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Medicare Part D is the program that helps pay for prescription drugs prescribed by a doctor. This does not include over-the-counter drugs that you can buy without a prescription. Part D is optional and every Medicare recipient is offered coverage. If you are new to Medicare, you should consider your Plan D options carefully. All plans are not created equal.
You may sign up when you first become eligible for Medicare. Even if you are not taking many prescription drugs today, it may be smart to enroll when you are first eligible, to avoid potentially paying a penalty if you do not have creditable (see note below) prescription drug coverage or don't get Extra Help (see section below). To learn how these plans work go to Learn How Plans Work.
Note: Creditable Prescription Drug Coverage is defined as Prescription drug coverage (for example, from an employer or union) that's expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.
What Drug Plans Cover
Each Medicare Prescription Drug Plan has its own list of covered drugs and these are sometimes placed in "tiers". These tiers are important because drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier.
How to Get Drug Coverage
There are two ways you can be covered by Part D:
- With a stand-alone Part D Prescription Drug plan that is run by an insurance company or other private company approved by Medicare. These plans (sometimes called "PDPs") add drug coverage to Original Medicare. Each plan can vary in cost and drugs covered, OR
- With a Medicare Advantage Plan (Part C) that offer Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans.
Note: You cannot enroll in both a stand-alone Part D plan and a Medicare Advantage plan that includes Part D. Be sure to review the plan's drug list when deciding on a plan. Your drugs coverage and costs vary by plan so be sure to review the plan carefully. Look at annual deductibles, premiums and copays, in addition to your anticipated drug needs, when deciding.
Whatever plan you choose, Medicare drug coverage will help you by covering brand name and generic drugs at pharmacies that are convenient for you.
Part D Prescription Costs
Part D plans vary by list of covered drugs and costs like the annual deductible and copays. You'll want to consider all your costs when choosing a plan. You can call toll free to: (877) 734-3441 TTY:711 or get information at our compare plans page to get specifics for your circumstances.
Here's a table of potential costs to consider:
|Monthly premium for drug plans
|Most Medicare Prescription Drug Plans charge a monthly fee that varies by plan. You pay this in addition to the Medicare Part B premium. If you belong to a Medicare Advantage Plan (Part C) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium you pay to your plan may include an amount for drug coverage.
|Your premium could be higher based on income
|A small group—fewer than 5% of all people with Medicare—may pay a higher monthly premium for Medicare Part D coverage based on their income. This includes Part D coverage you get from a Medicare Drug plan or a Medicare Advantage Plan or Medicare Cost Plan that includes drug coverage. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain limit, you'll pay an extra amount in addition to your plan premium. Usually, the extra amount will be deducted from your Social Security check.
|Yearly deductible for drug plans
|This is the amount you must pay each year for your prescriptions before your Medicare Prescription Drug Plan begins to pay its share of your covered drugs. Deductibles vary between Medicare drug plans. No Medicare drug plan may have a deductible more than $325 in 2013. Some Medicare drug plans don't have a deductible.
|Copayment/coinsurance in drug plans
|Copayment, or coinsurance, is the amount you pay for each of your prescriptions after you have paid the deductible (if your plan has one). Some Medicare Prescription Drug Plans have different levels or "tiers" of copayments or coinsurance, with different costs for different types of drugs.
|Costs in the coverage gap – the "donut hole"
|Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2013, once you and your plan have spent $2,970 on covered drugs (the combined amount plus your deductible), you're in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won't enter the coverage gap. Once you enter the coverage gap, you get a 50% manufacturer-paid discount plus an additional 2.5% paid by the Medicare Part D plan on covered brand-name drugs. Although you'll only pay 47.5% of the price for that brand-name drug, the entire price will count as out-of-pocket costs which will help you get out of the coverage gap.
When Can I Join A Medicare Drug Plan?
Generally, you can join, switch, or drop a Medicare drug plan:
- When you first become eligible for Medicare due to age (the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65).
- If you get Medicare due to a disability, you can join during the 7-month period that begins 3 months before your 25th month of entitlement to disability payments, includes your 25th month, and ends 3 months after your 25th month of entitlement to disability payments.
- During open enrollment, from October 15 – December 7. If you make a change during open enrollment, your coverage will begin January 1st of the following year.
- At any time, if you qualify for Extra Help.
- You're getting care in an institution, like a skilled nursing facility or long‐term care hospital.
Special Enrollment Periods
You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs) and are in addition to the regular enrollment periods that happen each year. Rules about when you can make changes and the type of changes you can make are different for each SEP.
For more information about SEPs, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. They are available 24 hours a day, 7 days a week.
What Plan is Best For Me?
There are quite a number of different plans under Part D that provide different levels of coverage for different drugs. Currently there are over 1,800 plans nationwide. It can be quite confusing trying to figure what plan is best for you. Medicare has a number of free booklets that can help. Here are some links to worthwhile information:
Medicare Prescription Drug Plan Finder
The Medicare site also lets you find and compare drug plans, view your current drug plan, and enroll in a drug plan. For more information, click on the Medicare Prescription Drug Plan Finder.
State by State Information
Drug plans vary by state, so the Medicare web site also has booklets for each plan that is available in each state. To download the information for a specific type of plan in your state, click on Medicare's Landscape of Local Plans State-by-State Breakdown. You can also download a chart that lists Plan D premiums by state for 2013. You can access this at Medicare Part D Prescription Drug Plan (PDP) Availability. To talk with someone who can help tailor a plan to your specific needs, call (877) 734-3441 TTY:711 or fill out our quick online form.
Programs for People with Limited Income and Resources
With certain income and resource limits, you may qualify for Extra Help to pay the costs of Medicare prescription drug coverage.
Drug costs in 2013 for most people who qualify will be no more than $6.60 for each brand name and $2.65 for each generic/$6.60 covered drug.
Other people may pay only a portion of their Medicare drug plan premiums and deductibles based on their income level.
You may qualify if you have up to $11,570 in yearly income and resources as an individual or $23,120 for a married couple.
Countable resources include:
- Money in a checking or savings account
- Stocks
- Bonds
Countable resources do not include:
- Your home
- One car
- Burial plot
- Up to $1,500 for burial expenses if you have put that money aside
- Furniture
- Other household and personal items
If you don't qualify for Extra Help, your state may have programs that can help pay your prescription drug costs. Contact your State Medical Assistance (Medicaid) office or your State Health Insurance Assistance Program (SHIP) for more information. Remember, you can reapply for Extra Help at any time if your income and resources change.


