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Moldova will step up an investigation into the disappearance of more than $1 billion from three banks, the head of the central bank told Reuters on Tuesday, after around 10,000 people protested over the scandal at the weekend.
Last year Moldova placed Banca de Economii, Banca Sociala and Unibank under central bank administration after a series of non-performing loans bankrupted the lenders, which together account for up to 20 percent of the tiny former Soviet republic's banking system in terms of assets.
Central bank head Dorin Dragutanu said foreign investigators would be appointed by the end of May in the second phase of a probe into the loss of the money, which is equivalent to around an eighth of Moldova's gross domestic product.
"There appears to have been a deliberate plan to gain control of each of the banks and subsequently manipulate transactions to gain access to credit, whilst giving the appearance to the contrary," the report said.
At the end of the day, the paper machines changed hands on paper; the lenders that loaned the $31.8 million got their money back; Enhanced and the other broker, Stonehenge Community Development of Baton Rouge, Louisiana, pocketed $2 million in fees; and the equity investors – the people or funds that put up the $8.2 million that was not repaid as one-day loans – were promised $16 million in Maine tax credits, which are redeemable over seven years.
In other words, Maine's taxpayers provided the equity investors, who faced little risk, with a $7.8 million profit. And despite the fact that the mill closed and went bankrupt, there's no way for the state to wriggle out of its commitment to pay the investors the $16 million.
For more than a decade after her husband died, Laura Coleman Biggs paid her mortgage to a Bank of America subsidiary. She was never told, even as she was weeks from losing her home, that her husband had actually protected her against foreclosure.
George "Kenny" Mitchell had taken out a special lender-pushed insurance policy to pay off most of his loan if he died.
But when he passed away on April 26, 2003, the subsidiary of Charlotte-based Bank of America did not arrange a payoff of the $100,000 policy and continued to charge his widow an insurance premium every month along with her mortgage payment.
Now Bank of America, Select Portfolio Servicing – a company that collects mortgage payments – and a Florida insurer all face a federal lawsuit in California seeking compensatory and punitive damages, alleging negligence and fraud for their treatment of Biggs.
The Wall Street bonus pool for last year is roughly double the total earnings of all Americans who work full time at the federal minimum wage.
Wells Fargo, one of the largest subprime car lenders, is pulling back from that roaring market, a move that is being felt throughout the broader auto industry.
The giant San Francisco bank, known for its stagecoach logo and its steady profits, has been at the center of the boom in making loans to people with tarnished credit scores. Wall Street, meanwhile, has been bundling and selling such loans as securities to investors, reaping big profits while allowing millions of financially troubled borrowers to buy cars.
Now where did I hear this thing before….
They are people like Zheng Hui Dong, a Chinese immigrant who bought a 2010 Honda Civic from a dealership in Queens for a total cost over the life of the loan of $42,000 — or nearly four times the resale value of the car, according to court records. And Beatriz Rodriguez of Queens, who filed for bankruptcy last year, but still tries to keep up with her $900 monthly payments on the Honda she uses to take care of her grandchildren.
"Let that sink in," he told the audience. "That means it is not uncommon today for a family with subprime credit to take a loan at 110 percent of a used car's value that they will be paying off for seven years."
Nope. No clue. Anybody?
The Daily Telegraph's chief political commentator has resigned and launched a blistering attack on the paper's management and owners over its lack of coverage of the HSBC tax story, which he described as a "fraud on its readers".
Peter Oborne, associate editor of the Spectator and a familiar face on Channel 4 Dispatches documentaries, claimed the paper deliberately suppressed stories about the banking giant, including last week's revelations that its Swiss subsidiary helped wealthy customers dodge taxes and conceal millions of dollars in assets, in order to keep its valuable advertising account.
He said it was a "most sinister development" at the broadsheet title, which he described as "the most important conservative-leaning newspaper in Britain", but where he alleged the traditional distinction between the advertising and editorial departments had collapsed.
Oborne claimed it was a pattern that could be seen elsewhere in the paper's reporting, including its coverage of last year's protests in Hong Kong.
Oborne said the Telegraph's coverage of HSBC, by putting the interests of a major international bank above its duty to report the news, was a "form of fraud on its readers".
Before the latest HSBC revelations were published, and while discussions were continuing over the material, the bank put its advertising with the Guardian's parent company, Guardian News and Media, "on pause".
This time, it's a $4.2 billion fine. That's how much UBS, HSBC, Citibank, JP Morgan Chase, Bank of America, and the Royal Bank of Scotland are collectively paying to U.S., U.K., and Swiss regulators for rigging the foreign-exchange, or FX, market.
Just another day on Wall Street.
This latest malfeasance was something regulators hadn't worried about before, because they didn't think it was possible. The $5.3 trillion FX market, you see, should be far, far too big for any one bank to profitably manipulate it or front-run their clients. And it is. The problem, though, is that big banks have just colluded instead for the past decade. Traders at supposedly competing firms worked together to rig the benchmark FX rates in their favor. They deliberately triggered clients' stop-loss orders—the price they'd automatically sell at to limit losses—to boost their own profits. Along with revealing what trades their customers were about to make, which would let them all make it first.
And, of course, the bankers set up chatrooms charmingly named things like "the 3 musketeers" where they planned all this out in semi-grammatical English. "I'd prefer we join forces" to try to push the price of the euro up, one trader said. "Perfick," the other replied. "Let's double team them."
The lesson is that, with so much money at stake, you should never underestimate how far bankers will go to game the system.
(Reuters) – The euro fell sharply against the dollar on Tuesday after Reuters reported the European Central Bank was looking at buying corporate bonds as soon as December in its efforts to revive the stagnating euro zone economy.
The move, if realized, would expand the private-sector asset-buying program the ECB began on Monday, adding to the number of new euros the bank can put into circulation without politically controversial purchases of government bonds.
"Headlines on the market today about the ECB potentially buying corporate bonds has reinvigorated attention on the downside for the euro," said Richard Cochinos, head of Americas G10 FX strategy at Citi in New York.
"What the headlines have done is remind the market that essentially policy is dynamic and alternative options could potentially be considered," he said.
One might call it "chutzpah," as several irate lawmakers did, or "rubbing salt in the wounds" of the American taxpayer. But to a few Wall Street financiers, a lawsuit that accuses the government of shortchanging the American International Group in its 2008 bailout is something else: a promising investment in a cause they support.
Maurice R. Greenberg, 89, the former A.I.G. chief executive who still holds a large stake in the insurance company, filed the lawsuit on behalf of fellow shareholders. He has now raised several million dollars from three Wall Street companions to help cover the cost of the case. The investors, who are entitled to a cut of any damages Mr. Greenberg collects from the government, contributed about 15 percent of the tens of millions of dollars in legal costs, according to people with knowledge of the arrangement.
The lawsuit, which seeks more than $40 billion from the government, does not dispute that A.I.G. needed a $182 billion lifeline to survive the financial crisis. It instead challenges the onerous nature of the rescue. The government took what became a 92 percent stake in the company — a step it did not pursue with other bailed-out Wall Street giants — imposed a steep interest rate and steered billions of dollars to the insurer's trading partners. Those decisions, the suit says, cheated A.I.G. shareholders and violated the Fifth Amendment, which prohibits the taking of private property for "public use, without just compensation."
Well, let's get established that a "just compensation" for those who caused the crisis in 2008 is a bullet in the head. That should end the lawsuit pretty damn quick.
Former House Majority Leader Eric Cantor (R-VA), who resigned last month after losing renomination to an underfunded college professor, spent much of his 13-plus years in the U.S. Congress advancing the agenda of Wall Street investment firms. This week, he announced that he will be joining a Wall Street investment bank as its new vice chairman.
Cantor will be joining Moelis & Co., the investment bank said, to "provide strategic counsel to the Firm's corporate and institutional clients on key issues," to "play a leading role in client development," and to "advise clients on strategic matters." The announcement press release praised Cantor as a "leading voice on the economy and job creation," who worked in Congress "to lower taxes, eliminate excessive regulation, strengthen small businesses, and encourage entrepreneurship." The deal reportedly includes a $1.4 million signing bonus and at least a $2 million annual compensation package.
As Burger King heads north for Canada's lower corporate tax rate, we speak to Rolling Stone contributing editor Tim Dickinson about his new article, "The Biggest Tax Scam Ever." Dickinson reports on how top U.S. companies are avoiding hundreds of billions of dollars by parking their profits abroad — and still receiving more congressionally approved incentives. Dickinson writes: "Top offenders include giants from high-tech (Microsoft, $76 billion); Big Pharma (Pfizer, $69 billion); Big Oil (ExxonMobil, $47 billion); investment banks (Goldman Sachs, $22 billion); Big Tobacco (Philip Morris, $20 billion); discount retailers (Wal-Mart, $19 billion); fast-food chains (McDonald's, $16 billion) – even heavy machinery (Caterpillar, $17 billion). General Electric has $110 billion stashed offshore, and enjoys an effective tax rate of 4 percent – 31 points lower than its statutory obligation to the IRS."
And small business is not benefiting from all these tax games that multinationals are able to play, and they're having to compete with these companies here.
So, Apple has this amazing deal, where they've got essentially a shadow company in Ireland. And it's incorporated in Ireland, but for Irish purposes, it's an American company, and for American purposes, it's an Irish company. And so you end up with this black hole of taxation where in fact this Apple subsidiary files a tax return to no government in the world. And so, it can use all kinds of accounting tricks to funnel money to this company, and they sit there essentially absolutely untaxed. Just there's no tax return. And so you have billions of dollars sitting there. And again, when Apple needs billions of dollars to fund its American operations, it has bond offerings, and its cost of borrowing here in the United States is incredibly low. Just investors are virtually paying Apple to raise this money, because it's secured by these massive piles of cash, technically abroad, although they're actually banked reportedly in Manhattan.
