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Specializing in education and research in management, HEC Paris offers a complete and unique range of educational programs for the leaders of tomorrow: Masters Programs, MBA, PhD, Executive MBA, TRIUM Global Executive MBA and Executive Education open-enrolment and custom programs.
Founded in 1881 by the Paris Chamber of Commerce and Industry and founding member of Université Paris-Saclay, HEC Paris has a permanent faculty, more than 4,400 students and over 8,000 managers and executives in training every year.
The Grande École curriculum is divided into a generalist phase and a specialization phase. The first phase concentrates on business fundamentals, while the second one focuses on acquiring an expertise (chosen according to the professional goals of the student). The unique structure of the curriculum enables students to acquire both an excellent grounding in general management and expertise in a specific field. We firmly believe this combination is the key success factor in training future leaders and making a lasting impact on the careers of our students. The second year of the Master's program Cycle is composed of a specialized and professional curriculum, and the composition of a research paper.
Specialized Masters are one-year Master's degrees taught in French. They are designed for students who already hold a Master's degree in an other field and wish to specialize in a specific field of management. MSc programs are one-year Master's degrees taught in English. They are designed for students who hold a Bachelor degree in any field from leading international universities.
Custom designed for managers between the ages of 25 to 35 with previous work experience averaging 6 years, the MBA program addresses both functional and crossfunctional skills, through a fundamental and a customized thread to cover all areas of management in depth. Highly selective, the program has around 250 participants per year, from 52 different nationalities with diverse backgrounds and experiences.
Participants gain hands-on, practical experience through seminars integrated into the curriculum, such as the MBA Tournament and the off-campus leadership seminar at St-Cyr Military Academy.
The Executive MBA is a transformational experience which offers senior managers and executives from all around the world the opportunity to select one of the 8 majors that take place in 14 international locations, and also to take classes in any of its different tracks in France or Qatar.
The EMBA is an interactive and intensive program developed to provide executives with an understanding of the international business context, as well as the comprehensive, practical and innovative knowledge and skills they need, to put their vision into action.
TRIUM Global Executive MBA enables executives to understand the world, as it is today and will be tomorrow.
Ranked #3 Executive MBA worldwide by the Financial Times, it is a unique degree jointly awarded by 3 world-renowned universities: HEC Paris, London School of Economics & Political Science, New York University Stern School of Business.
Speed up your career!
Executive Education offer training programs for business leaders and host over 8,000 executives and managers from the whole world, to assist companies in training managers, future managers and leaders.
Our desire is to offer executive education programs specifically built for managers and executives. They allow you to gain perspective by revisiting your convictions, learn from the diversity of participants in the class and offer proximity and access to corporate issues. HEC Executive Education relies on the excellence of the faculty of HEC Paris, the expertise of its external speakers and the international reputation of its research in order to offer its customers a unique and unforgettable experience.
Your Gateway to a career in research and academia
The mission of the PhD Program is to train top-level researchers in the major areas of management, and thereby faster the reputaion of HEC Paris in the best business schools in the world (MIT, Harvard; Princeton, LBS, INSEAD, Oxford, Cambridge,...). Since 2015, HEC Paris delivers the 'Doctorate in Management Science' degree in partnership with the University of Paris Saclay.
Intensive course training during the first two years
7 specializations in management
Close supervision by international, research-driven, young and renowned Faculty members
Full involvement in the research ethos of HEC Paris
Financial support for research visits and conferences
Tuition waiver and financial support for living expenses guaranteed for the first 4 years
We look forward to welcoming a new generation of leaders to our innovative and intensive Summer Programs.
Two offerings are proposed:
- The Summer School for university-level students or recent graduates who are eager for an academic challenge in one of 10 domains of expertise.
- The Youth Leadership Initiative for high school students who wish to develop their leadership potential.
We intend for participants to leave HEC Paris informed, equipped and inspired to take their learning into the world.
The faculty is central to knowledge creation and dissemination at HEC. Our 108 research faculty (over 66% from outside France) work on internationally acclaimed research in most of the major disciplines of management, reflecting the diversity of thought and cultures, the open-mindedness and the exacting intellectual standards promoted at HEC.
The permanent faculty is reinforced by affiliate professors bringing their academic and professional skills to HEC's students and program participants.
All these professors enhance HEC's courses and programs through their research work, original teaching materials, and personal interaction with the business world; they contribute to corporate reflection on management issues and are involved in national and international scientific community debates.
At HEC Paris, companies find what they are looking for: interns, young graduates, MBA graduates, executive education programs, professors to work with on research or teaching projects. Drawing from this positive experience, some of them decide to support HEC's development and become HEC corporate partners.
In the 'News Room', find everything you need to know about HEC Paris, our programs, faculty, international relationships, corporate partnerships and life on campus. In the blink of an eye, discover what the press says about HEC with our latest news postings.
If you're looking for a logo, photo or someone to contact, you can also find it here!
Management Science
Departments: Strategy & Business Policy, GREGHEC (CNRS)
Keywords: firm alliances, matching, competitive advantage
We consider the formation of alliances that potentially create complementarities, that is, when the value function is super-modular in firm resources. We show that, in a frictionless world where information is perfect and managers optimize, firm alliances disproportionately increase the value of high-resource-level firms, resulting in higher variance and higher skewness of the distribution of firm value; moreover, higher-value alliances are subject to regression to the mean at a faster rate. These effects are magnified if the degree of complementarities is endogenously determined by each firm's investment. We also consider alliances where matching and/or information about firm resources are imperfect, and show that complementarities are a necessary but not sufficient condition for alliances to cause an increase in firm value; and that complementarities are neither a necessary nor a sufficient condition for alliances to be correlated with higher firm value
Strategy Science
Departments: Strategy & Business Policy, GREGHEC (CNRS)
Journal of Management
Departments: Strategy & Business Policy
Keywords: organizational resilience; social and environmental practices; strategic and tactical practices; global financial crisis; survival analysis
Even though organizational researchers have acknowledged the role of social and environmental business practices in contributing to organizational resilience, this work remains scarce, possibly because of the difficulties in measuring organizational resilience. In this paper, we aim to partly remedy this issue by measuring two ways in which organizational resilience manifests through organizational outcomes in a generalized environmental disturbance—namely, severity of loss, which captures the stability dimension of resilience, and time to recovery, which captures the flexibility dimension. By isolating these two variables, we can then theorize the types of social and environmental practices that contribute to resilience. Specifically, we argue that strategic social and environmental practices contribute more to organizational resilience than do tactical social and environmental practices. We test our theory by analyzing the responses of 963 U.S.-based firms to the global financial crisis and find evidence that support our hypotheses
Journal of Business Ethics
Departments: Strategy & Business Policy, GREGHEC (CNRS)
Keywords: Environmental proactivity, Firm profitability, Resource-based theory, Stakeholder orientation, Stakeholder theory
The impact of socially responsible corporate behavior on economic performance is a major preoccupation of managers today. This article explores the links between narrowly defined constructs: stakeholder orientation, environmental proactivity and profitability, from the perspectives of stakeholder theory and resource-based theory. We collected data on the food and beverage, and household and personal products industries. Using structural equation modeling, this paper makes two contributions. We found a negative link between companies simply having a higher stakeholder orientation and profitability. Importantly, however, environmental proactivity not only had a positive impact on profitability, but also appeared to mediate the relationship between stakeholder orientation and profitability. In other words, if a company is more environmentally proactive, it will be more attentive to a broad array of stakeholders, and this will in turn contribute positively to profitability
Entrepreneurship: Theory and Practice
Departments: Strategy & Business Policy, GREGHEC (CNRS)
Keywords: family firms, community, embeddedness, network
In this paper, we investigate family firms' position in the intercorporate ownership network. Rooting our predictions in the Behavioral Agency Model and a Network analytical framework, we predict and find that family involvement decreases the likelihood of business group affiliation and of cross-group ties leading to a lower embeddedness within the overall network. We predict and find the opposite effect for community involvement. We use the complete longitudinal dataset of publicly listed firms' corporate ownership ties in India (2001, 2005, and 2009). Theoretical and substantive contributions are to research on family businesses and to research on interorganizational networks
The Dean of Faculty's office
HEC Paris
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HEC Paris - 1, rue de la Libération
78351 Jouy en Josas Cedex
Phone: +33 (0)18.104.22.168.00
Fax: +33 (0)184.108.40.206.00