text:
Bye-Bye, Body on Frame?
New models won't make it with a truck chassis. But body-on-frame vehicles haven't seen their last hurrah.
Let's answer the question Autoweek posed here Wednesday: No, the Chevrolet Trailblazer will not ever come back to the U.S. as a reborn, full-size SUV.
Partially, it's because Chevrolet already sells two full-size SUVs (Tahoe, Suburban), a full-size crossover (Traverse), and a smaller crossover (Equinox). Then there's the Acadia, a GMC-only midsize SUV. But the real reason? Body-on-frame trucks, at least in the U.S., are a surefire way to kill a new model before it even has time to linger.
Just ask Kia, which introduced the body-on-frame Borrego for 2009 and gave it the sweep that same year. When my colleague Bill Griffith tested one for The Boston Globe, he wrote that the "V8 version's ride was rough enough to be disconcerting, even after trying lower tire pressures." Like a garbage truck.
The Nissan Pathfinder is switching to unibody construction for 2013, the once popular Ford Explorer has ditched both the V8 and truck frame, and the Lincoln Town Car -- the only body-on-frame sedan still on sale here -- is departing forever after this year.
Unibody construction makes for a more carlike experience. The body floor, pillars and roof are welded together as one unit, and the engine and suspension hang off on subframes. They are lighter and more rigid than a body-on-frame chassis, which uses two thick steel beams braced together under a separate, mounted body.
Some off-road purists say that body-on-frame vehicles, because they allow more torsion, tend to take a beating better, and they're mostly right. That's why every pickup truck, save for the Honda Ridgeline, and full-size van uses a body-on-frame design. Their tough, simple construction allows for superior towing, payload and overall durability in heavy-duty use. Plus, as Hemmings notes, body-on-frame vehicles are cheaper to repair after an accident -- hence the reluctance for taxi companies and police agencies to give up their Crown Vics. They're also heavier, meaning a fuel-economy penalty is unavoidable.
But has the unibody truly decimated the body-on-frame chassis? By my count, 22 body-on-frame vehicles are on sale in the US, excluding pickups, vans and heavy-duty commercial trucks. Let's take a quick look at why they still exist when compared with their typically better-handling, better-riding and more efficient unibody competition.
Ford Expedition/Lincoln Navigator – These hulking dinosaurs have hardly been updated since their 2000s-era heyday and aren't as popular as the GM SUVs.
Jeep Wrangler – The original American rock-crawler won't ever change its beefy body-on-frame design. It's the last bastion between real trucks and wannabes.
Nissan Xterra – With the Pathfinder becoming "softer," the Xterra is a less expensive, more hard-core ride for committed SUV buyers.
Nissan Armada – The owner of a dog-grooming business down the street from me uses an Armada to haul her 165-pound Great Dane. She needs this truck more than anyone.
Nissan Pathfinder – The 2013 Pathfinder will share its unibody platform with the brand-new Infiniti JX. The current Pathfinder is simply old.
Infiniti QX56 – Everything is enormous and overkill on this superluxe rig. For some reason, everything that fails to gain attention in the Lincoln Navigator -- huge V8 engine, houselike proportions, is working for Infiniti.
Toyota Land Cruiser/Lexus LX 570 – The Land Cruiser and LX 570 are old classics that are almost as nice as a Range Rover for somewhat less money.
Toyota FJ – Another classic, albeit with three windshield wipers. See Jeep Wrangler.
Toyota 4Runner – See Nissan Xterra.
Lexus GX 460 – This body-on-frame SUV not only looks awkward, but handled so badly that Consumer Reports issued a "Don't Buy" rating in 2010.
Land Rover LR4 – It's heavy, about 5,500 pounds, and floats above the earth. But it's also one of the most serious SUVs imaginable when the road gets rough. None of its buyers care that it gets 13 mpg in real-world driving.
Range Rover Sport – The bigger Range Rover rides on a unibody developed in tandem with BMW. The Sport rides on the LR4 chassis, yet there is nothing sporty about it; buyers, meanwhile, eat up the Sport like free-range chicken.
Chevrolet Tahoe/GMC Yukon/Cadillac Escalade – These brutes continue to sell well, thanks to their simple styling and rugged specs. The Escalade continues to be stolen very often.
Chevrolet Suburban/GMC Yukon XL/Cadillac Escalade ESV – I drove an Escalade ESV for one day in Boston and then hid the keys. If I were a bus driver, I'd have been very happy.
Lincoln Town Car – The very last rear-wheel-drive, full-size American sedan without a unibody chassis. Livery drivers are seriously worried that no other car will replace the Town Car's smooth-riding, long-lasting performance for the money.
Mercedes-Benz G-Class – The Cold War relic that keeps on giving. Built on the same chassis since 1979, this German troop transport defies any and all logic, especially when the sticker gets to $130,000.
Absolutely none of these vehicles returns decent fuel economy. Many, like the Infiniti and Rovers, are ultrapricey. Others, like the Wrangler and FJ, are in unbeatable niches. Most, if not all, make no sense to European citizens crushed under $8-per-gallon gasoline.
So while it's tough, if perhaps even impossible, to launch a completely new body-on-frame truck, it's apparently quite simple to keep the gas-guzzling brutes we have. What red-blooded, truck-loving Texan would disagree?
Clifford Atiyeh has spent his entire life driving and riding in cars he doesn't own. He was raised in Volvos and has grown to love fast, irresponsible vehicles of all kinds. He lives in Boston, is a member of the New England Motor Press Association, and has reported for The Boston Globe, Car and Driver, Popular Mechanics and The Times of London.
Body on frame construction is stronger and lasts much longer but is naturally heavier. Look at the long term taxis, police cars and construction pickups used for the past 40 years and you won't find any without a frame. Plus if you are in an accident the framed vehicle always wins. Placing numerous airbags in these newer unibodies does help protect the occupants but just look at the structural damage difference.
Newer isn't always better.
@Shrimp roll,
The statement that body on frame vehicles transfer the force of the collision to the passenger is not the slightest bit true. The laws of physics cannot be denied. The stronger vehicle always wins in an accident. The test you mentioned with the '59 Chevrolet was rigged in many ways. For example, the '59 car had the engine, transmission, radiator, and drive shaft removed. It also had the steering column disconnected from the mounting point under the dash board, among other things. The test Dummy was also not wearing a seatbelt, and the front seat was unbolted from the floor of the car. Hardly a representative test, but they are trying to sell you the new Impala, not the '59 model. How did you expect the test to turn out under those conditions?
Rare and expensive vehicles and the stories behind their discovery.
Cars are cool, and here at MSN Autos we love everything about them, but we also know they're more than simply speed and style: a car is an essential tool, a much-needed accessory to help you get through your day-to-day life. What you drive is also one of the most important investments you can make, so we'll help you navigate your way through the car buying and ownership experiences. We strive to be your daily destination for news, notes, tips and tricks from across the automotive world. So whether it's through original content from our world-class journalists or the latest buzz from the far corners of the Web, Exhaust Notes helps you make sense of your automotive world.
Have a story idea? Tip us off at firstname.lastname@example.com.

subset: commoncrawl


text:
Metal Gear Scanlon - Part 11
Become Premium to Watch
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Forza Horizon 2 is a solid open-world racing game that takes Forza's slavish devotion to car culture in a friendlier direction.
A sequel that's just as crazy and ridiculous and fun as its predecessor, even if it suffers from many of the same faults.
This perfectly competent open-world game gets a heck of a lot more interesting when it throws an endless host of savage, dynamic AI enemies into the mix.
Character »
Defender for Real Madrid Football Club.
Defender for SSC Napoli.
Striker for Liverpool Football Club.
Goalkeeper for Liverpool Football Club.
Young midfielder for Liverpool Football Club.
Defender for Liverpool Football Club.
Daniel Agger comes from Denmark
Young French Striker for Bolton Wanderers Football Club.
Versatile forward for Liverpool Football Club.
Defender for Liverpool Football Club.
Striker for Chelsea Football Club. Regarded as one of the greatest forwards in Europe. Chelsea signed Torres from Liverpool for over 50 million pounds in 2011. He scored his first Chelsea goal against West Ham in April 2011.
The Chelsea F.C player who appears in many football video games and is a cover athlete for FIFA 10.
Versatile midfielder for Manchester City Football Club, also has international caps for England.
Defender for Liverpool Football Club and current vice-captain.
Midfielder for Barcelona Football Club.
Midfielder for Liverpool Football Club.
Terry is a defender and captain of Chelsea football club and former captain of the England squad.
Lionel Messi is a soccer player for FC Barcelona. He is considered by many to be the best player in the world. In 2011, he signed a multi-year deal with EA Sports to become the new face of the best-selling FIFA Soccer franchise.
Rafael Benítez, commonly known as "Rafa," was dismissed on 3 June 2010 as manager of Liverpool F.C. He is best known in Liverpool for winning the 2004-2005 Champions League in Istanbul. He was appointed as manager of F.C. Internazionale Milano on June 8th, 2010. He was sacked December 23, 2010.
Irish striker, formerly of Tottenham Hotspur, contracted to Los Angeles Galaxy of MLS. He is the Irish National Team's all-time record goalscorer with 41 goals.
Ryan Babel is a winger for Liverpool FC, a British football (soccer) club which is in the England's Premier League
An english football player of Manchester City, plays the position of left back.
Midfielder who previously played For Liverpool football club, but now plays for Real Madrid.
Midfielder for Chelsea Football Club.
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text:
Archived:On device debugging not supported in the first Nokia 95 release (Known Issue)
From Nokia Developer Wiki
Archived: This article is archived because it is not considered relevant for third-party developers creating commercial solutions today. If you think this article is still relevant, let us know by adding the template {{ReviewForRemovalFromArchive|user=~~~~|write your reason here}}.
Article Metadata
Tested with
Devices(s): Nokia N95, sw version 10.0.018Compatibility
Platform(s): S60 3rd Edition, FP1Article
S60 3rd Edition FP1
S60 3rd Edition FP1
Created: User:Technical writer 1 (20 Aug 2007)
Last edited: hamishwillee (19 Jun 2012)
On-device debugging (TRK) does not work in the first sales release (10.0.018) of the Nokia N95.
No solution for the first firmware release. This will be corrected in the next release (11.0.025), expected to be available in the beginning of May via Nokia Phone Software Update utility: http://europe.nokia.com/support/product-support/device-software-update


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Thanks for visiting our website
Serving the PICKERING area, Cars 101, located at 1698 Bayly Street in PICKERING, ON, is your premier retailer of Preowned vehicles. Our dedicated sales staff and top-trained technicians are here to make your auto shopping experience fun, easy and financially advantageous. Please utilize our various online resources and allow our excellent network of people to put you in your ideal car, truck or SUV today!


