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The American College of Gastroenterology (ACG) released new treatment guidelines on the diagnosis and management of gastroesophageal reflux disease (GERD) in the March issue of The American Journal of Gastroenterology. This blog post will present highlights from the updated guidelines, particularly those that are most relevant to the management of GERD in the hospice setting. Some of the recommendations may surprise you, as many of these recommendations are not routinely followed in clinical practice.
Management of GERD
Risks Associated with PPIs
Reference: Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroeneterol 2013; 108: 308-328.
Access the complete guidelines here: http://gi.org/wp-content/uploads/2013/03/ACG_Guideline_GERD_March_2013.pdf
Hospice patients with COPD, lung cancer, or other respiratory illness frequently use inhaled respiratory medications to combat symptoms of shortness of breath and lung inflammation. There are many types of inhaled medications, and many agents within each subclass, which complicates the use of these medications and often leads to substantial therapeutic overlap within a patient's medication regimen.
Furthermore, these medications are almost universally expensive. Most are available only as brand name medications, and the complex delivery devices increase the cost of these products.
Download the Outcome Resources Inhaled Medications Chart to help you sort through the many therapies available. The chart groups the medications by therapeutic class and will help you compare dosing regimens, mode of delivery, and cost.
Insomnia is a common complaint in hospice care, and the "Z drugs" – zolpidem (Ambien, others), zaleplon (Sonata) and eszopiclone (Lunesta) are commonly used to treat it. These non-benzodiazepine hypnotic medications, which act on the GABA receptor in a similar fashion to the benzodiazepines, have substantial risks which need to be weighed carefully against their potential benefits. These risks – including falls, fractures, driving incidents, memory loss, daytime fatigue, tolerance and addiction – tend to be more pronounced in our hospice patient population due to advanced age and comorbidities. Recently, the FDA has made many changes to the labeling of these drugs (particularly zolpidem) as new information has come to light regarding their side effects.
Back in January of this year, the FDA reduced the recommended initial dose of zolpidem products, because the use of the higher dose can increase the risk of next-day impairment of driving and other activities that require full alertness – especially in women. The following recommendations were made (please see our blog post for complete information regarding this warning):
This month, the FDA further heightened its warning regarding extended-release zolpidem (Ambien CR), advising that patients taking extended-release zolpidem should not drive or engage in any activity requiring mental alertness during the entire day after taking the drug, because of the profound "hangover" effect with the extended-release product.
Recently, a study was published in the British Medical Journal (1) examining the clinical efficacy of these medications in the treatment of insomnia. According to the investigators, previous meta-analyses of the Z drugs have been prone to publication bias, such as unavailability of unpublished trials and selective reporting of results. In their meta-analysis, they used only data provided to the FDA for drug approval. Since drug companies are required to provide information on all sponsored trials, published or not, when applying for drug approval, their claim is that the FDA files contain a more complete and less biased dataset of published and unpublished trials.
Thirteen clinical trials with 4,378 participants met the inclusion criteria. The meta-analysis of the study results found that, while the Z drugs do improve objective and subjective sleep latency compared with placebo, the effect size is small and of questionable clinical significance (a difference relative to placebo of 22 minutes for polysomnographic sleep latency and only 7 minutes for subjective sleep latency) – and the placebo response accounted for about half of the total drug response. They also found that the drugs had a greater effect on sleep latency when used in larger doses, for longer durations, and in younger patients – none of which typically apply to our hospice patient population.
According to the investigators, the data suggest that the placebo response is a major contributor to the effectiveness of the Z drugs, and that the remaining effect contributed by the drug itself needs to be balanced against the associated harms. The substantial proportion of the drug response accounted for by the placebo response indicates how important it is that we first address non-pharmacologic factors in the treatment of insomnia, such improved sleep hygiene and psychological interventions. The Z drugs should be used only after very careful consideration, especially in patients of very advanced age, female patients, and patients with comorbid cognitive dysfunction, renal or hepatic impairment, or high fall risk. They should be used at the lowest possible dose for the shortest possible treatment duration, and extended-release zolpidem should perhaps be completely avoided.
Reference: Huedo-Medina TB, Kirsch I, Middlemass J, et al. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. British Medical Journal 2012; 345: 8343.
Proton pump inhibitors (PPIs) are commonly used in hospice for patients with gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), symptoms of gastric upset or nausea, or GI protection when patients are taking medications such as NSAIDs or steroids. There are currently 6 PPIs on the market, and while there is no clinically significant difference between the PPIs in terms of efficacy or side effects, there are important differences between them in terms of dosing, administration and cost. Click here to download a chart which compares the PPIs and can be used to help you select the most cost-effective PPI for your hospice patients.
Dr. Julia Harder, PharmD CGP
In what many have found to be a surpising decision, the FDA has decided not to block generic versions of the original Opana ER (extended-release oxymorphone). Endo Pharmaceuticals, Inc. is the sponsor of the original Opana ER (no longer on the market) and the reformulated version, designed to be more difficult to abuse and misuse. Endo claims that allowing generic versions of the original, non-abuse-deterrent version of Opana ER will lead to an increase in drug abuse and misuse, and therefore petitioned that the FDA block all new applications for generic versions of the original Opana ER, as well as suspend the manufacture of the generics already on the market (by Actavis and Impax Pharmaceuticals). Endo's citizen petition to the FDA cited company data showing that the abuse rate of new Opana ER was 79% lower than the abuse rate of generic, non-tamper-resistant versions.
The FDA denied Endo's petition, a controversial decision from the agency who says it will "continue to encourage the development of abuse-deterrent formulations of opioids." After an extensive review, the FDA concluded that the original formulation of Opana ER "was not withdrawn from the market for reasons of safety or effectiveness" – in other words, that Endo's new abuse-deterrent formula doesn't actually prevent drug abuse significantly better than the earlier version. As a result of the FDA's decision, generic versions of the original formulation can continue to be approved and marketed.
Specifically, the FDA's conclusions include:
The FDA also refused Endo's bid for new labeling language that would describe Opana ER's "abuse-deterrent properties." Douglas Throckmorton from the FDA's Center for Drug Evaluation and Research told the Wall Street Journal: "We think the public health would not be served if a company can market itself as 'abuse deterrent,' if the scientific evidence did not support that claim."
The FDA's decision comes just month after it said it would not approve any generic versions of the original OxyContin formulation. That decision led many to expect that the FDA would approve Endo's petition. However, the FDA's decision drew a clear distinction between Opana ER and OxyContin. In the decision document, the FDA rejected Endo's assertion that the abuse-deterrent properties of the reformulated Opana ER are "virtually identical" to the reformulated OxyContin, calling this claim "misplaced and without merit."
Endo was "surprised and extremely disappointed" by the FDA decision, said Ivan Gergel, the company's chief scientific officer. "We believe the approval of non-abuse-deterrent opioids will contribute to a significant increase in prescription drug abuse." Indeed, allowing generic Opana ER to remain on the market will be troubling to some law-enforcement and community-based groups, since there was an increase in abuse of older Opana formulations after OxyContin launched its reformulated drug in 2010.
Furthermore, the Opana ER decision illustrates how challenging it will be for companies trying to convince the FDA a painkiller is abuse-deterrent, and sets the precedent that the FDA's standards are high in this regard.
