enable social communication and maintain quality of life in people with AD residing in care facilities. Further work is needed to examine the effects on different aspects of cognitive function, to clarify the differential impact of individual neuroleptic drugs, and to determine whether the impact upon cognition is sufficient to interfere with everyday activities.
The results of the current study must be interpreted within the context of a number of limitations. In particular, the sample size was much smaller than intended, conferring limited statistical power, and the number of deaths and withdrawals precluded meaningful analysis of data beyond the 6 mo follow-up. In addition a sizeable proportion of patients did not start their allocated treatment for a variety of reasons, mainly related to frailty and concurrent illnesses. The sample size achieved was short of the 220 target due mainly to problems identifying eligible patients, which in turn led to slow recruitment, bringing on more centres, and ultimately curtailing recruitment due to a lack of resources. Given the vulnerability of the study population, a substantial number of deaths and withdrawals are an almost inevitable problem to contend with. Probably the only solution would be to exclude people with profound dementia or with a certain degree of physical frailty, but this would then diminish the validity of drawing more general conclusions from the results. Although it is difficult, therefore, to see how this problem could have been avoided, the high number of drop-outs must be considered when interpreting the results.
In addition, the reason for the initial prescription of neuroleptic drugs was unclear in the majority of instances. Most prescriptions had been instigated by primary care physicians and, as a number of the individuals had changed their primary care physician, or been admitted to a care facility, or changed care facility since neuroleptics were first prescribed, the clinical indication for the original prescription was often lost. Although in many ways this lack of information is unsatisfactory, it does reflect real clinical practice, so that the population studied and the information available were representative of what faces clinicians in their routine practice. As few individuals were under specialist care, it is unlikely that treatment-refractory symptoms were a reason for neuroleptic use in most of the participants. The data regarding outcome and the baseline severity of symptoms do, however, provide a useful basis for clinical decisions. It is possible that the profile of the original symptoms for which the neuroleptics were prescribed may have influenced outcome, but this possibility could practically be investigated only in people with neuroleptic prescriptions of shorter duration, for which the presenting symptoms would be easier to ascertain.
For most patients with AD, withdrawal of neuroleptics had no overall detrimental effect on functional and cognitive status and by some measures improved functional and cognitive status. Neuroleptics may have some value in the maintenance treatment of more severe neuropsychiatric symptoms, but this possibility must be weighed against the unwanted effects of therapy. The current study helps to inform a clinical management strategy for current practice, but the considerable risks of maintenance therapy highlight the urgency of further work to find, develop, and implement safer and more effective treatment approaches for neuropsychiatric symptoms in people with AD.
Supporting Information
Text S1. CONSORT Checklist
Other DART AD investigators: Timothy Smith, Ruth Elvish, Claire Maddison, Carol Bannister.
Data Monitoring and Ethics Committee: Clive Holmes (Chair), John Geddes and Robert Clarke.
DART-AD Pharmacists: (North East) Vranda Barbieri, Kay Carson, Gavin Mankin; (Oxfordshire) Michael Marven, Kim Gray; (London) Charlotte Gibbs.
Author Contributions
CB, RMS, RJ, and EJ designed the experiments/the study. MML, MT, SD, and KK collected data or did experiments for the study. RMS, LY, and EJ analyzed the data. MML, MT, SD, and RJ enrolled patients. CB and EJ wrote the first draft of the paper. SD, RMS, RJ, and EJ contributed to the writing of the paper. MT collected all the data for the Oxfordshire patients over the first two years. SD managed the trial in Newcastle for the majority of its running time, collecting data and also setting up the trial in London. SD also entered data and helped to track down missing data prior to analysis, proof read the manuscript and offered suggestions for changes. RJ contributed to the writing of the grant application and was one of the holders of the grant from the Alzheimer's Research Trust. RJ was also a principal investigator for the study and supervised the collection of the clinical data in the Oxford (UK) patients. KK identified patients, collected data, and wrote the follow-up protocol for the study. LY critically reviewed the manuscript. EJ was the trial statistician and part of the trial management group which met every 2 months. EJ presented regular interim analyses to the Data Monitoring Committee, and co-authored the annual report to the funder. EJ co-wrote the statistical analysis plan and was senior reviewer of the final statistical report.