text:
So 2 days ago i started using the regimen. The first night i used it i only put the BP on my T-zone and chin because those are the only areas i had acne, but i put the lotion everywhere on my face. The next morning i woke up with a swollen face (i think it was from the lotion), i cancelled my plans and stayed home all day trying to make the swelling go down. It was so bad, under my eyes, both my cheeks, and on my jawline. I iced it all day, took medicine, used aloe gel, jojoba oil, put tea bags on my eyes, and gently massaged my face. The swelling when down a little bit, but i still looked like a chipmunk. Then in the middle of the night last night my face started itching so bad i couldn't sleep! I but anti-itch cream on it and took more medicine and it made it stop itching long enough for me to fall asleep. Then this morning i woke up and my face is twice as swollen as it was yesterday! I'm so sick of trying to make the swelling go down if its just going to get worse tomorrow! I'm going on vacation in 1 day and i don't want to be like this! Its so embarrassing and impossible to cover up. I stopped using all of the new products i just spent 60 dollars on. I need something to make this go away fast! Please help!
Posted 07 July 2013 - 02:04 PM
Posted 07 July 2013 - 02:56 PM
Unfortunately, it may be that you are allergic to BP. Give your face a few days to calm down and maybe try again with a pea sizedamount for the first week, once a day.
Keep us posted either way and try to enjoy your vacation
Posted 07 July 2013 - 03:16 PM
I don't think it is the BP because i didn't put any of it on the area's that are swollen! I think it might be the lotion...
Posted 08 July 2013 - 03:41 AM
Well stop using everything for a few days and then try reintroducing BP and regular moisturizer and see how it goes. A little swolleness is normal, a lot , is not
Good Luck
Posted 08 July 2013 - 06:21 AM
Posted 02 August 2014 - 10:03 PM
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6 U.S. Code § 321h - Use of national private sector networks in emergency response
Source(Pub. L. 107–296, title V, § 519, formerly § 508,Nov. 25, 2002, 116 Stat. 2215; renumbered § 519,Pub. L. 109–295, title VI, § 611(6),Oct. 4, 2006, 120 Stat. 1395.)
Section was formerly classified to section 318 of this title prior to renumbering by Pub. L. 109–295.
The table below lists the classification updates, since Jan. 3, 2012, for this section. Updates to a broader range of sections may be found at the update page for containing chapter, title, etc.
The most recent Classification Table update that we have noticed was Tuesday, August 13, 2013
An empty table indicates that we see no relevant changes listed in the classification tables. If you suspect that our system may be missing something, please double-check with the Office of the Law Revision Counsel.
|Description of Change
|Session Year
|Public Law
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LII has no control over and does not endorse any external Internet site that contains links to or references LII.


text:
Last Updated on Sunday, 16 January 2011 19:59
Copyright © 2010-2011 Cpnweb.org. | Term of Use. The use of this site is governed by the Terms of Use. By using this site you acknowledge that you have
read the Terms of Use and the disclaimers and caveats contained in this site, and that you accept and agree to be bound by the terms thereof.


text:
Houston • A black sheet shrouded the easel. "What is under there?" everyone wondered. Former Jazz center Mark Eaton and Darryl Dawkins sat in courtside seats at the Toyota Center and traded guesses.
Who was under there?
|Join the Discussion
|Post a Comment
"Jordan?" Eaton and Dawkins wondered to one another.
Jeremy Evans, the lightly known, infrequently played Jazz reserve would not win this Slam Dunk Contest. He would not become the fourth player — a group that includes Michael Jordan — to win in back-to-back years at the popular All-Star Weekend event. In a contest whose winner was determined by popular vote, Toronto guard Terrence Ross won with 58 percent. But even those who ultimately voted against Evans must have found themselves struck by the fragility of the scene.
"What is under there?" they surely wondered.
Two years earlier, Blake Griffin jumped over a car. Touch a car with your toe, it does not move. Bang your knee on a window, and the window likely wins. But a mystery piece of art, supported by three willowy legs — why, a cheer from the upper level might blow it over.
Evans had to be perfect. This dunk, whatever it would prove to be, would be in the detail.
Spoiler: He dunked over it. Because what would this story be if he didn't? He got a running start from halfcourt, took three dribbles, flew spread eagle over the easel and finished the dunk with a left-handed windmill. After he came down, he walked to the front of the easel and pulled off the sheet.
Moments before he dunked, Evans had grabbed a microphone and said, "I feel like dunking is an art."
He explained that he draws. And he paints. The shy Arkansas native takes sketch pads on road trips. He has drawn a detailed rendering of the Salt Lake LDS Temple. And for a week and a half, he followed the advice of Jazz player development assistant Johnnie Bryant, and returned from road trips and practices to quietly work on a piece that he told few people about.
He painted a dark background, and then twin strips to represent video boards. He made the crowd red, because the Toyota Center is the home of the Rockets.
Then he began to draw a body. At first, it could have well been Jordan. The long brown arms and legs. The separation between the man and the court. But then he filled in the details. A long blue ribbon striped the side of a white jersey. Yellow piping hugged each side of the strip. The No. 40.
And then, he painted an easel, shrouded by a black sheet.
For years, players have dunked over other players. Last year, Evans dunked over teammate Gordon Hayward. Earlier in the contest he dunked over and grabbed a ball from a seated Eaton on his way to a reverse dunk. On his final dunk, he would leap over Dallas Mavericks guard Dahntay Jones.
But, by god, Jeremy Evans was going to become the first player to dunk over himself.
However, some details couldn't be filled in prior to leaving for Houston on Thursday. Evans' shoes, for example. He hadn't known which pair he would wear. And the ball. Don't they use a special ball in the dunk contest? So he packed his paints and brushes and shipped the unfinished work to the edge of Texas.
After a late-night practice on Thursday, Evans tucked one of the red and white balls away and took it back to his hotel to serve as his model.
"I just finished it last night," he confessed after the competition, with the painting propped behind him.
It, too, will travel back to Salt Lake City on Sunday, and in one way or another will benefit a charity.
Despite being the defending champion, Evans entered Saturday's event once again as an underdog. After losing, he said, "I actually felt better after that contest than I did last year."
He was certainly more creative. He pulled the 7-foot-4 Eaton out of the crowd just hours after asking him if he might be willing to participate. Eaton, whose one All-Star appearance was in 1989 in Houston, sat on a green block and did his part, although he and Evans had never practiced the actual dunk.Next Page >
Copyright 2014 The Salt Lake Tribune. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
Swedish Vallhund Puppy
Receive an email alert when additional Swedish Vallhund puppies are added. It's easy and free!
BREED: Swedish Vallhund Puppy
INCLUDES: akc reg., vet exam, health certificate, shot record, microchip offered
Puppies come with FREE Pet Insurance when adopted from NextDayPets.com! *Please ensure your breeder participates
Stonewall Farm
Member Since: March 2007
Location: Springfield, Missouri
Basset Boy "Yella Fella" Full AKC reg.~Euro
• Male • $700
Basset Boy "Maho" Full AKC reg.~Euro
Basset Boy "Harrison" Full AKC reg.
• Male • $500
Basset Boy "Rusty" Full AKC reg.
• Male • $600
Clancy's Boy
Basset Girl "Twila" Euro~AKC reg.
• Female • $600
Basset Girl "Libby" Euro Full AKC
• Female • $1,200
Basset Girl "Lemon Drop" Full AKC reg.


text:
ICHEC Software
Information about software packages installed on the ICHEC systems.
Versions Installed
Stokes: 06 v1_0_2
Stoney: 06 v1_0_2
The CRYSTAL package performs the computation of the electronic structure using either Hartree-Fock or Density Functional theory. In each case the fundamental approximation made is the expansion of the single particle wave functions as a linear combination of atom centred atomic orbitals (LCAO) based on Gaussian functions. Powerful screening techniques are used to exploit real space locality. The code may be used to perform consistent studies of the physical, electronic and magnetic structure of molecules, polymers, surfaces and crystalline solids. CRYSTAL has been applied to studies of defects in ionic materials, the stability of minerals and oxide surface chemistry. The CRYSTAL software was jointly developed by the Theoretical Chemistry Group at the University of Torino and the Computational Materials Science Group at CCLRC Daresbury Laboratory (UK).
Access to the executables can be granted to academic researchers in Ireland.
Additional Notes
In order to run Crystal06 you'll need to load the crystal module, copy your input file to a file called INPUT and then call runPcry06 which will launch the parallel version of Crystal.
cp xyz.d12 INPUT
Further information can be obtained at www.crystal.unito.it.