Dr. Julia Harder, PharmD, CGP
The FDA has approved BREO ELLIPTA for the long-term, once-daily, maintenance treatment of COPD. BREO contains 100 micrograms fluticasone furoate (an inhaled corticosteroid, or ICS) and 25 micrograms vilanterol (a long-acting beta-agonist, or LABA) administered using ELLIPTA, a new dry powder inhaler (DPI). There are currently three other ICS/LABA combination products on the market: Advair (fluticasone propionate/salmeterol), Symbicort (budesonide/formoterol) and Dulera (mometasone/formoterol). The difference between BREO ELLIPTA and these other three products is that BREO ELLIPTA is approved for once daily use, while all the other products must be used twice daily.
The safety and efficacy of Breo Ellipta were evaluated in 7,700 patients with a clinical diagnosis of COPD. Those treated showed improved lung function and reduced exacerbations compared to placebo. Therefore, BREO ELLIPTA will carry two indications: the maintenance treatment of airflow obstruction in patients with COPD, and the reduction of exacerbations of COPD in patients with a history of exacerbations.
As with all other LABAs, BREO ELLIPTA will carry a boxed warning that LABAs increase the risk of asthma-related death. The safety and efficacy of Breo Ellipta in patients with asthma have not been established, and it is not approved for the treatment of asthma. Futhermore, BREO ELLIPTA should not be used as a rescue therapy to treat acute bronchospasm.
BREO ELLIPTA may cause serious side effects, including increased risks of pneumonia and bone fractures. The most common side effects reported by patients included inflammation nasopharyngitis, upper respiratory tract infection, headache, and oral candidiasis.
BREO ELLIPTA was developed by GlaxoSmithKline in collaboration with San Francisco-based Theravance, and is expected to be available in the USA during the third quarter of 2013. The cost of the therapy is not known at this time, but given that it is a new drug formulation in a novel inhaler design, there is likely to be a price premium compared with other therapies.
Dr. Julia Harder, PharmD, CGP
At Outcome Resources, we have noticed many costly claims for brand name Vicodin (hydrocodone/acetaminophen). Typically, when a prescriber writes a prescription for a brand-name medication for which a generic equivalent is available, the dispensing pharmacy will substitute the generic version, unless the prescriber specifically indicates on the prescription that no generic substitution is allowed. When the prescription is for a combination product like Vicodin, the strengths of all ingredients must be equal in order for generic substitution to be allowed -- so if a prescriber writes for Vicodin 5/500, only generic hydrocodone/APAP in the specific combination of 5 mg of hydrocodone + 500 mg of acetaminophen can be dispensed.
In order to avoid adverse events associated with acetaminophen toxicity, most importantly liver failure, the FDA has recently limited the acetaminophen content of acetaminophen-containing prescription products. These products, such as Vicodin, can now contain no more than 325 mg of acetaminophen per tablet. Vicodin brand products, which previously contained 500 mg of acetaminophen per tablet, have been reformulated to contain only 300 mg of acetaminophen per tablet. Available strengths now include:
Now, when a prescriber writes a prescription for Vicodin, pharmacies may only dispense a generic substitute that contains 300 mg acetaminophen per tablet -- and there is only one generic manufacturer currently making hydrocodone/APAP combination products containing 300 mg of acetaminophen. This single-source generic version of Vicodin is just as expensive as the brand name product. So whether the pharmacies dispense brand-name Vicodin or the single-source generic version, the cost to the hospice is high.
To avoid this increased cost, hospice prescribers need to write for generic hydrocodone/APAP, and specify an acetaminophen content of 325 mg (e.g., hydrocodone/APAP 5/325 1 tablet orally every 4 hours as needed). There are many generic hydrocodone/APAP products that contain 325 mg of acetaminophen, and the cost of these products is substantially lower. The slightly increased amount of acetaminophen contained in these products (325 mg versus 300 mg) will not be clinically significant.
Our clinical pharmacists analyze our hospice partners medication utilization every month and help alert them to situations such as these to reduce costs. Does your hospice have a proactive pharmacy partner? Find out More Information.
The cost of a medication does not solely depend on the amount of active ingredient contained within it. Intuitively, it would seem that this should be the case, but experience shows us it is not. Competition in the marketplace is a major determinant of medication cost, and at the moment, there is only one generic manufacturer making hydrocodone/APAP combination products containing 300 mg of acetaminophen -- so they can charge more. When more generic manufacturers start making these products, the cost will go down.
Vicodin and Lortab used to be therapeutically equivalent, when Vicodin contained 500 mg of acetaminophen per tablet. Now that Vicodin has been reformulated to contain 300 mg of acetaminophen per tablet, they no longer are. Now we have Lortab (500 mg APAP), Norco (325 mg APAP), and Vicodin (300 mg APAP) -- plus generic versions of all of these... So confusing! In my opinion, the easiest way for prescribers to get the exact product they want is to write for generic hydrocodone/APAP and specify the strength of each component (for now, avoiding the 300 mg APAP products because they are so much more expensive). -- Julia Harder Posted 6/3/2013 08:18:27 AM |
Excuse my ignorance, but why would a medication containing 25 less mg of acetamenaphen cost more money to make than the usual 325mg that have been used for years? Also I have found that prescribers 75-80% of the time order Lortab 7.5/325 or 10/325 which in brand or genetic form is less expensive and if I learned anything in pharmacology class there would be no difference in the medication Vicodin vs Lortab or have I been taught incorrectly? -- G Faulk, RN Posted 5/27/2013 09:48:39 PM |
Dr. Jim Joyner, PharmD, CGP
One question from our hospice partners that we hear frequently is:
Is it legal to fax a Schedule II prescription to the pharmacy for our hospice patients?
Federal law (Controlled Substances Act) pertaining to Schedule II prescriptions is quite strict in this regard and in most cases pharmacies cannot legally fill a Schedule II prescription that has been faxed to them. They must have the original written prescription in hand at the time the controlled substance is actually dispensed, however, there are some important exceptions to this rule.
The Drug Enforcement Agency (DEA) has granted three exceptions to the facsimile Schedule II prescription requirements. The fax of a Schedule II prescription may serve as the original prescription in each of these three situations as follows:
Reference: (21 C.F.R. Section 1306.11 (e), (f), and (g))
More information can be found at these websites:
Code of Federal Regulations (C.F.R.), Title21, Parts 1300-1321, Drug Enforcement Administration implementing regulations pertaining to the Controlled Substances Act:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=1306.11 <Assessed 05/02/2013>
Drug Enforcement Administration Pharmacists Manual
http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/ <Assessed 05/02/2013>
Drug Enforcement Practitioners Manual
www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html <Assessed 05/02/2013>
Dr. Julia Harder, PharmD CGP
The FDA has expanded the indications for oral lubiprostone (Amitiza®, Sucampo Pharmaceuticals Inc/Takeda Pharmaceuticals USA Inc.) to include opioid-induced constipation in chronic pain patients, at a dose of 24 mcg twice daily. This is the third indication for lubiprostone, which is already approved for the treatment of chronic idiopathic constipation in adults, also at a dose of 24 mcg twice daily, and irritable bowel syndrome (IBS) with constipation in women 18 years of age and older, at a dose of 8 mcg twice daily.
