text:
What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
How to setup a system to Send form to various locations?Asked by tony williams on August 25, 2016 at 02:37 AM
As a nubie i am trying to set up a form that will:
1/ be send to 3 different clients email addresses.
2/ only certain fields to be shown to the clients.
3/when the client opens the email if he likes the form email he can press a payment button eg paypal then be sent to the full form details.
Can you tell me if this is possible with your form please.
Mr Williams
JotForm Support
These functions are possible here in JotForm.
1. Be send to 3 different clients email addresses.
Yes, you can set a single notification to be sent to multiple recipients. Please refer to this guide: Send-Notifications-to-Multiple-Recipients.
You can also create 3 notifications separately and assigned a recipient for each one of them. Here's a guide: Setting-Up-Email-Notifications.
2. Only certain fields to be shown to the clients.
The email content can be configured through the email editor. You can remove a field answers or question and you can customize the content.
3. When the client opens the email if he likes the form email he can press a payment button eg paypal then be sent to the full form details.
I need to create a separate thread for this question. Here's the URL: https://www.jotform.com/answers/915482. We'll attend to that thread shortly.
Hope this helps. Thank you.


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Guarana Paullinia cupana Herb SEED IPHYM Kunth.
Guarana Paullinia cupana Herb SEED IPHYM Kunth.
The guarana seed improves concentration, memory, mental calculation.
The advice of your pharmacist
Used for : memory, concentration, mental calculation, mental calculation
This product is no longer in stock
Warning: Last items in stock!
Availability date:Preview the Shipping Fees - Free Shipping from 99€*
Guarana Paullinia cupana Herb SEED IPHYM Kunth.
Latin Name: Paullinia cupana Kunth.
Family: Sapindaceae
Common Names: Guarana
Parts used: seeds, grains
Origin: Guarana (Paullinia cupana) is a native shrub of the Brazilian Amazon.
The seed contains Guarana caffeine many (more than 4.5 g per 100 g) - sometimes called guaranine for advertising purposes - but also other alkaloids such as theophylline (0.4 g) and theobromine (0.005 g ).
Properties of guarana seeds
Guarana is a popular herbal medicine plant. It is known for its stimulating effect due to caffeine and probably other substances that could act on the intellectual faculties, including other xanthines such as theobromine.
Indications and uses of guarana seeds
The guarana seed improves concentration, memory, mental calculation.
Guarana is also beneficial in addition to dieting.
Dosage of guarana seeds
Recommended associations with guarana seeds
Botanical description of guarana
The red fruit reveals, when ripe, white flesh and seeds.
Pharmacology guarana seeds
Guarana seed contains various alkaloids and precursors such as adenine, caffeine, guanine, hypoxanthine, theophylline, theobromine, xanthine.
Guarana seed also contains other elements: mucilage, pectin, tannins, amino acids, essential fatty acids, minerals (calcium, potassium, phosphorus, iron, copper, zinc, magnesium), trace elements (selenium, germanium, strontium) and vitamins (A, E, B1, B3 and PP).
This is a psychotropic stimulant, also used in traditional medicine among the natives of South America to cure many ailments (tonic, anti-diarrhea, anti-neuralgic).
Today No. 1 pharmaceutical herbal IPHYM the Group PHARMA & PLANTS is a pharmaceutical company established in 1972, specializing in herbal medicine. Their mission: the well-being of all the plants.
Its main atous:
A laboratory Quality Assurance and Quality Control integrated.
Maximum security: a responsible pharmacist ensures compliance with pharmaceutical regulations.
Traceability: control form available for all products.
AFSSAPS Certification: we are regularly verified by the French Agency for the Safety of Health Products, which validates our status as a pharmaceutical laboratory.
GMP Certification: our production teams are formed with Good Manufacturing Practices.
Medicinal Plants: Our doctors of pharmacy, training herbalist, have referenced plants from a rigorous selection from around the world and produced in a precise specifications to ensure optimum quality in active ingredients. Our medicines are not processed and their quality is monitored at every stage of their production. Do not mix from different backgrounds, each batch of medicinal plant is uniform in quality. Careful drying and storage of medicinal plants, guarantees impeccable quality. The constant renewal of our stock of medicinal plants guarantees maximum freshness, the best price.
Save time by using the quick order form. With a few clicks , you can easily order your favorite references.
Be fan of our Facebook page and get 5 % discount!
If you are not logged in to Facebook, please first log in and then refresh this page before clicking the Like button. Otherwise, you will not get your voucher.

subset: commoncrawl


text:
The city physically reflects the paradox of Indian Ocean calm and enterprise. High-rise residential buildings and gleaming office blocks have grown up around the city centre and certain suburban areas, and yet the old character of its periodically Arabic, German and British colonial and African past is still much in evidence in the low-rise red-tiled roofs on the main streets and in the makuti- thatched suburbs. Laden ocean-going tankers cruise across the horizon, and in their wake Arab dhows skim the waves and dock on shores green with mangroves and palms. Despite confusion over the role of Dar es Salaam – officially demoted from capital city in 1973, but still awaiting the actual transfer of government to Dodoma – it remains the most urbanized centre in Tanzania and its commercial capital, so it acts as a good mirror of the country's economic state. The range of new businesses, cafes, bars, restaurants and products now available reflects the success of the market reforms urgently introduced in 1986. That said, on your Tanzania holiday, Dar is not an itinerary imperative!
Where to stay
There are a number of large 4* business hotels in Dar where the majority of travellers tend to stay. There is little to distinguish between the popular options, but we tend to choose Dar es Salaam Serena and the Southern Sun (the old Holiday Inn) as our first choices.
Further outside town, the Sea Cliff is a similar-styled option with better views, but the only really high quality boutique option in town is The Oyster Bay – a small 8 roomed hotel owned by the people responsible for Selous' famous Beho Beho lodge. The accommodation at Oyster Bay is stunning and the food and service impeccable, however the price tends to push most travellers towards the larger hotel options. For the budget option there is no better choice than the Souk at the Slipway with rooms starting from as little as $60 per night.


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Set the luridly powerful GTI and Golf R aside for a second--or steer over to our reviews of that singular sensation on another page. We're talking about economy here, instead, and when it comes to great performance of that kind, there's just one Golf you need to shop--the TDI.
The TDI gets its lofty performance, of a fuel-economy kind, from its turbocharged diesel engine. It's rated at just 140 horsepower, but the 2.0-liter four also sports 236 pound-feet of torque. That makes it just a tick or two slower than its gas-powered counterpart, but its low-end torque is smooth and very strong--it's ideal for urban driving for that reason, even before it reaches for stellar economy of 30/42 mpg. VW rates it at a 0-60 mph time of about 8.6 seconds, about on par for the class, and the customary diesel vibration and noise are well quieted. It's offered with a choice of the typically notchy VW six-speed manual, or our choice, a six-speed dual-clutch automatic with paddle shifters, one of the best transmissions you can buy, and well-suited to the diesel's powerband.
The five-cylinder gas engine won't thrill users, but it's adequate. With 170 horsepower and 177 pound-feet of torque, it's unexciting and flat in response to the throttle. The vague-feeling five-speed manual that comes with as standard equipment with the three-door Golf is better swapped out for VW's better six-speed automatic; the five-door only comes with the automatic. It's a bit quicker to 60 mph with this engine, about a half-second quicker, and fuel economy can be as high as 23/33 mpg, but the five-cylinder Golf just doesn't feel as engaging.
The Golf's handling, no matter which version you choose, is a strong point. Its electric power steering is well-sorted for good driving feel, and the ride is taut, not jarring. Diesels are set a bit more sporty, and it's not punishing at all. The front strut and independent rear suspension absorb big bumps with nary a crash or bang, and braking on the cars tested feels strong and controllable.


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Thanks to its Project Imagine initiative, Suddenlink Communications added numerous HD channels to various markets last week.
Project Imagine calls for approximately $350 million of capital investments nationwide through 2012, above and beyond the company's traditional capital spending levels. In addition to adding more channels via analog-to-digital conversions, Suddenlink has launched DOCSIS 3.0-based data tiers this year, and it also expanded its phone service through Project Imagine.
Suddenlink recently wrapped up its all-digital conversion projects in El Dorado and Mountain Home, Ark., which led to the addition of the following channels: Cinemax HD, Starz HD, CBS College Sports HD, Versus HD, Speed HD, Sportsman Channel HD, The Tennis Channel HD, truTV HD, CNN HD, Spike HD, Comedy Central HD, Cartoon Network HD, Nickelodeon HD, MTV HD, VH-1 HD, CMT HD, Turner Classic Movies HD, ESPNU HD, Golf Channel HD, Encore HD, Hallmark Channel HD, Lifetime Movie Network HD, E! HD, WGN HD and BET HD.
Suddenlink, the nation's seventh-largest cable operator, also added HD channels in Natchitoches and DeRidder, La., which included: BET HD, CBS College Sports HD, WGN HD, truTV HD, E! Entertainment HD, Headline News HD, Turner Classic Movies HD, Lifetime Movie Network HD, Speed HD, ESPNU HD, ESPNews HD, Golf Channel HD, Hallmark Channel HD, Sportsman Channel HD, Versus HD, Encore HD and The Tennis Channel HD. In Natchitoches, standard-definition versions of The Tennis Channel and Turner Classic Movies were also added.
Suddenlink also recently announced more HD channels in several of its Louisiana cable systems, including Lake Charles, Sulphur, Bossier City and Haughton, as well as in Branson, Mo.
In past all-digital upgrades, Suddenlink has used digital terminal adapters from Huawei.