text:
The Nanny Diaries (2007)
A college graduate goes to work as a nanny for a rich New York family. Ensconced in their home, she has to juggle their dysfunction, a new romance, and the spoiled brat in her charge.
Links: IMDb, Posters, Official website, The Weinstein Company
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text:
Joker forced to play youth. Youth forced to learn quickly.
Click here to read the full story.
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WTVQ.com supports children's privacy rights. All persons under the age of 13 MUST have parental permission to use this website and direct parental supervision is strongly recommended.


text:
Rupert Murdoch has lawyered up. Now that the FBI has opened an investigation into News Corp., the company has retained a criminal defense attorney. He's the guy who defended ex-Marine (and Fox News host) Oliver North during the Iran-Contra scandal.
News Corp. Hires Criminal Defense Lawyer
Pending approval Remy Stern


text:
Product Reviews
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pendant attachmentApril 10, 2013
For years I have been looking for a product to be used to attach a pendant to a chain or clasp that could be removed if you wanted a different look or changed to a different pendant. This pearl enhancer can be used for just that. Also check out the other pearl enhancer at Artbeads. You may be surprised what you canned do with them.
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Live Herb Plants Make an Instant Garden
Looking for instant paradise or at least some fresh home-grown herbs for your fire escape?
If you can't make it to the local nursery or farmers' market, there's an alternative. You can shop online and have them Fedex'd to your apartment or office.
We recently got an incredibly lush and healthy basil plant ($19.50) from Bloomscape and it's doing great on our fire escape here at AT headquarters. We pluck the leaves and sprinkle them on our lunch.
Bloomscape also carries oregano, rosemary, Italian parsley and tomato plants.
10 Comments
$19.50 for a basil plant? That's an outrageous price!
I was going to say the same thing, edmf. For that price it better make itself into fresh pesto for me. This is a huge ripoff. Do people not leave their houses anymore in your world? $24.50 with shipping when you can go to Trader Joe's and get one yourself for $3.50?
indeed. the cost of a plant a cab or even *gasp!* public transportation would surely be less than $20...
Maybe the fine folks at Bloomscape will chime in and let us know what makes their plants worth the cash...
I'd love to comment. I hope this helps...
Compared to a Trader Joe's plant, there is a big price difference, but there are some big plant differences too. Ours come in a 7" pot and have 4 plants in each one. They are grown pretty large, so you are immediately receiving enough basil to actually use right away. Each plant also comes with moisture retaining gel in the soil to reduce the amount of time you have to spend watering them. To keep it simple, we include a packet of slow release fertilizer with the plant.
We wanted to sell a plant that could be placed in a fire escape but still produce enough basil for a decent amount of use. And it's delivered.
Never mind the prices - $37.50 for a Boston Fern? - I thought you guys always preached buying local.
Hi Martybird,
Thanks for commenting.
Indeed, we do support buying local, and we practice what we "preach" as much as possible, although we do try not to be too "preachy."
That said, there are always exceptions. Bloomscape seems like a great way to give the gift of a plant (which is how we ended up with the basil on our fire escape) so we wanted to share it with readers. One could argue that tending a plant is the ultimate in buying local: you only go so far as your garden to "buy" your herbs. Not everyone has access to a locally sprouted and raised basil plant. And unless you are buying your bunches of basil at your local farmers' market, check the label on the next bunch of basil you buy: it probably traveled a fair distance to get to you.
We will continue to spend the majority of our time and energy on the local stuff, but now and then there's a nice opportunity for a diversion. Our path isn't always perfectly straight.
This site has been talking local for a long some time now. But please don't misunderstand me. I have no problem buying basil at the market. But how could some mysterious 'moisture retaining gel in the soil' and $24.50 in cash, be any better than dirt seed water time if you are encouraging fresh herb gardens on fire escapes?
holy crap that's expensive! I hope it's a big plant for that price. I can get bedding plant sized herb plants for less than $3 at my local fruiterie.
This strikes me as a paid ad disquised as an entry. Thats the only way a post about a $19.50 basil plant makes any sense.


text: Items 133 to 144 of 231 total Previous 1 ... 10 / 11 / 12 / 13 / 14 ... 20 Next View: 12 / 24 / 48 Great system By Corey on 6/24/2013 Corey would recommend this product to a friend This has been a great system. I make about 30 gals of RO/DI water each week. I love the TDS meter that is provided this is the only way to know what the system is providing. Very easy to install and maintain. I have had the system just under a year and the only media I have replace is the DI Resin. Best prices anywhere. I have had no problems at all with BRS. Great product from a great company! By Cody on 6/17/2013 Cody would recommend this product to a friend I ordered this unit and received it with a few days. It was super easy to install to my sink. It went from the box to producing water in 5 minutes! I plan to hook it up in my laundry room. I wasn't sure which fitting I needed so I emailed them and they replied quickly with the links to the fittings needed. I wouldn't order an RO/DI unit from anyone else! Love it By Charles on 6/12/2013 Charles would recommend this product to a friend I purchased this as I was tired of driving 30 minutes and paying for my water. It was very easy to set up and use. I ran the hose under my carpet and keep it hooked up to my bathroom sink. All I do is turn the water on at night before and let it run until the morning. I would recommend this product. Plug and play By Brian on 6/10/2013 Brian would recommend this product to a friend Great product and a great price . Item does it all and with built in TDS meter no guessing when filters need replaced. Great product By Dwayne on 6/5/2013 Dwayne would recommend this product to a friend Have had this product for 6 months. Works great. No complaints. It arrived with a damaged pressure gauge. One call to BRS and a new one was sent no questions asked. Great service. Solid Purchase By Jeff on 6/1/2013 Jeff would recommend this product to a friend Unless there is a significant problem with your water source, this is what you want if your system is within 150 gallons. Below are the readings I get at my place using this item: Bathroom Sink - 20-25ppm in, and 0ppm out Kitchen Faucet - 20-25ppm in, and 0ppm out Garden Water - 40-45ppm in, and 0ppm out Easy to hook up and use By Chavinpat on 6/1/2013 Chavinpat would recommend this product to a friend The RO/DI unit arrived this afternoon. I unpack, hook it up, flush the system for about an hour, and made the water right way. 0.21 TDS went in 0.0 TDS came out. perfect By dangdriver on 5/27/2013 dangdriver would recommend this product to a friend if everything i order form BRS is as good as this i will never have a complaint . works perfect right out of the box no leaks no drips no errors. Very pleased so far. By Rzalph on 5/22/2013 Rzalph would recommend this product to a friend I only recieved the unit earlier this week, but I have since done a water change. At 75gpd this makes water at a perfect rate for my needs (30g cube), a 5g bucket for water change and another for top off through out the week. Probably only takes less than an hour and a half to make 5g worth. Everything came very well packaged, with good instructions, all I had to do was hook it up to the hose bib. It took less than 2 minutes. Great Value By Scott on 5/20/2013 Scott would recommend this product to a friend Awesome system and everything I needed to start making my own RO/DI water. Construction is very well done as only BRS can do. Economy 4 stage RO/DI By rustyjames on 5/16/2013 rustyjames would recommend this product to a friend I bought the 4 stage RO/DI in early 2012 after my tank had been set up so I only needed top off and water change water on a 40 breeder. Came fully set up and gave me 0 tds water till February 2013 when we had a nasty cold spell (unit was setup in my garage). The faucet adapter froze. Took my lazy butt till May to order a new one after checking a few local hardware stores. While I was at it I ordered a new new filter set for only $20 or so. Don't think they needed to be changed but it was cheap and the unit sat for a few months. They were easy to change and I'm good to go making absolutely pure water for my reef. Great RO/DI system By Rooster on 5/15/2013 Rooster would recommend this product to a friend Received my RO/DI system and hooked it to my garden hose using the included adapter. System worked great producing 10 gallons of TDS free water in about 3 hours. Used the rejected water to for the plants in my backyard. Write Your Own Review You're reviewing: BRS 4 Stage Value PLUS RO/DI System - 75GPD *How do you rate this product? *Would you recommend this product to a friend? Yes No *Nickname *Summary of Your Review *Review Submit Review