And any international company NOT doing this would be facing shareholder lawsuits over it.
BOA Logo (2014)Bank of America will pay roughly $4 billion less to the government after-tax than the $16.65 billion it agreed to in a settlement over soured mortgage securities, because parts of the settlement will be tax deductible, the bank said Thursday.
The bank has already taken some of the savings from the settlement's tax deductions in previous quarters, so the savings won't all come in the current third quarter. But tallying the total tax savings to roughly $4 billion "would be fair," a bank spokesman said.
Federal law allows companies to deduct large portions of the costs of settling with federal agencies on their tax returns. But that effectively shifts part of the settlement's burden to taxpayers, and some lawmakers and consumer advocates have expressed concerns that the public can be misled when regulators tout giant settlement amounts that companies aren't fully paying. …
Fines and penalties imposed as part of a settlement can't be deducted, so that knocks out the $5.02 billion in fines Bank of America agreed to pay. But other amounts paid can be deducted as ordinary business expenses—including the $4.63 billion in compensatory payments that Bank of America agreed to pay, and the costs it incurs in providing $7 billion in mortgage modifications for struggling homeowners and other consumer relief.
So there you go – fines are just a business expense.
We received trade execution reports from an active trader who wanted to know why his larger orders almost never completely filled, even when the amount of stock advertised exceeded the number of shares wanted. For example, if 25,000 shares were at the best offer, and he sent in a limit order at the best offer price for 20,000 shares, the trade would, more likely than not, come back partially filled. In some cases, more than half of the amount of stock advertised (quoted) would disappear immediately before his order arrived at the exchange. This was the case, even in deeply liquid stocks such as Ford Motor Co (symbol F, market cap: $70 Billion). The trader sent us his trade execution reports, and we matched up his trades with our detailed consolidated quote and trade data to discover that the mechanism described in Michael Lewis's "Flash Boys" was alive and well on Wall Street.
The main waiver at issue involves "well-known seasoned issuer," or WKSI, waivers to companies.
A WKSI waiver is a coveted tag that lets companies raise money immediately through securities offerings without waiting for SEC approval.
Companies convicted of crimes or found liable for fraud can lose the status, but the SEC can agree to provide the company a waiver so they retain the WKSI tag.
In April, two SEC commissioners dissented over a waiver granted to the Royal Bank of Scotland Group Plc after one of its units struck a criminal plea deal over manipulation of the Libor benchmark interest rate.
A 'flash crash' can knock a trillion dollars off the stock market in minutes as elite traders fleece the little guys. So why aren't the regulators stepping in? We talk to the legendary lawyer preparing for an epic showdown
A billionaire businessman at the heart of a $2.6 billion state bank scam, the largest fraud case since the country's 1979 Islamic Revolution, was executed Saturday, state television reported.Authorities put Mahafarid Amir Khosravi, also known as Amir Mansour Aria, to death at Evin prison, just north of the capital, Tehran, the station reported. The report said the execution came after Iran's Supreme Court upheld his death sentence.
The fraud involved using forged documents to get credit at one of Iran's top financial institutions, Bank Saderat, to purchase assets including state-owned companies like major steel producer Khuzestan Steel Co.
Khosravi's business empire included more than 35 companies from mineral water production to a football club and meat imports from Brazil. According to Iranian media reports, the bank fraud began in 2007.
A total of 39 defendants were convicted in the case. Four received death sentences, two got life sentences and the rest received sentences of up to 25 years in prison.
THE number of billionaires in the UK has exceeded 100 for the first time and London has become home to the highest number of super-rich of any city in the world.
The Sunday Times Super-Rich List, published today, reveals that London has 72 residents whose fortune is more than £1bn, more than Moscow (48) or New York (43). In total the UK boasts 104 billionaires, worth a total of £301bn.
Wow, with so many job creators there, I'm sure there's total employment!
Every day brings multiple new scandals. At least they used to be scandals. Now they're simply news items strained of ethical content by business journalists who see no evil, hear no evil, and speak not about evil. The Wall Street Journal, our principal U.S. financial journal ran two such stories today. The first story deals with tax evasion, and begins with this cheery (and tellingly inaccurate) headline: "U.S. Banks to Help Authorities With Tax Evasion Probe." Here's an alternative headline, drawn from the facts of the article: "Senior Officers of Goldman Sachs and Morgan Stanley Aided and Abetted Tax Fraud by Wealthiest Americans, Failed to Make Required Criminal Referrals, and Demanded Immunity from Prosecution for Themselves and the Banks before Complying with the U.S. Subpoenas: U.S. Department of Justice Caves in to Banker's Demands Continuing its Practice of Effectively Immunizing Fraud by Most Financial Elites."
Oh, and the feckless DOJ (again) did not require any officer who committed the felony of aiding and abetting tax fraud to resign or to repay the bonuses he "earned" through his crimes. But not to worry, the banks – not the bankers – may have to pay fines as the cost of doing their felonious business. The feckless regulators did not even require Goldman Sachs and Morgan Stanley to disclose to shareholders their participation in the program.
A former BP executive who led the company's cleanup of the 2010 Deepwater Horizon oil spill has agreed to pay $224,000 in penalties and restitution in a settlement with the Securities and Exchange Commission for allegedly trading on inside information on the disaster.
SEC regulators say Keith A. Seilhan, 47, a 20-year veteran of BP plc, sold his family's $1 million portfolio of BP securities after learning that the public estimates of the extent of the Gulf of Mexico spill were grossly underestimated. The regulators say the sale of the stock and options saved Seilhan from more than $100,000 in losses.
Seilhan has agreed to pay a $105,409 civil penalty and the same amount in "ill-gotten gains," as well as more than $13,000 in prejudgment interest, Reuters says.
"In his position as Incident Commander [in Houma, La.], Seilhan learned of nonpublic information relating to the seriousness of the disaster, including initial oil flow estimates from the sunken rig that were significantly greater than the public estimate of 5,000 barrels per day. Indeed, those private estimates were between 52,700 and 62,200 barrels per day — a 10x increase than that provided to the public.
"After he learned of this information, Seilhan [liquidated his portfolio.] … By doing so, Seilhan and his family were able to avoid over $100,000 in losses as BP's share price eventually declined 48%. Later, after BP announced it had successfully capped the well, Seilhan repurchased shares of the BP Stock Fund (composed nearly entirely of BP shares) at a lower basis."
Mary McNamara, an attorney for Seilhan, said her client wanted to "avoid further distraction and protracted litigation" by settling the matter, according to Reuters.
"Mr. Seilhan is widely respected for his work helping to lead the cleanup and containment efforts in the Gulf of Mexico in 2010," McNamara added.
Four years ago Chris Christie, the governor of New Jersey, abruptly canceled America's biggest and arguably most important infrastructure project, a desperately needed new rail tunnel under the Hudson River. Count me among those who blame his presidential ambitions, and believe that he was trying to curry favor with the government- and public-transit-hating Republican base.
Even as one tunnel was being canceled, however, another was nearing completion, as Spread Networks finished boring its way through the Allegheny Mountains of Pennsylvania. Spread's tunnel was not, however, intended to carry passengers, or even freight; it was for a fiber-optic cable that would shave three milliseconds — three-thousandths of a second — off communication time between the futures markets of Chicago and the stock markets of New York. And the fact that this tunnel was built while the rail tunnel wasn't tells you a lot about what's wrong with America today.
Who cares about three milliseconds? The answer is, high-frequency traders, who make money by buying or selling stock a tiny fraction of a second faster than other players. Not surprisingly, Michael Lewis starts his best-selling new book "Flash Boys," a polemic against high-frequency trading, with the story of the Spread Networks tunnel. But the real moral of the tunnel tale is independent of Mr. Lewis's polemic.
Think about it. You may or may not buy Mr. Lewis's depiction of the high-frequency types as villains and those trying to thwart them as heroes. (If you ask me, there are no good guys in this story.) But either way, spending hundreds of millions of dollars to save three milliseconds looks like a huge waste. And that's part of a much broader picture, in which society is devoting an ever-growing share of its resources to financial wheeling and dealing, while getting little or nothing in return.
Not only have the nation's banks fully recovered from the financial crisis, their bottom lines are now healthier than ever.
On Wednesday, the Federal Deposit Insurance Corp. said profits at U.S. lenders hit an all-time high in 2013. For the year, the nation's banks made a collective $155 billion. That's up 10% from a year ago, and it was more than the $148 billion the banks made back in 2006, the last time profits peaked.
For the last three months of 2013, banks made $40.3 billion. That was also an all-time high, and a rebound. Bank profits were down in the second and third quarters of the year.
The FDIC noted a large portion of the bottom line boost, though, came from an accounting maneuver that other regulators have cautioned about.
But banks aren't just buying stuff, they're buying whole industrial processes. They're buying oil that's still in the ground, the tankers that move it across the sea, the refineries that turn it into fuel, and the pipelines that bring it to your home. Then, just for kicks, they're also betting on the timing and efficiency of these same industrial processes in the financial markets – buying and selling oil stocks on the stock exchange, oil futures on the futures market, swaps on the swaps market, etc.
Allowing one company to control the supply of crucial physical commodities, and also trade in the financial products that might be related to those markets, is an open invitation to commit mass manipulation. It's something akin to letting casino owners who take book on NFL games during the week also coach all the teams on Sundays.