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In Oracle 10g SQL Programming training, students learn how to create, retrieve, and manipulate objects in Oracle 10g Structured Query Language (SQL).
SQL (Structured Query Language) is a recognized standard language designed to organize, manage, and retrieve data from a database. SQL is used to communicate with a database. According to ANSI (American National Standards Institute), it is the standard language for relational database management systems.
All attendees will learn:
Learner will be able to apply key concepts of relational databases and SQL Programming Language
Exam Number : 1Z0-047
Associated Certifications: Oracle Database: SQL certified expert
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Velma, Kevanee, Dawn, Chamilia & Selwyn
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Welcome to our currently updated selection of 18x18 ceramic tiles that will uplift any living environment.
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Internal Medicine of Milford participates with many insurance carriers. We do, however, require your insurance information prior to your appointment to verify eligibility. If you have questions regarding your insurance coverage prior to your visit, please call your insurance company and our billing office (203-878-3531 x3035). We are unable to waive co-payments due to contractual terms with our carriers. Thank you for your understanding.
Please be prepared to show your insurance card at every visit as well as a form of ID. The latter is to protect your financial information.
We do not participate with any state sponsored insurance program. We will see you as a self pay patient if you are covered by one of these plans. Please speak with our billing staff prior to scheduling your visit.
Co-payments are the patient's responsibility and are to be paid at the time of service. Any patient balances are expected to be paid when invoice is received or within 30 days. If you need to set up payment arrangements, please contact the number above for our billing office. Payments may be made by cash, check, VISA or Mastercard.
To make payment by mail please use the following address:
Internal Medicine of Milford
Attn: BILLING
40 Commerce Park
Milford, CT 06460
Our billing staff is always willing and available to discuss billing matters with you.
We currently participate with the following insurance carriers:
- Aetna
- Anthem BC/BS
- Cigna
- Connecticare
- Coventry
- First Health
- Harvard Pilgrim
- Healthy Connecticut
- Humana (CHN solutions network)
- Medicare (existing patients only)
- Multi Plan
- Oxford
- PHCS (Private Health Care systems)
- Railroad Medicare (existing Patients only)
- TriCare (depends on the region-call Insurance)
- United Healthcare
- WellCare – (Medicare only, existing patients only)
If your visit requires laboratory tests, x-rays, special x-ray studies and other services done outside of our office, a referral may be required by our physicians. IMM will provide these specialists and facilities with your billing information. Our staff will contact your carrier when it is required. Patients are ultimately responsible for knowledge specific to their individual plans so we ask that you take an active part in knowing your plan requirements.


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|Out of stock
Nordica brings its world cup construction all the way down to a 90-flex boot with the Dobermann GP 90.x It features the same shell as its top end race boots; complete with its two-piece injection molded cuff and lower that provides an unmatched level of performance and precision. With a slightly softer liner that the stiffer models, it's a bit more comfortable for younger skiers who want the feel of a race boot that they can happily spend some time in outside of the gates. Aggressive young skiers making the jump out of a junior-specific race boot will definitely find the fit and performance they're looking for in the Dobermann GP 90.


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1. 2018 Commencement. Judge Brett M. Kavanaugh, United States Court of Appeals for the District of Columbia Circuit, will deliver the Law School's 129th Commencement Address on Friday, May 25. Judge Kavanaugh has a deep reservoir of experience, achievement, and service to draw upon in offering advice to our graduates.
Read more here
Robert Fulton Dashiell '73 honored by Black Law Students Association
John Ring '89 was approved by the Senate to serve on the National Labor Relations Board, a five-member board, which is tasked with resolving labor dispute cases
The Honorable Vytas Varekojis Vergeer '93 spoke at the CUA Law Pro Bono Reception
Willie Burden (2L) was awarded the 2018 Peggy Browning Summer Fellowship
Rebecca DeVerter (2L) and Mariah Hosie (1L) were awarded the Women's Bar Association Foundation Founders Fellowship
Latena Hazard (3L) was inducted into the U.S. Navy Jag Corps on April 13, 2018
Initiated by the Law School's Board of Visitors in 2013 to honor then new dean, Daniel F. Attridge, the Dean's Dinner has become an important spring tradition at CUA Law as a means of raising scholarship donations for students. This year's event was held at the St. Regis in Washington, D.C. where there was a reception and dinner featuring keynote remarks from Francis X. Coonelly '86, president of the Pittsburgh Pirates. It was a record breaking event in both participation and fundraising for the Law School.
Read more here.
On April 23, 2018, CUA Law hosted the Inaugural Lecture for the Center for Religious Liberty with United States Ambassador-at-Large for International Religious Freedom, Sam Brownback. The Center for Religious Liberty is a part of the CUA Law Path Forward Initiative. The Center seeks to attract top legal scholars, provide important public commentary, and to fully engage in the important ongoing discussion about the proper role of individual and organizational religious liberty in a diverse democracy.
Read more here.
Moot Court at CUA Law continues to grow and stay competitive. The law school's National Trial Team had their final competition of the academic year in Puerto Rico, from April 14–15. The Securities Law Program Moot Court Team impressed at the Kaufman Securities Moot Court Competition at Fordham Law School in New York City.
Plus the Moot Court Association at CUA Law saw significant progress in its 2017-2018 season. This year saw record growth in participation on Moot Court for all grade-levels, new competitions hosted by the University, better training, streamlined faculty roles, and national success amongst competitors.
Also on Friday, April 13, 115 first-year Lawyering Skills Program (LSP) students argued before 60 alumni and friends of CUA Law, who volunteered to provide oral and written critiques of their advocacy. This was the culmination of the semester-long first-year appellate advocacy problem, which closed with a mediation exercise on April 17.
Thank you to all those alumni and friends of CUA Law, who have volunteered and supported our students within these programs.
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Why donate $21? Because $21 x 11,797 alumni for a total of $250,000
Don't underestimate your ability to make a big difference.
With just $21 you — collectively with other alumni — can provide
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Make a gift before April 30 to help our incoming students next fall.
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Alumni Calendar
& Upcoming Events
NYC Dean's Reception with Presentation of the New York Distinguished Alumni Awards
May 3, 2018
The Yale Club of New York
Institutes and Special Programs Certificate Ceremony
Thursday, May 24, 2018
Columbus School of Law
Columbus School of Law Commencement Ceremony
Friday, May 25, 2018
Basilica of the National Shrine of the Immaculate Conception
Dean Attridge Farewell Reception
Wednesday, June 27, 2018
Columbus School of Law
CUA Law Reunion
Weekend 2018
Celebrating the Class Years 1963, 1968, 1973, 1978, 1983, 1988, 1993, 1998, 2003, 2008, and 2013
October 19 & 20, 2018
Columbus School of Law
Support CUA Law
Every gift, whether large or small, helps to advance Catholic Law's distinctive mission. Your support is greatly appreciated.
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End of Fiscal Year Fast Approaching!
With the fiscal year ending on April 30th, please consider making a gift to the CUA Law Annual Fund today! Support to the Annual Fund goes directly to our top priority-student scholarships. Every gift makes a difference for the future of our law school and for its students.
Visit www.law.edu/give to make your gift. Thank you for your support in ensuring a strong close to our fiscal year!
For questions about the Annual Fund please contact Manager of Annual Giving and Stewardship, Lauren McDonald at 202-319-4638 or email@example.com.


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ICAP's 21st Charity Day raises £9.5 million
London, 4 December 2013 - ICAP plc (IAP.L), a leading markets operator and provider of post trade risk mitigation and information services, announces that it has raised £9.5 million (US$15.5 million) worldwide on its 21st Charity Day, held yesterday. This is equivalent to approximately 3 percent of ICAP's full year pre-tax profits and brings the total amount raised through ICAP's Charity Day since 1993 to £110 million.
Michael Spencer, Group Chief Executive Officer of ICAP, said: "This is again an incredible achievement and I'd like to thank our employees, customers and suppliers as well as our distinguished guests. They have all made an enormous effort to raise this figure for the 200 charities we are supporting around the world."
100% of ICAP's revenues and 100% of its brokers' commissions from the day go directly to charities. This year, ICAP is supporting 200 charities globally, having supported more than 1,400 charities since the first Charity Day in 1993. A full list of the charities ICAP supported this year as well as more information about how ICAP's donation will make a difference can be found at www.icapcharityday.com.
Serra Balls
Head of Public Relations, ICAP
+44 (0)20 7050 7124
About ICAP
ICAP is a leading markets operator and provider of post trade risk mitigation and information services. Group companies provide services that match buyers and sellers in the wholesale markets in interest rates, credit, commodities, FX, emerging markets and equity derivatives through voice and electronic networks. Through our post trade risk and information services we help our customers manage and mitigate risks in their portfolios. For more information, please go to www.icap.com.