Opioids cause constipation via multiple mechanisms. When opioids bind to peripheral opioid receptors in the gastrointestinal (GI) tract, two main things happen:
Lubiprostone targets the second mechanism. it is a specific activator of CIC-2 chloride channels in the intestinal epithelium, which counteracts the increased electrolyte absorption caused by opioids, and helps increase the amount of fluid that remains in the GI tract. Approval for the new indication was based on results of three phase III, placebo-controlled trials of patients receiving opioids including morphine, oxycodone, and fentanyl for non-cancer pain. At a dose of 24 mcg twice daily, two of the three studies met their primary efficacy endpoint.
According to the manufacturers, the effectiveness of lubiprostone in patients taking methadone has not been established, and it is possible that lubiprostone will be ineffective in patients taking methadone. In the 3 clinical trials that led to the drug's approval, methadone was not included. In other clinical trials, methadone appeared to prevent beneficial effects of lubiprostone, and laboratory studies have demonstrated that methadone blocks lubiprostone's stimulation of CIC-2 channels.
How should we use lubiprostone in hospice and palliative care?
According to the manufacturers, the effectiveness of lubiprostone in patients taking methadone has not been established, and it is possible that lubiprostone will be ineffective in patients taking methadone. In the 3 clinical trials that led to the drug's approval, methadone was not included. In other clinical trials, methadone appeared to prevent beneficial effects of lubiprostone, and laboratory studies have demonstrated that methadone blocks lubiprostone's stimulation of CIC-2 channels. -- Julia Harder Posted 5/24/2013 08:49:30 AM |
Why should Lubiprostone not be used with patients taking methadone?
Just curious . -- Marsha Farrell Posted 5/16/2013 12:21:40 PM |
Julia Harder, PharmD, CGP
On Tuesday April 16th, the same day that the patent on the old, non-abuse-deterrent OxyContin formulation was set to expire, the FDA decided to block potential generic versions of the original formulation from being produced. The FDA has issued a statement that it will not approve any abbreviated new drug applications for generics that are based on the original formulation.
The FDA approved the original formulation of OxyContin in 1995. This formulation did not have any abuse-deterrent properties. Drug abusers found that crushing the extended-release tablets enabled rapid release of the drug all at once, producing a fast, powerful high when snorted, injected or even sprinkled on food. OxyContin became known as "hillbilly heroin." That abuse, the FDA said, increased "the risk of serious adverse events, including overdose and death."
In April 2010, the FDA approved Purdue's reformulated version of OxyContin, designed to resist abuse. The tablets are harder to crush, break or dissolve, and instead of becoming a fine, snortable powder when crushed or broken, a viscous hydrogel is formed, that cannot be easily snorted or injected. Purdue voluntarily withdrew the original OxyContin formulation once the new abuse-deterrent version became available.
The OxyContin reformulation did decrease OxyContin abuse, as demonstrated in a study published in the New England Journal of Medicine in July 2012 (read more about this study here). According to the researchers, before the release of abuse-deterrent OxyContin, 35.6% of patients entering treatment programs throughout the United States were using OxyContin as the primary drug of abuse. Twenty-one months later, after the release of the abuse-deterrent formulation, just 12.8% selected OxyContin as their drug of choice.
The FDA's decision to block generic OxyContin most certainly represents a win for Purdue Pharma LP, the manufacturer. OxyContin has long been one the nation's top-selling prescription painkillers with sales of more than $2.8 billion last year. The FDA's decision effectively protects Purdue from lower-price competition by requiring generic companies to develop their own abuse-deterrent designs. Purdue's abuse-resistant formulation doesn't go off patent until 2025.
The FDA's decision also represents a win for those concerned about a resurgence of OxyContin abuse. In a statement, Republican Representative Hal Rogers of Kentucky, a state with a high level of OxyContin abuse, called the FDA decision not to approve generic OxyContin "a huge win for our region and for the thousands of families who have seen painkillers become pain makers. The FDA undoubtedly saved our nation from another deadly tidal wave of oxycodone abuse and overdoses."
Unfortunately for hospice care providers, the FDA's decision also means that the price of OxyContin is unlikely to decrease any time soon. One of the struggles we face in hospice is the high price of almost every long-acting opioid available on the market today. The following chart compares the cost to the hospice (based on average wholesale price, or AWP) of a 15-day supply of equianalgesic doses of some of the more commonly-prescribed long-acting opioids.
Dose Cost
OxyContin 80 mg PO Q12H $422
Opana ER 40 mg PO Q12H $400
Fentanyl patch 100 mcg Q72H $189
Morphine ER tablet 100 mg PO Q12H $106
Avinza 180 mg PO Q24H $500
Kadian 200 mg PO Q24H $420
Methadone 10 mg PO Q12H $12
With the exception of methadone and the lowest strengths of extended-release (12-hour) morphine, long-acting opioids generally cost at least $100 per prescription, and often cost 4-5 times that. Of the long-acting opioids most commonly used in hospice care (morphine ER, fentanyl patch, OxyContin and methadone), OxyContin is, by far, the most expensive – and is likely to remain that way for quite some time.
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Cancer in Kenya -The harsh reality
- Posted on Thursday 19 July 2012 - 09:32Joyce J Wangui, AfricaNews reporter in Nairobi, KenyaKenyans are slowly coming into grips with cancer, a deadly disease that many perceived to be for the west and the rich. Though statistics remain scanty, Pact Kenya Cancer Assessment estimates that 50 people die every day from different forms of cancer while 80,000 new diagnoses are done each year.Such figures are scary, given the fact that the country has limited facilities to diagnose and treat the disease.
Kenyans awoke to the sad news of the demise of Alexandra Ajoy, who until her untimely death was the youngest survivor of Leukemia-the cancer of blood. The 4 year old has been diagnosed with the deadly cancer at the age of 2. Her condition required a bone marrow transplant which could only take place in India since Kenya has no facilities to treat her case.
If successful, Baby Lexie, as she is fondly known by her family, could have had a new lease of life. Due to the prohibitive costs, her family solicited for financial support via social media and she successfully underwent the procedure. However, she only had 10% chances of survival. Misfortune reared its ugly head when little Lexis suffered organ rejection and she had to be again transferred for stem cell transplant in the United States.
Until her death, she had endured insurmountable pain which only her family can relate to. She had also been under heavy medication. Baby Lexie came into the public fore during the launch of the Africa Cancer Foundation in July last year, an NGO that supports the fight against cancer in Africa. Her condition prompted Kenyans to realize that cancer does not chose age, contrary perceived as the disease of the elderly.
From time to time, the local media had featured her progress as well as challenges. Hers is not an isolated case. A visit to the IE Ward at Kenyatta National Hospital confirms the harsh reality of children suffering from different forms of cancer. Some have stayed in the cancer unit for so long that they call it home.
The minister of Medical services Prof. Anyang Nyong, himself a prostate cancer survivor and a fiery cancer activist notes that Kenya has recorded significant progress in the treatment and care of cancer patients due to the opening and expansion of several cancer centers in hospitals. But the largest government hospital, Kenyatta National Hospital still uses two outdated machines to diagnose cancer, namely Cobalt-60.