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Use on yourself, underwear, pads and pantyliners, pantyhose, workout wear, to feel clean, fresh, and confident throughout the day, everyday.
Shake well and remove cap. Spray external vaginal area, undergarments, pads, or pantyliners. Hold can at least 8 inches from body, clothing , or external paper products.
FLAMMABLE. Do not use product near fire, flame or sparks. Do not expose to heat. Do not use if spray button is missing or defective. Keep out of reach of children. Use only as directed. Avoid spraying in eyes. Intentional misuse by deliberately concentrating and inhaling the contents can be harmful or fatal. For external use only. Spray at least 8 inches from skin. Do not apply to broken, irritated or itching skin. Persistent, unusual odor or discharge may indicate symptoms for which a physician should be consulted. Discontinue use immediately if rash, irritation or discomfort develops.
Active Ingredients
Isobutane; Isopropyl Myristate; Corn Starch; Magnesium Stearate; Mineral Oil; Fragrance; Sodium Bicarbonate; Zinc Ricinoleate; Lanolin Alcohol; Oleyl Alcohol; Benzyl Alcohol; Laureth-3; Tetrahydroxypropyl Ethylenediamine; Propylene Glycol


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Winter Housing 2013-2014
The NYC residence halls close for winter break on December 21, 2013 at 12:00 noon. Students who need to remain in the residence halls during the break (those with documented academic commitments or other significant conflicts that prevent them from leaving by noon on 12/21) must contact their Resident Director to discuss an extension. The residence halls will reopen at 9:00 AM on Saturday January 25, 2014.
Winter break housing is not included in the academic year housing contract. It must be applied for and paid for separately. Below you will find complete information about winter break housing. If you need winter break housing, you must complete the following online form by December 6, 2013 to apply for winter break housing:
Winter Break Housing Application - Pace NYC
- The ontime deadline for applying for winter break housing has passed. Click here for the LATE 2013-2014 Winter Break Housing Application
Winter Break Housing Charges
- If you wish to remain on campus for any portion of winter break, you must apply for break housing. All students remaining for winter break will be billed $1000 (to their Fall 2013 term account; applied to their account AFTER December 6) to cover the cost of break housing. Students staying on campus for any portion of the winter break must pay for the entire winter break. There are no partial charges for winter break housing.
Winter Break Housing Requirements
- Students applying for winter break housing must also provide a valid reason that they must be on campus during the winter break. Approved reasons for staying on campus may include distance from home that prevents the student going home for the break, a job or internship that the student must attend during the break, or enrollment in a winter break class. Documentation may be required upon request from the housing office.
- Students are only permitted to stay in university housing if they are returning to university residence for the Spring 2014 semester.
Relocation of Maria's Tower Residents for Winter Break
- Maria's Tower is COMPLETELY CLOSED for the duration of the winter break. No student may stay in Maria's Tower during the break. All MT residents who are approved for winter break housing will be temporarily assigned to another residence hall. These assignments will be made purely on the basis of availability. Preferences cannot be guaranteed. MT students remaining in the residence halls must be prepared to move out of their primary residence and to their temporary assignment NO LATER THAN December 21, 2013. MT residents will be required to RETURN to their permanent assignments on FRIDAY JANUARY 24, 2014.
Winter Break Housing Guests
- There will be NO GUESTS permitted in 182 Broadway, 106 Fulton or 55 John Street for the duration of winter break. The community desk in these halls will reopen at 8AM on Monday January 17, 2014. Students with a critical need to have a guest during the break must complete a guest exception form (available in the housing office), and submit it to their residence director for approval BEFORE Monday December 16, 2013. Guests at St. George will be permitted as proscribed by EHS policy.
Winter Break Judicial Process
- During the break, all judicial action will be summary in nature. This means that any reasonable allegation that a student has violated university policy may result in summary removal from the residence halls for the remainder of the break period. Judicial hearings for alleged violations of policy during the break will be held in the first weeks of the spring semester.
- New York City Campus
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Conservative Care For Mid-Portion Achilles Tendinopathy
- Volume 23 - Issue 11 - November 2010
- 30239 reads
- 3 comments
Given the common nature of mid-portion Achilles tendinopathy, this author reviews the literature and shares insights on a variety of conservative modalities ranging from eccentric loading exercises and activity modification to prolotherapy injections and shockwave therapy.
Achilles tendinopathy is a common cause of pain and disability in people with an active lifestyle, particularly middle-aged men.1-5 The mid-portion of the Achilles (2 to 6 cm distal to the insertion) is the most commonly affected region.6 It is one of the most common sports overuse injuries, which repetitively load the Achilles tendon.1-3,7
Achilles tendinopathy has a 24 to 52 percent lifetime incidence in former runners and a current prevalence of 6.5 to 18 percent among runners.8,9 Mid-portion Achilles tendinopathy can also affect the sedentary population, suggesting that physical activity may exacerbate symptoms rather than cause them.10,11
This article will focus on Achilles tendinosis, the term employed when ultrasound reveals structural changes in the Achilles tendon, as this is by far the most common form of Achilles tendinopathy.12 Ruptures, peritendinopathy and insertional tendinopathy are outside the scope of this article.
Key Insights On Tendon Pathophysiology
An understanding of tendon pathophysiology is essential when you are considering treatment options. A number of studies in the last 10 years have shown that Achilles tendinopathy is largely a non-inflammatory process.13-19 In 2002, Khan and colleagues alerted all medical practitioners dealing with tendon injuries with the slogan "time to abandon the 'tendinitis' myth."12 The four main events that occur in tendinopathy are cellular activation and increase in cell numbers; increase in ground substance; collagen disarray; and neovascularization.20
In situ intratendinous microdialysis studies have revealed no difference in concentrations of prostaglandin E2 (PGE2) between healthy tendons and tendons with tendinosis (i.e., there is no chemically mediated inflammatory process). Higher concentrations of glutamate (a powerful pain modulator) and lactate are also present in tendons with tendinosis in comparison to normal tendons.13,15,19
Researchers have conducted studies on tendons with tendinosis using gene technology (using complementary DNA (cDNA) arrays and real-time polymerase chain reaction (PCR)).16,21 These studies have found a down-regulation of matrix metalloproteinase-3 (MMP-3) and an up-regulation of type I and type III collagen, MMP-2 (the enzyme involved in degrading processes), the fibronectin receptor involved in healing processes (FNRB) and vascular endothelial growth factor (VEGF). There is also no regulation of genes for a variety of cytokines known to be involved in the inflammatory process.22
Following tendon injury, nitric oxide synthase (NOS) induces nitric oxide (NO) in rats. Research has shown NOS activity to be up-regulated in rat Achilles tendinopathy while tendon healing increases with the addition of more NO.23,24
Excellent explanation and recommendation on the technique of "no concentric contraction on the affected side."
I have a patient who has suffered with chronic post-static dyskinesia in the Achilles tendon mid-substance area for 2 years. He has slight discomfort before running, the pain subsides with running and then the pain returns about 1 hour after running.
X-rays show a large Os trigonum and MRI is negative for inflammatory changes around the OS, Achilles or FHL. Is it possible that this Os is just an incidental finding and that the focus should be on eccentric stretching? This large Os somewhat limits his ability to raise onto his toes and plantarflex his foot. Surgical excision of the Os may allow more plantarflextion but is it worth the risks of painful scar tissue formation, neuritis, etc.? Five weeks of physical therapy helped relieve the pain but within 3 weeks of easing back into a jogging routine, the insidious onset of pain returned.Reply to this comment »
Certainly, the patient history sounds like Achilles tendinopathy. Did the MRI or physical exam demonstrate thickening of the Achilles tendon? Is the Achilles tendon tender to palpate (see '"What to look for in the examination" section)? The os trigonum could be a red herring. Perhaps you could try the eccentric program +/- a corticosteroid injection around the os trigonum. Good luck!Reply to this comment »
Great work Kent!Reply to this comment »