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Since it's very first project about 14 years ago, Onio is known for introducing
game-changing innovation into the products it touches. The game-changer elements
appear in both – macro & micro contexts and it's a pleasure to see how users
and customers recognise the innovation bits, although it's hidden under the 'design' tag.
This obsession with innovation has made Onio cruise the territories effortlessly
from consulting on products to brands to strategy & business innovation.
For us at Onio it has been evident that innovation is necessary,
but certainly not a sufficient condition for customer / user delight.
At times, the efforts needed to make a product better are much more
than product innovation. From the numerous (and often unsuccessful) assignments,
the factors surrounding a successful design story appears to be quite diverse and
distinctly specific to each case. However two ingredients have always
surfaced in all successful cases.
A clever idea and a touch of fun!
In hindsight, these two factors have always guided the design team in ways like-
- Getting more empathetic to the users, since the cleverness and fun
claims have to be validated from users' perspective
- Getting emotionally involved with the product and saving ourselves
from making drab & dry runs of ideas
- Keeping the mind open as there is no such thing as 'final' design,
if one is pushing for clever & fun ideas
- Inadvertently keeping the boring concepts at bay, and saving ourselves
from pushing 'workable' design ideas into client presentations
Keeping positive pressure for constructive feedback on 'just critics'
within us and within the clients' teams
Prakash Khanzode


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Cartier Snake-motif necklace in platinum with yellow diamond eyes, emeralds, briolette-cut beads and diamonds. PHOTO: Vincent Wulveryck © Cartier 2011.
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Understand Win/Loss In One Page (Or Less!)
Our Win/Loss One-Pager will give you the low-down on Nail It!, Scale It, Defend It - what win/loss is, what is should be for you, and on how Win/Loss is crucial for improving Customer Success. Fill-out this short form and get your one-page today!


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Alternative Titles
Synonyms: Sayonara Watashitachi, Toki o Kakeru Mae ni, Before Crossing Time, Otouto-kun, Little Brother, Shitsuren Family Restaurant, Heartbreak Family Style Restaurant, Us, You and Me, Good-bye, Us, Good-bye My Life, Farewell, Us
Japanese: さよなら私達
Type: Manga
Volumes: 1
Chapters: 5
Status: Finished
Published: Jul 13, 2005 to May 28, 2009
Authors: Ayuko (Story & Art)
Serialization: Deluxe Margaret
Score: 7.321 (scored by 336 users)
1 indicates a weighted score. Please note that 'Not yet published' titles are excluded.
Ranked: #55572
2 based on the top manga page. Please note that 'R18+' titles are excluded.
Popularity: #7645
Members: 1,087
Favorites: 1


text: Mamiya say: "Mamiya are pleased to announce that initial production tests of the ZD camera have been successful. To ensure that the camera meets the high demands and requirements of the professional photographer there are significant field tests now taking place in Japan. It is estimated that these tests will conclude at the end of March and that once any modifications have been implemented full production will start and then be launched during summer 05." Prices to be confirmed, but "no more than £8,000" for the body has been mentioned.


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First post 😌
I was meant to run for 25 mins for this run but as I run on a track I'd estimated that I'd do 9 laps... but MJohnson said I'd completed when I'd only done 8.5 laps!!! I felt I needed to complete the 9 laps but instead I got carried away and did 10 instead... total 4K 😁 in total think I ran for 28 mins.
Should I be pushing myself to go for longer if I feel comfortable or just stick to the plan? I know next week is 28 mins but then I think I might want to do the whole 12.5 laps.


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Mr Ralph Black
Commercial Finance Brokers UK
Ralph Black, 54, is a founding owner of CFB, a whole of market and independently owned commercial finance brokerage. He is also a board member of the National Association of Commercial Finance Brokers, and was chair of the compliance committee for 4 years. Ralph, a business studies graduate, has been organising funding with his colleagues at CFB for care homes since CFB was established nearly 10 years ago and fully understands the dynamics of the sector and how to structure funding packages for care home owners and operators.
Care Sector Finance – Your Options in 2018
This seminar will provide an overview of care sector finance in 2018, explain the financial options open to care home businesses and the challenges with each. It will also provide a guide of how to successfully apply for finance and the support that is available. It will finish with a short Q&A session.