text:
- Manufacturer: Fox Racing
- You can never have too many Fox head logos, and the Fox Slapstick Flexfit Hat proves that with flying colors--oh, and the great fit and premium quality construction don't hurt either.
- Repeated logos along front.
- Medium profile with natural curve bill.
- 98% cotton, 2% elastane.
- Flexfit


text:
Watermelon-Strawberry Pops
These kid-friendly frozen treats are the perfect afternoon snack on a hot summer day.
- Yield: Makes 10
Source: Everyday Food, July/August 2009
- 2 pounds seedless watermelon, cut into cubes
- 1/2 pound strawberries, halved and hulled
- 1/2 cup sugar
- 3 tablespoons fresh lime juice
Working in batches, puree watermelon in a blender. Strain through a fine-mesh sieve into a large bowl (discard solids). Puree strawberries; add to bowl. Add sugar and lime juice and stir until sugar has completely dissolved.
Pour mixture into ten 3-ounce ice-pop molds and insert sticks. Freeze pops until solid, 2 1/2 to 3 hours (or up to 1 week).
Reviews Add a comment
VelvetHeart6724 JUN, 2013Solid recipe! My effort actually yielded 12 pops and they all looked just as delicious as the picture posted for this recipe. I used 1/4 cup of sugar and a touch of Stevia...these pops are so refreshing and taste amazing.Reply
MSGODIN21 JUN, 2013Left out the sugar again, these are so good! Also made them with swirled in yogurt (both plain & vanilla) & equally delicious!Reply
kdka302 AUG, 2011So pretty! And much better than store bought.Reply


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Track and Field – We had a number of students move on to the City Finals this year with our Grade 4 Girls Team winning the overall TDSB West Division Title.
Also Kenny La in Grade 5 finished first overall in the Grade 4 Boys Shot Put and set a new TDSB record of 8.32m.
That now gives Tumpane P.S the most Track and Field Records of any elementary school in the city with a total of 5!!!!!
Coaches: Bair, Haye, DaSilva and Harvey
Soccer – Both the boys and girls soccer teams did very well this year in their regional tournaments (boys team finished in first place and the girls finished in second). However neither teams made it past the TDSB West Division Finals Tournament this year. We played very close games and showed great skill and sportsmanship throughout.
Well Done teams,
Coaches: Harvey and Dasilva
Ultimate Frisbee – Our Ultimate Frisbee team were West Division Finalists and won a banner that now hangs proudly in our gym. The team also showed great sportsmanship and were awared the Spirit Banner for this year too!!!
Great job to all the players!
Coaches: Cardarelli and Brandsma
Co-Ed Baseball – The Co-ed Baseball team only had 4 days of practice and they were able to perform very well at the Family of Schools tournament held at Gosford Public School on June 17th. They finished with 2 wins and 2 losses which had them placed 4th! The team played really well considering the limited amount of practice time we had.
Great Job Team!
Coaches: Campagna and Harvey


text:
Meta4 solutions release corporate HR professionals from solely concentrating on the administrative side of people and payroll management across the organization. In fact, it goes further than that; they endow corporate HR the means for developing strategic value with effective people management processes that supports business decision-making processes.
Meta4 also lets corporate HR dedicate more time to work in tandem with corporate business leaders to strategically optimize workforce performance and create competitive edge.
Strategic value depends on how easy it is to extract and analyse the right information fast from a disparate global workforce to:


text:
Aldec will be presenting a seminar at 11am (Pacific Daylight Time) on Thursday, July 17, 2008. Previous presentation in this thread ("Understanding Assertions – The Key to Efficient Usage") provided solid theoretical background for PSL usage in hardware design and verification. Using this background, current presentation shows how to use PSL in real life designs to make verification more efficient.
- Clocking PSL properties
- Popular property patterns
- Properties in assertions and functional coverage
- PSL examples for typical design units
- Common coding mistakes
- Methods of binding verification units to design units
- PSL embedded in the HDL code vs. saved in separate files
More info: Advanced Verification Methodology Seminars


text: The MX600 intelligent bench top heatstaking system has advanced closed loop system controls. It is designed for heatstaking and insertion applications that require exceptional process, repeatability, and precision. Features include a touch screen operator interface, menu driven parameters, lock out security codes, and collapse distance measurement. It offers an extremely rigid, enhanced anti-deflection frame and primary and secondary post cooling features.


text:
Login | Register
If you just need to know your visa eligibility or have a few short questions.
If you have an immigration issue or unclear about your visa options.
If you want VisaPro's expert guidance and accurate preparation of your case.
Your information will only be used for our newsletter.
The Department of State has proposed to amend and improve the Exchange Visitor Program regulations by providing greater specificity and clarity to sponsors of the Secondary School Student category with respect to the execution of sponsor oversight responsibilities under the exchange visitor programs. The Department is proposing to amend existing regulations regarding the screening, selection, school enrollment, orientation, and monitoring of overall quality assurance on behalf of student participants; and the screening, selection, orientation, and quality assurance monitoring of host families.
This program is recognized as one of the Department's most valued exchange initiatives. The Department believes, however, that the lack of sufficient specificity in the regulations or lack of suitable, minimum industry standards may have contributed to the placement of students with unacceptable, or poorly screened, host families thereby putting at risk the health, safety and well-being of this most vulnerable group of exchange visitors. The Department also recognizes that local coordinators, who serve as representatives (employees or volunteers) of the Secondary School Student sponsors and who have responsibility for obtaining school enrollment and locating and recruiting host families, are the critical link to a successful exchange program.
Local coordinators exercise a degree of independent judgment when determining whether a potential host family is capable of providing a comfortable and nurturing home environment for a Secondary School Student, whether that family is an appropriate match for the student, and whether they have adequate financial resources to undertake hosting obligations. Accordingly, the Department proposes the adoption of an annual testing and certification program for all local and regional coordinators that will entail, inter alia, specifying more clearly the Department's regulatory requirements as well as all sponsoring organization specific training required by the organization for whom the local and regional coordinators work.
DATES: The Department will accept comments
from the public up to February 22, 2010.
ADDRESSES: You may submit comments, identified by any of
the following methods:
Persons with access to the Internet may view this notice
and provide comments by going to the regulations.gov Web site at: http://www.regulations.gov/index.cfm.
Mail (paper, disk, or CD-ROM submissions): U.S. Department of State, Office of Designation, SA-5, Floor 5, 2200 C Street, NW., Washington, DC 20522-0505.
E-mail: firstname.lastname@example.com. You must include the title and RIN in the subject line of your message.
FOR FURTHER INFORMATION, YOU MAY CONTACT: Stanley S. Colvin, Deputy Assistant Secretary for Private Sector Exchanges, U.S. Department of State, SA-5, Floor 5, 2200 C Street, NW., Washington, DC 20522-0505; or e-mail at firstname.lastname@example.com.
Call: 202-787-1944
Email: Info at visapro.comVisit Us


text:
LG is a leading player in the manufacture of consumer electronic products and they have again made a giant leap in the smartphone market by the launch of heir latest product LG Optimus Sol. The smartphone is expected to make use of Android 2.3.4 operating system that comes with improved performance. The product comes with a maximum weight of 110 grams. And the smartphone is available in three colors mainly Black, white as well as Gray. The smartphone comes with a display size of 3.80 inches that comes with a screen resolution of 480 x 800 pixels. The screen makes use of ultra AMOLED display as well as multi-touch capacitive touch screen technology. Other features include the presence of Light sensor, proximity sensors as well as the presence of a scratch resistant glass.
LG Optimus Sol makes use of single core 1000 MHz of ARMv7 processor and the graphics processor that the smartphone makes use of is Adreno 205. The device comes with a RAM capacity of 512MB. And the product is further enhanced by the presence of 32GB of expandable microSD card slot. The smartphone comes with a whopping 5 mega pixel rear facing camera with a resolution of 1280 x 720 pixels that provides 720p of high definition video recording as well as 0.3 mega pixels of front facing camera. The camera also makes use of auto focus technology.
The multimedia features comprise of audio player as well as video player formats that include MP3 as well as MPEG4. Other additional multimedia features include the presence of FM radio as well as You Tube player. The smartphone also comes with an in-built GPS technology that helps in satellite navigation. The phone book feature that is present in the smartphone is comprised of features like unlimited entries, caller groups, and search by both first and last name as well as the presence of picture ID and Ring ID. The messaging features include the presence of SMS, MMS and e-mail.
The connectivity features in LG Optimus Sol includes the presence of Bluetooth connectivity as well as the presence of 802.11 b/ g/ n Wi-Fi connectivity. Other connectivity features includes the presence of USB 2.0 ports as well as a 3.5 mm audio jack. The sensors present in the smartphone include accelerometer. The smartphone makes use of 1500mAh of lithium-ion battery that provides 4 hours of talk time as well as 100 hours of stand by time.
The price tag of LG Optimus Sol has not yet been officially announced, but expects to be around Rs 20, 000.


text:
Product Information
Pinda Oil
Additional Information
|Item Code
|Pack Size
|Arya Vaidya Sala Kottakal
Arya Vaidya Sala Kottakal Pinda Oil
Pinda Thailam is an Ayurvedic oil, used to relieve pain especially due to gout arthritis. It is used for external application only.
Pinda Tailam Uses:
It is used to treat pain related to gouty arthritis- vatashonita and allied burning, swelling ,redness and pounding pain. It is also used in other types of arthritis.
Vatashonita patients should apply this oil daily over the body before bathing.
How to use:
It is used to apply externally. It is used in Ayurvedic treatments like Abhyanga, Januvasti, Dhara etc.
Pinda Thailam side effects:
- There are no side effects with this oil on external application.
- This oil is not meant to be taken orally. If you accidentally take it orally, consult your doctor immediately.
- Keep out of reach and sight of children.
- Store in a cool, dry place.
- Madhuchhista – Honey bee wax – 280 g
- Manjishta – Rubia cordifolia – 455 g
- Sarjarasa – Resin of Vateria indica – 186 g
- Sariva – Hemidesmus indicus – 455 g
- Taila – Oil of Sesamum indicum – 6 liters
- Water – 24 liters
The above combination is heated till Taila is prepared. (Till all the moisture content is evaporated). Then the oil is filtered and preserved.
- Be the first to review this product