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Authorities in Nacogdoches County have found a man who has been wanted since Saturday.
Nacogdoches County Sheriff Jason Bridges tells us that Thomas Howell was located in an abandoned house on Henderson Lane in the Central Heights area Friday morning.
Thursday night, authorities set up a perimeter around the same home Howell is believed to have committed a burglary at. Bridges says canine units and a search helicopter were also used in the search that ended at midnight, then started again at 4:00 a.m. on Friday.
Howell was wanted on warrants for first-degree burglary of a habitation to commit assault, sexual assault, assault family violence, retaliation and violation of a protective order.
As of Friday, he is facing six felony charges.
Howell is accused of breaking into a residence of his ex-girlfriend on Friday, January 25 and assaulting her.
Thomas Howell is in the Nacogdoches County Jail. Sheriff Bridges tells us he is awaiting arraignment Friday morning.
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OBJECTIVE: This study examined whether implementation of managed care in a public mental health system affected return visits to psychiatric emergency services within 180 days of an index visit. METHODS: Data were taken from an administrative database of 75,815 patient visits made to a hospital-based psychiatric emergency service for mental health care between January 1, 1995, and December 31, 2002. Rates of return visits for patients whose index visit occurred at least 26 weeks before a system of managed care was implemented in 1999 were compared with rates for patients whose index visit occurred after the implementation but at least 26 weeks before the data collection period ended. Declining-effects modeling was used to adjust for patients' gender, ethnicity, age, and admission status. RESULTS: A total of 37,371 patients met study criteria for inclusion: 21,135 before managed care was implemented and 16,236 after managed care was implemented. In the pre-managed care group, 3,687 patients (17 percent) made a repeat visit within 26 weeks of their index visit; 2,369 patients (15 percent) in the post-managed care group made such a repeat visit. For any given index visit to the psychiatric emergency department, patients who presented for treatment after managed care were only 90 percent as likely as patients who presented before managed care to have a return visit within the first five weeks after the index visit. However, there was essentially no difference between groups in the likelihood of a return visit by week 26 after the index visit, suggesting that managed care delayed, but did not eliminate, return visits. In addition, the number of police-accompanied index visits continued to rise after managed care was implemented (from 32.0 to 52.6 percent of all index visits), suggesting that increasing numbers of patients with mental illness in need of treatment were coming to the attention of law enforcement officials after managed care was implemented. CONCLUSIONS: Managed care strategies are often used to reduce reliance on emergency services. In this study, managed care delayed, rather than prevented, return visits to the psychiatric emergency service.
By 2003 public mental health services were being administered under some system of managed care in 27 states (1), and this structure was under consideration in another 21 states. Although the consumer's experience in seeking and receiving treatment is assumed to have changed under these rapidly emerging new structures (2), assessing clinical outcomes continues to be a challenge (3,4,5,6). Since deinstitutionalization the use of psychiatric emergency services has been studied as one way of assessing outcome in community-based systems of care (7,8,9,10). As in the past, examination of emergency service revisit patterns may provide information about the equity of, and access to, care provided under evolving managed behavioral health treatment systems.
Even though psychiatric emergency services were originally conceptualized as an essential resource for persons with mental illness who reside in the community (11), frequent and repeated use of such services in lieu of alternative care has historically been viewed as undesirable (12,13,14). For example, a "bounceback" visit to the emergency department—that is, a visit occurring within days of inpatient discharge—is generally viewed as an indicator of inpatient treatment failure (15). If stringent limits placed on inpatient care result in the premature discharge of large numbers of marginally stabilized patients, an increase may be observed in the frequency of "bounceback" visits to the psychiatric emergency service (16).
In addition, characterization of "revolving door" patients—that is, frequent users of psychiatric emergency services—has historically helped identify groups of consumers whose needs are not adequately met by outpatient systems of care (16,17,18,19). Some fear that diminished treatment dollars associated with managed care structures result in decreased availability of intensive, community-based services for persons who are the sickest and most vulnerable (20,21,22). If true, because the psychiatric emergency service is the most accessible point of care in the public mental health system, emergency service rosters should reflect increased numbers of repeat visits by patients with severe and persistent mental illness.
Finally, reduction in resources after implementation of managed care systems is thought not only to leave vulnerable patients without adequate care but also to promote increasing "transinstitutionalization," defined as the de facto management of mentally ill patients in the criminal justice system (23,24,25). If this concern is valid, an increase in both initial and repeat visits to the psychiatric emergency service during which the patient is accompanied by the police might be observable under managed care structures.
The introduction of a regional system of managed mental health care in our public mental health catchment area in 1999 provided the opportunity for a natural experiment to test these assumptions. This study compared the rate of return visits to the psychiatric emergency service for patients presenting before and after adoption of the new system.
In July 1999 the phase-in of a system of behavioral managed health care, called NorthSTAR, was begun in seven north Texas counties, including Dallas County where the study hospital (Parkland Hospital) is located. NorthSTAR is described by its architects as a blended-funding, integrated, behavioral health carve-out that eliminates the separation of treatment silos for substance abuse and mental health treatment. By December 1999 it functioned both as a full-risk, capitated, per-member, per-month 1915b Medicaid waiver program and a flat-fee reimbursement program for the medically indigent. These functions are rolled into a private sector-operated open system of care in which consumers are given a choice of providers (26). About 30 percent of the funding and patient base for the program came from Medicaid.
At implementation, the NorthSTAR region ranked 35th out of 40 in Texas for mental health expenditures, and Texas ranked 42nd out of 50 states in per capita expenditures for mental health (27). Despite the underresourced system into which it was introduced, NorthSTAR had as a primary goal improved access for all covered patients—for example, it sought to eliminate long wait times before treatment enrollment.
NorthSTAR divided local functions into organizations designated as treatment "providers" and one "authority" appointed to oversee how care was being provided. Existing care structures were absorbed into new provider networks, and a handful of new providers emerged. Pre- and post-managed care systems used essentially the same menu of services, including medication and case management; psychotherapy; assertive community treatment for individuals with severe illness, a history of multiple hospitalizations, or both; and supported housing and employment. However, the number of consumers who received assertive community treatment services increased from 79 to 450 in the first 18 months after NorthSTAR was implemented.
According to NorthSTAR creators, between July 1999 and December 2002 the major change in provision of care associated with NorthSTAR implementation was more of a "culture shift"—a change in approach to care delivery—than a change in the quantity or type of care. The new system included prospective and concurrent clinical review and fixed rates of reimbursement, but eligible "priority populations" remained unchanged. These included patients in crisis with a Global Assessment of Functioning score of 50 or less; a primary diagnosis of major depressive disorder, bipolar disorder, or schizophrenia was necessary to obtain ongoing services. The total population of consumers served increased from 6,000 to 8,000 per month in 1998 to more than 13,000 per month in 2001 (28), while the wait for outpatient service dropped from weeks to a mandated maximum of 96 hours after initial telephone contact.
No change in policies regarding the use of mental health emergency services was apparent during the implementation of NorthSTAR, and examination of hospitalization and aftercare plans in the first 42 months under the new system revealed no major shifts in aftercare referral patterns for the psychiatric emergency service. In March 2001 (20 months after managed care implementation) NorthSTAR designated three local "front door" crisis sites that provided 23-hour observation before hospital admission. After this change potential inpatients from the study hospital's psychiatric emergency department were diverted to these sites before or instead of inpatient admission. For the nine months after this change, the study hospital's psychiatric emergency census increased by an average of 33 patient visits per month.
By using a hospital-based database of all patient visits made to Parkland Hospital's psychiatric emergency service between January 1, 1995, and December 31, 2002, this descriptive study examined bounceback and revolving-door visits as well as visits initiated by the police. We sought to determine the frequency of each type of visit before and after NorthSTAR was implemented. In addition, we attempted to characterize subgroups of patients in the psychiatric emergency service who appeared to adapt less readily to the new system of care.
Parkland Hospital's psychiatric emergency service averaged 800 to 900 patient visits per month throughout the study period and served as one gateway into mental health services in the public sector. Other than changes in procedures related to the structure of public mental health care, there were no detectable major changes in mental health care policy, population distribution, substance abuse patterns, or legal policies for offenders with mental illness in Dallas County during the study period. Patterns of psychiatric emergency department visits were therefore assumed to be one reasonably sensitive indicator of the impact of NorthSTAR on help-seeking behavior among persons with mental illness receiving care in the public sector. This study was approved by the institutional review board of the University of Texas Southwestern Medical Center.