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German vintage postcard, published by Verlag Gruner & Simon, Berlin. Series 2027 3. Romantic motif.
Unused. Dated to the 1930'. Slight surface wear. Free shipping.
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- Research article
- Open Access
- Open Peer Review
Pain treatment for nursing home residents differs according to cognitive state – a cross-sectional study
© The Author(s). 2016
- Received: 15 February 2016
- Accepted: 31 May 2016
- Published: 17 June 2016
Communication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents' impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Aim of this study was the analysis of differences in assessment and pharmacological treatment of pain in nursing home residents relative to their cognitive state and ability to articulate pain.
Data stems from the baseline of a non-experimental pre-post-study in 12 Austrian nursing homes. Residents' pain prevalence in relation to pain assessment and cognitive decline was assessed, data on medical diagnoses and prescriptions were retrieved from the nursing homes' documentation (n = 425). Residents were first divided into two groups: Residents with MMSE ≥ 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE ≤ 17 were selected into group CI (cognitively moderately to severely impaired). CI residents were then sub-grouped according to their ability to communicate pain via the Verbal Rating Scale (VRS) (i.e. group CI-V, group CI-NV). Pain behavior of CI residents was assessed with a modified German version of PAINAD. Group differences were tested with ANOVA and H-test, 95 % confidence intervals were calculated and associations were tested with log-binomial regression.
Pain prevalence in CI residents irrespective of their ability to communicate pain was 80 % and exceeded the CUS group prevalence significantly by 14 %. CI residents had significantly less analgesic prescriptions. Furthermore, CI residents have a significantly higher risk of getting no analgesics when in pain than CUS residents (CI-V: RR =2.6, CI-NV: RR =3.4). Use of antipsychotics was high in all groups (49 – 65 %) with more prescriptions in the cognitively impaired group.
Results point toward an underuse of pain medication in cognitively impaired residents, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.
- Pain
- Analgesic treatment
- Nursing home residents
- Cognitive impairment
- Assessment
Pain is common in older people [1, 2], particularly in nursing home (NH) residents [3, 4] and those with cognitive impairment [5, 6]. Old age exposes individuals to different types of pain, most commonly related to musculoskeletal, gastrointestinal, neurological and cardiac conditions, genitourinary infections, injuries, as well as pressure ulcers in bed ridden individuals, with particularly high pain prevalence rates in those suffering from cognitive impairment [6, 7]. One recently published investigation based on health insurance claims data reported no difference in the diagnoses indicating pain between participants with incident cognitive impairment and cognitively fit controls [8].
Since cognitive impairment is common in many nursing home residents [9, 10], assessment and management of pain is particularly demanding for physicians and nurses due to ambiguity in communication leading to the reasonable assumption that pain in persons with cognitive decline is both under-diagnosed and under-treated [11–13]. In addition, use of analgesics has been reported with higher quality of life in individuals with cognitive impairment [14]. There is evidence that persons with advanced cognitive decline either receive pain treatment, notably opioids, less frequently or in lower insufficient doses as compared to their cognitively fit counterparts [12, 15–19], whereas only few studies have reported a possible overuse of analgesics, particularly paracetamol, in patients with cognitive impairment [20]. On the other hand, there is lack of information to which extent the severity of cognitive decline affects the use of other kind of medication, i.e. antipsychotics, since pain is not only a frequent cause of behavioral and psychological symptoms in dementia (BPSD) [7, 21], but may also, among others, stem from the under-treatment of pain [7, 22]. Pain-induced disruptions run the risk of being misinterpreted as BPSD, provoking inappropriate prescription of psychotropic drugs (i.e. antipsychotics) which, in turn, have been associated with compromised cognition, falls and fractures and increased risk of death [23]. As mentioned above, there is broad consensus within the literature that the challenge of accurately identifying pain in cognitively impaired individuals is the paramount cause of sub-optimal management of pain [24]. Hence in 2009, the American Geriatric Society recommended a comprehensive, disease-specific assessment to establish adequate pain management on an individual level [25]. While individuals with mild to moderate cognitive impairment are often able to report pain either verbally or by use of rating scales [3, 26], these options are not applicable for those with advanced cognitive impairment when the ability to communicate is severely impaired. Thus, self-reported pain may not always be reliable in people with advanced cognitive impairment and pain should be indirectly delineated by raters using a validated observational instrument [27]. Various numerical and visual scales are available for self-reported experience of pain, all of them lacking soundness in persons with cognitive impairment due to their subjection on memory, abstract thinking and speech comprehension [28].
Are there any differences in the prevalence of pain relating to cognitive state and mode of assessment? Are there differences in diagnoses indicating pain relating to cognitive state?
Are there any differences in pharmacological pain treatment relating to cognitive state? Are cognitively impaired residents at higher risk of experiencing pain without analgesic medication than their cognitively better performing counterparts?
Are cognitively impaired residents at a higher risk to receive antipsychotics?
The presented cross-sectional data were collected as part of a baseline investigation of a non-experimental pre-post study with semi-standardized interventions for optimizing pain management in nursing homes (NH) in Austria (OSiA = Optimiertes Schmerzmanagement in Altenpflegeheimen, German for: Optimized pain management in nursing homes). Residents' pain prevalence in relation to pain assessment and cognitive state was assessed and data on medical diagnoses and prescriptions were retrieved from the nursing homes' documentation (n = 425). The study was approved by the ethical committee of Salzburg (415-E/1412/4-2011 v. 07.10.2011). A written consent was obtained from the nursing home residents or from their legal representatives.
Institutions and study participants
Inclusion and exclusion criteria
Inclusion and exclusion criteria
Inclusion criteria
Exclusion criteria
- Age ≥ 60
- Short-term care (up to 6 weeks) and day care
- Living permanently (>3 months) in the NH
- Congenital permanent mental disabilities
- All levels of cognitive impairment
- Insufficient German language skills and/or aphasia
- All levels of physical impairment
- Acute illness and life-threatening situations
- Written consent from resident or his/her legal representative
Classification according to cognitive state
A validated German version of the Mini Mental Status Examination (MMSE) [29] as suggested by Kaiser et al. [30] was engaged to classify residents into groups according to their cognitive abilities. Residents with MMSE ≥ 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE 17 and lower were selected into group CI (cognitively moderately – severely impaired) [31]. CI residents were then sub-grouped dependent on their ability to communicate pain verbally via the Verbal Rating Scale (VRS) [32, 33]: Residents who were able to communicate pain verbally via the VRS were termed group CI-V (verbally communicating), residents not able to communicate by VRS were termed group CI-NV (not verbally communicating).
Measurement tools
Data collection was conducted by trained research assistants with experience in geriatric care. Prevalence and severity of pain of CUS were investigated by a standardized questionnaire. Raters used tablets with online versions of the questionnaire [computer assisted personal interview (CAPI)]. The questionnaire included a 5-item Verbal Rating Scale VRS (no – mild – moderate – strong – unbearable pain) [32, 33]. Whenever possible, VRS was also used for CI residents. Pain was assessed at rest and during mobilization (see PAINAD-Gm). Maximum pain was defined as the residents' maximum pain rating, both at rest or during mobilization.
A modified German version of the Pain Assessment in Advanced Dementia Scale (PAINAD-Gm) [34–36] was engaged for observational assessment of pain behavior of all CI residents. In accordance with [37], PAINAID-Gm was assessed by means of standardized movements (lifting arms, lifting legs, rolling over in bed or getting up from a chair). A cut-off of two or more points out of ten was used to identify residents probably experiencing pain [38]. For group CI-V, maximum pain was recorded as the residents' maximum pain score either on the VRS or the PAINAD-Gm.
Data on medical diagnoses, prescriptions and level of care were recorded from the nursing homes' documentation. Diagnoses were categorized according to organ systems with diagnoses most likely associated with pain (according to expert opinion) being labelled 'Red Diagnoses' (Table 2).
Medicines prescribed to the residents were classified on the basis of the Anatomical Therapeutic Chemical (ATC) classification system recommended by the WHO [39] additionally distinguishing between prescriptions scheduled permanently (PP) and medications prescribed 'as needed' (PRN).
Since the risk of not receiving any analgesics was assumed to be highest in residents who neither had PP analgesics nor PRN analgesics prescribed, analyses regarding the risk of having no analgesic medication though in pain were based on a corresponding subsample.
Statistical analysis
Sample characteristics are presented as descriptive statistics. Differences between cognition-groups were tested with ANOVA for quantitative variables and with H-test for dichotomous variables. Post-hoc analyses were conducted via t-test and Dunn's test. 95 % confidence intervals and their fluctuation range for group differences were calculated. Associations were tested with log-binomial regression and calculated as risk ratios (RR). Type-1 error (2-sided) was set to 5 % a priori.
Characteristics of participants - descriptive statistics
Characteristics of participants
Sample size (n (%))
425 (100 %)
243 (57.2 %)
116 (27.3 %)
66 (15.5 %)
Sex female (n (%))
315 (74.1 %)
172 (70.8 %)
88 (75.9 %)
55 (83.3 %)
Age (Mean ± SD)
83.6 ± 8.8
82.5 ± 9.4
84.4 ± 7.8
86.1 ± 7.5*
Level of care (Median of range 1–7)
Length of stay in months (Mean ± SD)
29.7 ± 23.9
27.8 ± 20.8
31.2 ± 27.8
34.5 ± 26.3
Number of diseases (Mean ± SD)
7,4 ± 4.3
8,0 ± 4.7*
6.8 ± 4.0
6.5 ± 3.2
Disease categories (n (%))
305 (73.3 %)
179 (76.2 %)
83 (72.2 %)
43 (65.2 %)
295 (70.9 %)
145 (61.7 %)*
91 (79.1 %)
59 (89.4 %)
228 (54.8 %)
133 (56.6 %)
64 (55.7 %)
31 (47.0 %)
204 (49.0 %)
128 (54.5 %)*
46 (40.0 %)
30 (45.5 %)
Subgroups of 'Red Diagnoses' (n(%)a)
Injuries and trauma sequelae
108 (49.1 %)
67 (48.6 %)
27 (54.0 %)
14 (43.8 %)
74 (33.6 %)
50 (36.2 %)
13 (26.0 %)
11 (34.4 %)
Disorders of spine and extremities
67 (30.5 %)
49 (35.5 %)
11 (22.0 %)
7 (21.9 %)
22 (10.0 %)
15 (10.9 %)
4 (8.0 %)
3 (9.4 %)
Number of prescriptions scheduled permanently (PP) (Mean ± SD)
9.0 ± 3.9
9.7 ± 3.9
8.8 ± 3.9
6.8 ± 3.2*
Prevalence of pain, mode of assessment and diagnoses indicating pain
Pain prevalence and 'red diagnoses' – descriptive statistics and group differences
Pain prevalence and 'Red Diagnoses'
Descriptive statistics
Group differences
CUS vs. CI-V
CUS vs. CI-NV
CI-V vs. CI-NV
Diff % (±FR)
Diff % (±FR)
Diff % (±FR)
Pain prevalence
14.6 (±9.2) **
13.9 (±11.3) *
−0.7 (±12.0) n.s.
At least 1 'Red Diagnosis'
−15.2 (±9.2) **
−10.2 (±13.6) n.s.
5.0 (±5.0) n.s.
58.7 % of CUS residents, 43.5 % of CI-V and 48.5 % of CI-NV residents exhibited at least one 'Red Diagnosis', displaying a significant difference between CUS and CI-V (Table 3).
Pharmacological pain treatment
Prescribed analgesics – descriptive statistics and group differences
Prescribed analgesics
Descriptive statistics
Group differences
CUS vs. CI-V
CUS vs. CI-NV
CI-V vs. CI-NV
Diff % (±FR)
Diff % (±FR)
Diff % (±FR)
Sum of analgesics (PP and PRN) (Mean ± SD)
2.11 ± 1.64
2.32 ± 1.63
1.90 ± 1.62
1.66 ± 1.61
0.4 (±0.35) *
0.7 (±0.45) **
0.3 (±0.5) n.s.
At least one analgesic (PP and PRN) (%)
−8.7 (±8.7) *
−10,4 (±11.2) *
−1.7 (±12.8) n.s.
At least one analgesic (PP) (%)
9.3 (±11.0) n.s.
22.0 (±13.4) **
12.7 (±15.0) n.s.
At least one analgesic (PRN) (%)
−8.0 (±10.4) n.s.
−8.2 (±13.1) n.s.
−0.2 % (14.7) n.s.
The most frequently prescribed analgesics (PP and/or PRN) were weak cyclooxygenase (COX) inhibitors (Metamizol, Paracetamol), found in 80.1 % of residents with at least one analgesic prescription, where the differences between the cognition-groups were negligible. Topical analgesics (e.g. diclofenac gel) were used by 40.5 % of all residents with analgesic medication and 39.9 % used opioids. Systemically administered NSAIDs were prescribed in 36.7 % of all residents with at least one analgesic prescription. Use of NSAIDs differed significantly between all groups, with 44.4 % in group CUS, 28.9 % in group CI-V and 18.4 % in group CI-NV. Other pharmacological painkillers were rarely used and due to small number not further statistically analyzed (Table 5).