text:
Submit News
IOS, Android-Powered Devices to Make Way Onto Defense Networks Next Year
Tiffany Kaiser
February 27, 2013 5:52 PM
Recipient E-mail
Sender E-mail
Apple and Google-powered smartphones and tablets will be used on classified Department of Defense networks for the first time
BlackBerry (formerly known as Research in Motion, or RIM) had a strong hold on mobile device competition in the Pentagon, but that's about to change as Apple's iOS and Google's Android operating systems move in.
The U.S. Defense Department announced yesterday that it will open its communications networks to iOS and Android devices by next February.
The Pentagon uses more than 600,000 mobile devices, where about 470,000 are BlackBerrys, 41,000 are Apple devices and 8,700 Android-powered. However, several of the iOS and Android devices aren't connected to the Defense Department networks.
The Defense Department uses two communications networks: one for unclassified information and another for classified information. Most BlackBerrys work only on the unclassified network, but with the new rules, commercial devices from BlackBerry, Apple and Google will be able to work on the classified network for the first time.
"This is not simply about embracing the newest technology – it is about keeping the department's workforce relevant in an era when information accessibility and cybersecurity play a critical role in mission success," said Teri Takai, the Department of Defense's chief information officer.
This certainly
isn't good news for BlackBerry
, which had a lot of issues in the past and proved to be troublesome for government users. For instance, the Transportation Security Administration (TSA) ditched their BlackBerrys in May 2012 in favor of iPhones while the Immigration and Customs Enforcement followed suit in September. In October, the Defense Department left its BlackBerrys behind and chose to go with Android and Apple devices instead while the National Transportation Safety Board (NTSB)
left BlackBerry for a new fleet of iPhone 5s
the Transportation Security Administration (TSA) ditched their BlackBerrys in May in favor of iPhones. Immigration and Customs Enforcement followed suit in September, and in October, the Defense Department left its BlackBerrys behind and chose to go with Android and Apple devices instead. - See more at: http://www.dailytech.com/Yet+Another+Government+Agency+NTSB+Drops+BlackBerry+/article29248.htm#sthash.z4CKBncd.dpuf
However, BlackBerry is attempting to make a comeback with its
new BlackBerry 10 software and line of devices
. The new line was announced last month, and they'll be released in the U.S. next month.
The Defense Information Systems Agency is currently looking for a company or several companies to develop the new architecture. It plans to make a selection by early summer.
"Then they pop up and say 'Hello, surprise! Give us your money or we will shut you down!' Screw them. Seriously, screw them. You can quote me on that." -- Newegg Chief Legal Officer Lee Cheng referencing patent trolls
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text:
Answered By: Dean Smith Last Updated: Jan 18, 2017 Views: 173
You can use Texas Legal Forms at any Library location or remotely using your active Library Card number. This database offers thousands of online legal forms specific to Texas that you can fill out on a computer and then print, or print and fill out with a pen. Click the Gale LegalForms logo at the top left anytime you want to return to the legal forms home page.
Use the search box to locate a form. For example, to find a rental form, type rental agreements or residential leases.
If you don't see what you need, try changing the search type from Categories to Titles. Also try using fewer search terms, if possible.
Explore forms by Most Popular Legal Form Searches, Main Categories, Sample Searches or alphabetically.
These options are on the homepage; click the Legal Forms Library logo in the upper left if needed.
Once you find a form, download the MS Word or Rich Text. You can enter your information directly into the form and print it.
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Learn the basics with these Video Tutorials. For additional search advice, you can Ask a Librarian but please note that we cannot affirm whether a form is the correct one to use. For that you will need a lawyer.