The two are only limited for therapeutic radiotherapy, meaning that patients who require chemotherapy are locked out or are forced to seek medication from private hospitals, which are by far, very expensive.
With the list of cancer patients swelling by the day, the country has to grapple with yet another challenge-the few number of specialists for cancer surgery. In most cases, the few accredited specialist surgeons are overwhelmed by the workload, particularly in the government hospital and so patients are left under the care of general surgeons who operate on a broad range of diseases.
This, according to medical specialists in the private sector, means that cancer patients are not afforded the opportunity to get quality care.
The growing cases of cancer in Kenya are worrying. The magnitude of the disease brings with it physical, emotional, spiritual and financial trauma to the infected and the affected. According to David Makumi, Manager, Cancer Program – Aga Khan University Hospital, Nairobi and Vice Chairman, Kenya Cancer Association, most cancers are diagnosed at an advanced stage (level4), making it difficult to save the life of patients.
"It is regrettable that Kenyans are dying of cancers which can be treated, if diagnosed early," he says, referring to cervical cancer which he says can be detected as early as a woman is in her teens. "Its progression in the cells takes long and can be tamed at early stages, but Kenyan women are shying away from early screening."
Makumi, also the President of the Kenya Cancer Association (KENCASA) says that another factor hampering the management of the disease is the fact that many people don't have insurance.
"Treatment is quite expensive. Many families watch as their loved ones die in pain. The disease gets to a stage where managing pain is the most critical aspect to allow patients die in dignity."
At the government hospital, Radiotherapy treatment for cancer for six weeks cost Sh9,000 while chemotherapy cost Sh4,000, a cost which is far much less than in private hospitals. Only a paltry number of Kenyans afford medication in private hospitals while the more advantaged lot seek treatment abroad.
Kenyans in general want a comprehensive cancer policy which will address among other things, an effective drug regulatory authority that ensures that patients get the most effective treatments. The government should also ensure that it regulates the costs of treating cancer.
Francis Kariuki, a prostate cancer survivor wants the government to hasten nationwide campaigns on information surrounding the scourge, "This will help early mitigation and also create awareness," he says.
The country has made significant progress in managing cancer. The adoption of the Alcoholic Drinks Control Act, 2010, was a milestone step in mitigating the disease.
The Act aims to restrain the consumption of alcoholic beverages in the country as experts say alcohol is a major risk factor for cancers of the mouth and throat.
The anti-tobacco Bill has enabled Kenyans to limit on smoking as they are now aware that smoking accounts for almost 30% of all cancer-related deaths, worldwide. It causes lung cancer.
The current campaigns aired on television are also a wake up call for Kenyans to adapt a healthy lifestyle and avoid sedentary lifestyles. This includes consuming healthy foods, frequent exercises and limiting on alcohol and smoking.
- Posted on Tuesday 09 October 2012 18:38
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Young Horseshoe Crab. (mamomof5)
I'm Hannah. Twenty years strong and a strawberry blonde with a wandering mind. Gamer by heart, SFX make up artist and artist in general by trade, I'm always looking to improve. I don't bite, so fill my ask with any questions. No, I'm not single, thank you. But I WILL Make you a sandwich! -------------------------------------------------------------------------------------------------------------------------------------------- Cephalo: Ball python, Morph unknown. Possible Pastel Atrus: Normal Hognose Unnamed: B. Albopilosum
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The 2013 measurements calendar has been set.
You have done some changes that need a new test on your boat ? You have a protoand wish to compete in the Transat thus need a stability test this year ? You have a production boat and wish to help us for the 2013 measurement campaign ?
Please contact Annabelle at the office.
Dates are:
April 29th - 30 th and May 1st in La Trinité sur Mer
May 20th - 21st in Lorient
June 18th and 19th in Douarnenez?
July 3rd and 4th in Lorient
July 21st and 22nd in Port Bourgenay
The Centre Nautique of Lorient proposes two days of preparation (21-23 May) and the exam (May, 29th) to obtain the Short Range Certificate.
Information about the exam (in French)If the wind was not at the rendezvous, the warm welcome of the Yacht Club of La Grand Motte and the motivation of the 19 skippers have done this first qualifying race a success.
See the picturesOfficial name : | ? |
Type of ship : | protoserie |
Design : | SCHIKLER 2WIN650 |
Year of first launch : | 2009 |
National flag : | ? |
Course | Coureur | classement |


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Welcome to the fundraising page for the Everest Challenge 2012. Phil Purdy successfully reached the summit of Mount Everest (8850m) on the morning of Friday 25 May 2012, overcoming extremely harsh conditions that pushed him to the limit both physically and mentally. His climb was in aid of Cancer Research UK, specifically towards research into oesophageal and pancreatic cancer being carried out in Cambridge. For an up to date total on everything raised so far click here.
There is also an official website and blog to look back on Phil's progress over this incredible ten week challenge.
We have reached our target of £50,000!In fact we have raised £122,155.90and are still going strong
Donations in support of:
Cambridge: supporting our centre ...
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The wall is for members of Everest Challenge 2012 Fundraising Page to post messages, fundraising tips and notifications
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from all at CEMA Ltd
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Monthly donation from all at Cema Ltd
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Everest Challenge 2012 page owner
At the summit!
The official website and blog is now live! To follow click here The Blog provides an opportunity for everybody to have their say on Phil and Jeff's challenge. This is also a great way for family and friends to keep updated on progress at all stages and hopefully be e...
The official website and blog is now live! To follow click here
The Blog provides an opportunity for everybody to have their say on Phil and Jeff's challenge. This is also a great way for family and friends to keep updated on progress at all stages and hopefully be entertained in the process. To post your wise words, encouragement or abuse (nothing too offensive please), you will need to create a log-in with password etc. Click on 'register', enter your preferred username and E-mail address. You will then be sent a password which can be changed once you have logged-in for the first time. Please then click on 'comment' to add your bit if you wish. All contributions are welcome. Once Phil & Jeff are in Nepal, there should be a running commentary on their efforts provided there are no problems with communication.
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Complaints, eh.
Complaints are magical little moments that allow you, as a waiter, to look deep into the soul of the guest and see what makes them tick. You see beyond the well-dressed (or otherwise) exterior and deep down into their insecurities and paranoid psychosis. Or something, not that I want to over-think things. Sometimes a steak is just an overcooked piece of meat and not the start of a mental breakdown.
But quite often when a customer complains it's less about you or your restaurant's inability to sling three appetizing courses over two hours down onto a table, and more about the punter and their state of mind. Honestly some days I know they're only one overcooked tuna away from a William "D?Fens" Foster moment.
Take this bed wetter extraordinaire who asked me to change his steak as there was a grilled tomato on his plate.
"Yeah I don't eat tomato, don't like them. Never have done, they taste yuck."
He actually said yuck. This fully-grown, professional looking, man of about 40, maybe 45 years old, said tomatoes are, "YUCK." I was tempted to ask if they made him sicky in his tum-tum. But I didn't.
So you want a new steak?