The situation has opened a Pandora's box of horrifying new corruption possibilities, but it's been hard for the public to notice, since regulators have struggled to put even the slightest dent in Wall Street's older, more familiar scams. In just the past few years we've seen an explosion of scandals – from the multitrillion-dollar Libor saga (major international banks gaming world interest rates), to the more recent foreign-currency-exchange fiasco (many of the same banks suspected of rigging prices in the $5.3-trillion-a-day currency markets), to lesser scandals involving manipulation of interest-rate swaps, and gold and silver prices.
But those are purely financial schemes. In these new, even scarier kinds of manipulations, banks that own whole chains of physical business interests have been caught rigging prices in those industries. For instance, in just the past two years, fines in excess of $400 million have been levied against both JPMorgan Chase and Barclays for allegedly manipulating the delivery of electricity in several states, including California. In the case of Barclays, which is contesting the fine, regulators claim prices were manipulated to help the bank win financial bets it had made on those same energy markets.
And last summer, The New York Times described how Goldman Sachs was caught systematically delaying the delivery of metals out of a network of warehouses it owned in order to jack up rents and artificially boost prices.
The top Obama administration officials working on the Trans-Pacific Partnership came to government from investment banks who will benefit immensely from its provisions, which severely curtail countries' ability to pass laws regulating banks and other corporations. These top advisors, who came from Bank of America and Citigroup, were given multimillion-dollar exit bonuses when they left their employers for government. For example, the US Trade Representative, Michael Froman, was handed $4M from Citigroup as a goodbye gift on his way into his new job.
A third of the mansions on the most expensive stretch of London's "Billionaires Row" are standing empty, including several huge houses that have fallen into ruin after standing almost completely vacant for a quarter of a century.
A Guardian investigation has revealed there are an estimated £350m worth of vacant properties on the most prestigious stretch of The Bishops Avenue in north London, which last year was ranked as the second most expensive street in Britain.
But he argued against increasing taxes on unoccupied homes, which he said would be an "annoyance" that would make buyers choose Monte Carlo or Milan instead of London.
So there's a housing shortage in London, and "people with no economic or cultural ties to the city will move out" is supposed to be a threat?
The rich buying enormous houses so they can sit and rot then complaining people might actually want to tax them for it and threatening to take their "buying an enormous house to sit and rot" business elsewhere is such a breathtakingly good metaphor for the state of the world.
An estimated 2,500 demonstrators braved the cold and snow this evening to protest against the pending partial sale of state-owned energy provider DONG to US investment firm Goldman Sachs.
Parliament's Finance Committee is set to vote on the controversial deal tomorrow. If it pass, Goldman Sachs take a 19 percent stake in DONG at a cost of eight billion kroner.
The partial sale of DONG Energy to Goldman Sachs took a shocking turn this morning after Annette Vilhelmsen, the head of government coalition party Socialistisk Folkeparti (SF), announced that she would step down as head of the party and the party would leave the government coalition.
Vilhelmsen called a meeting this morning after she was unable to obtain a consensus in her party on agreeing to the government's pending DONG/ Goldman Sachs agreement, which is set to be decided on in parliament later today.
"It's been a dramatic 24 hours. I must admit that there has been disagreement in the party, at a national level and in the parliament group," Vilhelmsen said at the press conference at Christiansborg. "I couldn't gather the party."
Not only is this Goldman Sachs, the 19 percent they are buying are being sold at almost half of it proper evaluation, there where pension funds that where willing to pay more and Goldman Sachs would have veto right despite only owning 19 percent.
It makes you wonder which politicians they paid.
Global inequality has increased to the extent that the £1 trillion combined wealth of the 85 richest people is equal to that of the poorest 3.5 billion – half of the world's population – according to a new report from development charity Oxfam.
Boris Johnson has launched a bold bid to claim the mantle of Margaret Thatcher by declaring that inequality is essential to fostering "the spirit of envy" and hailed greed as a "valuable spur to economic activity". In an attempt to shore up his support on the Tory right, as he positions himself as the natural successor to David Cameron, the London mayor called for the "Gordon Gekkos of London" to display their greed to promote economic growth…
In highly provocative remarks, Johnson mocked the 16% "of our species" with an IQ below 85 as he called for more to be done to help the 2% of the population who have an IQ above 130.
The lovely Boris, 49, in the most difficult decision of his life, decides he'll say nice things to rich people.
A lot of people all over the world are having opinions now about the ostensibly gigantic $13 billion settlement Jamie Dimon and JP Morgan Chase have entered into with the government.
The general consensus from most observers in the finance sector is that this superficially high-dollar settlement – worth about half a year's profits for Chase – is an unconscionable Marxist appropriation. It's been called a "robbery" and a "shakedown," in which red Obama and his evil henchman Eric Holder confiscated cash from a successful bank, as The Wall Street Journal wrote, "for no other reason than because they can and because they want to appease their left-wing populist allies."
This is Madoff all over again, only on a much huger scale. Ten years from now, bet on it, the Wall Street Journal will be denouncing everyone from Eric Holder to Lanny Breuer to the SEC and DOJ officials in the Bush administration for failing to protect investors from predatory companies like Bear Stearns, Washington Mutual and their parent, JP Morgan Chase.
Right now, however, these papers are still stuck in the denial phase, which is to be expected, I suppose. But it doesn't mean we have to take these ridiculous editorials about Chase's victimhood seriously.
A few more notes on the deal. This latest settlement reportedly came about when CEO Jamie Dimon picked up the phone and called a high-ranking lieutenant of Attorney General Holder, who was about to hold a press conference announcing civil charges against the bank. The Justice Department meekly took the call, canceled the presser, and worked out this hideous deal, instead of doing the right thing and blowing off the self-important Wall Street hotshot long used to resolving meddlesome issues with the gift of his personal attention.
Only on Wall Street does the target of a massive federal investigation pick up the telephone and call up the prosecutor expecting to make the thing go away – and only in recent American history would such a tactic actually work.
Considering the scale of the offenses involved (one could make the argument that Bear Stearns and Washington Mutual by themselves did enough damage and cranked out enough toxic loans to cause the 2008 crash) the state could have taken the hardest of hard lines. Instead, they once again took a big fat check to walk away.
A 41-YEAR-OLD native of Monaco increasingly looks to be to banking what Edward Snowden is to American surveillance. In 2008 Hervé Falciani walked out of the Geneva branch of HSBC where he'd worked for three years, clutching five CD-Roms containing data on tens of thousands of account holders. The theft has lobbed a bomb into Europe's private-banking market, spawning raids and tax-evasion investigations across the continent. In the latest, 90 Belgian agents swooped on the homes of two dozen HSBC clients this week, including several diamond dealers in Antwerp.Mr Falciani went on the run when the Swiss charged him with data theft. After moving to Spain he was jailed, but freed after a judge denied a Swiss extradition request. At one point, he claims, he was kidnapped by Mossad agents who wanted a peek at the client names. He has now taken refuge in France, where the government has offered him protection in return for assisting in its hunt for tax dodgers.


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Today is water day…and I want to be part of a water movement that brings clean water to every person on the globe.
Because it's a compelling cause:
–The water crisis is at the heart of a daily emergency faced by a billion of the world's most vulnerable people–a crisis that threatens life and destroys livelihoods on a devastating scale. Unlike war and terrorism, the global water crisis does not make media headlines, despite the fact that it claims more lives through disease than any war claims through guns. Unlike natural disasters, it does not rally concerted international action, despite the fact that more people die each year from drinking dirty water than from the world's hurricanes, floods, tsunamis, and earthquakes combined. This is a crisis that is holding back human progress, consigning large segments of humanity to lives of poverty, vulnerability, and insecurity. The church of Jesus Christ can see an end to this silent crisis experienced by the poor and tolerated by those with the resources, technology, and the political power to end it. – Chris Seay
Because it's pursued by visionary communities:
Edmund Burke described visionary communities as "God's little platoons"–little concerts of benevolence committed to the pursuit of something great. Even if my daughter and daughter-in-law weren't among the following "companies of friends," I would want to join these water movements. Both strike at the very heart of the water crisis. Laurie and I are privileged to be part of these heavenly platoons–making significant contributions today to each. We'd love for you to join us. Click on either image below to explore options.
Because it challenges the status quo.
Movements like The Adventure Project and One Billion Thirsty refuse to accept reality–they embrace it, they acknowledge it, they even lament it–but they wont "accept" it. All movements kick back at the darkness. One Billion people in need of clean water?? Crazy. Wrong. But solvable.
All movements both "criticize" and "energize." They never criticize alone; they also bring energy to bear–creating a new reality. Whether it's investing in well-mechanics repairing broken wells in northern India or in new deep water wells in a repairing Sierra Leone, movements like these are taking action. Ideas are one thing, action is another.
Because nothing is easy.
All true revolutions take place in an evolutionary way. Movements that solve the water crisis require thousands of "tiny strategic" actions persevered over the long haul. Movements take time–a long time. Getting clean water to One Billion people won't happen overnight. It won't be easy. It will be hard. But who wants to be part of something easy? Not me. I want to do something that many think can't be done.
And when it's done–how fun will that be!

subset: commoncrawl


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I have to attest my feelings. I have directly experienced Dr. Bill's coaching. I was in a terrible self defeating place in my life. I lost everything, became homeless and was doing everything wrong in my life. I knew I had to change or continue to be a failure. I reached out to Dr. Bill and submitted to his program. After a short time of going through the 1st Level of his Personal Philosophy program and his R.E.S.E.T program my life has begun to significantly change. I got a job and my mindset is shifting. I envision my life and feel completely different. Dr. Bill is a powerful coach who coaches from his heart and has a highly evolved knowledge of how to help people reach what they want for themselves. He is a true genius. Thank you for my life again.