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Ample research has been done on the differences in financial behavior between men and women, and today, many financial advisors who are incorporating behavioral finance principles in their practices are taking note of these elements.
Now, though, more advisors are going to have to figure out the best ways to relate to women. According to the most recent "Financial Experience & Behaviors Among Women" study by Prudential Financial, a growing number of women are becoming the sole breadwinners for their families and are increasingly, if not wholly, responsible for their families' financial futures.
More importantly, though, the study showed that women are less confident about their financial planning capabilities, admitting to a lack of knowledge about financial solutions that can help them.
Whether it's because more women are reaching the top levels in their chosen profession, or because the economic downturn has resulted in their spouses losing their jobs, the increase in the number of women as primary breadwinners seems to have "an indirect correlation with a decline in confidence," says Caroline Feeney, president of agency distribution at Prudential Financial. "Women can manage their households, they want to be able to ensure that any education plans that were started for their children continue and so on, but in facing these tougher economic times, women are also worrying more about what they should do. They're not feeling confident enough to be able to maintain their lifestyles in retirement."
In today's unsure economy, where more women are going to be in charge of their families' financial futures and many are feeling the pressure thereof, the challenge to financial advisors, Feeney says, is threefold: Understand women's financial planning behavior, boost their confidence, and do so without being patronizing or condescending to them.
"As much as we as a company have found that women are less confident about their financial abilities and as much as we see there's a need to educate more women about finance and financial planning, we feel it's most important for an advisor to first listen to a female client," Feeney says. "Advisors need to understand first what's important to women, and they need to realize that they cannot push women to take decisions they are not comfortable with."
Working with women today, Feeney says, is not about pushing and directing: It's about building a strong relationship that creates trust, which in turn will build greater confidence in more women.
Financial advisors working with women can also help a great deal in boosting their confidence by reinforcing the areas that women are strong in, says Lee Ann Fatalo, a financial representative at BayState Financial Services. Studies have shown that women are more confident with respect to managing their household finances, she says, and women are more focused on protection and risk management than men. Addressing these characteristics will help create a platform from which an advisor can help women overcome their concerns over their financial health, she says, and open the door for a more in-depth dialogue on the investments and financial strategies that are important for their and their families' futures.
"If an advisor understands where a woman's concerns are coming from, they will be a lot more successful in helping her," Fatalo says.
There's no denying that women are an important and growing segment of the market; this means that financial advisors must be able to adjust to women and their needs, Feeney says.
"Women are not going to adjust to us," she says. "We are going to have to adjust to them, and our financial professionals are going to have to understand what is important to women and work around them: their buying preferences, the way in which they take their time to make decisions, and even what's easiest and most convenient for them in terms of organizing meetings."