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Hundreds of victims of the Robert Courtney drug-tampering scheme and their family members watched as the former pharmacist was sentenced to 30 years on Thursday. The sentence drew mixed responses from those watching the proceedings.
Robert Courtney, the former Kansas City pharmacist who has admitted to diluting prescriptions given to thousands of patients, faced sentencing on Thursday.
Under a plea agreement, U.S. District Judge Ortri Smith can give Courtney from 17 1/2 to 30 years in prison.
Hundreds of victims and family members are expected at the courthouse. Among them will be Marge Vermillion, whose husband died soon after taking cancer treatments mixed at Courtney's pharmacy.
So many people go to the Municipal Corrections Institution because they couldn't post bond that some call it the "debtors' prison."
Young traffic offenders are incarcerated alongside convicted felons. Following staff cuts MCI became so overcrowded that 16 convicted violent offenders had to be released in August.
The City Auditor says a city shouldn't be in the prison business at all.
KCUR's Steve Bell visited the jail and talked with various city officials who have a stake in what will become of the facility.


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African comic strips exposed
- Posted on Tuesday 6 May 2008 - 08:45Picha.nlFunny, horrifying, critical or just pleasant to look at. African comic strips are more popular than ever and African comic drawers are active in every part of the continent, festivals are organized and more comic strip magazines are published throughout the continent.
This photo gallery is exclusively selected for AfricaNews by the organizers of the Picha exhibition in the Afrika Museum in Berg en Dal, the Netherlands. Comics from South Africa to Ivory Coast are revealed.
please see the photo's from many African countries below.
Visit the website of the exibithion, www.picha.nl
- Posted on Tuesday 06 May 2008 12:22
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OTTAWA — It's awards season in the new car business, as numerous automotive publications, consumer advocacy groups and professional associations announce their favourite new cars and trucks for 2013, all with a view to helping consumers choose the best vehicle for their needs.
I recently spent a week in southern Ontario, driving some of the newest vehicles on the market at Testfest, the linchpin of the Automobile Journalists Association of Canada's process for selecting its Canadian Car and Utility Vehicle of the Year.
AJAC isn't the only group gearing up to name its favourite new vehicles: there's also a North America-wide award, voted on by a jury of automotive writers across Canada and the United States. Numerous publications, large and small, give out their own prizes, such as Car and Driver magazine's 10 Best, Popular Mechanics' Auto Excellence Awards, the Auto123.com Awards, and Autos.ca's Top Picks.
Most of the time, these awards echo popular opinion, but not always. In 2012, AJAC chose the economical and inexpensive Hyundai Elantra as Canadian Car of the Year, but in 2008, it awarded the same title to the Audi R8, a two-seat sports car with a six-figure price tag. It pays to remember that many automotive writers are car enthusiasts who sometimes favour sexy cars that few can afford over the ones that wind up in suburban driveways. Still, last year AJAC members voted the Hyundai Veloster as having the best new design, overlooking the drop-dead gorgeous Jaguar XKR-S. So there's no telling which cars will come out on top.
The perceived value of "best of" awards can be tough to gauge among drivers. I conducted a very informal poll, and responses ranged from outright distrust of any sort of "best of" awards, to the opinion that such programs go a long way toward helping people select a new vehicle. In between, I found drivers who simply ignore awards, test-drive every vehicle in their price range that suits their needs, and make their own "best of" judgment.
"When my wife and I first started thinking about buying a new car last February/March, one of the first things we did was check out which cars had won awards," says Ottawa resident Jeremy (who asked that I not use his last name). "We also checked out related reviews with specific factors of fuel efficiency and safety in mind. So yes, absolutely we considered buying a car that had won an award."
Dylan Edgar is more skeptical.
"Awards mean absolutely nothing to me when purchasing a new car," he says. "Given that most car companies have award-bestowing companies in their back pocket, I tend to be highly suspicious of 'car of the year' or 'best in class' awards."
Keith Michaud, general sales manager at Myers Cadillac Chevrolet Buick GMC, says he hears quite a lot of feedback about award-winning vehicles from the customers who come through his Baseline Road showroom.
"Absolutely," he says, when asked whether awards have an impact on showroom traffic. He uses a simple metric to measure that impact. "We see it when customers come in and they talk to us about it, that they saw that the car has won an award, or they see an ad in the newspaper. They call in and say, 'we'd like to come in and try out the new (Cadillac) ATS; we saw it won an AJAC award.' "
The ATS has proven popular among auto reviewers. It's up for North American Car of the Year, and took home AJAC's Best New Luxury Car laurels, which puts it in the running for Canadian Car of the Year as well. It also won 2013 Luxury Compact Car of the Year from Auto123.com.
Hyundai's redesigned Santa Fe has also earned praise early on in the 2013 new car awards process. AJAC named it Best New SUV/Crossover in the $35,000 to $60,000 price bracket, so it's a contender for the Canadian Utility Vehicle of the Year title and, like the ATS, is also highly regarded by the North American Car of the Year jury, which has shortlisted it for North American Truck/Utility of the Year.
But one local Hyundai dealership doesn't think that is contributing to the Santa Fe's strong sales.
"I'd say a very small percentage of (our dealership's) traffic would come in from the awards," says Eli Nassrallah, general sales manager at Hyundai on Hunt Club. "Most of the traffic comes in from the advertising and promotions on the vehicle." He adds that many shoppers mention hearing that a vehicle like the Santa Fe has won an award, but "wouldn't say it's a huge contributor" to sales. He says that the launch of a brand-new design is a bigger draw.
The other finalists in the Canadian Car and Utility Vehicle of the Year contests include four Fords: the all-electric Focus EV, the high-performance Focus ST, the Escape crossover powered by the 1.6-litre turbocharged EcoBoost engine, and the Fusion Hybrid sedan.
Hyundai's Elantra GT hatchback is in the running, along with the Mazda3 SkyActiv sedan, Honda's all-new Accord sedan and Porsche's 911 Carrera S and Boxster.
A number of those vehicles are also found in the North American Car and Truck/Utility of the year shortlists, including the Accord and Escape, meaning that those two, along with the Santa Fe and ATS, have a chance to be named the best car both in Canada and in North America.
Canadian Car and Utility Vehicle of the Year winners will be announced in February 2013 at the Toronto International Auto Show; the North American Car of the Year prizes will be awarded Dec. 12, 2012 in Detroit, Michigan.


text:
Car show benefits autistic boy
Updated: October 1, 2012
Organizers say they pick a new charity every year, and this year they wanted to help Tyler Auten. The 6-year-old was diagnosed with autism a few years ago.
His dad, Tim, says the service dog will help keep an extra eye on the little boy and help curb some of his behavioral issues. He says he couldn't be more grateful to see such wonderful community support.
The service dog will cost about $20,000. The family has to pay $13,000. 4 Paws for Ability will cover the rest.
If you'd like to donate to the Auten's, just visit: http://www.facebook.com/4PawsForTyler


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Deborah Hicks Escapes Appalachia, Returns As A Teacher
By Shawn Wen, Frank Stasio and Christina Blyde
Deborah Hicks grew up in an Appalachian paper mill town she hoped to escape. Her education opened doors for her to leave and travel to other parts of a country, but she returned time and again to Appalachia as a teacher. Deborah has dedicated her life to educating those that need her most - focusing on young girls in poor neighborhoods. She is the founder and director of PAGE, Partnership for Appalachian Girls' Education, in Madison County.