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Bri's Flab to Fab Challange (April 25th- May 21st 2011)
Monday, April 25, 2011 2 comments
Good Morning Sparkers :) I hope everyone had a hoppy easter
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Good Morning Spark people :) Since I have rejoined spark I have been making slow but steady progress and am doing pretty good with tracking my calories and eating only nutritious foods however exercise has been a struggling point for me. It...
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Im back and ready to lose the second half of my weight (wth pic.)
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I have missed spark oh so much! It has been about a month since I posted a blog and a go...
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28 LBS and counting...
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HEllo all my
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Im Wearing What???? (With Pic)
Friday, February 04, 2011 7 comments
So today is another good day! Today my waiste feels small and my smile is giant! Today my skin is glowing (with no makeup on thank you very much) and my jeans are to big on me! Today my face is slim and my hair is working for me ...
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Just Checking In
Thursday, February 03, 2011 5 comments
Hi All Just checking in with you all today. My progress has been steady the past few days, Ive been losing weight fairly quickly this time around probably because I already have all the knowledge and skills that I had to learn last time. Im...
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I'm Back and Have Progress to Share! (Wth Pic.)
Tuesday, February 01, 2011 5 comments
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Thursday, January 06, 2011 7 comments
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Tuesday, December 21, 2010 5 comments
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Why I'm sober as of Day 59 and a WARNING for all ladies out there!!
Monday, December 20, 2010 56 comments
So Day 58 was NOT a good day! Actually it was a complete nightmare! For all the ladies out there please listen to this and please be cautious when you are out and about especially over this holiday weekend...... It started out nice enough, ...
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Why I'm officially a Vegetarian on Day 57
Friday, December 17, 2010 11 comments
Today is Day 57 of my 70 day countdown to New Years and the new me. Today is the start of something new for me and something that I felt like the world was just "forcing" me to do, today is the start of me officially being a Vegetarian! ...
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Another YAY BABY kinda day :)Day 55 with Pics!!!
Wednesday, December 15, 2010 20 comments
176!!! ...
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A Huge WOO-HOO!!! to Day 54
Tuesday, December 14, 2010 14 comments
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Day 53 The countdown Contiunes.. SLOWLY!!
Monday, December 13, 2010 7 comments
Hi All!! Sorry I have been MIA on my teams, blogging and just plain gone off spark the past week. I had the flu :( I was in bed or by the toilet all last week, I couldnt eat anything except chicken broth and water! EGHh... I hate being sick...
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Day 47..Getting back to the basics
Tuesday, December 07, 2010 6 comments
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From lifelong friendships to powerful life lessons to everlasting memories of thrilling victories, there are many reasons for your kids to play sports.
As a parent, you can encourage your kids to participate in, or at least try, youth sports. With so many other factors and activities pulling them in different directions, it's important to properly frame and discuss the many rewards of playing sports.
Liberty Mutual Insurance Play Positive™ sat down with US Youth Soccer Coach Mike Zile to get his thoughts on the importance of playing sports along with the life lessons he learned.
In our exclusive TAKE 5 interview, Mike, who coaches 2014 Region II Presidents Cup Champion Under-16 Boys Mid Rivers SC - Tigers (MO), told us that he believes the biggest life lesson taught by sports is to focus on what you can control.
"The biggest life lesson that I believe I learned through sports is to control what you can control and forget about what you cannot," said Mike. "This lesson applies to so many other aspects of life."
Mike added that sports also teach kids to live and perform on an even keel in order to achieve the best possible results.
"Another key life lesson that sports can teach, if fostered appropriately, is to never get too high or too low from the outcome of a match," said Mike. "Thirty minutes after a big win or devastating loss, kids will be on to something else…and that is how it should be."
Mike said that he has discussions with his youth athletes about "controlling what we can control," and told us a bit about the nature of those conversations in our exclusive interview.
Mike believes that the game of soccer is especially powerful when it comes to teaching these valuable life lessons.
"Soccer can be one of the most beautiful games in the world," said Mike. "One of the things that makes it so is its simplicity. Also, whether you have access to the best equipment in the world or not, most kids can participate in soccer from a very young age."
To read the full TAKE 5 interview with Mike, visit PlayPositive.com. And come back next month for another exclusive TAKE 5 interview!
At Liberty Mutual Insurance, we constantly look for ways to celebrate the countless acts of sportsmanship and integrity shown by people every day. We created Play Positive™, as part of this belief to help ensure that our kids experience the best that sports have to offer in environments that promote and display good sportsmanship. We believe kids can learn valuable life lessons when coaches and parents come together to support winning on and off the field.
©2014 Liberty Mutual Insurance Company


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When is the Festival?
June 30 to July 7, 2018
Where is the Festival located?
The Festival takes place in beautiful Traverse City, Michigan! Although many of the events take place at the Open Space (near the corner of Union Street and Grandview Parkway) there multiple locations across town. Check the event calendar for specific locations.
Where can I park?
Parking is located throughout downtown Traverse City and is managed by the City of Traverse City. The City boosts several parking garages as well as street parking. For more information on parking in Traverse City, visit this website. The National Cherry Festival also offers free shuttle service in cooperation with Bay Area Transportation Authority (BATA).
Is there a lost and found?
If you've misplaced an item, be sure to fill out a form on our lost and found page here.
Where can I pick up the Shuttle?
Each year, a few weeks before the Festival, BATA publishes the festival shuttle route. Parking for the shuttle is located at Northwestern Michigan College and Thirbly Field (off of 14th Street). The Shuttle drops of festival attendees at Garland street, across from the Open Space. An 2017 schedule will be published here when it is available.
Can I bike to the festival?
Yes, yes you can! We offer valet parking (sponsored by AAA and brought to you by Norte) located in the Open Space.
Where is the accessible parking located?
The National Cherry Festival reserves two parking lots for accessible parking. One is located in Parking lot B (see City Parking lot map here) and the other is the public parking at the Clinch Park Marina. To enter the Marina parking lot, you must pass through the permit parking area. As these spots fill up fast, we also offer an accessible location that will allow the driver to drop off passengers and then park off site. That location will be available when the 2017 maps are released and posted here.
When are you open?
The office is open regular business hours during the year. Since our hours do fluctuate a little, check out our contact us page for hour changes. During Festival Week, the Festival Open Space is open from 10 am to 10pm daily! The Midway (operated by Arnold Amusements) is open from 11 am to Midnight.
How much does it cost?
We have over 150 events and 85% of those events are free! Check out our event calendar to see if your event has a cost associated with it.
Are dogs (or other animals) allowed?
Only service animals are allowed at the National Cherry Festival. However, we do have a few pet friendly events, include the Kids Pet Show and Ultimate Airdogs.
What route does the parade take?
For information on the parade routes click here.
What is the Chair Policy for the Parade Routes?
2017 Chair Policy will be posted here when it is available.
Is there accessible seating for the Parades?
Yes. Please check the Parade map for the location of the accessible seating.
What do I need to do to be a street vendor during the parade?
This opportunity is only open to children. If your child would like information on selling along the parade route, please click here.
What boater information do I need to know?
Safety is the primary concern of the National Cherry Festival, United States Coast Guard and the Grand Traverse Veterans Coalition. The U.S. Coast Guard Great Lakes Marine Sector, in cooperation with the FAA, has issued a Marine Permit that authorizes restrictions on boating during these events. We will make every effort to minimize any inconvenience these restrictions may cause you.
The timeframe for these restrictions may change slightly from these published times. Please listen for all Notice to Mariners broadcasts from the U.S. Coast Guard on Channel 16.
We appreciate your cooperation and hope you enjoy these events from your boat.
The Federal Aviation Administration requires areas under an aerobatic box to be clear of all spectators. These restrictions protect the spectators and help eliminate distractions to the air show performers. The restricted area will be marked by orange and white buoys and will be patrolled. The patrol vessels will begin to move boaters out of the area beginning at approximately 11:30 am and we anticipate the area to be closed to all vessels from 12:30 p.m. until about 3:30 p.m. each day. This restriction includes transiting vessels. If you intend to move north or south of the restricted area you must be in position before 12:30 p.m. and will not be able to return until after 3:30 p.m. Please listen to Notice to Mariner broadcasts concerning the restrictions on channel 16.
I have a general admission ticket to a Bay Side Music Stage Concert, do I need to bring a chair?
You may bring a chair, please bring it without a bag, as all bags are searched at the gate. If you choose not to bring a chair, there are two sets of bleachers and plenty of standing room.
Is accessible seating available in the Bay Side Music Stage area?
Yes, please visit the seating charts for each show to see the accessible seating areas. The 2017 seating charts will be posted here when available.
Where can I pick cherries?
The Grand Traverse Area is home to many U-Pick farms and orchards. For a full list, click here.
Are the cherries local?
From the cherries in the pies to the cherries in the products, many are from our local farms! We happily represent Cherries from across the nation during the National Cherry Festival.
Can you tell me about Travel & Accommodations?
Sure! Please click here to visit our Travel & Accommodations page for more information.
How can I be a vendor?
To be a vendor at the Downtown Traverse City Area (DTCA) Arts & Crafts Show or to see if there is availability as a Mobile Marketer or as a Vendor in the Open Space area, please visit our Vendor page.
Can I bring my drone?
The National Cherry Festival is a NO DRONE ZONE. Federal law prohibits flying a drone within 5 Nautical Miles of Cherry Capital Airport with permission from the FAA and Traverse City Air Traffic Control Tower. Violators may face federal, civil and criminal penalties. Questions? Contact 231-486-2900


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Sanrio's New Character Is a Cute Red Panda That Is Secretly Filled With Rage
This morning, I helped my kid put on a Hello Kitty shirt before she went to school. Then I sat down and watched the debut of the latest cutie pie mascot from that character's creators. She needs a hug in the worst way.