Focusing on PP analgesics, the most frequently prescribed subgroups were opioids, found in 50.2 % of all residents with PP analgesics, followed by topical analgesics with 47.5 %, weak COX-inhibitors with 32.3 % and NSAIDs with 26.7 %. There were no significant differences between the cognition-groups.
Subgroups of analgesics - descriptive statistics
Subgroup of analgesicsa
weak cyclooxygenase (COX) inhibitors (Metamizol, Paracetamol)
PP and PRN
80.1 %
79.7 %
78.9 %
83.7 %
32.3 %
31.2 %
35.7 %
30.4 %
82.6 %
81.4 %
81.1 %
90.2 %
Topical analgesics
PP and PRN
40.5 %
43.0 %
38.9 %
32.7 %
47.5 %
49.3 %
48.2 %
34.8 %
15.7 %
15.7 %
23.2 %
22.0 %
PP and PRN
39.9 %
41.1 %
42.2 %
30.6 %
50.2 %
50.0 %
50.0 %
52.2 %
21.6 %
20.9 %
27.2 %
14.6 %
PP and PRN
36.7 %
44.4 %*
28.9 %*
18.4 %*
26.7 %
30.4 %
23.2 %
13.0 %
29.3 %
35.5 %*
20.3 %*
19.5 %
No analgesics though in pain - Associations between cognition groups (Log-binomial regression)
No analgesics despite pain
CI-Vb in relation to CUSa
(1.3 – 5.1)
CI-NVc in relation to CUSa
(1.6 – 7.2)
Antipsychotics PP - Associations between cognition groups (Log-binomial regression)
Antipsychotics PP
CI-Vb in relation to CUSa
(1.0 – 1.6)
CI-NVc in relation to CUSa
(1.0 – 1.9)
Our data confirm that pain is still a frequent symptom in Austrian NH residents. More than two thirds either self-report pain (VRS) or indicate prevalence of pain on the PAINAID-Gm observational assessment. These findings are in line with previously published data [37, 40].
In addition, reports of residents on their pain varied depending on cognitive function and pain-assessment instruments. Assessing moderately to severely cognitively impaired individuals' pain under standardized conditions resulted in a high frequency of pain (approximately 80 %) compared to the literature [5, 6, 41]. Since CI-V residents' observational assessment showed significantly higher pain prevalence than their self-report, the true ratio of CI-V residents in pain is at issue. Against this background and considering communication deficiencies in this group, the possibility of higher pain prevalence than indicated through self-report should be considered. By assuming the presence of pain, if at least one of both instruments indicates pain – as was done in this study – sensitivity is aimed for, however, specificity of pain detection may be lowered.
In contrast to literature [12], our results demonstrate differences in pain-associated diagnoses relating to cognitive state with significantly more diagnoses indicating pain in the CUS group in comparison to the CI-V group. This discrepancy cannot be interpreted from our data, but may reflect a decreasing awareness in determining medical diagnoses for the cognition-groups with advanced decline.
Our data adds to the evidence that persons with advanced cognitive decline less often receive pain treatment [12, 15–19] and, is therefore, conflicting with reports from other European countries suggesting that analgesic use is higher among people with cognitive impairment as compared to older adults without cognitive impairment [8, 20, 42]. This may be explained by differences in national prescription habits and configuration of medical supply. It has to be pointed out though that frequency of analgesic prescription is not necessarily a sign, whether (or not) an adequate analgesic treatment is being prescribed to the right people at the right time [7].
It is noteworthy to add that we investigated the percentages of permanently scheduled analgesics (PP) and analgesics prescribed 'as needed' (PRN) in relation to the different cognition-groups. In all groups, more analgesics were prescribed PRN (64.1 – 72.3 %) than PP (35.9 – 58.0 %), with no significant group differences for the PRN prescriptions. In contrast, PP prescriptions dropped with cognitive decline, with 58.0 % for group CUS, 48.7 % for group CI-V and 36.0% for group CI-NV. The difference between groups CUS and CI-NV reached significance suggesting that advanced stages of cognitive decline are associated with a reserved attitude to medical treatment. This is also supported by the mean numbers of prescriptions, which exhibit a decline from group CUS (9.7 ± 3.9) to groups CI-V (8.8 ± 3.9) and CI-NV (6.8 ± 3.2), again reaching significance between CUS and CI-NV.
According to the literature, pain medication in individuals with cognitive impairment is generally of low dosage and stronger drugs such as opioids are less likely to be considered [7]. In our sample, the most frequently prescribed PP pharmacological subgroups were opioids with 50.2 %, followed by topical analgesics with 47.5 %, weak cyclooxygenase inhibitors (Metamizol, Paracetamol) with 32.3 % and NSAIDs with 26.7 %. No differences between the cognition-groups were detectable. Notably, the number of opioid prescriptions is remarkably high in comparison to recent literature [15, 19], as is the overall number of PP in our study. The high number of opioid prescriptions is in accordance with other investigations reporting an increasing opioid use in several countries [43].
Merging PP and PRN prescriptions, the use of NSAIDs diminishes significantly with the loss of cognitive function, showing a prevalence of 44.4 % in group CUS compared to 28.9 and 18.4 % in groups CI-V and CI-NV, respectively. This trend also partially applies to PRN prescriptions. The lower NSAID prescription behavior as cognition declines could, however, be also due to the recommendation to prescribe this class of medication less frequently due to its detrimental side-effects on particularly the geriatric population [44–47].
Cognitively impaired individuals seem to experience intensity and affective components of pain differently than their cognitively fit counterparts [7]. Moreover, the decline in the ability to communicate results in considerable challenges for detecting pain, particularly in advanced stages of cognitive impairment. Cognitively impaired individuals may embody pain by BPSD, such as agitation, denial or withdrawal, giving rise to misinterpreting pain as a psychiatric condition and resulting in the inappropriate treatment with antipsychotic medication [7, 21].
In our sample, prescription of antipsychotics was strikingly common, as reported previously for Austrian NH residents by Richter (2012) [48]. The high number of antipsychotic prescriptions is likely to be an indicator for a perceived or actual lack of strategies to manage BPSD [48]. Antipsychotics were prescribed in nearly half of the participants of our study with the difference between CI-V (47.0 %) and CUS (37.0 %) residents demonstrating a trend and the difference between CI-NV (51.6 %) and CUS (37.0 %) residents reaching statistical significance. In addition, residents with advanced cognitive decline had a significantly higher risk of suffering from pain without having an analgesic prescription, giving rise to the assumption that pain-associated BPSD indicate antipsychotic rather than analgesic treatment. This finding adds to an ongoing discussion, since some studies demonstrated that treatment of pain might decrease incidence and severity of BPSD [22, 49], whereas a recently published meta-analysis does not support strong associations between pain and BPSD [50].
To our best knowledge, our investigation is the first of its kind to address the relationship between prevalence of pain, prescription of analgesics and the application of different assessment tools adjusted to the cognitive state of NH residents. Connecting these aspects, CI-V residents had a 2.6-fold higher risk of suffering from pain without having any analgesics prescribed as compared to CUS residents; for CI-NV residents, this risk was even 3.4-fold. These findings suggest cognitive impairment as a hindering factor for receiving sufficient medical pain treatment. Against the background of communication deficiencies, these considerable disparities may be traced back to lacking or inadequate pain detection, which further points toward the necessity of meticulous and standardized pain assessment adapted to the residents' cognitive state as a prerequisite of adequate treatment. Moreover, such an assessment is mandatory to find the balance between sufficient analgesia, side effects and futile treatment, since patients are often restricted in reporting the effect of therapy [40]. Along these lines, recording the effect of pain treatment over time might be a pivotal measure to warrant optimized pain management and to avoid inadequate medications.
We concede some limitations to our work: Due to the cross-sectional study design, it is difficult to make causal conclusions about the data. Additionally, considering nursing homes in Austria, it should be noted that requirements related to staffing and facility structure are regulated by federal law. Although our sample only consisted of nursing homes from one Austrian nursing home operator, which limits its generalizability, differences in staffing and facility structure between the nursing homes in our sample and other nursing homes are expected to be rather negligible. The quality of the medical documentation in the nursing homes did not allow the use of standardized tools to rate cumulative illness, thus, limiting the comparability of disease burden between the cognition- groups. Moreover, the medical documentation only included information about prescribed medication, but not if the prescribed medication was actually given to or taken by the resident. The classification of cognitive abilities was based on the current assessment of the MMSE. Therefore, definitive assignment to clinical entities or etiology is not warranted. The use of antipsychotic drugs might be biased by the presence of BPSD, which were not recorded systematically in the medical documentation of the nursing homes. Due to different cognitive states of the participants different pain assessment methods were used.
Results point toward an underuse of pain medication in nursing home residents with advanced cognitive decline, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.
ATC, anatomical therapeutic chemical; BPSD, behavioral and psychological symptoms in dementia; CAPI, computer assisted personal interview; CI, cognitively moderately – severely impaired; CI-NV, cognitively moderately – severely impaired/not verbally communicating; CI-V, cognitively moderately – severely impaired/verbally communicating; COX, cyclooxygenase; CUS, cognitively unimpaired, slightly impaired; MMSE, mini mental status examination; n, sample size; NH, nursing homes; NSAID, nonsteroidal anti-inflammatory drugs; OSiA, optimiertes schmerzmanagement in altenpflegeheimen; PAINAD-Gm, pain assessment in advanced dementia (modified German version); PP, prescriptions scheduled permanently; PRN, prescribed 'as needed'; RR, risk ratio; VRS, verbal rating scale (pain assessment); WHO, World Health Organization
We thank the nursing home residents and the nursing staff for participating in this project. Further, we'd like to thank Firuzan Sari Kundt for her valuable advice in writing an English manuscript.
The project was funded by an Austrian nursing home operator (SeneCura Kliniken- und HeimebetriebsgmbH, Vienna/Austria). The funder didn't have any influence on design, collection, analysis and interpretation of the data as well as the writing of the manuscript.
Availability of data and materials
The dataset supporting the conclusions of this article is available in the FigShare repository. DOI: 10.6084/m9.figshare.3364315. Hyperlink: https://figshare.com/articles/Article_Variables_sav/3364315.
Authors' contributions
UB participated in the conception and design of the study, participated in data collection, performed the statistical analyses and drafted and wrote this manuscript. SP participated in data collection, performed the statistical analyses and drafted and wrote this manuscript. MS conceived and coordinated the study, participated in data collection and was involved in drafting the manuscript. JO conceived the study and gave final approval of the version to be published. RA was involved in the categorization of medical data. BI participated in the conception of the study, carried out categorization of medical data, drafted and wrote this manuscript and made substantial contributions to the interpretation of data. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The study was approved by the ethical committee of Salzburg, Austria (415-E/1412/4-2011 v. 7.10.2011). A written consent was obtained from the nursing home residents or from their legal representatives.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Authors' Affiliations
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- Husebo BS, Ballard C, Cohen-Mansfield J, Seifert R, Aarsland D. The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatr. 2014;22(7):708–17.View ArticleGoogle Scholar
- van Dalen-Kok AH, Pieper MJ, de Waal MW, Lukas A, Husebo BS, Achterberg WP. Association between pain, neuropsychiatric symptoms, and physical function in dementia: a systematic review and meta-analysis. BMC Geriatr. 2015;15:49.View ArticlePubMedPubMed CentralGoogle Scholar