She is also a research scholar at the Social Science Research Institute at Duke University. Deborah joins host Frank Stasio to talk about her work as an educator and her new book, "The Road Out: A Teacher's Odyssey in Poor America " (University of California Press/ 2013).


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George Soros, Chairman of Soros Fund Management LLC addresses the audience during an economic speech in Frankfurt in this April 9, 2013 file photo. The billionaire investor reported a 7.9 percent passive stake in J.C. Penney Co. April 25, 2013, sending shares of the struggling department store chain up more than 7 percent. REUTERS/Ralph Orlowski/Files (GERMANY - Tags: BUSINESS HEADSHOT)
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Bringing back ol' Nute
Thursday, September 6, 2012
MILTON — There's a saying among craftsmen that if you take care of your tools, they'll take care of you. A few years back a group of area residents decided to use that philosophy on a grander scale and formed the Friends of Nute High School and Library. Their goal is to "improve and restore the physical environment and school spirit of Ol' Nute for generations past, present and future." |


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British Foreign Secretary William Hague said he deplored the fact that North Korea "has chosen to prioritize this launch over improving the livelihood of its people."
Neighboring countries said the rocket had taken off Wednesday morning and flown south over the Japanese island of Okinawa.
The Japanese government said it believed one part of the rocket came down in the sea off the Korean Peninsula, a second part dropped into the East China Sea and a third fell into waters near the Philippines.
"It is extremely regrettable that North Korea forced the launch despite our protest," Japanese Chief Cabinet Secretary Osamu Fujimura said at a news conference in Tokyo. "It is not acceptable, and we strongly protest against it."
South Korea's semi-official news agency Yonhap reported that President Lee Myung-bak has convened an emergency security meeting in Seoul.
A launch had seemed unlikely to take place so soon after North Korea announced Monday that it was extending the launch window into late December, citing technical issues in an engine.
Previous launch attempts by the North in 1998, 2006, 2009 and April this year failed to achieve their stated goal of putting a satellite into orbit and provoked international condemnation.
Pyongyang had said this rocket launch would be "true to the behests" of Kim Jong Il, the late North Korean leader and father of Kim Jong Un, head of the ruling regime.
Kim Jong Il died on December 17 last year, so the first anniversary of his death falls within the launch window that North Korea has announced.
Experts had also speculated that Pyongyang wanted this launch to happen before the end of 2012, the year that marks the centenary of the birth of Kim Il Sung, the founder of North Korea and grandfather of Kim Jong Un.


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The UK will become host of the ICC Champions Trophy in 2013, using Cardiff, Edgbaston and the Oval for the 3 week tournament in June. The last Champions Trophy to be held in the UK saw England's defeat against the West Indies in the final of the 2004 competition. This time England will face their long standing rivals, Australia, for their first game of the tournament, with further group matches against Sri Lanka at the Oval on June 13 and New Zealand at Cardiff a day later. See your favourite team at the ICC Champions Trophy in one of England's most prestigious cricket grounds with Emirates Live.
Find out more
Packages offered by Emirates Live, in partnership with Tui Travel Sport Division, include:
All packages may listed include flights which can be purchased upon booking at an additional cost; however Skywards members can now secure Emirates Live packages excluding flights. Find out more
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Watch this woman fail to solve world's easiest math problem
3/19/2012Check out this soon-to-be-famous (and/or divorced) couple as they debate how long it takes to drive 80 miles at 80 mph. Beautiful, blonde Chelsea devises a complex formula based on her running times, the estimated speed of a car relative to a minute, and a bizarre need to take said time and "cut it in half," coming up with ... 58 minutes! Hubby Travis insists that using "science and math" it would take -- wait for it -- one hour. "Chel" isn't convinced, and is offended that he claims to know the answer. While Chelsea's math "skills" have gone viral, a contrite Travis has promised her a "new shopping budget."
Update: Chelsea's not mad anymore.
Want to read more trends like this? Check out the msnNOW home page.
Would you ever forgive your spouse for putting this online?
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This case study features the ten 2007/2008 Citizen Conferences, each consisting of 8 to 10 New Mexican Adult Citizens and lasting 9 hours. This series of deliberative events was convened by the New Mexico Department of Transportation (NMDOT) and the University of New Mexico's Institute for Public Policy (IPP) to gather public feedback, so that the State could best meet the transportation needs of its citizens.
Note: This article is in need of assistance with editing and content. Please help us complete it.
This case study features a series of workshops, assemblies, and information sessions to promote civic engagement in the renewal of a municipal square in Italy. After the participant selection process, which paid special attention to children, three phases of participation took place. The project ultimately fostered community discussion and understanding before the renovation of the square.
Problems and Purpose
In April 2001, the Canadian government established the Romanow Commission to deliberate with citizens on the future of healthcare in Canada. However, the commission overlooked the serious issue of engaging marginalised groups such as Aboriginal people, and did not provide separate participatory spaces for such groups. While some Aboriginal people participated in the dialogues, the outcomes did not fully reflect Aboriginal health issues.
El Proceso Metodológico para la Elaboración de la Agenda Para el Desarrollo Social de San Pedro Garza García
Para la elaboración de la Agenda para el Desarrollo Social de San Pedro Garza García, se establecieron tres principios básicos:
1. Incorporar una amplia participación ciudadana.
2. Promover una participación activa y coordinada de las diferentes dependencias del Ejecutivo Municipal en su construcción.


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StyleBlazer Must Reads:
- Fashion Forward: 12 Savvy Entrepreneurs To Take Note Of
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- Musicians At The Movies: 15 Rock Stars, Rappers, And Pop Icons Who Received Their Own Film Vehicles
- 15 Musicians With The Biggest World Tours!
- Hollywood Slim Down: 15 Stars Who Lost Major Weight
- In Light Of Yahoo's Big Day: 10 Fashion Tumblrs You Need To Follow
- Powerball Flashback: A Look At Winners Past


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Arrowleaf's two alpine lodges are nestled in the heart of Empire Pass at Deer Valley Resort. These stunning two and three bedroom residences feature state-of-the-art kitchen facilities, elegantly decorated living areas complete with gas fireplaces and accessibility to the some of the most sought after terrain at Deer Valley Resort. This mountain lodge features amenities such as private ski lockers, a game room with pool tables, cozy lounge area and heated underground parking garage. After a long day on the slopes, guests can relax while soaking in one of the two slope-side outdoor hot tubs or spend time lounging by the outdoor fit pit. ly housekeeping services, a washer/dryer and on-site concierge services. This unit may accommodate four guests.
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The Indian town of Ayodhya has been the stage for a centuries-long battle over a mosque that escalated in 1949.
Jawaharlal Nehru, independent India's first prime minister, worried about the impact of the idol's installation on the secular society he was trying to build.
Hashim Ansari, a local tailor in Ayodhya, holding a picture of the Babri Masjid in his home. He has been a key participant in the dispute on the Muslim side since 1950.
The Babri Masjid in a photo from 1950.