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2453 results total, viewing 1 - 10
Sports Scores for April 9 [Photo gallery]
Scores for April 9 more
Posted by Thomas Williams
OHHS crowns its royalty [Photo gallery]
With packed stands and school spirit in full force, Ogemaw Heights High School announced its homecoming king and queen during halftime of the Falcons' game against Cadillac more
By Greg Buckner
Whittemore Speedway closes season with invitational [Photo gallery]
Whittemore Speedway closed out it's 2013 racing season with it's annual end-of-the-season invitational Saturday, Sept. 15. More than 70 cars turned out to battle it out in six classes of racing. more
Posted by Eric Young | firstname.lastname@example.com
FFA students compete in Districts [Photo gallery]
FFA students from Standish-Sterling, Ogemaw Heights, Whittemore-Prescott, Alcona and Alpena competed in district contests at Standish-Sterling Feb. 6. more
Posted by Tim Barnum
First Michigan Mud Jam packs Hale [Photo gallery]
HALE — The first Michigan Mud Jam filled up the Iosco County Fairgrounds in Hale over the weekend, as people traveled from all over the country to participate in the event. There were a number of activities, camping and mud, of course. Saturday, a freestyle event was held featuring a number of drivers from around the U.S., as well as Grave Digger driver Dennis Anderson and his mud truck King Sling. more
Posted by Eric Young | firstname.lastname@example.com
No major injuries in Business Loop accident [Photo gallery]
WEST BRANCH — A two-car accident occurred on the Business Loop, in front of the Glen's Market parking lot, in West Branch Dec. 7, but no major injuries were reported. more
Posted by Greg Buckner
WEST BRANCH — The stands were packed at Ogemaw Heights High School March 17 for "The Big Game in God's Country" basketball fundraiser, which had the Detroit Lions facing off against the Ogemaw County Crime Stoppers All-Stars. more
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Scores for Sept. 17 [Photo gallery]
Scores for Sept. 17 Cross Country Mount Forest Meet:SSCPinconningTawas Alpena MeetOHHS Fairview North Star … more
9/17/13 | 9843 views
Sports scores for Oct. 28 [Photo gallery]
Sports scores for Oct. 28 VolleyballMio 3 (25-25-25)Hale 0 (10-10-19) AGSOscoda more
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Hale heats up with Winterfest [Photo gallery]
Hale was the place to be Saturday, Jan 5, as people packed the area for the Hale YES Winterfest. There were a number of different activities, including a chicken shuffle, snowmobile and ATV drag races, an antique snowmobile show, a chili cook off and outhouse races, just to name a few. more
Posted by Eric Young
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24 Waverley Road
BD7 3HT Bradford, Great Britain
Rafael Plastering Service is a private company categorized underOrnamental Plastering and located in Bradford, United Kingdom. Companies like Rafael Plastering Service usually offer:
Attic Insulation Installation, Batt Insulation Installation, Foam Insulation Installation, Insulation Installation and Roof Insulation Installation.
Related products and services: Drywall and Insulation Contractors, Plastering, drywall, and insulation in Bradford, Plastering, Drywall, And Insulation, Nsk
Number of page views: 500


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For a few weeks this spring the Environmental Protection Agency (E.P.A.) considered an air permit threshold of 250 tons per year (tpy) of carbon dioxide equivalent (CO2e) emissions. Even a relatively small 3 line bakery will emit about 6,500 tonnes of CO2e each year. A tonne is 2,204.6 U.S. lbs.
For the bakery above, sources of CO2e are the carbon dioxide from the burning of fossil fuels such as diesel, petroleum and natural gas both on-site, about 2,000 tonnes, and from the purchase of electric power, about 3,500 tonnes. In addition, wastewater treatment gases such as methane, about 200 tonnes, and refrigerants such as the release of hydrofluorocarbons, about 800 tonnes, could be in the count. Methane and refrigerants are converted to a carbon dioxide equivalent.
For government reporting, fuel for cars and trucks probably will be counted by refineries not individual plants. Biogenic sources such as carbon dioxide emissions from fermentation and from trees are not counted now.
One program to calculate a carbon footprint for energy use is found at Carbon Footprint, www.carbonfootprint.com/businesscalculator.aspx. (See Milling & Baking News of May 5, 2009, Page 26).
Fortunately, on June 29, 2012, the E.P.A. issued a final rule titled, Prevention of Significant Deterioration and Title V Operating Permit Greenhouse Gas (G.H.G.) Tailoring Rule Step 3 and G.H.G. Plantwide Applicability Limits that does not revise the greenhouse gas (G.H.G.) permitting thresholds established in 2011. These emission thresholds determine when Clean Air Act permits under the New Source Review Prevention of Significant Deterioration (P.S.D.) and Title V Operating Permit programs are required for new and existing industrial facilities. Additional rule elements were published Aug. 13, 2012.
According to the E.P.A. 2011 thresholds, new facilities with G.H.G. emissions of at least 100,000 t.p.y. CO2e and existing facilities with at least 100,000 t.p.y. CO2e making changes that would increase G.H.G. emissions by at least 75,000 t.p.y. CO2e are required to obtain P.S.D. permits. Facilities that must obtain a P.S.D. permit anyway, to cover other regulated pollutants, must also address G.H.G. emissions increases of 75,000 t.p.y. CO2e or more. New and existing sources with G.H.G. emissions above 100,000 t.p.y. CO2e also must obtain operating permits. The E.P.A. uses a U.S. ton of 2,000 lbs. (www.epa.gov/nsr/actions.html#2012.)
After evaluating comments on the proposed 100 t.p.y. and 250 t.p.y. thresholds, the E.P.A. determined that state permitting authorities have not had sufficient time to develop necessary permitting infrastructure. At this time, the agency concluded that is not appropriate to apply P.S.D. and Title V permitting requirements to additional, smaller sources of G.H.G. emissions.
Industries that are captured by the rule include electronics manufacturing, petroleum and natural gas systems, electric transmission and distribution equipment, imports and exports of equipment pre-charged with fluorinated G.H.G.s or containing fluorinated G.H.G.s in closed-cell foams, geologic sequestration of carbon dioxide, manufacture of electric transmission and distribution equipment, injection of carbon dioxide.
The primary G.H.G. is carbon dioxide. According to the annual report, titled "Trends in global CO2 emissions," released by the European Commission's Joint Research Centre and The Netherlands Environmental Assessment Agency, global emissions of carbon dioxide (CO2), the main cause of global warming, increased by 3% last year, reaching an all-time high of 34 billion tonnes in 2011. In China, the world's most populous country, average emissions of CO2 increased by 9% to 7.2 tonnes per capita. In the European Union, CO2 emissions dropped by 3% to 7.5 tonnes per capita. The United States remains one of the largest emitters of CO2, with 17.3 tonnes per capita, despite a decline due to the recession in 2008-2009, high oil prices and an increased share of natural gas.
The 3% increase in global CO2 emissions in 2011 is above the past decade's average annual increase of 2.7%. The top emitters in 2011 were: China (29%), the United States (16%), the European Union (11%), India (6%), the Russian Federation (5%) and Japan (4%).
The trend for concern about climate change will continue. Based on analyzing a number of indirect measures of climate such as ice cores, tree rings, glacier lengths, pollen remains, and ocean sediments, and by studying changes in Earth's orbit around the sun, Natural Research Council scientists have constructed a time-line dating back hundreds of thousands of years.
Scientists on the Intergovernmental Panel on Climate Change have concluded that the global average temperature increased by more than 1.4°F over the last 100 years. According to the National Oceanic and Atmospheric Administration, the decade from 2000 to 2010 was the warmest on record, and 2010 was tied with 2005 as the warmest year on record. The Panel also concluded that rising global temperatures have been accompanied by other changes in weather and climate. Many places have experienced changes in rainfall resulting in more intense rain, as well as more frequent and severe heat waves. The planet's oceans and glaciers also have experienced changes: oceans are warming and becoming more acidic, ice caps are melting, and sea levels are rising.
All of these changes are evidence that our world is getting warmer and that the price of energy will increase as the number of related government regulations increase.
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mixgirl83 31-35, F 9 Answers 0 Mar 27, 2014 in Parenting & Family
At your age you shouldn't have to. Simply avoid them as much as is possible. You should love them, but you don't have to like them. You can't change people, they have to have some kind of epiphany, and with those kind of traits, it's highly doubtful that they will.
Best Answer
If your age range in your profile is correct, you shouldn't HAVE TO deal with them at all.....
Best Answer
Explain your feelings to them and see what happens, if they don't change than its best to ignore, and realise that they will never change.
Best Answer
You sound like a child of EP parents.
Best Answer
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I tried to do LED and nothing was working. I thought crappy lights. Are you saying there's a trick to it?Gregory_Miller wrote:Vacuumed it out and replaced the dome light with an LED style. Looks as bright and will run much cooler. Has to installed correctly or no light. I touched it to the terminals in both directions just to see if it had steering diodes to make it polarity indifferent.
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A new Gran Turismo 5 Trailer for the Sony PS3 is now available but as the video is still being processed; the quality is lower than we had hoped. However, it does give us a chance to see a little more from the game and who knows – quality could improve once the processing is fully complete.
The new trailer has already produced a number of comments, most of which are positive. Many readers from N4G point out the obvious – how superb Polyphony's lighting engine is – those night races will certainly look good. We do not wish to be biased here but based on what we have seen so far, GT5 could blow its competition away.
We are still waiting for a release date but we know that one is just around the corner – we hope anyway. Many of N4G readers were not bothered about purchasing the new game, but they have since suggested that they will have to swallow their pride and get it once released.