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Each year, you and I create a social change project through Be Who You Are Productions, Inc. These creative endeavors stretch our skills, talent and vision, and serve to create community in diverse areas. They do not have a profit motive, and often are run on a shoestring budget. But together, we make it happen.
Below are my projects to date. Each one has been a collaboration of many of you who have gifted your time and talents to the make the world a better place, even if just a little. I extend my heartfelt thanks to each one of you who has been involved, even if only in the sharing of the project. And I welcome those of you who will join us in the future. Want to know more? Visit BeWhoYouAre.com.


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Change the medical world as a primary physician with a bachelor's degree in psychology.
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10 in stock
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Shipping Information• Shipping charges on all domestic products will be charged Rs. 150/-.
• We charge shipping Rs.200 on all products marked imported.
• Stock Items will be delivered same day if order is received before 1:00 PM. (Currently only for Lahore)
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• All orders above Rs.30,000/- worth, 50% advance payment is must. Once the customer confirms the order of the products, our representative will contact for payment information and details and account details will be communicated afterwards these order will be shipped via a traceable courier service.


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Wednesday, September 10, 2008
Stuck Forks
Hold the phone here. I'm not done with the blog. I loves my bloggy, yesh I do, yesh I do! I've not written because I haven't been feeling very well, which leaves me not feeling especially funny or wordy. I feel much better today. I feel funny. Feel me. See? Feels funny.
Before I was not feeling too well I'd come to the conclusion that there are a couple aspects to my existence that are over. One held my interest but has run it's course because it stopped having any potential for growth. The other is something I'd abandoned long ago but had left the door open to because I thought I might want to return. Now I'm done. Just....done.
Wait, the previous paragraph isn't funny. God, you better feel me again. Just trim your nails this time Raggedy Anne.
I'm finding this process fascinating. That's why I didn't mention the subjects in which I'm done. Ultimately those are neither here nor there. Closing doors opens other doors. Some of those doors open into rooms that smell like vegetable soup or public restrooms. Some of these doors open to rooms that smell like pumpkin pie. Just trying to figure out which doors to put on my plate is awesome.
In a way this goes along with my husband's dietary lifestyle change. We are eating quite a lot of vegetables, only some of which have been made into soup, and twenty of his pounds have snuck off. They probably found life more pleasant behind the public restroom door. Don't let the door hit ya in the ass on the way out.
So...what's next? I dunno yet...and that's wonderful.
13 comments:
I'm still trying to figure out how you're gonna put a door on your plate. I'm lucky to get a window on mine.ReplyDelete
I don't think that matters as long as you chew thoroughly.ReplyDelete
Wow, that was ... confusing. I'm a simple girl. I don't like to think. I need things laid out nice and simple-like.ReplyDelete
I'm only having the pie.... k thnx.ReplyDelete
- Anonymous9/10/2008 1:10 PM
I am glad u still like your "bloggy," and thats not one of the doors that u are closing.ReplyDelete
Since u meantion pumpkin here is a pumpkin soup recipe in case u want to try it:
INGREDIENTS (Nutrition)
3 tablespoons margarine, softened
1 tablespoon brown sugar
1/4 teaspoon ground cinnamon
4 slices whole wheat bread
1 cup chopped onion
2 tablespoons butter, melted
2 (14.5 ounce) cans chicken broth
1 (15 ounce) can pumpkin puree
1 teaspoon salt
1/4 teaspoon ground cinnamon
1/8 teaspoon ground ginger
1/8 teaspoon ground black pepper
1 cup heavy whipping cream
Preheat oven to 400 degrees F(200 degrees C). Combine butter, brown sugar, and cinnamon. Spread butter mixture evenly over one side of each bread slice. Place bread, buttered side up, on a baking sheet. Bake 8 to 10 minutes, or until bread is crisp and topping is bubbly. Cut each slice of bread into 8 small triangles or squares.
Saute onion in butter in a medium saucepan until tender. Add 1 can chicken broth; stir well. Bring to a boil; cover, reduce heat, and simmer 15 minutes.
Transfer broth mixture into the container of a blender or processor. Process until smooth.
Return mixture to saucepan. Add remaining can of broth, pumpkin, salt, ground cinnamon, ground ginger, and ground pepper; stir well. Bring to a boil; cover, reduce heat, and simmer 10 minutes, stirring occasionally..
Stir in whipping cream and heat through. Do not boil. Ladle into individual soup bowls. Top each serving with Cinnamon Croutons.
Dont let a pumpkin hit ya in the ass. Those things (the pumpkin not your tushie, i have to specify huh) are big and might hurt.
- Anonymous9/10/2008 3:01 PM
arent closing even,,,,ReplyDelete
perhaps one of the doors u can open is a door to a typing class for me, lol
You haven't learned how to type yet? Sheesh...didn't we take the course together?ReplyDelete
I am done with a couple of things too. Starting to eat more vegetables as well.ReplyDelete
I don't think I could find any more similarities :p
I'm peluda and you aren't...or are you?
I'm peluda. I got a bad night's sleep last night because my leg hairs were poking into the sheets and whatever.ReplyDelete
Heh...that's kinda pathetic.
If I have to quit something just to eat more vegetables...count me out.ReplyDelete
I think I'm allergic to all things green.
Well, except money.
Is your gallbladder issues making you go through midlife crisis??? Sounds like you need girl talk. Call me!ReplyDelete
It's not my gallbladder. It's the Thetans.ReplyDelete
- Anonymous9/11/2008 2:58 PM
Typing was the only course in took in high school that i flunk. I was fast but once they took -10 words per error off i was into negative words per minute.ReplyDelete
Thank goodness they didnt have spelling in high school cuz i flunk that in grade school, lol
PS: i hope u are feeling better to day,,,can i have a feel :P
Absent Minded Archives
- ► 2014 (22)
- ► 2013 (88)
- ► 2012 (85)
- ► 2011 (101)
- ► 2010 (95)
- ► 2009 (177)
- The Burning Bush
- Head of State
- Rebuttal
- Squeal like a pig
- He puts the lotion in the basket
- My Blue Heaven
- Ahhh push it...push it good.
- There is no wool over my eyes.
- Morning Minutia X
- Thar's a hole in the bucket, dear Liza dear Liza
- Mu-mu
- Sauerkraut-isms
- Stuck Forks
- Flushed II
- Goals accomplished.
- Fruit flavored Tums
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Despite the downturn in the telecom industry, some leading vendors are attempting to hit the few hotspots in the market with products designed to convince frugal carriers of the revenue and cost savings potential inherent in new investments.
Two such vendors, Cisco Systems Inc. and Nortel Networks Corp., unveiled two such offerings at a downcast NFOEC 2002 conference in Dallas last week. The companies rolled out enhancements and extensions to their portfolios for metropolitan-area SONET networks, one of the lone flickering stars in a telecom constellation that's gone dim over the past 18 months.
As expected, Cisco announced a SONET grooming switch that the vendor described as a "bigger brother" to its popular ONS 15454 metro transport system. The new ONS 15600 is designed for high-density aggregation switching of SONET/SDH traffic collected from multiple ONS 15454 rings.
A key feature of the ONS 15600 is its ability to groom traffic at the 52M bit/sec STS-1 level, which makes more efficient use of bandwidth by packing SONET rings with more traffic.
Nortel, meanwhile, added Gigabit Ethernet service interfaces to its OPTera Connect DX SONET/SDH switch. The dual-port Gigabit Ethernet interfaces enable the DX to support 32 per bay for Ethernet-over-SONET aggregation and switching in the metro core.
Indeed, Nortel says the DX enhancements will help position the switch away from its traditional niche in the depressed long-haul market - where the fiber/bandwidth glut is most prevalent - and into the metro.
"The metro area is the hot area," says Deb Mielke, principal at Trelliage Network Strategies. "It's certainly not long-haul right now."
Cisco believes it just got hotter with the introduction of the 15600. The STS-1 switch combines the functions of a SONET add/drop multiplexer (ADM) with an optical cross-connect, says Dave Lively, senior manager of optical strategies at Cisco.
This helps service providers save money by eliminating the need for multiple ADMs at the core central office to aggregate rings from the edge, Lively says.
The 15600 supports 128 OC-48 interfaces and 320G bit/sec of switching capacity per shelf. Three shelves can fit into a single telco rack.
Sixty-four protected rings can be configured with the switch. For SONET, it supports unidirectional path switched ring and bidirectional line switched ring configurations.
Lively claims that through some Cisco patent-pending innovation in cooling, each slot in the 15600 is 160G bit/sec-capable, meaning a shelf can achieve a total system throughput of 1.28 terabit/sec, or 4 terabit/sec per rack. These same innovations allow the 15600 to achieve restoration times of 15 to 25 msec vs. SONET's 50 msec restoral, Lively asserts.
The switch was under development at Cisco for 18 months, he says, and it will ship in the fourth quarter.
The 15600 is currently in trials at US Signal and Looking Glass Networks.
On the competitive front, Lively says the 15600 will compete most directly with digital and optical cross connects from several vendors. It may also bump up against Nortel's DX, which gained optical Ethernet capabilities with the addition of the Gigabit Ethernet interfaces.