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My colleague Samer just discovered this funny video of a southern gentleman giving his thoughts on the USMNT drawing Portugal. It turns out that this guy also posts quick video reviews of Game of Thrones episodes on his YouTube channel, and each one of them is a ridiculous treasure. I present a handful here, along with some of my favorite lines from each one, for your enjoyment.
Season Four, Episode Six:
Favorite lines:
- "They were bitchin' about everything from her dragons burnin' up their goats, to all those fuckers she nailed up on those crosses."
- "Peter Dinklage is a bad motherfucker, I'll tell ya."
- "Should I give spoilers or not? Alright here it is: spoiler warning, I guess. You got about five seconds to bail on this video if you haven't already."
- The part where he pauses to spit some dip into a soda bottle.
- "Ended on a high note with Dinklage gettin' down. Swingin' big fucking midget dick all over the place."
Season Four, Episode Seven:
Favorite lines:
- "She did bang ol' dude. She's trying to start a little controversy between a couple of her head dogs, it seems like now."
- "That little freaky kid—I love him—he's in this episode, he flips out again and goes nuts. I love that kid. His mom's a little bitch: Lysa."
- "There was some titties. The Red Woman, got a nice look at her titties for a few seconds in this episode—probably longer than that, probably 20 seconds of Red Woman titties."
- "That's about it. Some man ass, no floppy weiner."
Season Four, Episode Eight:
Favorite lines:
- "I extremely apologize if you're watching this. This is a horrible review, but that ending still has me baffled. Crushed a man's skull with his bare hands."
- "His woman freaked out. So did I. I also made a reaction video here on YouTube. I had to edit out all the sound, it was a pain in the butt, whatever, so anyhow, that's the review. I'm sure you saw it; I thought it was a great episode. What'd you think?"
- "The final scene was shocking, but awesome before that. Oberyn was talkin' some major smack, had ol' dude all messed up. Then he gets tripped, grabbed by the throat, punched, eyes gouged out, skull crushed, game over. Tyrion: screwed."
Season Four, Episode 10:
Favorite lines:
- "Khaleesi can't have those sad stories every Sunday morning, so she locked the dragons up."
- "Stannis comes to town, takes the wildlings captive. Jon Snow let's him know, like, 'Eh, dude, Ned Stark was my old man.' So everything was cool, obviously, apparently. Just about everybody likes the Starks, except the Lannisters. More on them later."
- "Ooooh Brienne of Tarth and the Hound went head-to-head in a major battle. Brienne of Tarth took him [eye roll] somehow. Whatever."
- "Brandon Stark, yeah man, he lost one of his compadres."
- "Some weird stuff goin' on underneath that tree. Don't fully understand that."
- "First Cersei does some weird shit. She goes in, tells her dad everything's true. Then she goes in and seduces Jamie, pretty much just grabs his balls, starts making out with him. They get it on."
- "Whatever. So that's my wrap, I'm sure I forgot some shit. The Heat lost to the Spurs. Go Tim Duncan."
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And a bonus live reaction to the Oberyn-The Mountain showdown:
This guy kills me.