Take a look at the new Gran Turismo 5 Trailer for the PlayStation below and let us know what you thought.
Follow us on Facebook, Twitter or Google Plus.
Also See: New Gran Turismo 5 Spec II announced, early adopters angry?


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Individual and Center-Level Factors Affecting Mortality Among Extremely Low Birth Weight Infants
OBJECTIVE: To examine factors affecting center differences in mortality for extremely low birth weight (ELBW) infants.
METHODS: We analyzed data for 5418 ELBW infants born at 16 Neonatal Research Network centers during 2006–2009. The primary outcomes of early mortality (≤12 hours after birth) and in-hospital mortality were assessed by using multilevel hierarchical models. Models were developed to investigate associations of center rates of selected interventions with mortality while adjusting for patient-level risk factors. These analyses were performed for all gestational ages (GAs) and separately for GAs <25 weeks and ≥25 weeks.
RESULTS: Early and in-hospital mortality rates among centers were 5% to 36% and 11% to 53% for all GAs, 13% to 73% and 28% to 90% for GAs <25 weeks, and 1% to 11% and 7% to 26% for GAs ≥25 weeks, respectively. Center intervention rates significantly predicted both early and in-hospital mortality for infants <25 weeks. For infants ≥25 weeks, intervention rates did not predict mortality. The variance in mortality among centers was significant for all GAs and outcomes. Center use of interventions and patient risk factors explained some but not all of the center variation in mortality rates.
CONCLUSIONS: Center intervention rates explain a portion of the center variation in mortality, especially for infants born at <25 weeks' GA. This finding suggests that deaths may be prevented by standardizing care for very early GA infants. However, differences in patient characteristics and center intervention rates do not account for all of the observed variability in mortality; and for infants with GA ≥25 weeks these differences account for only a small part of the variation in mortality.
- confidence interval
- continuous positive airway pressure
- extremely low birth weight
- gestational age
- National Institute of Child Health and Human Development Neonatal Research Network
- odds ratio
What's Known on This Subject:
Significant variation in the mortality of preterm infants has been observed among NICUs. Factors explaining this variation have been difficult to identify.
What This Study Adds:
Sizable center differences in mortality exist, even among similarly sized NICUs in academic centers. Patient characteristics and center treatment rates explain some of the center effect, especially for the youngest infants, but a significant portion of these differences remains unexplained.
Both patient factors (eg, gestational age [GA]) and preventive or therapeutic interventions (eg, antenatal corticosteroids) are known to affect the mortality risk of very preterm infants.1 The hospital in which care is provided also affects mortality risk. Variability in mortality rate by center has been observed in several populations and networks.2–7 Two factors may contribute to these center differences: (1) the inherent risk of the patient population served by a center and (2) the patient care delivered at the center. Existing models to predict neonatal mortality at birth are based on individual patient characteristics surrounding birth.1,8–11 These models are useful in providing outcome benchmarks and have been modified as clinical care has improved. They do not, however, adequately address the center effect on outcome. Variation in the patient populations accounts for some but not all of the differences in mortality among centers.12,13 Examining the effect of center on the mortality of extremely low birth weight (ELBW; ≤1000 g) infants may yield insights into ways to improve neonatal care.
The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN), a consortium of university-affiliated NICUs, has maintained a data registry of extremely premature infants using standard data collection and follow-up assessment methods since 1986. This data set allows examination of the variation in neonatal practice and outcomes among academic medical centers. It provides an opportunity to examine possible explanations for the center effect on mortality while controlling for infant and maternal characteristics. In this study, we estimated the variability of ELBW mortality among NRN centers. We assessed the effect of the rates at which centers use certain interventions on this variability in mortality, while adjusting for the effects of patient risk factors known to influence mortality.
Eligible infants from all NRN centers were identified, and patient risk factors and center intervention rates were extracted from records of neonatal and maternal characteristics and interventions available in the NRN registry. These variables were used to build models designed to predict mortality outcomes. Early mortality (≤12 hours) and in-hospital mortality were analyzed separately, first for all infants and then for 2 subgroups of infants, those with GA <25 weeks and those with GA ≥25 weeks.
Data Source
Infants born at NRN centers in 2006–2009 with birth weight of 401 to 1000 g and GA of 22 (0/7) through 28 (6/7) weeks were included. Infants with syndromes or major malformations were excluded. The final data set consisted of 5418 infants from 16 centers. NRN membership did not change during the period of study, 2006–2009.
The NRN ELBW patient registry was approved by the institutional review board at each participating site. Trained research personnel collected maternal, pregnancy, delivery, and infant data as well as morbidity and intervention data from birth until hospital discharge, death, or 120 days of age if still hospitalized. Hospital death after 120 days or survival to discharge was obtained for infants who were hospitalized for longer periods. Definitions for maternal and infant characteristics and interventions were predetermined and described in the manual of operations. GA was determined as the best obstetric estimate on the basis of the mother's last menstrual period and fetal ultrasonography. Patient risk factors and interventions were obtained from individual patient records. Center intervention rates were calculated from the patient data within a given center.
The 2 main outcomes examined in this study were mortality in the first 12 hours after birth (early mortality) and mortality before discharge (in-hospital mortality). These outcomes were not mutually exclusive, because in-hospital mortality included those infants who died early. Deaths that occurred in the delivery room were included in these mortality outcomes. These outcomes were additionally examined in 2 subgroups of patients, those with GA <25 weeks and those with GA ≥25 weeks. The rationale behind testing in these subgroups was that centers or individual physicians within centers may have different policies regarding the resuscitation of infants born at <25 weeks. We assumed that infants born at ≥25 weeks' GA were likely to receive aggressive obstetric and neonatal care, whereas infants born before 25 weeks might have had less aggressive care before and after birth.14
Patient Risk Factors
Patient risk factors used in this study included mother's educational level (less than versus high school diploma or higher), private health insurance coverage, prenatal care utilization, gender of the infant, race, ethnicity, birth weight, gestational age, 5-minute Apgar score (<5 vs ≥5), and multiple birth (versus single birth). Individual birth weights and gestational ages were expressed as differences from local NICU means.
Center Intervention Rates
Interventions available in the NRN registry that may be related to mortality were included in the analysis. These variables were as follows: provision of antenatal corticosteroids, mode of delivery, support given to the infant at delivery (continuous positive airway pressure [CPAP], tracheal intubation, epinephrine), NICU admission, prophylactic indomethacin, early antibiotics (started in the first 72 hours and given for ≥5 days), respiratory support in the NICU (supplemental oxygen, CPAP or assisted ventilation, surfactant, inhaled nitric oxide), postnatal corticosteroids, and any human milk feeding. Center rates of specific interventions (ie, percentage of mothers or infants receiving an intervention) were calculated by aggregating individual patient data for eligible infants over the period of the years 2006–2009 at each center.
Statistical Analysis
Multilevel hierarchical models were used to evaluate center differences in mortality and to evaluate 2 major sources of variation that might explain differences in mortality among centers: patient risk factors and center intervention rates. The assessment of center intervention rates by the presence or absence of patient-level risk factors in a hierarchical model was conducted by using 4 models (Table 1). The derivation and underlying assumptions of the models are described in Appendix 1.
Each model yields an estimated parameter that measures the average center mortality (in log odds terms) and the mortality variance, an estimate of the magnitude of variation or dispersion in center mortality. An estimated mortality variance significantly greater than zero indicates variation in mortality among centers that is unlikely to have occurred by chance alone. A decrease in the variance estimates from models with, to those without, center intervention rates indicates the degree to which these interventions explain the center difference in mortality. By using principal components analysis, all center intervention rates were assigned appropriate weights and combined into a single center intervention score for inclusion in the final models. Principal components analysis allowed this to be accomplished despite the collinearity (ie, high correlation between independent variables) among intervention rates. A technical description of the principal components analysis is provided in Appendix 2 and Appendix Table. The clinical implications of these models, ie, their ability to explain center variation in mortality rate, are described below.
Model 1: Intercept Only
This baseline reference model includes center mortality data and is used to assess the level of and variation in overall center mortality but does not include patient risk factors or the intervention score.
Model 2: Center Intervention Rates
This model extends Model 1 by adding the center intervention score as a predictor of mortality to assess the extent to which variation of center mortality can be explained by center intervention rates. Compared with Model 1, the decrease in the estimated mortality variance provides a measure of overall center mortality that can be explained by intervention rates, without correcting for patient population.
Model 3: Patient-Level Risk Factors
This model includes only infant and maternal characteristics. It is used to assess the magnitude of center variation in mortality while controlling for infant and maternal characteristics. Models 3 and 4 can be compared directly only with each other and not with Model 1 or 2.
Model 4: Patient Risk Factors and Center Intervention Rates
This model extends Model 3 by adding the center intervention score as a predictor of center mortality and includes covariates of the infant and maternal characteristics. This model is used to assess the effect of the intervention rates on center mortality after controlling for patient-level risk factors. A decrease in the mortality variance provides a measure of the center variation in mortality explained by center intervention rates after controlling for patient risk factors.
These models were derived for all infants and for the subgroups with GAs <25 weeks and ≥25 weeks. All modeling analyses were performed by using the Xtmelogit command in Stata 12 (StataCorp, College Station, TX).
Wide ranges in intervention rates and mortality were observed among NRN centers for infants of all GAs as well as for those with GAs <25 weeks and ≥25 weeks (Table 2, Fig 1). The ranges of the intervention rates for infants with GA <25 weeks were typically wider than those for infants with GA ≥25 weeks.
Our major estimation results from the multilevel models are summarized in the following paragraphs (Table 3).