text:
Retention in Care and Adherence to ART are Critical Elements of HIV Care Interventions
- First Online:
- Citations
- 1.8k Downloads
Retention in care and adherence to antiretroviral treatment (ART) are critical elements of HIV care interventions and are closely associated with optimal individual and public health outcomes and cost effectiveness. This literature review was conducted to analyse how the roles of clients in HIV care and treatment are discussed, from terminology used to measurement methods to consequences of a wide range of patient-related factors impacting client adherence to ART and retention in care. Unfortunately, data suggests that clients find it hard to follow recommended behaviour. For HIV, the greatest loss to follow-up occurs before starting treatment, though each step of the continuum of care is affected. Measurement approaches can be divided into 'direct' and 'indirect' methods; in practice, a combination is often considered the best strategy. Inadequate retention and adherence lead to decreased health outcomes (morbidity, mortality, drug resistances, risk of transmission) and cost effectiveness (increased costs and lower productivity).
KeywordsRetention Adherence HIV/AIDS Measurement ART
Retention in care and adherence to antiretroviral treatment (ART) are critical elements of HIV care and are closely associated with optimal individual and public health outcomes and cost effectiveness. Despite the significance of retention and adherence, a broad body of evidence suggests that many clients struggle to adopt the appropriate behaviours recommended by their health-care providers. This translates specifically to increased morbidity and mortality through suboptimal viral suppression, increased risk of drug resistance, and increased risk of HIV transmission; and more generally to higher health-care costs and a loss of or reduction in individual income, potentially translating to lower economic productivity at the country level.
Consequently, there is increasing concern about inadequate retention and adherence, due, in no small part, to the amount of financial and human resources investment required to sustain or expand health-care services. Through global effort, ART coverage increased by more than 2,500 % between 2002 and 2011 in low- and middle-income countries, resulting in treatment coverage of just over 8 million people living with HIV (PLHIV), or 54 % of those eligible are receiving treatment [1, 2]. Despite the expansion of HIV services, programme data indicates that PLHIV often encounter multiple challenges to accessing available health-care.
This paper reviews the published literature on retention in HIV care and adherence to treatment and aims to clarify terminology used, provide an overview of retention and adherence research, discuss measurement methods, and describe the consequences of inadequate retention and adherence.
Understanding the Concepts of Retention and Adherence
In the last four decades, literature on health care and public health has focused increased attention on the complexities and importance of the patient–health-care provider relationship, also understood as a supply (health-care provider and system)–demand (patient) paradigm [3]. With the steady increase in quality and reach of health services, some experts suggest that efforts to increase client involvement may have a greater impact on health outcomes than any other improvement in specific medical treatments [4].
Based on these definitions, a client can be 'retained in care' (e.g., attending a clinic appointment according to schedule), but not necessarily 'adhere to treatment' (e.g., fail to take medication as prescribed). However, in general, the best outcomes are achieved if a client is retained in care (so that they can be clinically monitored) and adheres to treatment. The above definitions rely on a minimum requirement that ARVs be available. An inadequate supply of ARVs at the facility or country levels can interrupt treatment, leading to poor adherence, and possibly to poor retention.
'Loss to follow-up' and 'attrition' are terms often used in the literature to represent clients who disengaged from care at any stage of the continuum of care. How loss to follow-up is quantified varies greatly in the field, and in some cases, even within some studies. Lamb et al.'s [13] study of the association of adherence support and services in relation to loss to follow-up and attrition, used two types of data analysis and two different definitions for loss to follow-up—cumulative analysis, in which patients were considered loss to follow-up if they had not visited a clinic within the previous three months 'without documented evidence of death or transfer to another clinic' and those who returned to care were no longer defined as lost to follow-up; and cohort analysis, in which patients were considered lost to follow-up after six and twelve months, regardless of whether or not they eventually returned to ART care. Loss to follow-up can also be more broadly defined, depending on the context, to consider those who choose not to continue with their treatment or encounter other barriers to continued access to treatment. In that respect, loss to follow-up is not an outcome by itself. The varied definitions of loss to follow-up within Lamb's study alone, underscores the challenge of comparing research on retention across the field.
Monitoring Client Retention and Adherence
A growing body of studies examine client retention and adherence rates, but interpretation needs to be handled with caution. At present, there is no consensus on period definitions for retention or what constitutes 'adequate' retention and adherence (e.g., what type or level of client behaviour). Similarly, indicators are not standardized making it difficult to compare across programmes, or differences in retention and adherence over time. In this sense, some studies consider clients to be lost to follow-up as early as one day after missing an appointment, while others begin count as late as 180 days or a year from the last client facility visit. Many programmes report on basis of dichotomous variables, such as in-care versus loss to follow-up or adherent versus non-adherent. There is also a lack of consistency with regard to the inclusion of deceased clients (and thus not following-up) [14, 15]. Other critical issues include self-transferred clients—when people decide to enrol in care at a new health facility without informing staff at their previous clinics—and unascertained death where vital registration data is not routinely collected in many resource-limited settings. Due to the high resource demand associated with tracking clients—compounded by the lack of unique client identifiers, especially in resource-limited settings—some studies may not succeed in identifying the true outcome of those who are lost to follow-up, consequently leading to over-reporting of loss to follow-up. Other issues that impair data comparability include the study settings (e.g., formal clinic trials vs. large-scale programmes in resource-limited settings) and the measurement method applied (e.g., self-reporting may be associated with an overestimation of retention in care and treatment adherence) [12, 16, 17, 18].
Inadequate retention and adherence affects virtually all client-health-service relationships, independent of the type of disease, however, there are differing observations with regard to client predictors of loss to follow-up and non-adherence, such as ethnicity, age, or gender [19, 20, 21, 22]. In general, retention and adherence rates appear to be higher for conditions with short course of illness [23, 24]. Also, there is some evidence that indicates better ART adherence in resource-limited settings compared to some resource-rich settings [25, 26]. Based on a meta-analysis of 569 studies, DiMatteo [27] found an average non-adherence rate of 24.8 % of clients, highest in HIV, arthritis, gastrointestinal disorders, and cancer, and lowest in pulmonary disease, diabetes, and sleep disorders.
Reaching adequate retention in HIV care and ART adherence may be more difficult and may have more complex challenges than for many other diseases. This is due to several factors: (1) HIV is a chronic condition requiring life-long treatment, (2) HIV-related stigma can be a significant barrier, and (3) complex treatment regimens that can also have undesirable adverse effects and drug interactions. Loss to follow-up and poor adherence undermine individual health outcomes, HIV prevention potential and could have implications on the cost effectiveness of HIV treatment.
Diagnosis—a major challenge in tackling the HIV epidemic is the failure to promptly diagnose HIV infections. In 2010, a median number of 55 tests per 1,000 adult population were conducted (up from 47 in 2009), with the highest number of tests occurring in Sub-Saharan Africa (82 per 1,000) and the lowest in East, South and South-East Asia (22 per 1,000) [2].1 Despite the increased scale up of HIV tests and testing facilities, the level of testing remains insufficient overall. PLHIV unaware of their status range from approximately 69 % in Congo and 31 % in Kenya [2] to 33 % in Europe [28] and 20 % in the US [29]. Failure to diagnose HIV infection is usually highest among clients who are not perceived to be at risk of HIV infection, or are marginalized (e.g., injecting drug users, men who have sex with men, immigrants) [30].
Assessment and initiation of care and treatment—once clients are diagnosed with HIV, it is crucial to link and enrol them to care and treatment services. Unfortunately, several studies suggest that only a fraction of people diagnosed with HIV actually start treatment. In their systematic review looking at retention in HIV care between HIV testing and counselling (HTC) and initiation of ART, Rosen and Fox [31] found that 59 % of clients are lost between diagnosis and assessment (receipt of CD4 count or clinical staging), 46 % of clients are lost between assessment and eligibility for ART, and 68 % between eligibility and ART initiation. Similarly, data from the Viet Nam Authority for HIV/AIDS Control lists only 31.6 % of (diagnosed) PLHIV as enrolled in care (pre-ART and ART) [2]. In contrast, Gardner et al. [32] estimate that ~75 % of newly diagnosed PLHIV in the United States are linked to HIV care within 6–12 months after diagnosis, and 80–90 % linked within 3–5 years. Measured by the number of days from diagnosis to the start of ART, delays for clients in South Africa were estimated at 78 and 34 days in Free State Province [33] and Cape Town, South Africa [34], respectively, and about 40 days in Cambodia [35].
Retention in care and adherence to treatment—once ART is initiated, clients need to be retained and they need to adhere to treatment. A systematic review of 33 sources describing 39 cohorts and 226,307 clients in sub-Saharan Africa calculated that a median of 86.1 % of clients remained in the programme at 6 months, 80.2 % at 12 months, 70.0 % at 24 months and 64.6 % at 36 months. Of those reported as lost to follow-up, an average of 41 % of clients were identified to be deceased [36]. In 2011, data from 149 low- and middle-income countries indicated an average retention rate of 81 % at 12 months, 75 % at 24 months, and 67 % at 60 months from 92, 73, and 46 countries, respectively [2]. It is noteworthy that loss to follow-up in both studies was highest in the first 12 months, presumably due to early mortality on ART.
In terms of adherence to treatment, i.e., how reliably clients follow the prescribed medication regimen, Ortego et al. [26] found that an average rate of 62 % of clients reported ≥90 % adherence. In this meta-analysis, good adherence was more likely in studies with "higher proportions of men who have sex with men (MSM) and lower proportions of injection drug users (IDU), with participants in an earlier stage of HIV infection, [and] in countries characterized by lower Human Development Index (HDI) scores" [26]. Similar results were reported from a meta-analysis conducted by Mills et al. [25], who found that a pooled estimate of 55 % of the populations in North America and 77 % in twelve sub-Saharan African countries achieved adequate levels of adherence. Gardner et al. [32] reports that ~60 % of US clients in need of ART and ~80 % of those on ART are adherent/achieve viral suppression.
Measuring Retention and Adherence
Health intervention effectiveness is highly dependent on understanding the role of patient/client behaviour and appropriately measuring the levels of both retention and treatment adherence. Health-care providers need to 'measure what they manage', in other words, monitor clients' behaviour during care and treatment to optimize outcomes. It is also crucial to recognize that if the effectiveness of an intervention is evaluated based on outcomes with differing measurement approaches of client retention and adherence, this impairs comparability and consequently the identification of appropriate responses in a given setting [37, 38].
While it is clear that measuring retention to care and adherence to treatment is critical, doing so accurately is complex and, at present, no globally agreed on 'gold-standard' of measurement exists. Measuring adherence objectively in routine-care settings is often a challenge because of potential issues related to approaches originating from feasibility, cost, and health-care providers' time. Programmes and research use different methods to measure adherence to treatment, each with specific advantages and disadvantages. Approaches are usually divided into direct and indirect methods [9, 39]: 'direct' refers to monitoring of the implementation of the intervention or its immediate outcomes; and 'indirect' refers to the use of proxy indicators that are associated with adherence. Consequently, direct approaches are often regarded as more accurate, while indirect methods may be more feasible to implement (and thus also more commonly used) [16].
Direct approaches to measuring adherence include: directly-observed treatment and biochemical analysis of compounds in bodily fluids. An example for direct observation would be handing out and taking drugs in the presence of health care staff. Alternatively, biochemical analysis of compounds in bodily fluids measures drug adherence through detection of either the medication itself (or its metabolites) or non-toxic markers that have been added to the regimen.
Indirect approaches to measuring ART adherence include viral load monitoring, client self-reporting (i.e., client interviews, questionnaires and diaries), pill-counting, prescription claims/pill refill, electronic monitoring devices, client clinic attendance, and provider reporting. Client self-reports are widely employed, however, they are inherently subjective, prone to recall bias, and often overestimate adherence if patients shy from reporting any lapses in adherence due to fear of criticism from their care providers [12, 16, 17, 18]. Another, widely employed indirect measurement method is pill-counting, which is usually performed during clinical appointments and, if the date of the last refill is known, allows calculation of drug adherence. However, pill counting at the clinic may lead to 'pill dumping' if a client knows that this may be routinely assessed. Unannounced home visits for pill counting have also been employed as part of adherence monitoring in clinical trial settings. The downside of this method is that it is time consuming and clients may perceive it as 'policing', thus posing a challenge to client-provider trust. Additionally, it can be difficult to ascertain whether the client has followed the prescribed frequency and/or dosage through pill counting alone. Prescription claims/pill refills follow a similar logic, using the timing and/or frequency of these as indicators, and is potentially immune to social desirability or reporting bias. A comparison of different adherence monitoring approaches indicates that pharmacy records more accurately correlate with ART adherence compared to self-reporting. Electronic monitoring devices are a relatively new but expensive measurement method that records the date and time the drug container is opened—providing detailed information on patterns of medication taking. This method is not commonly used in routine care settings due to high costs associated with it. Client intervention outcomes may also be used as indicators of adherence, as clinical (e.g., return to health) and biological outcomes (e.g., suppressed viral load), in certain cases, can only be achieved with adequate adherence. Client clinic attendance monitors timing and frequency of clinic visits, and is the most common measurement method to assess retention in care. However, most programmes do not routinely monitor retention in care, and routine programme cohort analysis needs to be strengthened in several settings.
The selection of the most appropriate measurement approach needs to be at least reliable (i.e., consistent across time and settings) and valid (i.e., measures what it purports to measure) [40, 41]. It also needs to take into account: goal of measurement (i.e., research/documentation vs. routine care), type of intervention (e.g., drug intervention vs. life-style changes), length of intervention, number of and access to clients, available resources, and ethical and legal considerations. In practice, combining more than one measurement method, e.g., subjective client self-reporting with more objective pharmacy-based pill refills, is often considered the most feasible approach in resource-limited settings [12, 40, 42], or reflecting the impact of the intervention, as in viral load suppression. With regard to the latter, for those taking ART, viral suppression is usually an indication that they are adhering effectively to prescribed medicines. The converse may not always be true as someone may be adhering to their ART but if they had been given a regimen which was effective against their viral strain this would not result in viral suppression.
Retention and Adherence in the Response to HIV
Retention and adherence play a critical role in the response to HIV, spanning across the whole continuum of care: from diagnosis and assessment to the initiation and continuation of treatment. Retention in care and adherence to antiretroviral therapy (ART) need to be maintained for life—presenting significant challenges for clients and health-care providers alike as the epidemic evolves from one requiring an emergency response to one necessitating long-term comprehensive care.
Several factors underscore the importance of retention and adherence in the response to HIV. UNAIDS and WHO estimate that the rate of new HIV infections are decreasing—by 19 % between 2002 and 2011—indicating that prevention efforts have been successful in many settings (although 2.5 million new HIV infections occurred in 2011) [1, 2]. This success is due in part to the significant expansion of access to HIV related-health services in low- and middle-income countries where ART coverage increased more than 2,500 % during 2002–2011 [1, 2]. For the 34 million people presently living with HIV, most will reach CD4 cell count levels requiring treatment initiation within this decade (as of 2011, approximately 8 million PLHIV were receiving ART, with 6.8 million still eligible) [1]. In addition, the effectiveness of ARVs is improving, substantially reducing morbidity and mortality [46, 47, 48, 49], and simpler, less toxic ARV regimens are gradually being introduced in low-income countries.
Consequences of Inadequate Retention in Care and Adherence to ART
As a consequence of suboptimal health outcomes, insufficient retention and adherence also negatively affect cost effectiveness of health interventions (i.e., increases direct health-care costs and indirect loss of income/productivity). In the case of health-care costs, these are largely dependent on the health-care financing systems of a country. For loss of income/productivity, the implications may be greater if the consequences of reduced productivity on an individual level and its effects on other, healthy, individuals are taken into consideration (i.e., reduced productivity of one individual may impair productivity for other individuals).
Retention in care and adherence to ART have significant implications on health outcomes and cost effectiveness of HIV interventions for both PLHIV and society as a whole. Failure to diagnose HIV and/or delayed care and treatment initiation ('late presentation') are associated with higher rates of on-going HIV transmission, greater risk of opportunistic infections, reduced treatment effectiveness, and significantly increased short-term mortality in 'late presenters' compared with clients who are diagnosed and start treatment earlier [51, 52, 53]. Several studies have identified poor treatment adherence, second only to CD4 cell count, as a strong predictor of HIV progression to AIDS and ultimately death [54, 55, 56].
Relatively small differences in medication intake can trigger major differences in viral suppression. Using different methods of measuring data, several studies analysed the relationship between adherence and viral load and/or mortality. Grossberg et al. [57] found that a 10 % increased adherence rate was associated with viral load decreases of 0.12 log c/mL (adherence measured through drug refills). Similarly, Paterson et al. [58] found that virologic failure occurred in only 22 % of clients with 95 % or greater adherence compared to clients with 80–94.9 % adherence (61 %) and those with under 80 % adherence (80 %) (adherence was measured through electronic intervention monitors). In terms of mortality, adherence has also been shown to be a critical determinant of client survival. A population-based analysis of 1,282 ART-naive HIV-positive individuals in British Columbia found that clients who used antiretroviral drugs intermittently (adherence level < 75 %) were 2.97 times more likely to die (after adjustment for other prognostic factors, measuring adherence through drug refills) [56]. Similarly, Nachega et al. [59] analysed survival among 6,288 HIV-1-infected South African adults enrolled in a private-sector AIDS management program and found that adherence levels below 80 % were associated with a 3.23 higher mortality. When drug adherence was divided into quintiles (20 % each), each quintile had lower survival rate than the next higher one (adherence measured through prescription claims). Using clinic visits as the predictor, Giordano et al. [60] also come to comparable findings: based on a total of 2,619 men followed for a mean of more than 4 years, clients with visits in three quarters, two quarters, and one quarter in the first year had a 1.42, 1.67 and 1.95 higher mortality respectively compared with clients with visits in all four quarters.
In addition to increases in morbidity and mortality, inadequate adherence reduces treatment effectiveness due to drug resistances, and also limits ARV options. There has been extensive discussion on the relationship between client adherence levels and the prevalence of drug resistance [61, 62]. Earlier studies indicate a bell-shaped curve (i.e., suppression of drug resistances is best at medium–high levels, less at low- and near-perfect adherence). More recently, studies have shown that each regimen class may have different adherence-resistance relationships [63, 64]. Gardner et al. [65] have found that 'differential' adherence—defined as any difference in self-reported adherence levels to individual antiretroviral drugs at the same time (when on a multiple-pill drug regimen)—is associated with increased antiretroviral resistance. HIV treatment guidelines from both WHO and the US Department of Health and Human Services stress the importance of adherence to suppress drug resistances and improve health outcomes [66, 67].
While inadequate retention and adherence negatively impact individual health outcomes, evidence suggests that it also has population-level implications. Transmission of drug resistances following poor treatment adherence can lead to suboptimal response to first-line therapy in newly diagnosed PLHIV [68]. However, the prevalence of transmitted drug resistances is increasing, but at lower rates than some had feared based on the significant expansion of ART coverage [69]. Treatment adherence has also a critical role in prevention of HIV transmission. Knowledge of HIV status allows PLHIV to adopt risk-reduction behaviours. Evidence from the randomised control trial HPTN 052 confirmed findings from previous cohort studies that by reducing virus levels in bodily fluids, ART has the potential to significantly reduce HIV transmission [70, 71, 72]. However, in order to harness the prevention benefits of ART, clients need to adhere to medication.