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[JURIST] Ecuador swore in 21 replacement legislators on Tuesday night, thus establishing a quorum for future legislative sessions after the Supreme Electoral Tribunal [official website, in Spanish] dismissed 57 of 100 lawmakers [JURIST report] in early March. The controversy began when Ecuador's unicameral Congress [official website, in Spanish] and President Rafael Correa [official website, in Spanish; BBC profile] submitted to the tribunal differing versions of a referendum on amending the constitution [JURIST report]. The tribunal accepted Correa's version, which permitted the constitutional assembly to retroactively fire legislators. In turn, the 57 legislators voted to dismiss four of the tribunal members, prompting the tribunal to fire the 57 legislators [JURIST report] for illegally interfering with their decision. Ecuador's Constitutional Tribunal [official website] then rejected the lawmaker's appeal [JURIST report], leading to violence between the fired lawmakers and police as the lawmakers attempted to enter Congress last Tuesday. AP has more.
In January, Correa became the eighth president [JURIST report] of Ecuador [JURIST news archive] in ten years on a platform promising to overhaul the nation's economy to fight poverty. Correa has characterized the Congress as a "sewer of corruption" and has expressed admiration for the policies of Venezuela's Hugo Chavez [JURIST news archive].


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49ers' Culliver visits with LGBTQ crisis support group
If you recall, San Francisco 49ers cornerback Chris Culliver didn't exactly have the best Super Bowl week. After his anti-gay comments during media day became a major distraction leading up to the game, Culliver struggled in Super Bowl XLVII as Joe Flacco targeted the second-year corner frequently during the Baltimore Ravens' 34-31 win.
While Culliver won't be able to show his football development on the field until September, he does appear to be working on his off the field growth this offseason. On Monday he followed through on his commitment to meet with The Trevor Project, an organization that provides crisis and suicide intervention to lesbian, gay, bisexual and transgender youth.
Via @Cullyinthehouse:
Great time at LGBTQ the Q is for (question)
While only Culliver knows if this is a genuine attempt to understand more about the struggles of gay teens or solely a PR move, the 24-year-old did spend the entire day at the group's Los Angeles office, along with 49ers vice president of football affairs Keena Turner and public relations director Bob Lange. According to the Sacramento Bee, Culliver also met Sunday with the group's executive director.
Via Sacramento Bee:
Trevor Project spokeswoman Laura McGinnis said that if Culliver follows through on becoming a volunteer, there are several things he could do, including becoming a crisis intervention volunteer or working with programs directed at young people, ages 13-24. McGinnis said there was no reason to suspect that Culliver wasn't sincere in his desire to understand and help at-risk youth.
"Chris is a young guy himself," she said. "He reached out to The Trevor Project. And that's a good thing."
Culliver's tweet was the only comment he's made so far on his visit, although he did issue an initial statement back in February after his remarks went public in which he said that "I was wrong, and I want to learn how to make it right."
Monday's visit was a step in that direction. Whether Culliver takes any additional ones without a camera or the team's PR staff in tow is entirely up to him.


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The Winton Visitor Information Centre is located at 50 Elderslie Street in Winton.
This accredited visitor information centre offers a one stop shop for travel information including maps, brochures, and itineraries. Staffed by skilled and knowledgeable locals, the Winton Visitor Information Centre can provide advice on the things to see, things to do and where to eat. Discuss with the friendly staff your travel plans or make a booking.
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Weld County finds mosquitoes with West Nile virus
Mosquito's carrying West Nile have been trapped in Weld County.
County officials say the mosquitoes were found this week in two of the three testing zones in the county.
Dr. Mark Wallace, executive director of the Weld County Health Department, says the overall risk posed by the virus remains low, but he notes that in recent years it usually hasn't shown up until July.
Initial human symptoms of the virus can include fever, headache, nausea, vomiting, muscle aches, weakness and rash.
More severe symptoms can include stupor, disorientation, coma, tremors, vision loss, paralysis and even death.


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There are 495 people playing Halo 4's multiplayer, if you count the cooperate Spartan Ops mode. That's over three times more than the amount of people that were playing just yesterday, and the game still has four more days before its November 6 release.
Maybe more people are logging on as the weekend nears? Power slowly coming back up in the North East after Sandy? People losing bets as to how long they can hold out before jumping online? Your guess is as good as mine.


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That show went on so long, I think all of her friends were either killed off or accused of murder. I couldn't for the life of me understand why ANYONE would be friends with her! Too risky!oleander wrote:yAs for Murder She Wrote, yes, i know the pain of having to sit through endless episodes. Oh, how i don't miss the days of one tv per household.
Very true, so much nicer having multiple televisions in a house and with Tivo and other cool devices. Skipping commercials and replaying stuff you missed. I can remember watching a show, missing part of it and then waiting forever to catch the rerun so I would know what I missed!


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Two Of Kate Gosselin's Kids — Alexis & Collin — Expelled From School For Fighting!
Kate Gosselin's kids are acting out at school and suffering major consequences. In Touch reports that two of her eight children aren't allowed to go back to their Pennsylvania private school.
This is very sad, but not terribly surprising. Last week we reported that one of Kate and Jon Gosselin's sextuplets had been suspended from school for fighting. Now In Touch magazine is reporting that all of the Gosselin kids (twins Cara and Mady, 10, and 6-year-old sextuplets Hannah, Aaden, Leah, Joel, Collin and Alexis) are starting to have serious behavioral problems. The magazine reports that two of the 6-year-old sextuplets Collin and Alexis have been expelled from their private school in Pennsylvania and are now being homeschooled!
"They've fought with their peers, called them nasty names and made fun of other kids," a source close to the family tells the In Touch. It seems that some of the kids have started using rather colorful language, much to the surprise of their father, Jon. "The things they are saying are not words they should know. They are learning them somewhere — but Jon doesn't know where."
Any parent of school-age children will tell you that they learn a lot more than just reading and math once they step on the school bus, but still it's upsetting to hear that the kids are cursing!
According to the Gosselin family insider, a few of the famous eight are having "rage issues" since filming began on their newest reality show for TLC Kate Plus 8. "There have been problems with anger management," says the source, who is quick to point out that their 35-year-old mom seems oblivious to her children's bad behavior. "The show is her biggest priority. If the kids are unhappy, she doesn't let that stop her." That's interesting! Remember yesterday when we told you about how Eric Roberts thinks Kate needs anger management classes? Apparently, he's on to something!
If that's true, then shame on Kate. Considering that Jon went wild right after their split last year, I'm shocked that he's currently acting like the more protective parent. What do you think, HollyMoms?