Infants of All GAs: Early Mortality
Model 2 indicates the intervention score had a significant association with center mortality (odds ratio [OR]: 0.79; 95% confidence interval [CI]: 0.74–0.84) and reduced the center mortality variance from 0.38 to 0.07. After controlling for patient risk factors in Models 3 and 4, the association of the intervention score remained significant (OR: 0.76; 95% CI: 0.67–0.86) and the mortality variance was reduced by from 0.64 to 0.27.
Infants of All GAs: In-Hospital Mortality
Before controlling for individual risk factors, the intervention score significantly reduced the odds of the overall center in-hospital mortality (OR: 0.87; 95% CI: 0.83–0.90) and reduced its variance from 0.16 to 0.03. After controlling for patient characteristics, the effect of the intervention score also remained significant (OR: 0.84; 95% CI: 0.77–0.91) and reduced the variance of the center mortality rate from 0.31 to 0.14.
Infants With GA <25 Weeks: Early Mortality
The intervention score was significantly related to mortality (OR: 0.76; 95% CI: 0.72–0.79) and accounted for all variation in mortality among centers as evidenced by the variance estimate of 0 for Model 2. After accounting for patient risk factors, the intervention score was still significant (OR: 0.67; 95% CI: 0.61–0.74) and reduced the mortality variance from 1.08 to 0.08.
Infants With GA <25 Weeks: In-Hospital Mortality
Before correcting for patient characteristics, the intervention score was significantly related to odds of mortality (OR: 0.83; 95% CI: 0.78–0.88) and reduced the mortality variance from 0.35 to 0.05. After controlling for individual risk factors, the intervention score remained significant (OR: 0.79; 95% CI: 0.71–0.87) and reduced the mortality variance from 0.62 to 0.20 among centers.
Infants With GA ≥25 Weeks: Early Mortality
The association of the intervention score with early mortality was significant for infants with GA ≥25 weeks but had a wider CI than that among all infants or the <25-week subgroup (OR: 0.84; 95% CI: 0.73–0.96). Including the intervention score reduced the center mortality variance from 0.21 to 0.11. After controlling for patient risk factors, the association of the intervention score became borderline significant (OR: 0.86; 95% CI: 0.73–1.01) and reduced the variance of the center mortality rate from 0.25 to 0.17.
Infants With GA ≥25 Weeks: In-Hospital Mortality
The association of the intervention score was not statistically significant either before or after accounting for patient risk factors.
The mortality variance estimates from all models, in all subgroups of each outcome, after accounting for patient risk factors were significantly greater than zero. Thus, center variation in early and in-hospital mortality exists even after controlling for intervention rates and patient risk factors.
Our study yields a number of interesting points for consideration. First, it reveals that in the NRN, there was significant variation among centers in ELBW mortality. This result was true for both early and in-hospital mortality for each GA subset; it is shown in the observed center death rates and also by the significant center mortality variance estimates from Model 1, which did not include center interventions or patient risk factors, for each outcome and subgroup. Second, our modeling results cast doubt on the commonly held concept that variation in outcomes is due largely to differences in patient population. The center mortality variance estimates after correcting for patient risk factors (Model 3) were still significant for all outcomes and subgroups. Finally, center intervention rates predicted mortality outcomes and reduced differences in the outcomes among the centers. In deriving the intervention scores, interventions not generally given in the first 12 hours of life were excluded for the early mortality outcome. As indicated by the weighting factors used in the principal components analysis (Appendix 2), the intervention scores were primarily composed of the averages of the center intervention rates of NICU admission, respiratory support, supplemental oxygen, surfactant, and, for infants of <25 weeks' GA, antenatal corticosteroids, cesarean delivery, and tracheal intubation. The intervention scores showed significantly positive association with both early and in-hospital mortality in the all-GA population and in the <25-week GA subgroup, but they showed only a trend toward significance in the ≥25-week GA subgroup. In addition, the center mortality variance was greatly reduced when the intervention score was included in the models. These intervention scores reduced the mortality variance estimates substantially for both early and in-hospital mortality for the all-GA group, and in the <25-week GA subgroup the reductions were even greater. This finding was true even after correction for patient risk factors. Therefore, a substantial number of additional infants would be predicted to survive both past 12 hours and until discharge should the utilization of the examined interventions be increased for infants at the earliest gestational ages (<25 weeks). One potential explanation for the finding that increased intervention is especially beneficial for infants with GA <25 weeks concerns the wider range of the centers' use of supportive therapies in the intrapartum period and the first hours of life. In particular, there was large practice variation among centers in the use of antenatal corticosteroids, cesarean delivery, respiratory support, and NICU admission for these most premature infants. Our derived intervention score more effectively represents the specific intervention therapies examined among infants with GA <25 weeks than among infants with GA ≥25 weeks. More research is needed to identify and determine other factors associated with mortality among infants with GA ≥25 weeks.
This study's strengths include the use of high-quality data from the centers of the NRN collected by trained research staff applying standardized methods. The use of prospectively collected data has presumably limited the probability of selection bias and misclassification of covariates and outcomes. The use of the hierarchical modeling method allowed us to separate the effects of patient- and center-level variables and to assess the impacts of center-level variables both on mortality and on its variability among centers. Limitations of the study include the relatively small number of centers. Also, capturing all variability in care is unlikely given the limited number of elements in the NRN database, even after correcting for patient-level differences. Thus, some interventions or approaches not available in the NRN database may affect center mortality rates. This observational study reveals an association between interventions and survival, but intervention trials are required to demonstrate a true causal link between specific interventions and patient survival. Finally, our study was not able to examine variability in physician-level care within centers or the quality with which interventions were implemented, which are additional possible contributors to variation in outcome.
Our results show that even though aggressive intervention with more infants would increase survival, the use of the interventions we studied does not fully explain the center variation in mortality, which implies that there are unaccounted-for variables that affect the center differences in mortality. Previous studies have postulated what these factors may be. Horbar et al12 found that patient volume and the presence of a residency program were not predictive of outcomes. Rogowski et al13 found that the percentage of Medicaid beneficiaries, type of hospital ownership, and presence of a teaching hospital were not significant predictors of outcomes. These investigators also found that very low volume centers had worse outcomes and that the outcome was related to the level of NICU. These findings do not explain the variation in mortality among NRN centers, which are all high-volume, high-level centers.
Our results suggest that decisions of whether to resuscitate very preterm infants affect mortality and are detectable at the center level. This observation raises ethical issues. However, creating clear policies on the appropriateness of resuscitating ELBW infants is extremely difficult,15,16 and a thorough examination of this topic is beyond the scope of this study. This report simply highlights that increased survival is possible, and the authors believe that decision makers (parents and physicians) should be aware of this fact. More aggressive intervention of these neonates would increase their likelihood of survival. The current study does not address the impact of more aggressive intervention on the likelihood of "intact" survival, ie, survival without major neurodevelopmental impairment, but this association has been shown in this network.17 More active intervention of extremely preterm infants may benefit not only these infants but also more mature infants; centers in which intensive care is more frequently provided to extremely preterm infants have been shown to have better outcomes, too, for preterm infants of later gestation.18
Neonatal care has been advanced by the development and testing of beneficial therapies.19 It is important to note that the magnitude of the center effect on ELBW mortality is larger than the intervention effects of even the most potent therapies, such as antenatal corticosteroids and surfactant replacement therapy. This fact underscores the importance of stratification by center in all multicenter clinical trials in neonatology. The findings of our study support a role for comprehensive, well-designed, quality-improvement trials focusing on the care of very early GA infants.
There are large differences among centers in the mortality rate of extremely preterm infants. Patient characteristics do not adequately account for this variability. Center use of certain interventions predicts survival for the lowest GA infants, but it explains little of the observed variability in in-hospital mortality for infants born at ≥25 weeks. Some as-yet-unmeasured characteristics of the centers account for the remainder of the observed variability. The variation in mortality among centers may be reduced through standardization of care for very early GA infants. However, other center differences may explain the residual differences in mortality.
Appendix 1: Specifications of Multilevel Hierarchical Models
Denote the outcome variable by an indicator yij, such that patient i in center j will die (yij = 1) or survive (yij = 0). Let aj be a random variable and uj be a normally distributed random-error term with a mean of 0 and an SD of σ for center j. Let PCJ be the principal components score from the center intervention rates with coefficients γ1 and x1ij … x9ij representing the 9 patient and maternal characteristics with corresponding coefficients (β1 … β0). The 4 model forms used for the probability of death, P(yij = 1), are as follows.
Model 1
Patient-Level Model
Center-Level Model
Model 2
Patient-Level Model
Center-Level Model
Model 3
Patient-Level Model
Center-Level Model
Appendix 2: Composition of First Principal Components of Center Intervention Rates
Principal components analysis is a method to reduce the number of variables under consideration. We have included as many as 15 types of interventions in this study. It is unrealistic to include all of these interventions simultaneously in the multilevel models, but we can try to derive an index from these intervention rates and use it as a predictor. The principal components generated from the intervention rates are such indices in the form of linear combinations of the intervention rates and can best represent the variation of these intervention rates among centers. A brief description of the method follows.
Let X represent a matrix in which each column contains the intervention rates for a center and β represent a standardized vector of the weighting factors in the linear combination of the intervention rates such that β′β = 1. For simplicity of notation, the intervention rates are deducted by their means so that they have a mean of 0. Then, linear combinations of the intervention rates can be represented for all centers as β′X.
A variance estimate of linear combination of the intervention rates will be as follows:
Note that XX′/(n − 1) is a variance estimate of the intervention rates and often denoted by Σ. Principal components analysis produces a set of uncorrelated linear combinations whose variances, added together, are identical to that in Σ. Usually, they are ordered by their variances, and the proportion of variance to total variance indicates their relative importance. The first principal component that has the maximum variance is often of particular interest Those principal components with a small variance may be ignored.