Another perspective of the Babri Masjid in 1950.
The idols installed in the Babri Masjid in 1949, shown in a 1950 photo.
A replica of the idol of an infant Ram placed in the Babri Masjid. The replica was purchased in a souvenir shop in Ayodhya.
A close-up of the replica of Ram Lalla, the infant Ram.
Details of engraving at the Babri Masjid in a 1950 photo.
Gopal Singh Visharad, who filed the first case in the long-running legal dispute between Hindus and Muslims, in an undated photo.
Rajendra Singh, son of Gopal Singh Visharad, with his wife. He heard the news of Ram's appearance in 1949 and is still involved in the legal dispute today.
Rajendra Singh in his home today. He has retired after a career in a bank.
Haji Mahboob Ahmad is the son of Haji Phenku, one of the first Muslim defendants in the legal dispute. He now represents his father, who is deceased.
The district court in Faizabad, Uttar Pradesh, where the legal dispute over the Babri Masjid played out for decades before the cases were transferred.
Lawyers and typists meet and prepare documents for clients at the Faizabad district court complex, in Faizabad, Uttar Pradesh.
Bhaskar Das, head of the Nirmohi Akhara, a sect of sadhus who have dedicated their lives to Ram, at the sect's ashram in Faizabad.
A shrine at the Nirmohi Akhara's ashram in Ayodhya.
Zufar Ahmad Farooqui, chairman of the Uttar Pradesh Sunni Central Board of Waqfs, in Lucknow. The board maintains Muslim places of worship and is a litigant in the court fight to take ownership of the Babri Masjid site.
Akshaya Brahmachari in later life. The sadhu opposed the Hindu takeover of the Babri Masjid and was banished by other sadhus from Ayodhya. He is pictured with his disciple, Meera Behen.
Meera Behen, a disciple of Akshaya Brahmachari's since her college days, today.


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- Caption: Annual "I Have a Dream Foundation" Gospel Brunch at the House of Blues Sunset Strip in West Hollywood, CA 2011 3/6/11 photo by Scott Kirkland-globe Photos @ 2011 Moon Bloodgood
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Moon Bloodgood
- Event:
13th Annual "I Have a Dream Foundation" Gospel Brunch
March 6, 2011 - Location: West Hollywood, CA, USA
- Image Number: 0917589
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- Photographer: Globe-Photos
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Narrator is a screen reader that reads text on the screen aloud and describes events like error messages so you can use your PC without a display.
Narrator is available in English (United States and United Kingdom), French, German, Japanese, Korean, Mandarin (Chinese Simplified and Chinese Traditional), and Spanish.
There are different ways to start Narrator. These are the three shortcuts many people prefer:
If you want to quickly exit Narrator, press Caps Lock+Esc.
Another way to get to Narrator is to use search:
Swipe in from the right edge of the screen, and then tap Search.(If you're using a mouse, point to the upper-right corner of the screen, move the mouse pointer down, and then click Search.)
Enter Narrator in the search box, tap or click Apps, and then tap or click Narrator.
If you want to get started right away, after you open Narrator, press the Caps Lock key+F1. This keyboard combination will show you all of the Narrator commands.
If you want to use Caps Lock to capitalize letters while you're using Narrator, press the Caps Lock key twice in quick succession.
Windows 8 and Windows RT have new actions and new locations for common commands. Here are a few important gestures to get you started.
Swipe in from the right edge with one finger
Open the charms (Search, Share, Start, Devices, Settings)
Swipe in from the left edge with one finger
Switch apps, snap them to the side, and close them
Swipe in from the top or bottom edge with one finger
Show app commands like Save, Edit, and Delete
The press and hold gesture isn't supported in Narrator.
Windows 8 and Windows RT have new keyboard shortcuts too. Here are a few helpful ones. To find the rest, go to Keyboard shortcuts.
Snap apps to the side
Switch apps
Here are some of the main settings you might want to use:
Lock the Narrator key so you don't have to press it for each command (Caps Lock). When you choose this option, you won't have to use the Caps Lock key with the Narrator keys. For example, instead of pressing Caps Lock key+F1, you can simply press F1.
On a 106 keyboard, Ctrl+Alt+Z won't lock the Narrator key.
Start Narrator minimized. This option keeps the Narrator window out of your way.
Echo keyboard keystrokes while typing. You can choose whether or not Narrator reads each key you type.
Read out voiced Narrator errors. Choose this option if you want Narrator to read the actual error in addition to playing an error tone.
Enable visual highlighting of Narrator cursor. This option lets you show or hide the box that highlights where Narrator is on your screen.
Play audio cues. This option lets you turn on or off the extra sounds that Narrator plays when you do certain actions.
Read hints for common items. This option controls whether Narrator will read hints about how to interact with common items such as buttons, links, list items, and sliders.
Lower the volume of other apps when Narrator is running. This option makes other apps quieter so it's easier to hear Narrator.
Retain notifications to be read for. This drop-down menu lets you control how long notifications will be retained for being read by Narrator.
Control whether Narrator starts automatically. This link takes you to the Ease of Access Center where you can choose to have Narrator on automatically.
Read and interact with the screen using the mouse. This option controls whether Narrator mouse mode is on. When mouse mode is on, Narrator will read what's currently under your mouse cursor.
Activate keys on the touch keyboard when you lift your finger. If touch mode is on, you can turn on this setting so you can type faster using the touch keyboard. With this setting, you can drag to find the item you're looking for and lift your finger to press the key.
Enable the Narrator cursor to follow the keyboard focus. This adds a blue box to your screen that moves with the keyboard focus, so that if you tab through items the Narrator cursor will follow.
Select the speed, volume, or pitch of the voice. You can customize the voice with these three sliders.
Select a different voice for Narrator. With this drop-down menu you can select different types of voices in Narrator, if they are available in your language.
Click this option to see a list of existing shortcut keys for Narrator. You can always change these shortcuts if you like. The most important keyboard shortcut to know is Caps Lock+F1. Pressing this keyboard combination will show all Narrator commands. For reference, the following table lists the commands too.