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I Manage My Shop is one of the ventures of Helios Solutions. The app provides comprehensive e-commerce shop administration for iPhone, iPad,iPod Touch,Android devices.
The objective of this application is to give ease of management of an e-commerce shop anytime anywhere through your smartphone or tablet. All the shop owners using shop system like Magento, VirtueMart, ubercart and osCommerce can take advantage of the free application on iPhone, iPad,iPod Touch and Android.
I Manage My Shop release 1.0 is the first step towards giving independence to the e-commerce shop owners. Based on the respons we get from customers we will be adding advanced features like managing product, price, quantity, client, generating customized reports, updating product picture, product details, etc.


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On March 9th and 10th, MIT Mechanical Engineering Professor David Wallace and the MIT Office of Digital Learning hosted the Education Design-a-thon, an education hacking event for MIT students and anyone interested in education. Organizations posed challenges and attendees chose one project to work on throughout the 32-hour event.
Projects ranged from the purely virtual -- video games teaching computer program cell phone apps to help dropouts resume their education -- to the extremely tactile: robotic drawing arms and hands-on tools to help teachers design curriculum.
~Shannon Morey
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Data protection
Data protection aims to regulate data subjects' rights and data users obligations while collecting, processing and disseminating personal data. It also regulates transfer of data across national boundaries, and roles and responsibilities in data processing value chain. Increasingly, it is a challenge to secure data protection objectives, while enabling societal transformation toward a digital society.


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Steam Autumn Sale starts tomorrow – report
Steam's fall sales is set to start tomorrow, if blog post from the developers of Secret of the Magic Crystals is any indication (via Reddit). Of course, Steam will have its sale, Valve has just been quite on when it will start as it likes to spring things on everyone. Runic outed the fact it was coming soon last week, so like death and taxes, it's inevitable. According to the blog post, the sale runs November 21-27 and the service's December sale will run from the 20th through January 4. Thanks, >PCGamesN.


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Three veteran educators have been named principals at Holy Cross Academy.
Three veteran educators have been named principals at Holy Cross Academy.
Bob Vero will serve as principal at the St. Joan of Arc campus at 120 Bordner Ave. NW. Vero has three decades of experience in teaching and school administration. Prior to St. Joan, he was assistant principal at Hartford Middle School.
Susan Hug has been named principal of the St. Joseph campus at 120 Columbus Ave. NW.
Hug has 33 years teaching experience in the Catholic Diocese of Youngstown, including St. Paul School in North Canton and at St. Joseph. She recently was named a member of the Stark County All-County Teaching Team and received the Excellence in Education award for private schools.
Sandy Fusillo has been named principal of the St. Peter campus at 702 Cleveland Ave. NW.
Prior to St. Peter's, Fusillo spent a decade teaching at St. Mary School in Massillon. In 2010, she was nominated for Stark County Teacher of the year and the diocese's 2011 Golden Apple Award. She also served on the technology committee at St. Peter's at the diocesan level.
The three campuses serve children in kindergarten though grade 8. For more information, visit www.StarkHolyCrossAcademy.com or call 330-526-8366.