Retention and adherence are also critical determinants of programme cost effectiveness: due to higher morbidity, client health-care needs increase, and potential drug resistance makes more expensive second-/third-line treatment necessary. In a study on cost implications from suboptimal medication adherence, Nachega et al. [73] followed 6,833 HIV-infected adults in South Africa between August 2000 and April 2006, monitoring ART, hospitalizations, consultations, investigations and non-ART medications. Clients were grouped in four adherence quartiles, with total mean costs ranging from $313 for highest adherence to $376 for lowest adherence per month (adherence was measured through prescription claims). Although ART costs alone were higher in clients with better adherence, the total mean costs were offset by significantly reduced hospitalization costs. Comparable results were found in two earlier studies: Knobel et al. [74], examining the influence of treatment adherence on hospital admissions in patients on HAART in Barcelona, calculated mean hospital days per admission of 3.73 for adherent clients (>90 % adherence), as opposed to 14.75 days for non-adherent clients (adherence was measured through client interviews and pill counts); and Paterson et al. [58], looking at combination ART with protease inhibitors in patients in Pittsburgh, found that clients with above 95 % adherence had fewer hospital days (2.6 days per 1,000 days of follow-up) and developed fewer opportunist infections than less adherent clients (12.9 days per 1,000 days of follow-up) (adherence was measured through electronic interventions monitors).
Drug resistances resulting in the need to start more costly treatment regimens earlier is emphasized by the significant price differences between first- and second-line ARV regimens. In 2010, the most commonly used adult first-line ART regimens in low- and middle-income countries cost on average $124 per person per year, compared with $554 for second-line drugs (price difference of 347 %) [2]. In this regard, Long et al. [75] calculated that total second-line outpatient health-care costs are 2.4 times higher than first-line. Predictably, the biggest increase came from higher costs of second-line drugs, with limited additional expenditure for laboratory services and clinic visits. Because of cost implications, Long et al. stress the importance of limiting or delaying the number of clients requiring second-line therapy. Furthermore, second-line treatment is often not widely available in resource-limited settings.
Treatment 2.0
- 1.
'Optimize drug regimens' calls for "effective, affordable, one pill, once daily potent ARV regimens with minimal toxicities or drug interactions". This can be expected to have significant positive impact on adherence, as several studies validate the relationship between ease of drug use, such as pill burden, and actual intake [77, 78, 79, 80].
- 2.
'Provide access to point-of-care and other simplified diagnostics and monitoring tools' addresses the insufficient level of HIV testing and counselling and CD4 testing and monitoring leading to late start of HIV treatment, which in turn is associated with increased morbidity and mortality [81, 82]. A recent study from Mozambique indicates that availability of point of care CD4 testing enables clinics to stage clients quickly on-site, reducing risks for pre-treatment loss to follow-up among those who are eligible for ART at time of assessment [83].
- 3.
'Reduce costs' emphasizes that it is necessary to ensure the most effective use of limited available resources (e.g., through pooled-drug procurement and diagnostics) [84]. While such activities would likely not directly affect retention and adherence, it is obvious that retention and adherence can maximise programme efficiency.
- 4.
'Adapt delivery systems' emphasizes the need for a decentralized HIV response, integrated with other health services. Recent studies from Zambia suggest that the provision of ART integrated with maternal and child health services significantly increased treatment initiation [85, 86]. Similarly, a study from South Africa indicates that integrating ART with tuberculosis care improves treatment coverage among co-infected clients [87]. Factors such as transport costs and waiting time have been identified as major barriers to retention and adherence [88, 89], indicating that proximity as well as convenience of service delivery are critical.
- 5.
'Mobilize communities' calls for a better integration and linkages of the 'informal' community sector in the response to HIV. Engaging communities in the creation, development, and implementation of programmes and services can provide a more enabling environment that supports quality of care, retention in care, and treatment adherence for their populations. While the health-care sector can strive to improve the availability and quality of HIV services, many barriers to retention in care and adherence to treatment exist outside their purview (e.g., disability, stigma, poverty). Unfortunately, the health-care sector is often not well positioned to address many of these issues. However, by actively involving communities—through coordination with and strengthening of health-care and other key sectors—significant improvements can occur at both the individual- and community-levels to overcome these barriers, resulting in increased access to HIV services, stigma reduction, retention in care, and treatment adherence [90, 91, 92].
The importance of retention and adherence is also reflected in the 2011 General Assembly Political Declaration on HIV/AIDS, which emphasizes the need to "address factors that limit treatment uptake and contribute…to poor adherence" and calls for the "mobilization and capacity-building of communities to support treatment scale-up and patient retention" as well as "programmes that support improved treatment adherence" [93]. A focus on the client side was also underscored by UNAIDS in their 2011–2015 strategy, which stated that "the demand side of treatment—the factors that make people enrol for treatment and adhere to it—has not received enough attention" [94].
Conclusions and Areas for Further Research
Retention in care and adherence to treatment are critical for health outcomes and cost effectiveness of health interventions. Disease-generic as well as HIV-specific data suggest, for a variety of reasons, that clients often face challenges following the behaviour recommended by their health-care providers. This holds true for both resource-rich and resource-limited settings.
Major challenges to the response to HIV include: prompt diagnosis of HIV infection, poor linkage to care, delayed treatment initiation, and insufficient adherence to treatment. Historically, attention was focused primarily on the latter stage (continuation of treatment); however, it becomes apparent when examining the continuum of HIV care that most client loss to follow-up happens following testing and before start of ART. On both the client- and population-levels, failure to link clients to care following testing and inadequate retention and adherence to ART, once in care, result in significant increases in morbidity and mortality and are associated with on-going transmission of HIV infection. Additionally, suboptimal viral suppression may result a higher risk of developing drug resistances, as well as the transmission of drug resistance. From a cost-effectiveness perspective, inadequate retention and adherence may lead to an increase of health-care costs.
Current suboptimal retention in care and adherence to ART threaten the benefits of the on-going scale up of HIV care and treatment, and may result in a failure to capitalise on the treatment and prevention benefits of ART. Therefore, it is crucial that retention and adherence are put at the heart of the HIV response: to better understand barriers to retention and adherence; to identify, design, and implement programmes to overcome these barriers; and to monitor and evaluate their impact and acceptability.
- 1.
Please note that these numbers relate to total number of tests, as opposed to individuals tested. The number of people testing is likely lower as some may take multiple tests over the course of a year.
- 1.Joint United Nations Programme on HIV/AIDS (UNAIDS). Together We Will End AIDS. Geneva: UNAIDS; 2012.Google Scholar
- 2.World Health Organization (WHO), United Nations Children's Fund (UNICEF), Joint United Nations Programme on HIV/AIDS (UNAIDS). Global HIV/AIDS Response: Epidemic Update and Health Sectors Progress Towards Universal Access. Progress Report 2011. Geneva: WHO; 2011.Google Scholar
- 3.Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001;25(5):331–42.CrossRefGoogle Scholar
- 4.Haynes RB, McDonald H, Garg AX. Montegue P. Cochrane Database Syst Rev: Interventions for helping patients to follow prescriptions for medications; 2002 (2):CD000011. [NOTE: updated 2005;(4):CD000011.].Google Scholar
- 5.DeMaria AN. Adherence, compliance, concordance, or the lack thereof. J Am Coll Cardiol. 2012;59(12):1120–1.PubMedCrossRefGoogle Scholar
- 6.Aronson JK. Compliance, concordance, adherence. Br J Clin Pharmacol. 2007;63(4):383–4.PubMedCrossRefPubMedCentralGoogle Scholar
- 7.Bell SJ, Airaksinen MS, Lyles A, Chen TF, Aslani P. Concordance is not synonymous with compliance or adherence. Br J Clin Pharmacol. 2007;64(5):710–1.PubMedCrossRefPubMedCentralGoogle Scholar
- 8.Steiner EM, Earnest MA. The language of medication-taking. Ann Intern Med. 2000;132:926–30.PubMedCrossRefGoogle Scholar
- 9.Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487–97.PubMedCrossRefGoogle Scholar
- 10.Cramer JA, Roy A, Burrell A, et al. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11(1):44–7.PubMedCrossRefGoogle Scholar
- 11.Bissell P, May CR, Noyce PR. From compliance to concordance: barriers to accomplishing a re-framed model of health care interactions. Soc Sci Med. 2004;58(4):851–62.PubMedCrossRefGoogle Scholar
- 12.World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: WHO; 2003.Google Scholar
- 13.Lamb MR, El-Sadr WM, Geng E, Nash D. Association of adherence support and outreach services with total attrition, loss to follow-up, and death among ART patients in sub-Saharan Africa. PLoS One. 2012;7(6):e38443.PubMedCrossRefPubMedCentralGoogle Scholar
- 14.Chi BH, Cantrell RA, Mwango A, et al. An empirical approach to defining loss to follow-up among patients enrolled in antiretroviral treatment programs. Am J Epidemiol. 2010;171(8):924–31.PubMedCrossRefPubMedCentralGoogle Scholar
- 15.Chi BH, Yiannoutsos CT, Westfall AO, et al. Universal definition of loss to follow-up in HIV treatment programs: a statistical analysis of 111 facilities in Africa, Asia, and Latin America. PLoS Med. 2011;8(10):e1001111.PubMedCrossRefPubMedCentralGoogle Scholar
- 16.Fairman K, Motheral B. Evaluating medication adherence: which measure is right for your program? J Manage Care Pharm. 2000;6:499–504.Google Scholar
- 17.Berg KM, Arnsten JH. Practical and conceptual challenges in measuring antiretroviral adherence. J Acquir Immune Defic Syndr. 2006;43(Suppl 1):S79–87.PubMedCrossRefPubMedCentralGoogle Scholar
- 18.Miller LG, Hays RD. Measuring adherence to antiretroviral medications in clinical trials. HIV Clin Trials. 2000;1(1):36–46.PubMedCrossRefGoogle Scholar
- 19.Mannheimer S, Friedland G, Matts J, Child C, Chesney M. The consistency of adherence to antiretroviral therapy predicts biologic outcomes for human immunodeficiency virus-infected persons in clinical trials. Clin Infect Dis. 2002;34(8):1115–21.PubMedCrossRefGoogle Scholar
- 20.Balkrishnan R. Predictors of medication adherence in the elderly. Clin Ther. 1998;20(4):764–71.PubMedCrossRefGoogle Scholar
- 21.Holzemer WL, Corless IB, Nokes KM, et al. Predictors of self-reported adherence in persons living with HIV disease. AIDS Patient Care STDS. 1999;13(3):185–97.PubMedCrossRefGoogle Scholar
- 22.Stone VE, Hogan JW, Schuman P, et al. Antiretroviral regimen complexity, self-reported adherence, and HIV patients' understanding of their regimens: survey of women in the her study. J Acquir Immune Defic Syndr. 2001;28(2):124–31.PubMedCrossRefGoogle Scholar
- 23.Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288(4):462–7.PubMedCrossRefGoogle Scholar
- 24.Cramer J, Rosenheck R, Kirk G, Krol W, Krystal J, VA Naltrexone Study Group 425. Medication compliance feedback and monitoring in a clinical trial: predictors and outcomes. Value Health. 2003;6(5):566–73.PubMedCrossRefGoogle Scholar
- 25.Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA. 2006;296(6):679–90.PubMedCrossRefGoogle Scholar
- 26.Ortego C, Huedo-Medina TB, Llorca J, et al. Adherence to highly active antiretroviral therapy (HAART): a meta-analysis. AIDS Behav. 2011;15(7):1381–96.PubMedCrossRefGoogle Scholar
- 27.DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200–9.PubMedCrossRefGoogle Scholar
- 28.Coenen T, Lundgren J, Lazarus JV, Matic S. Optimal HIV testing and earlier care: the way forward in Europe. HIV Med. 2008;9(Suppl 2):1–5.PubMedCrossRefGoogle Scholar
- 29.US Centers for Disease Control and Prevention (CDC). HIV surveillance—United States, 1981–2008. Morb Mortal Wkly Rep. 2011;60(21):689–93.Google Scholar
- 30.Girardi E, Sabin CA, Monforte AD. Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr. 2007;46(Suppl 1):S3–8.PubMedCrossRefGoogle Scholar
- 31.Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med. 2011;8(7):e1001056.PubMedCrossRefPubMedCentralGoogle Scholar
- 32.Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800.PubMedCrossRefPubMedCentralGoogle Scholar
- 33.Ingle SM, May M, Uebel K, et al. Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study. AIDS. 2010;24(17):2717–25.PubMedCrossRefPubMedCentralGoogle Scholar
- 34.Lawn SD, Myer L, Harling G, Orrell C, Bekker LG, Wood R. Determinants of mortality and nondeath losses from an antiretroviral treatment service in South Africa: implications for program evaluation. Clin Infect Dis. 2006;43(6):770–6.PubMedCrossRefGoogle Scholar
- 35.Thai S, Koole O, Un P, et al. Five-year experience with scaling-up access to antiretroviral treatment in an HIV care programme in Cambodia. Trop Med Int Health. 2009;14(9):1048–58.PubMedCrossRefGoogle Scholar
- 36.Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007–2009: systematic review. Trop Med Int Health. 2010;15(Suppl 1):1–15.PubMedCrossRefPubMedCentralGoogle Scholar
- 37.Urquhart J. Defining the margins for errors in patient compliance with prescribed drug regimens. Pharmacoepidemiol Drug Saf. 2000;9(7):565–8.PubMedCrossRefGoogle Scholar
- 38.Paes AH, Bakker A, Soe-Agnie CJ. Measurement of patient compliance. Pharm World Sci. 1998;20(2):73–7.PubMedCrossRefGoogle Scholar
- 39.Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Ther. 1999;21(6):1074–90.PubMedCrossRefGoogle Scholar
- 40.Vitolins MZ, Rand CS, Rapp SR, Ribisl PM, Sevick MA. Measuring adherence to behavioral and medical interventions. Control Clin Trials. 2000;21(Suppl 5):S188–94.CrossRefGoogle Scholar
- 41.Nunnally JC, Berstein I. Psychometric theory. 3rd ed. New York: McGraw-Hill; 1994.Google Scholar
- 42.McMahon JH, Jordan MR, Kelley K, et al. Pharmacy adherence measures to assess adherence to antiretroviral therapy: review of the literature and implications for treatment monitoring. Clin Infect Dis. 2011;52(4):493–506.PubMedCrossRefPubMedCentralGoogle Scholar
- 43.Chalker JC, Andualem T, Gitau LN, et al. Measuring adherence to antiretroviral treatment in resource-poor settings: the feasibility of collecting routine data for key indicators. BMC Health Serv Res. 2010;19(10):43.CrossRefGoogle Scholar
- 44.Ross-Degnan D, Pierre-Jacques M, Zhang F, et al. Measuring adherence to antiretroviral treatment in resource-poor settings: the clinical validity of key indicators. BMC Health Serv Res. 2010;19(10):42.CrossRefGoogle Scholar
- 45.Steel G, Nwokike J, Joshi MP. Development of a Multi-Method Tool to Measure ART Adherence in Resource-Constrained Settings: The South Africa Experience. Submitted to the USAID by RPM plus. Arlington, Va: Management Sciences for Health; 2007.Google Scholar
- 46.Herbst AJ, Cooke GS, Bärnighausen T, KanyKany A, Tanser F, Newell ML. Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa. Bull World Health Organ. 2009;87(10):754–62.PubMedCrossRefPubMedCentralGoogle Scholar
- 47.Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS Clinical Trials Group 320 Study Team. N Engl J Med. 1997;337(11):725–33.PubMedCrossRefGoogle Scholar
- 48.Michaels SH, Clark R, Kissinger P. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med. 1998;339(6):405–6.PubMedCrossRefGoogle Scholar
- 49.Chan KC, Wong KH, Lee SS. Universal decline in mortality in patients with advanced HIV-1 disease in various demographic subpopulations after the introduction of HAART in Hong Kong, from 1993 to 2002. HIV Med. 2006;7(3):186–92.PubMedCrossRefGoogle Scholar
- 50.World Health Organization (WHO). WHO Global Strategy for Containment of Antimicrobial Resistance. Geneva: WHO; 2001.Google Scholar
- 51.Phillips A, Pezzotti P. CASCADE Collaboration. Short-term risk of AIDS according to current CD4 cell count and viral load in antiretroviral drug-naive individuals and those treated in the monotherapy era. AIDS. 2004;18(1):51–8.PubMedCrossRefGoogle Scholar
- 52.Sabin CA, Smith CJ, Gumley H, et al. Late presenters in the era of highly active antiretroviral therapy: uptake of and responses to antiretroviral therapy. AIDS. 2004;18(16):2145–51.PubMedCrossRefGoogle Scholar
- 53.Hocking JS, Rodger AJ, Rhodes DG, Crofts N. Late presentation of HIV infection associated with prolonged survival following AIDS diagnosis—characteristics of individuals. Int J STD AIDS. 2000;11(8):503–8.PubMedCrossRefGoogle Scholar
- 54.Bangsberg DR, Perry S, Charlebois ED, et al. Non-adherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS. 2001;15(9):1181–3.PubMedCrossRefGoogle Scholar
- 55.de Olalla PG, Knobel H, Carmona A, Guelar A, López-Colomés JL, Caylà JA. Impact of adherence and highly active antiretroviral therapy on survival in HIV-infected patients. J Acquir Immune Defic Syndr. 2002;30(1):105–10.CrossRefGoogle Scholar
- 56.Hoggs RS, Heath K, Bangsberg D, et al. Intermittent use of triple-combination therapy is predictive of mortality at baseline and after 1 year of follow-up. AIDS. 2002;16(7):1051–8.CrossRefGoogle Scholar
- 57.Grossberg R, Zhang Y, Gross R. A time-to-prescription-refill measure of antiretroviral adherence predicted changes in viral load in HIV. J Clin Epidemiol. 2004;57(10):1107–10.PubMedCrossRefGoogle Scholar
- 58.Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133(1):21–30.PubMedCrossRefGoogle Scholar
- 59.Nachega JB, Hislop M, Dowdy DW, et al. Adherence to highly active antiretroviral therapy assessed by pharmacy claims predicts survival in HIV-infected South African adults. J Acquir Immune Defic Syndr. 2006;43(1):78–84.PubMedCrossRefGoogle Scholar
- 60.Giordano TP, Gifford AL, White AC Jr, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007;44(11):1493–9.PubMedCrossRefGoogle Scholar
- 61.Bangsberg DR, Moss AR, Deeks SG. Paradoxes of adherence and drug resistance to HIV antiretroviral therapy. J Antimicrob Chemother. 2004;53(5):696–9.PubMedCrossRefGoogle Scholar
- 62.Green DA. There are no paradoxes of adherence and drug resistance to HIV antiretroviral therapy. J Antimicrob Chemother. 2004;54(3):694.PubMedCrossRefGoogle Scholar
- 63.Bangsberg DR, Kroetz DL, Deeks SG. Adherence-resistance relationships to combination HIV antiretroviral therapy. Curr HIV/AIDS Rep. 2007;4(2):65–72.PubMedCrossRefGoogle Scholar
- 64.Gardner EM, Burman WJ, Steiner JF, Anderson PL, Bangsberg DR. Antiretroviral medication adherence and the development of class-specific antiretroviral resistance. AIDS. 2009;23(9):1035–46.PubMedCrossRefPubMedCentralGoogle Scholar
- 65.Gardner EM, Sharma S, Peng G, et al. Differential adherence to combination antiretroviral therapy is associated with virological failure with resistance. AIDS. 2008;22(1):75–82.PubMedCrossRefPubMedCentralGoogle Scholar
- 66.World Health Organization (WHO). Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2010 Revision. Geneva: WHO; 2010. p. 2010.Google Scholar
- 67.Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Washington, DC: US Department of Health and Human Services; 2012.Google Scholar
- 68.Tang JW, Pillay D. Transmission of HIV-1 drug resistance. J Clin Virol. 2004;30(1):1–10.PubMedCrossRefGoogle Scholar
- 69.World Health Organization (WHO). WHO HIV Drug Resistance Report 2012. Geneva: WHO; 2012.Google Scholar
- 70.Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.PubMedCrossRefPubMedCentralGoogle Scholar
- 71.Attia S, Egger M, Müller M, Zwahlen M, Low N. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23(11):1397–404.PubMedCrossRefGoogle Scholar
- 72.Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375(9731):2092–8.PubMedCrossRefPubMedCentralGoogle Scholar
- 73.Nachega JB, Leisegang R, Bishai D, et al. Association of antiretroviral therapy adherence and health care cost. Ann Intern Med. 2010;152(1):18–25.PubMedCrossRefGoogle Scholar
- 74.Knobel H, Carmona A, Guelar A, Gonzolez A, Hernecki J, Diez A. Adherence in patients treated with HAART: influence in hospital admissions. Durban: International AIDS Conference; 2000 [abstract MoPeD2556].Google Scholar
- 75.Long L, Fox M, Sanne I, Rosen S. The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa. AIDS. 2010;24(6):915–9.PubMedCrossRefGoogle Scholar
- 76.World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS). The Treatment 2.0 Framework for Action: Catalysing the Next Phase of Treatment, Care and Support. Geneva: WHO; 2011.Google Scholar
- 77.Coleman CI, Roberts MS, Sobieraj DM, Lee S, Alam T, Kaur R. Effect of dosing frequency on chronic cardiovascular disease medication adherence. Curr Med Res Opin. 2012;28(5):669–80.PubMedCrossRefGoogle Scholar
- 78.Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23(8):1296–310.PubMedCrossRefGoogle Scholar
- 79.Reginster JY, Rabenda V, Neuprez A. Adherence, patient preference and dosing frequency: understanding the relationship. Bone. 2006;4(Suppl 1):S2–6.CrossRefGoogle Scholar
- 80.Ma A, Chen DM, Chau FM, Saberi P. Improving adherence and clinical outcomes through an HIV pharmacist's interventions. AIDS Care. 2010;22(19):1189–94.PubMedCrossRefGoogle Scholar
- 81.Kigozi IM, Dobkin LM, Martin JN, et al. Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in sub-Saharan Africa. J Acquir Immune Defic Syndr. 2009;52(2):280–9.PubMedCrossRefPubMedCentralGoogle Scholar
- 82.Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009;360(18):1815–26.PubMedCrossRefPubMedCentralGoogle Scholar
- 83.Jani AV, Sitoe AE, Alfai ER, et al. Effect of point-of-care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in primary health clinics: an observational cohort study. Lancet. 2011;378(9802):1572–9.PubMedCrossRefGoogle Scholar
- 84.Joint United Nations Programme on HIV/AIDS (UNAIDS). Breaking News Supplement: Meeting the Investment Challenge. Geneva: UNAIDS; 2012.Google Scholar
- 85.Torpey K, Kabaso M, Kasonde P, et al. Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting. BMC Health Serv Res. 2010;10:29.PubMedCrossRefPubMedCentralGoogle Scholar
- 86.Killam WP, Tambatamba BC, Chintu N, et al. Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation. AIDS. 2010;24(1):85–91.PubMedCrossRefGoogle Scholar
- 87.Louwagie G, Girdler-Brown B, Odendaal R, Rossouw T, Johnson S, Van der Walt M. Missed opportunities for accessing HIV care among Tshwane tuberculosis patients under different models of care. Int J Tuberc Lung Dis. 2012;16(8):1052–8.PubMedCrossRefGoogle Scholar
- 88.Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: a qualitative study. AIDS Behav. 2010;14(4):778–84.PubMedCrossRefPubMedCentralGoogle Scholar
- 89.Hardon AP, Akurut D, Comoro C, et al. Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. AIDS Care. 2007;19(5):658–65.PubMedCrossRefGoogle Scholar
- 90.Ware NC, Idoko J, Kaaya S, et al. Explaining adherence success in sub-Saharan Africa: an ethnographic study. PLoS Med. 2009;6(1):e1000011.CrossRefPubMedCentralGoogle Scholar
- 91.Wouters E, Van Damme W, van Rensburg D, Meulemans H. Impact of baseline health and community support on antiretroviral treatment outcomes in HIV patients in South Africa. AIDS. 2008;22(18):2545–8.PubMedCrossRefGoogle Scholar
- 92.Decroo T, Telfer B, Biot M, et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. J Acquir Immune Defic Syndr. 2011;56(2):e39–44.PubMedCrossRefGoogle Scholar
- 93.United Nations General Assembly. Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS. New York: United Nations General Assembly; 2011.Google Scholar
- 94.Joint United Nations Programme on HIV/AIDS (UNAIDS). Getting to Zero: 2011-2015 Strategy. Geneva: UNAIDS; 2010.Google Scholar