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Estée Lauder Cos., hammered recently by the strength of the U.S. dollar, on Monday reported stronger-than-expected earnings for its June quarter, though sales missed expectations and the company gave soft earnings guidance for its current quarter and new fiscal year.
Shares, which have rallied 16.6% this year, fell 2.1% in premarket trading.
Estée Lauder, which is home to brands like Clinique, MAC and Bobbi Brown, has been helped recently by stronger makeup sales and strength in the U.K. and emerging markets.
In the latest quarter, makeup sales fell 3.7% to $1.02 billion amid currency impacts, but would have grown 3% excluding currency fluctuations.
Skin-care sales fell 9% excluding currency fluctuations, while fragrance sales jumped 18%. Hair care sales gained 10% on a constant-currency basis.
Overall, Estée Lauder reported a profit of $153 million, or 40 cents a share, compared with $257.7 million, or 66 cents a share, a year earlier.
Total sales fell 7.4% to $2.52 billion.
Analysts polled by Thomson Reuters had expected earnings of 34 cents a share on sales of $2.57 billion.
Excluding currency impacts and the effect of accelerated retailer orders in the prior-year period, sales would have been up 7%
For its newly-started fiscal year, Estée Lauder forecast sales growth of 8% to 10% excluding currency impacts. Per-share earnings, excluding foreign currency and acquisitions, are expected to be up 8% to 10%, while analysts polled by Thomson Reuters had forecast 16% growth.
For the current quarter ending in September, Estée Lauder forecast constant-currency sales growth of 13% to 14% on a 3% to 6% drop in adjusted per-share earnings. Analysts are forecasting a 38% increase in adjusted per-share earnings.
Write to Chelsey Dulaney at firstname.lastname@example.com


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Some thoughts ....
- There seems to be an important connection between singing/worship (including the use of different instruments) and the manifestation of the Spirit. We see this also in the New Testament as Paul urges the Ephesians to be filled with the Spirit ... speaking to one another with Psalms, hymns and spiritual songs.
- The Spirit comes with power ... sufficient to change us into a different person (in New Testament parlance, a 'new creation', indwelt by the presence of God.
- The experience of God's Spirit/prophecy/God's presence brings a measure of guidance into our lives (I sense this is especially important for us as a community)
Carol and I feel compelled to set time aside during the summer months to get before the Lord, to enter into his presence and worship - making music in our hearts, to pray and to seek a greater manifestation of the gifts of the Spirit - especially that we might (all) prophesy. To this end, we want to open our home to any who would like to come on Thursday evenings from 7pm (when we are in town). So please come when you can, bring an instrument ... or at least your voice, come with expectation and hunger, come with the sick (for healing), come with a friend if you wish. I believe that this is a God-thing, so not just necessarily just a 'BridgePoint' thing. We want to promote the unity of the Body, and hence our connection with all believers.
I truly believe that the Lord wants to 'light a fire' so to speak in our lives and our missional communities/simple churches that will never go out. Just like the lamp that was to burn continually in the temple. A light that will touch the lives of many with whom we live and work. We need his presence, his guidance, his power as much as those first disciples needed it and were told by Jesus to wait together for it. So we want to gather and wait until the Lord pours out his glory and lights a revival fire for his glory in our city.


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The following market report on the anthology, Clones and Crucifixes, as well as the follow-up interview are courtesy of Market Scoops by D.L. Snell.
The Market
Publisher: Corpulent Insanity Press
Editor: Christopher Allan Death
Pay Rate: 1 cent/word
Response Time: 5-30 days
Reading Period: November 6-December 20
Description: An anthology of futuristic horror
Complete Guidelines: Writer's Guidelines
Note: Horror author D.L. Snell conducted the following interview to give writers a better idea of what the editors of this specific market are seeking; however, most editors are open to ideas outside of the preferences discussed here, as long as they fit the basic submission guidelines.
The Scoop
1. What authors do you enjoy, and why does their writing captivate you?
I enjoy lots of authors, for lots of different reasons. Carlton Mellick III is great because his imagination is off the wall, Wrath James White rocks because he knows how to make your stomach churn, and John Connolly kills because his stories are so atmospheric. But I'm not stuck on "household names." I'll read any author in the small press, so long as their tales are well-written and original. Right now I'm reading a novel by JG Faherty.
2. What are your favorite genres? Which genres would you like to see incorporated into submissions to this market?
Primarily, I'm looking for a cross between sci-fi and horror for this anthology. If it's just science fiction without a hint of horror, I'll pass. And if it's just horror without a hint of science fiction, I'll pass as well.
3. What settings most intrigue you? Ordinary or exotic locales? Real or fantasy? Past, present, or future?
Ordinary locales intrigue me most, but I'll consider anything, as long as it's interesting. As for time … all stories should be set in the future. Near or far.
4. Explain the type of pacing you enjoy, e.g. slow building to fast, fast throughout, etc.
Since the word limit for this anthology is so low, I'd prefer stories to start off with a bang. If you can take my breath away in the first paragraph and maintain suspense until the end, your chance of making the final cut is good. That said, I don't want continuous action. Blood and guts are fine, but there should be a well-thought plot as well.
5. What types of characters appeal to you the most? Any examples?
I prefer flawed characters. Regular Joes are fine, but raving druggies, closet murders, and crooked cops really get my blood pumping (not in a deviant way, mind you). The more bizarre, the better.
6. Is there a specific tone you'd like to set in your publication? What kind of voices grab you and keep you enthralled? Any examples?
In general, I'd like stories to be bleak, gritty, and real. Some humor is okay, but it shouldn't suck the suspense from the plot.
7. What is your policy for vulgarity, violence, and sexual content? Any taboos?
In general, I'm fine with anything, as long as it adds to the story. I'm not interested in page-long descriptions of rape or torture. Splatterpunk is fine … just keep the wheels churning.
8. What kind of themes are you seeking most in submissions to this market? In general, what themes interest you?
I'm intrigued by stories of human limitation. If you think about it, we've made lots of progress as a race, as a species, but there's still a lot we don't understand. We can't say for certain how old the world is, or when the universe came into existence. We can't even explain the phenomenon of ghosts. But we try.
9. Overall, do you prefer downbeat or upbeat endings?
Both upbeat and downbeat are fine. I suppose I prefer downbeat a bit more, but it depends on the story.
10. Any last advice for submitters to this market? Any critical do's or do not's?
The best advice I can give is this: heed the guidelines. If you have a trunk story about a boy who gets possessed in 18th Century London, don't send it. We're only interested in futuristic horror. Think Blade Runner and The Exorcist mixed together in a big, black, bionic cauldron.