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Print your shipping label. If you've selected 'Store Credit' or 'Exchange,' it's free! If you selected 'Refund,' we'll deduct $5.99 from your refund amount to cover the shipping fees.
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Pack it up. Place your item(s) (in unworn condition and with tags attached) and the order invoice in a securely sealed shipping package. (If you misplaced your invoice, simply go to My Account, click on your Order History, select the right order number, and print it out.)
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Send it off. Affix your printed shipping label to your package (making sure there are no other shipping labels or barcodes on it). Jot down the tracking number so you can follow its journey.
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Flow Society is committed in delivering lacrosse products at a reasonable cost. With that in mind, we have created the Flow Society "My Rewards" Loyalty Program for even more discounts towards your purchases. Register now to begin earning My Rewards points for product purchases, referrals, shares and more! Learn more here


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My heart was racing fast for him. He was a criminal,...
Hold Me Tight (ON HOLD)17291829
- by Niall's Oreo & Daytime Dreamer
- Rating:
- Published: 7 Feb 2014
- Updated: 9 Jun 2014
- Status: In Progress
Shy Jessica Bell's life isn't very jolly. Her father is abusive and alcoholic. However, when she suddenly runs away to her best friend, Gemma's house, she has to deal with her troublemaking, girl seducer, brother who she unlikely becomes fond of.
Credit to @LifeOfADemigod124 for the cover!
Credit to @LifeOfADemigod124 for the cover!
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It's been a big week for owls, what with the last Harry Potter film hitting theaters and an unfortunate British owl hitting a bedroom window. So it's rather fortuitous that this fantastic article from a 1930 issue of Modern Mechanics was brought to my attention.
This is my second favorite orthinological headline I've ever read. And in case you were wondering, here's the first.
[Via Modern Mechanix]


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Stop Learning, Start Churning
Jul 12, 2013 5:00 AM PT
Last year, I polled a group of respected CRM resellers to create a list spotlighting "forgotten features" -- tools and settings in CRM that many users overlook, even when they could bring great value to their businesses.
Some of them were defensive in nature -- for example, many implementations never set the security settings in CRM, making it possible for your valuable user data to walk out the door with departing employees. Most of them, however, were about performance of the CRM system. These included things like reminders, Web-to-lead forms and workflows.
Perhaps the most interesting forgotten feature was internal reporting; most companies using CRM rarely employ the software to measure how often and how effectively the software itself is being used.
Failure to grasp the full potential is dangerous; it can create the false impression that the CRM application you're using isn't cutting the mustard, and it can send flighty managers out in search of a replacement application. You know vendors are perfectly happy to sell you a new application if you convince yourself your current application isn't doing the job.
Just Do It?
What's the underlying root of this? Part of it is that CRM systems have become increasingly bloated with features -- in a good way. Most CRM buyers will never use all the features packed into their applications. Sadly, a lot of users never know those features are there; they fixate on the features that address the problems they face at the time of implementation and never grasp that the application's capabilities extend further.
Part of the problem is that the SaaS era led people to assume that because deployment could be easy, the use of the applications would be easy, too. That was reinforced by the battles within organizations to encourage adoption. There have been many occasions where I've heard sales people being advised that they could learn the application "just by using it." That's possible, but it's not always the best option.
In a related vein, part of the problem is that many businesses view training as a necessary evil or an afterthought. If implementation goes over budget, cutting training is one way to contain costs. However, it's a really bad one, because it will detrimentally affect your return on investment for the CRM application and, ultimately, lead to adoption battles within the business.
Continuing CRM Education
While training the rank and file in the use of CRM is important, there's a more pressing training issue. CRM managers are not getting the training they need -- it's not often offered, and it's not often solicited. As their businesses' needs change, and as CRM applications evolve and become more capable, they need to evolve with them. However, that requires an admission that they don't know something, and few people succeed within an organization by proclaiming their ignorance.
That means it's important for resellers -- and, particularly, CRM vendors -- to offer continuing education for their users, particularly for the people administering the applications in the field. These people are often also the decision makers about CRM replacement, so it pays to build relationships with them, especially in the era of on-demand CRM. Retention is the key to revenue, so vendors should view this effort as an investment in their retention efforts.
This should go beyond a quarterly webinar or an on-demand video sequestered somewhere on the vendor's website. This should be an in-person effort, when possible -- especially with larger CRM customers.
Granted, many CRM users may not wish to make the time commitment to continued education; time away from their core "jobs" is often cited as a reason for avoiding training. Still, vendors should be able to articulate in a compelling way how knowing your CRM well makes you a more effective CRM user. Who can argue with that?