text:
Monsters Den
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A party-based dungeon crawl tactical RPG. Create a party of up to four heroes, from five distinct character classes. Then battle to the depths of the dungeon, increasing in strength and finding powerful treasure.
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text:
Welcome to our practice!
We would like to welcome you to our practice. The professionals at our practice provide each patient with quality vision solutions and exceptional customer service. Our staff is experienced in all areas of vision care. Maintaining healthy eyes requires regular vision and eye exams. We look forward to serving you. If you have any questions or concerns, please feel free to email us at: email@example.com, or firstname.lastname@example.com.
Contact Us
1066 Boiling Springs Road
Spartanburg, SC 29303
Phone: 864-582-0286
Fax: 864-582-0279
Office Hours
Mon 9:00 am - 1:00 pm
Tue 9:00 am - 5:00 pm
Wed 9:00 am - 5:00 pm
Thu 9:00 am - 5:00 pm
Fri 9:00 am - 5:00 pm
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Website by Eyefinity


text:
Not sure if there is anything that can be done about this, but I just had a ticket from over a month ago reopened by an email reply. I have the limit on being able to reopen tickets (maximum age value) set to 15 days.
This topic was created during version 4.5.
The latest version is 7.5.00101.
16 Replies
Feb 19, 2010 at 8:01 UTC
Lawrie Dalman Consulting is an IT service provider.
Hi Justin,
have you tried just adjusting the maximum age out, have the ticket go live/open again and then set the maximum age back.
It might also be possible to adjust the ticket status in the db, but I'll have to test that in one of our test instances to know for sure.
It is a good question though, this could happen reasonably often.
Feb 19, 2010 at 8:10 UTC
Hi Lawrie, I'm not quite sure I follow your comment. The maximum age is the advanced value in helpdesk settings for maximum age a ticket can be reopened in days. Based on what is happening I am assuming that this is only applying to the user portal and not to email responses to the original thread.
In this case I just asked the user nicely to submit new tickets, but the one he reopened had been closed by a former employee so when it reopened no-one actively working got an alert and he was almost ignored.
Feb 19, 2010 at 8:43 UTC
Lawrie Dalman Consulting is an IT service provider.
Well worth trying, if you open the maximum age a ticket can be reopenned and sent an email to the helpdesk with the ticket number of the ticket you want openned, as long as the ticket is within the range of the maximum age tickets can be reopenned it should reopen. I think this setting is applied to the db process to open/reopen a ticket if ticket age > maximum age a ticket can be reopenned no don't open, if ticket age < maximum age a ticket can be reopenned then the flag on the ticket is changed and it's open again.
That's what I mean about making a little edit in the db, it's only one flag on the ticket for it to be reopenned.
Feb 19, 2010 at 8:47 UTC
Thanks, now I follow. I will fire up my test server and see what I can see.
Feb 24, 2010 at 7:25 UTC
Just happened again with the settings reset to 15 days, a user reopened a ticket closed 19 days ago by replying to the email thread.
Feb 24, 2010 at 8:34 UTC
Lawrie Dalman Consulting is an IT service provider.
Just happened again with the settings reset to 15 days, a user reopened a ticket closed 19 days ago by replying to the email thread.
Oooh, that doesn sound right, so the time out on closed tickets being reopenned is set to 15 days and a user successfully reopenned a ticket from 19 days ago..?
This 19 day old ticket is that 19 days from initial opening or 19 days from closure?
How are you evaluating the age of the ticket, from a report?
If so maybe check the report to ensure it is reporting days from ticket closure.
Feb 24, 2010 at 9:12 UTC
19 days from closure and I am going by the ticket comment value. This does happen only by email, User Portal is fine.
Feb 24, 2010 at 4:19 UTC
Lawrie Dalman Consulting is an IT service provider.
My understanding is this is rule based in SW and for the rule not to be obeyed by the code implies a bigger problem, sounds like something for SW to have a look at.
Perhaps there is something to be gleaned from the logs, are you up to speed with scoping out your SW logs? I'm still figuring it out, but there is lots to be seen there when there are problems.
Mar 15, 2010 at 2:23 UTC
In case it matters I have mine set to "Never" and they can still be re-opened with a comment back to the ticket thread.
Mar 15, 2010 at 4:26 UTC
Issue still occurs after upgrading to 4.6.
Mar 18, 2010 at 8:50 UTC
Agreed, this is happening with us also. Set to Never on our end, and a user replied via email and the ticket re-opened.
Jun 17, 2010 at 11:02 UTC
Has this been fixed in the newest version?
We just had a user open a ticket that had been closed for 6 months and max is set to 7 days.
Relevant Ticket comments:
Ticket closed
Jun 17, 2010 at 11:15 UTC
It has not been fixed. I just had someone reopen a ticket with a "Thanks" reply.
Jul 8, 2010 at 10:03 UTC
I am also having this problem. I have had two ticket reopened this morning with the user replying with a 'Thanks". I have mine set to "NEVER" as well...please fix this one ASAP..I beg you.
Jul 8, 2010 at 11:17 UTC
Please fix this ASAP...this is killing me today! Constant reopening of tickets by users...this is ridiculous.
Aug 16, 2010 at 8:51 UTC
Just ran into this issue today, someone replied to a ticket from May and reopened it. Please fix!
This discussion has been inactive for over a year.
You may get a better answer to your question by starting a new discussion.