text:
Please email Pat at email@example.com with questions.
Bartender Guidelines
Member Chits:
Have member fill out chit with Name, Date and Membership # and first drink order. Also enter last name at top of chit. Make certain that the quantity of each drink ordered is recorded on the initial chit. Chits are kept alphabetically behind bar in rack.
Record all drinks on chits.
Regular Brands: Note type of drink, i.e., vodka, scotch, bourbon, rum or gin and number ordered.
Premium Brands: Note name of drink, i.e., Absolut, Dewar's, Tangueray, Canadian Club, Jack Daniels, Myers or Mt. Gay and number ordered.
After Dinner Drinks: Note name of drink and number ordered.
Beer: Note name of beer and number ordered.
Soda: Note the type of soda. Only the first soda needs to be recorded.
Return used glasses to kitchen for washing.
Cash Customers:
Use the same procedures as noted above and keep chit on cash register to be totaled when the customer desires to pay (use cash price list). A dinner charge (Friday, $18) may also apply and should be entered on chit and totaled with bar charge. Change should be available in register. Checks can be accepted and made payable to YCHHI.
We believe that most lost drinks occur
because the initial chit filled out by the member
may not always contain the number of drinks ordered.
Thank you for your help.
Your service is an important cost saver to our club.


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Visiting the Cathedral of St Macartan, Monaghan Town, Ireland: vertically defying the former rules of the Ascendancy
Gothic features in abundance rising to 76.2 metres
Before Victorian times, when the rules of the Protestant Ascendancy in Ireland were somewhat relaxed, it used to be that Roman Catholic church buildings could not be as tall as Protestant ones. Thus it happened that, when this rule was rescinded, great efforts were made to 'reach for the skies' with tall, spired buildings which were supposed to outclass Protestant church buildings in their height and grandiosity.
The Cathedral Church of St. Macartan, Monaghan (Irish: Muineachán)(1), Republic of Ireland, was built between 1861 and 1892. Not only does its tower rise to an impressive height — 76.2 metres — from its base, the building also stands upon a hill overlooking Monaghan Town.
Interestingly, its height is broadly comparable with that of Trinity Church, 79 Broadway, New York City, which at 86 metres was the tallest building in New York City between 1846 and 1890.
It is executed in Gothic style.
We thus see in this striking structure repeated pointed arching and a profusion of pinnacles. The whole constitutes a quite spectacular display of this Medieval style revived optimistically in the 19th century.
The building's architect was J J McCarthy (1817-1882)(2). I have included a 19th century drawing of the building's design, as planned by the architect. St Macartan's Cahtedral is thus undoubtedly one of the most impressive buildings in Ulster (Irish: Ulaidh)(3).
September 11, 2013
(1) Both county town and the county itself are called Monaghan; hence differentiation is sometimes made between Monaghan Town and County Monaghan.
(2) Architect McCarthy was known for his ecclesiastical building designs; he specialized in Gothic style, especially popular during the Victorian era. His designs are often conpared with those of Augustus Pugin, who pioneered the Gothic Revivial in the 19th century.
(3) The term 'Ulster' is sometimes used to refer to Northern Ireland, but Monaghan, Cavan and Donegal — all situated in the Republic of Ireland — classify as three of the historic counties of Ulster.
Also worth seeing
In Monaghan Town itself, the Rossmore Memorial was built to remember a local landowner who tragically died young; other noted structures include Monaghan County Museum, located in Hill Street; St Patrick's Church and Monaghan Courthouse.
Clones (distance: 21 kilometres) is known for an impressive, old market cross, a ruined abbey and its Celtic round tower.
How to get there: Aer Lingus flies from New York and Boston to Dublin Airport , from where car rental is available. Distance from Dublin by road to Monaghan Town is 125 kilometres; Bus Éireann maintains a service on this route. Some facilities may be withdrawn, without notice. Please check with the airline or your travel agent for up to date information.
MJFenn is an independent travel writer based in Ontario, Canada.
Other of my hubpages may also be of interest
- Visiting the Rossmore Memorial, Monaghan Town, Republic of Ireland: remembering the transient nature
- Visiting Monaghan Town, Ireland and its Courthouse: a stately presence in Georgian style by Joseph W
- Visiting Clones, Ireland: attractive town in County Monaghan
- Visiting Lough Ramor at Virginia, Republic of Ireland: tranquil scenes and ripples of ancient confli
- Visiting Cuilcagh, and western Co. Cavan: hillwalking country in Ireland


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[Total: 0 Average: 0/5] You must sign in to vote Having spent most of my life in Alaska, the desert is a very different and very new place for me. Adapting to this new environment has been a learning process, for sure. Part of that learning process has involved doing things like this–photographing and identifying the local plants. Not only does this help me become familiar with what's around me, but it lets me do further research into the various uses for some of these plants. I'm not an expert in this area, so please feel free to comment on this video with any corrections you might have to my attempt at identification. There are a couple plants that I put question marks with–I could definitely use help on those ones. Video Rating: / 5
on 2017-06-04


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Andre Ward
World champion in the light heavyweight division Andre ward responded to the statement of Sergey Kovalev, American hits like a girl
"I'll have to make a distinction. The difference is that he can lie to the public, but he can't lie to me. I heard him "grunting" and nozzles when I miss my shots. So he cannot claim that he suffered damage. It's all a game. The reality is that I hurt you, I felt your exhaustion, saw him. So you don't need to tell me something, I know everything" – quotes the words of Andre ward championat.com with reference to BoxingScene.
Read also: Kovalev called ward's paper champion
The fight is a rematch between world champion WBO/WBA/IBF light heavyweight title to American Andre ward (31-0, 15 KOs) and former world champion Russian Sergey Kovalev (30-1-1, 26 KO's) will be held June 17 in Las Vegas (USA).
See also how the Russians are preparing for the upcoming fight.
According to the materials:


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Created by W.Langdon from gp-bibliography.bib Revision:1.4524
@InProceedings{Shanmugam:2002:CSCC, author = "Surendran K. Shanmugam and Vinay Varadan and Henry Leung", title = "Design of 1-{D} Piece-wise Maps for Multi-user {CDMA} Communications Using a Novel {GP}-{DNA} Algorithm", booktitle = "6th WSEAS International Multiconference on Circuits, Systems, Communications and Computers (CSCC 2002)", year = "2002", editor = "Nikos Mastorakis", pages = "444--481", address = "Rethymno, Crete, Greece", month = jul # " 7-14", publisher = "WSEAS", keywords = "genetic algorithms, genetic programming, dna computation, chaos, CDMA, orthogonal codes", annote = "The Pennsylvania State University CiteSeerX Archives", bibsource = "OAI-PMH server at citeseerx.ist.psu.edu", language = "en", oai = "oai:CiteSeerX.psu:10.1.1.538.8395", isbn13 = "960-8052-63-7", URL = "http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.538.8395", URL = "http://www.wseas.us/e-library/conferences/crete2002/papers/444-481.pdf", size = "6 pages", abstract = "This paper addresses the design of one dimensional piece-wise maps to generate optimal codes for short and long code multi-user CDMA systems. A novel approach, GP-DNA, that uses genetic programming to search in the functional space and DNA computation to obtain the optimal initial conditions has been proposed as the design methodology. This method automatically designs orthogonal codes for short-code CDMA and codes with good aperiodic correlation properties for long code CDMA. Monte-Carlo simulations illustrate the improved performance of GP-DNA compared to conventional code designs.", notes = "http://www.wseas.us/e-library/conferences/crete2002/", }
Genetic Programming entries for Surendran Shanmugam Vinay Varadan Henry Leung


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KENDRIS Compliance Flash
Yesterday, the Department of Justice announced that it has reached final resolutions with banks that have met the requirements of the Swiss Bank Program. The Program provided a path for Swiss banks to resolve potential criminal liabilities in the United States, and to cooperate in the Department's ongoing investigations of the use of foreign bank accounts to commit tax evasion. The Program also provided a path for those Swiss banks that were not engaged in wrongful acts but nonetheless wanted a resolution of their status. Banks already under criminal investigation related to their Swiss-banking activities and all individuals were expressly excluded from the Program.
Source: US DoJ