The administrative database from which emergency service information was extracted for these analyses was created by medical record review and included both demographic characteristics (age, gender, and ethnicity) and information about the visit—for example, whether the visit was voluntary or whether the patient had ever been seen in the hospital system before the index visit.
To study NorthSTAR's impact on psychiatric emergency service revisit rates, two patient cohorts were established within the database. The pre-managed care cohort included patient visits between January 1, 1995, and June 30, 1999; the post-managed care cohort included patient visits between July 1, 1999, and December 31, 2002. For this study we assumed that a return visit within 26 weeks of the index visit constituted a repeat visit within the same illness episode and was thus related to the nature of the treatment received after the index emergency visit. In contrast, any visit by the same patient more than 26 weeks after an index visit was regarded as a second index visit—that is, we assumed that this second index visit was associated with a new episode of illness. Therefore, the same patient could have more than one index visit during each study period.
The study sought to characterize patients' help-seeking patterns during any given illness episode before and after managed care was implemented. We stopped identifying new index visits 26 weeks before the end of each data enrollment period. To avoid overpopulating the post-managed care group with patients who had a previous use history, the post-managed care working sample included patients who reentered the emergency department on or after July 1, 1999, with no psychiatric emergency service use for the previous 26 weeks.
A declining-effects model (293031, unpublished manuscript, Trivedi MH, Rush AJ, Crismon ML, 2004) was adapted to measure the impact of managed care on return visit rates. This strategy enabled us to test for the ability of the managed care system to reduce repeat psychiatric emergency visits within one week of the emergency index visit. This model also includes a measurement of growth that was used here to examine whether the initial effect of managed care on emergency revisit rates increased, remained constant, or decreased as time passed over the 26 weeks after the index visit. Unlike survival analyses (32,33), which would focus on the first return visit, declining-effects modeling takes into account all return visits and allows for patients who may have more than one index visit. In this within-patient nesting modeling, patients serve as their own controls. Therefore, the design has the ability to control for a wide range of information related to the demographic and visit characteristics that are potential covariates while analyzing the impact of managed care on return visits to the psychiatric emergency service.
Mathematically, the Bernoulli hierarchical regression is
In the equation p is the probability that patient i will return on week t following the jth index visit. Iij=1 if the index visit occurred after managed care was implemented, and Iij=0 if the visit occurred before it was implemented. The symbol ui is a patient-level variate. The vector xij represents patient characteristics, with mean values xR.
When adjusted for mean characteristics (xR), the model allows investigators to estimate the expected probability that an average patient will have a return visit during the first week after the index visit either before (exp[β00]/[1+exp(β00)]) or after (exp [β00+ β01]/[1+exp (β00+β01)]) managed care was implemented. Expressed as an odds ratio, the difference in these adjusted rates measures the probability that managed care will affect rates of repeat visits during the first week after an index visit (exp[β01]). Rates of return visits are expected to decline (rate of exp[β10]) as time passes over the course of 26 weeks, both before and after managed care at a rate of (exp[β10+ β11]). The difference between the growth rates for pre- and post-managed care is the growth effect (exp[β11]), which accelerates or decelerates with time (rate of exp[β21]).
The estimated parameters were used to compute an adjusted cumulative probability that the average patient would have had at least one revisit by week t:
P(t)=1-[(1-p1)(1-p2)(1-p3) … (1-pt)]
With this model, multiple return visits for each patient over the 26 weeks after the index visit will lead to larger values of a cumulative probability.
Between January 1, 1995, and December 31, 2002, a total of 44,851 patients visited Parkland's psychiatric emergency service, generating 75,815 separate visits. Among these patients, 11,669 (26.02 percent) made at least one return visit within 26 weeks of a previous visit, accounting for 30,964 (40.8 percent) of the 75,815 visits. The interval between the index and the first return visit ranged from one day to 2,882 days. Of all study-defined repeat visits, 13.7 percent, 20.8 percent, 30.5 percent, and 63.0 percent were made within 1, 4, 8, and 26 weeks, respectively.
Using study-defined criteria for an index visit and requiring information on age to be present, we created a final analytic sample of 37,371 patients (83.3 percent of all patients): 21,135 in the pre-managed care group and 16,236 in the post-managed care group. Among the 37,371 patients, 2,271 (6 percent) made a return visit within one week, 3,106 (8 percent) within two weeks, 4,170 (11 percent) within four weeks, 5,162 (14 percent) within eight weeks, and 6,851 (18 percent) within 26 weeks. Compared with the excluded sample, the final analytic sample had more whites (20,409 whites, or 54.6 percent, compared with 3,940 whites, or 52.7 percent) and fewer African Americans (10,684 African Americans, or 28.6 percent, compared with 2,340 African Americans, or 31.3 percent) and Latinos (5,674 Latinos, or 15.2 percent, compared with 1,100 Latinos, or 14.7 percent) (χ2=24.91, df=3, p<.001). As shown in t1, rates of presentation for care by presenting complaint remained relatively stable across the two cohorts. However, visits for which the presenting complaint was the treatment of substance-related problems declined after NorthSTAR was implemented, and presentations in the "other" category increased by 4.1 percent.
Gender and ethnicity. At the time of the index visit, males were slightly more likely than females to be new hospital patients (51.4 percent of males compared with 46.7 percent of females; χ2=85.14, df=1, p<.001, Yates continuity correction) and to be escorted by police (44.8 percent of males compared with 38.0 percent of females; χ2=194.99, df=1, p<.001). When the analyses were adjusted for age, ethnicity, and characteristics of the index visit (whether there was a police escort, whether the patient was new to the hospital, and whether managed care had been implemented), males were 37.7 percent more likely than females to have a return visit to the emergency department (odds ratio [OR]=1.38, 95 percent confidence interval [CI]=1.33 to 1.42, p<.001). Male patients were more likely to revisit than female patients, both before managed care (OR=1.34, CI=1.29 to 1.41, p<.001) and after managed care (OR=1.41, CI=1.34 to 1.48, p<.001), and there was a 4.9 percent increase in the risk that males would enter psychiatric emergency services after managed care was implemented, although this result was nonsignificant.
African Americans were substantially less likely than the other ethnic groups, including Latinos, to present at the index visit as first-time hospital patients (29.0 percent of African Americans, compared with 57.4 percent of persons from other ethnic groups; χ2=2,691.57, df=1, p<.001). African Americans were not more likely than the other ethnic groups to be escorted by the police at the index presentation. After the analysis was adjusted for age, gender, and characteristics of the index visit, African Americans were more likely than whites to revisit the emergency department (OR=1.22, CI=1.17 to 1.27, p<.001). The risk of having a return visit did not vary significantly between African Americans and whites, either before or after managed care was implemented.
Latinos were slightly more likely than other ethnic groups to have their index visit be a first hospital encounter (55.7 percent of Latinos compared with 47.8 of persons from another ethnic group; χ2=120.48, df=1, p<.001). In addition, Latinos were somewhat less likely than other ethnic groups to present involuntarily for their index visit. After the analyses were adjusted for age, gender, and characteristics of the index visit, Latinos were not as likely as whites to have a return visit (OR=.79, CI=.75 to .83, p<.001). Following the implementation of managed care, revisit rates among Latinos increased compared with those of whites (pre-managed care, OR=.73, CI=.67 to .78, p<.001; post-managed care, OR=.85, CI=.80 to .92, p<.001; difference between pre- and post-managed care, OR=1.18, CI=1.06 to 1.31, p=.003).
In summary, males were 1.38 times as likely as females and African Americans were 1.22 times as likely as whites to have a repeat visit; the implementation of managed care did not produce a statistically significant difference in these risk factors. In contrast, before managed care was implemented, Latinos were only .78 times as likely as whites to have a return visit—a rate that increased to .85 after managed care was implemented. That is, managed care appears to have left unaffected the higher return rates found among African Americans and males, although it was associated with increased return rates among Latinos. Even so, after managed care was implemented, Latinos continued to have lower rates of return visits than whites.
Age. The association between age and return visits can be described as an inverted "U" shape, in which middle-aged patients (aged from 36 to 55 years) had the highest return rates, and very young and very old patients had the lowest rates. Specifically, children younger than 15 years and adults older than 65 years were less likely than middle-aged patients to return as patients (children younger than 15 years, OR=.78, CI=.72 to .85, p<.001; adults older than 65 years, OR=.78, CI=.69 to .87, p<.001). The effect size was smaller for young adults aged 15 to 25 years. Compared with their middle-aged counterparts, young adults aged 15 to 25 years were not as likely to make a repeat visit (OR=.95, CI=.905 to .989, t=2.43, p=.015).
Police escorts and first-time hospital visitors. As shown in t1, the proportion of patients accompanied by police on their first index visit increased significantly across the two periods (32.0 percent before managed care was implemented compared with 52.6 percent after managed care). However, these involuntary patients did not revisit the emergency department as often as voluntary patients. After the analyses were adjusted for other patient characteristics, patients who were escorted by the police to their index visit were not as likely to return as patients who presented voluntarily to their index visit (OR=.87, CI=.84 to .90, p<.001). By far, the most important predictor of return rates was whether the patient had previously used hospital services. Specifically, first-time users in both cohorts were not as likely to revisit as previous hospital patients (OR=.68, CI=.65 to .70, p<.001).