text:
Think Pink was the slogan for the Stratford High School student council's pink morning tea on Friday morning in support of the New Zealand Breast Cancer Foundation.
Staff at the school made a donation towards the charitable trust while enjoying a delightfully pink-themed morning tea that had been prepared by the student council.
Dressed in pink wigs and accessories, the students layed out a spread of pink treats in theme with Breast Cancer Action Month.
Student council chairperson Ashley Kowalewski says the morning tea was a huge success, with the students raising more than $200 to be donated to the New Zealand Breast Cancer Foundation.
"It was great to see the teachers digging deep in their pockets to donate towards such a great cause," says Ashley.
Ashley addressed the staff on Friday morning, sharing with them some of the more daunting facts, such as 3000 people are diagnosed with breast cancer in New Zealand every year, 20 of which will be men.
Wendy Walker, assistant principal, says she was thoroughly impressed with the students' enthusiasm towards the fundraising project.
"The students put in a lot of work to prepare all the food for the morning tea and it was great to see some of them get dressed up for the occasion," says Wendy.
Some of the staff even joined in with the pink theme.
Ashley says the student council had fundraised and made donations towards a range of different projects this year, such as the relief efforts following Cyclone Winston in Fiji, Hawera Intermediate School following a fire, Starship Hospital and Midhirst School pupil Campbell Robinson.
"It is great to get behind Breast Cancer Action Month because it affects so many people. It's just as important to raise awareness as well as funds," says Ashley.