Stop reading
Caps Lock+Esc
Exit Narrator
Caps Lock+Space
Do primary action
Caps Lock+Right arrow
Move to next time
Caps Lock+Left Arrow
Move to previous item
Caps Lock+Up arrow
Change view
Caps Lock+Down arrow
Caps Lock+F1
Show commands list
Caps Lock+F2
Show commands for current item
Caps Lock+F3
Jump to next cell in row
Caps Lock+Shift+F3
Jump to previous cell in row
Caps Lock+F4
Jump to next cell in column
Caps Lock+Shift+F4
Jump to previous cell in column
Caps Lock+F5
Read which row and column Narrator is in
Caps Lock+F6
Jump to table cell
Caps Lock+F7
Read current column
Caps Lock+F8
Read current row
Caps Lock+F9
Read current column header
Caps Lock+F10
Read current row header
Caps Lock+F11
Toggle touch mode on/off
Caps Lock+F12
Toggle keystroke announcements
Caps Lock+Z
Lock Narrator Key
Caps Lock+X
Pass keys to app
Caps Lock+V
Repeat last phrase
Caps Lock+Page Up
Increase voice volume
Caps Lock+Page Down
Decrease voice volume
Caps Lock+Plus
Increase voice speed
Caps Lock+Minus
Decrease voice speed
Caps Lock+D
Read item
Caps Lock+F
Read item advanced
Caps Lock+S
Read item spelled out
Caps Lock+W
Read Window
Caps Lock+R
Read all items in containing area
Caps Lock+Q
Move to last item in containing area
Caps Lock+G
Move Narrator cursor to system cursor
Caps Lock+T
Move Narrator cursor to pointer
Caps Lock+Tilde
Set focus to item
Caps Lock+Backspace
Go back one item
Caps Lock+Insert
Jump to linked item
Caps Lock+M
Start reading
Caps Lock+Close bracket
Read text from start to cursor
Caps Lock+O
Read text attributes
Caps Lock+H
Read document
Caps Lock+U
Read next page
Caps Lock+Ctrl+U
Read current page
Caps Lock+Shift+U
Read previous page
Caps Lock+I
Read next paragraph
Caps Lock+Ctrl+I
Read current paragraph
Caps Lock+Shift+I
Read previous paragraph
Read next line
Caps Lock+Ctrl+O
Read current line
Caps Lock+Shift+O
Read previous line
Caps Lock+P
Read next word
Caps Lock+Ctrl+P
Read current word
Caps Lock+Shift+P
Read previous word
Caps Lock+Open bracket
Read next character
Caps Lock+Ctrl+Open bracket
Read current character
Caps Lock+Shift+Open bracket
Read previous character
Caps Lock+J
Jump to next heading
Caps Lock+Shift+J
Jump to previous heading
Caps Lock+K
Jump to next table
Caps Lock+Shift+K
Jump to previous table
Caps Lock+L
Jump to next link
Caps Lock+Shift+L
Jump to previous link
Caps Lock+Y
Move to beginning of text
Caps Lock+B
Move to end of text
Caps Lock+N
Rewind while reading a document
Caps Lock+Comma
Fast-forward while reading a document
Caps Lock+C
Read current date/time
If you have a new PC that supports four or more contact points, you can use touch commands to control your PC.
Tap once with two fingers
Stop Narrator from reading
Tap three times with four fingers
Show all Narrator commands (including ones not in this list)
Double-tap or hold with one finger and tap anywhere with a second
Activate primary action
Triple-tap or hold with one finger and double-tap with a second
Activate secondary action
Hold with one finger and tap with two others
Start dragging or extra key options
Tap with three fingers
Show/hide Narrator settings window
Tap with four fingers
Tap or drag a single finger
Read what's under your finger
Double-tap with four fingers
Toggle search mode
Triple-tap with four fingers
Show Narrator commands list
Flick left/right with one finger
Move to next or previous item
Flick up/down with one finger
Change move increment
Swipe left/right/up/down with two fingers
Swipe left/right with three fingers
Tab forward and backward
Swipe down with three fingers
Start reading explorable text
Swipe up with three fingers
Read current window
Narrator provides basic screen-reading capabilities so you can use Windows when you don't have a more comprehensive screen reader. Narrator isn't designed to read content in all apps. For more info about screen readers and other assistive technologies, go to the Microsoft Accessibility website.


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Marketing Analytics Expert Bill Seely Returns to [x+1] as Vice President of Analytics
Seely brings deep expertise in analytics and strategic thinking to online marketing leader
NEW YORK, N.Y., July 14, 2011 – Online targeting platform leader [x+1], www.xplusone.net, announced today that Bill Seely has been named Vice President of Analytics, reporting to Leon Zemel, Chief Analytics Officer. He returns to [x+1] after a three-year hiatus in which he held senior analytics positions, most[...]
Peter Moritz
A digital media veteran, Peter Moritz comes to [x+1] after six years of running his own marketing strategy consulting business, PWM Associates, where he guided revenue strategies for agency, media, lead generation and technology companies. He is respected for his strategic vision, precision execution and deep expertise across industry sectors, and for his unique experience with data-driven advertising technologies that are reshaping the media industry.
Past Experiences:
- Prior to founding PWM Associates, he was recruited to Modem Media as senior business development director and ran Modem's new client acquisition group, reporting to the company's President from 1998-2006.
- From 1995-1998, he was hired by InterZine and led the company's sales and marketing teams and developed new online advertising and revenue models.
- Peter began his career with American Express Travel Related Services where he spent ten years. During that time he won top sales honors, was twice the number-one salesperson, won the Chairman's Award for Quality for his work in retail travel merchandising, and was elected President of the company's National Sales Excellence Club.
Peter Moritz Senior Vice President of Sales Contact »
John NardoneCEO and Chairman Contact »
Bill SeelyVice President of Optimization and Analytics Contact »
Ted ShergalisFounder and Chief Strategy Officer Contact »
Eric SimonVP of Business Operations Contact »
Leon ZemelExecutive Vice President, Chief Analytics Officer Contact »
PR Contact
- Greg Peverill-Conti
- Inkhouse Media & Marketing
- Office: 781-966-4100
- Email: email@example.com


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Heeeeey! Long time no talk. I even forgot this website existed. SO MANY things happen. I graduatede with really good grades, all As and Bs :)I got into a good college and I just finished my first week there. At first I thought I'm never going to make friends but there is A LOT of cool people in there and I even spotted a girl with a Korn t-shirt.
I'm in a very bad mental state because of two guys and the fact I still didn't patch things up with my best friend Vincent >.< All my friends have their prom dresses already and...I'm just there. At least I finished most of my exams (got only one left) so I can spend most of my time doing absolutely nothing. How about ya? :)
I'm should super busy as well. I'm on a study leave at the moment, but instead of studying I'm slacking off. I knew it's gonna happen. I had my English Literature exam today. Tomorrow it's Religious Studies and thursday Chemistry and second English exam. WHAT THE FUCK? I need a serious break, because at the moment I don't even have time to study for the exams. i have to study a day before the exam.
I didn't even know you had a boyfriend. I thought you and Justin were pretty tight, I'm quite confused. But not my business :3 Cool, you can speak Spanish? :D I've got only I.T. project to finish. I finished my art and theatre studies work, all in and ready to mark. Now I just have to study for the exams. I'm chilling at the moment and munching on some Ben&Jerry's. Gosh I looove ice cream! :P
Gosh, that sucks even more :( I won't go to prom if I wont find a cool dress. I don't want to spend too much. I'm such a picky person as well :O But anywho thanks for wishing me luck. my first exam was art and I already finished that. Then I had theatre studies - easy peasy :D Tomorrow I've got Citizenship Studies. Fuck me man I hate this subject with passion. Is extremely boooring :O
Sheesh, I think every school had their prom already except from mine :O I live in London, there suppose to be a lot of shops with prom dresses but guess what? Saturday I went to central London with my friends to look at some dresses and we couldn't find anything. Plus I still got exams to worry about. I can't take this pressure man D:
Sheesh, I'm second youngest from my year O.O You're lucky though, I had some work experience too, but it was me working in a shop for two weeks. It was compulsory >.< My manager was sooo sexy! You have no idea :D I guess, I've got a thing for older guys... Unfortunately older guys are not interested in a kid like me :(