The proportion of variance and the weighting factor β for the first principal component of the intervention rates for predicting early mortality and in-hospital mortality are shown below. It can be seen that the proportion of variance is higher for the intervention rates for early mortality and much higher among infants with GA <25 weeks. Also, these principal components are essentially an average of all center rates except for CPAP and epinephrine. The weighting factors for the center rates are nearly equal, but those for CPAP and epinephrine are close to zero. Similarly, the principal components score for in-hospital mortality is an average of all center rates except for CPAP, epinephrine, and prophylactic indomethacin.
Data collected at participating sites of the NICHD Neonatal Research Network (NRN) were transmitted to RTI International, the data coordinating center (DCC) for the network, which stored, managed, and analyzed the data for this study. On behalf of the NRN, Drs Abhik Das (DCC Principal Investigator) and Lei Li (DCC Statistician) had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.
The following investigators, in addition to those listed as authors, participated in this study:
NRN Steering Committee Chair: Michael S. Caplan, MD, University of Chicago, Pritzker School of Medicine.
Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island (U10 HD27904): William Oh, MD; Angelita M. Hensman, RN, BSN; Dawn Andrews, RN MS; Kristen Angela, RN.
Case Western Reserve University, Rainbow Babies and Children's Hospital (U10 HD21364, M01 RR80): Avroy A. Fanaroff, MD; Bonnie S. Siner, RN.
Cincinnati Children's Hospital Medical Center, University Hospital, and Good Samaritan Hospital (U10 HD27853, M01 RR8084): Kurt Schibler, MD; Edward F. Donovan, MD; Kate Bridges, MD; Barbara Alexander, RN; Cathy Grisby, BSN, CCRC; Holly L. Mincey, RN, BSN; Jody Hessling, RN; Lenora Jackson.
Duke University School of Medicine, University Hospital, Alamance Regional Medical Center, and Durham Regional Hospital (U10 HD40492, M01 RR30): Kathy J. Auten, MSHS; Kimberley A. Fisher, PhD, FNP-BC, IBCLC; Katherine A. Foy, RN.
Emory University, Children's Healthcare of Atlanta, Grady Memorial Hospital, and Emory University Hospital Midtown (U10 HD27851, M01 RR39): David P. Carlton, MD; Ann M. Blackwelder, RNC, BS, MS.
Eunice Kennedy Shriver National Institute of Child Health and Human Development: Stephanie Wilson Archer, MA.
Indiana University, University Hospital, Methodist Hospital, Riley Hospital for Children, and Wishard Health Services (U10 HD27856, M01 RR750): Brenda B. Poindexter, MD, MS; Dianne E. Herron, RN; Leslie Dawn Wilson, BSN, CCRC.
RTI International (U10 HD36790): W. Kenneth Poole, PhD; Jeanette O'Donnell Auman, BS; Margaret Cunningham, BS; Carolyn M. Petrie Huitema, MS; James W. Pickett II, BS; Scott E. Schaefer, MS; Kristin M. Zaterka-Baxter, RN, BSN.
Stanford University, Dominican Hospital, El Camino Hospital, and Lucile Packard Children's Hospital (U10 HD27880, M01 RR70): Krisa P. Van Meurs, MD; David K. Stevenson, MD; Marian M. Adams, MD; M. Bethany Ball, BS, CCRC; Melinda S. Proud, RCP; Andrew W. Palmquist, RN, BSN.
Tufts Medical Center (U10 HD53119, M01 RR54): Ivan D. Frantz III, MD; Brenda L. MacKinnon, RNC; Ellen Nylen, RN, BSN.
University of Alabama at Birmingham Health System and Children's Hospital of Alabama (U10 HD34216, M01 RR32): Monica V. Collins, RN, BSN, MaEd; Shirley S. Cosby, RN, BSN.
University of California–San Diego Medical Center and Sharp Mary Birch Hospital for Women and Newborns (U10 HD40461): Neil N. Finer, MD; Maynard R. Rasmussen MD; Paul R. Wozniak, MD; Kathy Arnell, RNC; Renee Bridge, RN; Clarence Demetrio, RN; Wade Rich, BSHS, RRT.
University of Iowa Children's Hospital (U10 HD53109, M01 RR59): John A. Widness, MD; Karen J. Johnson, RN, BSN; Nancy J. Krutzfield, RN, MA.
University of Miami Holtz Children's Hospital (U10 HD21397): Shahnaz Duara, MD; Ruth Everett-Thomas, RN, MSN.
University of New Mexico Health Sciences Center (U10 HD53089, M01 RR997): Kristi L. Watterberg, MD; Lu-Ann Papile, MD; Robin K. Ohls, MD; Conra Backstrom Lacy, RN; Rebecca Montman, BSN; Carol Hartenberger, BSN, MPH.
University of Rochester Medical Center, Golisano Children's Hospital (U10 HD40521, M01 RR44): Dale L. Phelps, MD; Linda J. Reubens, RN, CCRC; Erica Burnell, RN; Cassandra Horihan, MS; Rosemary Jensen.
University of Texas Southwestern Medical Center at Dallas, Parkland Health and Hospital System, and Children's Medical Center Dallas (U10 HD40689, M01 RR633): Pablo J. Sánchez, MD; Charles R. Rosenfeld, MD; Walid A. Salhab, MD; Luc P. Brion, MD; Alicia Guzman; Gaynelle Hensley, RN; Melissa H. Leps, RN; Diana M. Vasil, RNC-NIC; Nancy A. Miller, RN; Lizette E. Torres, RN.
University of Texas Health Science Center at Houston Medical School, Children's Memorial Hermann Hospital, and Lyndon Baines Johnson General Hospital/Harris County Hospital District (U10 HD21373): Kathleen A. Kennedy, MD, MPH; Jon E. Tyson, MD, MPH; Beverly Foley Harris, RN, BSN; Anna E. Lis, RN, BSN; Sarah Martin, RN, BSN; Georgia E. McDavid, RN; Patti L. Pierce Tate, RCP; Maegan C. Simmons, RN.
University of Utah Medical Center, Intermountain Medical Center, LDS Hospital, and Primary Children's Medical Center (U10 HD53124, M01 RR64): Roger G. Faix, MD; Bradley A. Yoder, MD; Karen A. Osborne, RN, BSN, CCRC; Karie Bird, RN; Jill Burnett, RNC; Cynthia Spencer, RNC; Kimberlee Weaver-Lewis, RN, BSN; Karen Zanetti, RN.
Wake Forest University, Baptist Medical Center, Brenner Children's Hospital, and Forsyth Medical Center (U10 HD40498, M01 RR7122): T. Michael O'Shea, MD, MPH; Nancy J. Peters, RN, CCRP.
Wayne State University, Hutzel Women's Hospital, and Children's Hospital of Michigan (U10 HD21385): Rebecca Bara, RN, BSN; Mary E. Johnson, RN, BSN; Elizabeth Billian, RN, MBA.
Yale University, Yale-New Haven Children's Hospital, and Bridgeport Hospital (U10 HD27871, UL1 RR24139, M01 RR125): Richard A. Ehrenkranz, MD; Harris Jacobs, MD; Patricia Cervone, RN; Monica Konstantino, RN, BSN; JoAnn Poulsen, RN; Janet Taft, RN, BSN.
We are indebted to our medical and nursing colleagues and the infants and their parents who agreed to take part in this study.
- Accepted March 15, 2013.
- Address correspondence to Edward F. Bell, MD, Department of Pediatrics, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242. E-mail: edward-bell{at}uiowa.edu
Mr Alleman participated in the conception and design of the study including the analysis plan and in the interpretation of the data and wrote the first and subsequent drafts of the manuscript and helped to revise it critically for important intellectual content; Dr Bell conceived and helped to design the study including the analysis plan, participated in the interpretation of the data, and revised the manuscript critically for important intellectual content; Dr Li helped to design the analysis plan and was responsible for the data management and analysis, performed the analysis with guidance from Mr Alleman and Dr Bell and with advice from Drs Das and Wallace, and helped to revise the manuscript critically for important intellectual content; Drs Dagle and Murray participated in the conception and design of the study, participated in the interpretation of the data, and helped to revise the manuscript critically for important intellectual content; Drs Smith, Ambalavanan, Laughon, Cotton, Shankaran, Walsh, Laptook, Ellsbury, and Higgins participated in the design of the study, participated in the interpretation of the data, and helped to revise the manuscript critically for important intellectual content; Dr Stoll participated in the design of the study, chaired the committee responsible for designing and managing the study from which the data were drawn, participated in the interpretation of the data, and helped to revise the manuscript critically for important intellectual content; Dr Goldberg and Carlo participated in the conception of the study, participated in the interpretation of the data, and reviewed the manuscript critically for important intellectual content; Ms Hale and Ms Newman participated in the design of the study, contributed to the data collection, and helped to revise the manuscript critically for important intellectual content; and Drs Wallace and Das participated in the design of the study and the plan for data analysis, were responsible for the data management, participated in the analysis, and helped to revise the manuscript critically for important intellectual content.
FINANCIAL DISCLOSURE: The authors have indicated that they have no financial relationships relevant to this article to disclose.
FUNDING: The National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) provided grant support for the Neonatal Research Network's Generic Database Study. Dr Higgins is employed by the NICHD. The institutions of the other authors (except for Dr Ellsbury) received grant funding from the NICHD in support of this study. Funded by the National Institutes for Health.
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- Copyright © 2013 by the American Academy of Pediatrics