text:
Text to speech software Panopreter Plus makes your PC speak and converts text to mp3
Panopreter.com released text to speech software Panopreter Plus which reads aloud text and converts text to mp3 and wave audio files.
Milpitas, CA - September 5, 2010 - Panopreter.com, the innovative software provider has released Panopreter Plus 3.3.1, the powerful and versatile text -to -speech software for Windows users. It's popular with business people, educators, writers, students, language learners and those with visual or vocal impairment, or learning disabilities.
As an easy -to -use and powerful text to speech software program, Panopreter Plus enables people to output their text material into natural -sounding spoken speech flexibly, makes documents, articles, books and web sites audible. The software reads aloud text with natural voices, and converts the text into wave and mp3 audio files, so user can listen to the speech by ear on a PC, or export the audio files to a portable devices such as iPod, smart phone or any other portable mp3 players for listening whenever and wherever they want. Panopreter Plus also makes surfing the web an enjoyable listening experience by including Panopreter toolbar for Internet Explorer which reads out web page and converts the text on the web page to wave or mp3 audio file.
The main features of Panopreter Plus include:
- Read aloud characters, words, phrases, paragraphs or even longer text you have inputted in the window and convert them to audio files.
- Read aloud text file, rft file, pdf file, MS word document and web page.
- Create audio files in wave (.wav) and mp3 format, batch files conversion supported.
- Include Panopreter toolbar for Internet Explorer which reads out the text on the web page and converts the text to audio files.
- Highlight the word or sentence being read.
- Customized volume and rate
- Text font size is adjustable.
- Support a variety of languages and voices.
- User friendly interface and simple to use
- The window is sizable to fit any screen resolution.
- Support every major windows platform, including Windows XP, Vista and 7.
Although Panopreter Plus has many advanced features, it's extremely easy to use and user friendly, all the functionalities are available with just a few mouse button clicks. It is absolutely a convenient, effective and inexpensive solution for people to process their daily digital information.
Panopreter Plus v.3.31 costs $29.95(US) and registered user can update to future version for free and get free support. You can test Panopreter Plus for free for 30 days. More information can be found online at http://www.panopreter.com
About Panopreter.com.
Panopreter.com is dedicated to innovating and delivering outstanding speech solutions for business and consumers around the world. Its technologies, applications, and services bring users more convenience by transforming the way people interact with daily information.
Fred Brook
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text:
- Trending Now: More Trending:
- Svengali syzygy hegemon repugnant white nationalist, white supremacist
close to someone's heart
Definition of close to someone's heart
: considered by someone as very much worth caring about Animal rights is a cause that is close to my heart.
Word by Word Definitions
: to move so as to bar passage through something
: to block against entry or passage
: to deny access to
: a coming or bringing to a conclusion
: a conclusion or end in time or existence : cessation
: the concluding passage (as of a speech or play)
: an enclosed area
: the precinct (see precinct 2a) of a cathedral
: a narrow passage leading from a street to a court and the houses within or to the common stairway of tenements
: having no openings : closed
: confined or carefully guarded
: high
: in a close position or manner
: some person : somebody
: a hollow muscular organ of vertebrate animals that by its rhythmic contraction acts as a force pump maintaining the circulation of the blood
: a structure in an invertebrate animal functionally analogous to the vertebrate heart
: breast, bosom
: love
: hearten
: to fix in the heart
Seen and Heard
What made you want to look up close to someone's heart? Please tell us where you read or heard it (including the quote, if possible).


text:
Make my money finance pvt. ltd
Company History
Make My Money Finance Pvt.Ltd. Can work for you. Whether you're taking out a loan or making an investment, either way it's the same set of formulas. This page gives you the formulas, shows where they came from, and works through lots of examples.
Whether you're thinking of building a new relationship with our Company or have been a loyal customer for many years, Loan is focused on the customer experience and is dedicated to providing you with the expertise, undivided attention and multiple product offerings to meet your financial needs
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text:
The Beetham Tower is a 47-storey skyscraper in Manchester city centre.
It is the tallest building in the UK outside of London and contains a Hilton hotel and private residential apartments and penthouses.
You can see it gets wider half-way up - I think they forgot a piece when they built it!
All pictures © Bill Miller. Please do not use my pictures without permission but do ask me about picture sales.


text:
Adelaide backman Brodie Smith doubts it can be repeated.
Adelaide's stirring AFL elimination final victory against the Western Bulldogs came with glaring statistical anomalies.
The Crows had less scoring shots – and less contested possessions, inside 50s, clearances and tackles.
And while Smith says winning the game by seven points despite losing such key areas is confidence-building, the trend can't be repeated in Friday night's semi-final against Hawthorn.
"Obviously a few areas of our KPIs (key performance indicators) were down at the weekend," Smith told reporters.
"But just the fight of the boys to get over the line and get the win, even though the game probably wasn't going our way at times, we get a lot of confidence out of that, to know that even if we're not winning those areas we can still find ways to win.
"But obviously on Friday night, we have got to win those areas."
The Crows haven't beaten Hawthorn since round one, 2011 – a five-match losing streak against the reigning premiers.
But Smith noted most of those matches had been relatively tight, with Adelaide's losing margins in the past four clashes being 29 points, 12 points, 11 points and five points.
"We have had a few tough games against Hawthorn but I don't think they have beaten us heavily," he said.
"If you go back to the game we played halfway through the year we probably didn't play four quarters of footy and that is what cost us.
"The last month, that is what we have been focussing on: just playing consistent four quarters of footy. And we know if we do that on the weekend and play our best, we can get over the line."