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Fortunately for scientists interested in these storms, the International Space Station offers an excellent vantage point at an altitude of about 400km. So Danish researchers devised a "Thor experiment"—named after the hammer-wielding Norse God—to study the phenomenon. As part of the experiment, an astronaut on board the station would image thunderstorms under certain conditions, and these observations would be correlated with data collected by satellites and ground-based radar and lightning detection systems.
It may sound easy to catch a few quick snaps of electrical storms, but given the station's movement at 28,000km/hour and ephemeral nature of these events, it's actually quite difficult. Sprites and other features got their otherworldy names precisely because they are so shortlived, lasting on the order of 20 milliseconds.
When Danish astronaut Andreas Mogensen spent 10 days on the station in September 2015 as part of ESA-Roscosmos contract that designated him a visiting crewmember, one of his primary tasks was to complete the Thor experiment. Perched in the station's cupola, with a Nikon D4 set at 6400 ISO and recording 24 frames per second, Mogensen readied himself to capture images at locations where forecasters predicted thunderstorm activity would occur below.
Mogensen succeeded. As the station passed over the Bay of Bengal, between India and Myanmar, Mogensen shot a 160-second video of the cloud turret of a storm that had 245 blue flashes. Meanwhile Doppler radar at a station in Machlipatnam, India, and elsewhere tracked the storm from the ground. Scientists recently reported their results in Geophysical Research Letters.
The study observed a majority of discharges between 18km and 40km, or as high as the upper stratosphere, and provided a new perspective on the electrical activity that occurs at the top of tropical thunderstorms, the authors say.
Notably, the discharges appear to play a significant role in the exchange of gases between the troposphere and the stratosphere. Previously scientists had understood that the red color of sprites was caused by nitrogen interacting with electricity in the upper atmosphere, but with the new data they were able to study the discharges, and found they release a comparably large amount of various oxides of nitrogen into the upper atmosphere. "They underscore that thunderstorm discharges directly perturb the chemistry of the stratosphere with possible implications for the Earth's radiation balance," the authors write.
Listing image by ESA/NASA
Quelle: ars TECHNICA


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The Source
Faculty Profile: Lance Inouye
August 01, 2013
The following Q&A is part of a series created by the Office of the Dean of the College of Arts and Sciences to introduce new faculty. Get to know Instructor in Music Lance Inouye, who joins the faculty this fall, in the interview below.
Education: D.M.A. 2013 (anticipated) College-Conservatory of Music, University of Cincinnati; M.A. 2000 Aaron Copland School of Music at Queens College, City University of New York; B.M. 1996 Berkley College of Music; additional studies, St. Petersburg State Conservatory of Music, Russia.
Research and teaching interests: Orchestral and opera repertoire from the Baroque through the 21st century.
What most excites you about joining the Lewis & Clark community?
I am excited about the diversity of the students, their eclectic interests, and the emphasis on exploring and discovering connections between diverse disciplines.
Describe the current trajectory of your scholarly research.
I am interested in examining the aesthetic of text-to-music adaptation, as it highlights linguistic and literary subtleties. Pushkin's verse-novel and Tchaikovsky's opera Eugene Onegin constitute an especially fascinating example of aesthetic choices, with regard to form and content, that underscore elements of structure, meaning, melody, harmony, rhyme, and symmetry.
What kind of hobbies or special activities do you enjoy outside of work?
I enjoy languages, burgers, sushi, water sports, travel, and biking.
What were your childhood goals/aspirations?
I wanted to be a race-car driver, fisherman, baseball player, film composer, or drummer.
What are you listening to in your car right now?
Rimsky-Korsakov, Tchaikovsky, Eidan Reichel, Eminem, Beethoven, Puccini, Bob Dylan, Arvo Pärt, Bob Marley, Black Eyed Peas, Stravinsky.
What was your favorite childhood story?
Green Eggs and Ham. I loved the rhyme, rhythm, and musicality of Dr. Seuss.