Return rates over time. When adjusted cumulative probabilities were tabulated, the referent patient had an adjusted first-week revisit rate of 2.70 percent before managed care was implemented (crude, unadjusted rate of 3.60 percent). After managed care was implemented, the referent patient had an adjusted first-week revisit rate of 2.32 percent (crude, unadjusted rate of 2.97 percent).
Weekly return rates (pt/[pt+1]) declined over time. The rate of initial decline before managed care was implemented was 81.8 percent of the rate of the previous week (exp[β10=.82, CI=.81 to .82, t=44.20, df=37,362, p<.001), while the rate of initial decline after managed care was implemented was 84.9 percent. Declining-effects analyses were also used to compare differences between pre- and post-managed care for patients with characteristics similar to those of the average patient in the referent population. We found that patients during post-managed care were 85 percent less likely to have a return visit than their pre-managed care counterparts (exp[β01]=.854, CI=.80 to .91, t=5.15, df=37,362, p<.001). (Note that the trivial difference in the 95 percent CI described in t2 is based on a parameter bootstrap, and the CI reported here is based on an exact estimate of the robust standard error taken from the covariance matrix of the estimated declining-effects model.) However, the post-managed care advantage did not appear to last over time, as post-managed care rates after a patient's index visit tended initially to increase by 1.04 percent per week more than the rates in the pre-managed care group: (exp[β11]=1.038, CI=1.02 to 1.05, t=5.63, df=37,362, p<.001), although this rate decelerated over time to only 99.87 percent of its preceding time rate (exp[β12]=.999, CI=.998 to .999, t=4.80, df=37,362, p<.001). Expressed another way, average time for managed care effects to expire following an index visit was 5.17 weeks (CI=2.537 to 9.148). This estimate was computed by solving the quadratic equation for time for the coefficients of the time and managed care interaction terms.
In short, post-managed care patients were only 85.3 percent as likely as their pre-managed care counterparts have had a return visit during the first week after an index emergency department visit (t=5.15, p<.001). However, this advantage seen in the post-managed care group did not extend to subsequent weeks after the patients' index visit. By 5.17 weeks after the index visit, the likelihood that a patient would return to the psychiatric emergency service for additional care was essentially the same before and after managed care (CI=2.54 to 9.15, p<.001).
As shown in t2, adjusted rates were computed for selected weeks after the index visit: weeks 1, 2, 5, 10, 15, 20, and 26. (CIs and significance tests were determined on the basis of bootstrapping the parameters 20,000 times.) Although some effects of managed care on revisit rates were observed during the first ten weeks after the index visit, there were no observable effects of managed care after that point. In fact, differences in the likelihood of return visits occurred largely during weeks one through five after the index visit. At the end of 26 weeks, there were no differences between the pre- and post-managed care periods in the overall probability that the patient would have revisited the psychiatric emergency service. This finding suggests that this managed care system may merely delay, rather than prevent, return visits to the psychiatric emergency service.
Because for-profit behavioral health systems are increasingly associated with capitated public mental health care delivery, it is extremely important to develop appropriate indicators that help monitor the provision of care to the most vulnerable among persons with mental illness (34,35). This article describes one updated tool: a measure of psychiatric emergency service revisit rates, which provides information about the impact of managed care on patterns of service use.
Previous attempts by managed care to reduce reliance on emergency services by increasing access to alternative providers have encountered mixed results (36,37,38,39,40). Our study supports the conclusions of some that it is possible, under managed mental health delivery structures, to shift a portion of the balance of care away from emergency departments, affording consumers increased continuity of care in specialty settings while reducing the high cost associated with treatment in emergency settings (41,42,43).
In this and other recent analyses the length of inpatient stay declined under managed care, but shorter stays did not precipitate increased post-discharge revisit rates to the psychiatric emergency department among poorly stabilized patients (42,43). However, when stays for psychiatric inpatients become as brief as they are now, there may no longer be a relationship between length of hospitalization and emergency department visits made shortly after discharge (44). Thus additional work is needed to determine whether visits to the psychiatric emergency service after inpatient stays continue to be a valid indicator of quality of care.
Penetration rates, defined as the percentage of eligible individuals who actually used services, under NorthSTAR were higher than in surrounding areas that did not implement NorthSTAR (45). Yet after managed care was implemented, high and stable revisit rates were observed among males, African Americans, and those who had previously used emergency services—patient groups that outpatient care has historically found difficult to engage (46,47,48,49) and for whom managed care may not provide equal or adequate access (50,51,52,53). These patient groups are those upon whom chronic mental illness takes its biggest toll (54), and patients with more severe and persistent mental illness have traditionally not fared well under managed care structures (4,55,56,57). Although our analyses did not reveal markers that suggested that these important patient groups have been grossly neglected under managed care, their revisit rates, combined with increasing rates of visits in which patients were brought to the emergency department by police, may indicate a failure of the outpatient care structure to accommodate persons with intractable illness.
In this study, a patient with multiple visits to the emergency department without a 26-week lapse between visits was understood to be experiencing a protracted illness episode for which nonemergency alternative care was not succeeding. These assumptions about the failure of alternative care and the length of an episode of illness obviously cannot go unchallenged. In particular, the notion that a "new" illness episode is associated with the absence of an emergency department visit for a minimum of 180 days is arbitrary. Here, this operational definition allows certain emergency visits to be considered part of a new-onset illness episode without penalty to the system providing non-emergency care.
This study's observational, single-center nature and the lack of modeling of some aspects of illness and psychiatric emergency help-seeking behavior (for example, diagnostic groups, medical and psychiatric comorbid conditions, and payer status) represent further limitations. However, the addition of three "front door" crisis sites 20 months after managed care was implemented did not eliminate the finding of delayed, resurgent rates of revisits, suggesting that study findings are likely robust and even understated. In effect, patients from some consumer groups who had previously used psychiatric emergency services (for example, persons with more chronic and severe illness) appear to have initially tried the new system of care but to have slipped back into old care-seeking patterns shortly thereafter, within months of exposure to the new model.
Determining the relative success of complex and rapidly evolving managed care structures that use public funds to treat persons with mental illness will require ongoing, multidimensional assessment (3,4). In this analysis, managed care with its concomitant emphasis on reduced inpatient, and increased outpatient, care provision did not result in increased rates of bounceback psychiatric emergency visits as expected. However, neither did it slow the rising numbers of visits during which the patient was accompanied by the police. While improved access to alternative care appears to have delayed the next crisis visit for many, it did not eliminate these visits for all. Further comparisons of revisit rates to the psychiatric emergency service among specific groups before and after managed care was implemented may provide specific information about persons who benefit from such systemic changes and those who do not.
This study was supported in part by Mental Health Connections, a partnership between what was formerly the Texas State Mental Health and Mental Retardation Service and the department of psychiatry at the University of Texas Southwestern Medical Center, which receives funding from the Texas State Legislature and the Dallas County Hospital District. The authors appreciate the consultation of Wendy Waddell, M.S.N., R.N., Cynthia McDonald, and Judy Thompson. They are also grateful to the following persons for providing information about NorthSTAR that is not available in published form: John Theiss, Ph.D., David Young, and James Baker, M.D. Finally, the authors thank Larry Thornton, M.D., for providing statistics on the decline in length of inpatient stay after the introduction of NorthSTAR into the study hospital catchment area.
Dr. Claassen, Dr. Kashner, Dr. Gilfillan, and Dr. Rush are affiliated with the department of psychiatry and Dr. Larkin is with the department of surgery at the University of Texas Southwestern Medical Center at Dallas. Dr. Gilfillan is also with psychiatric emergency services at Parkland Health and Hospital System in Dallas. Send correspondence to Dr. Claassen at 5323 Harry Hines Boulevard, Dallas, Texas 75390 (e-mail, email@example.com)
Characteristics of persons who visited a psychiatric emergency service, by managed care status of the emergency department during the first index visita
aFor patients with more than one index visit, only the first index visit was used in these analyses.
Differences in adjusted cumulative likelihood of returning to a psychiatric emergency service in the weeks after the index psychiatric emergency service visit, by managed care status of the psychiatric emergency service during the index visita
aAll rates shown are adjusted rates; CIs and significance tests for adjusted values were based on parameter bootstrapping; 2×2 chi square tests included continuity correction.
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SISLEY Phyto-Ombre Eclat eyeshadow
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Jax Fish House Opens on the Plaza Monday
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The EVG®610 is a highly flexible R&D system that can handle small substrate pieces and wafers up to 200 mm. The tool supports a variety of standard lithography processes, such as vacuum-, soft-, hard- and proximity exposure mode, as well as other specific applications, including bond alignment, nano imprint lithography (NIL) and micro contact printing. The system offers quick re-tooling with a conversion time of less than one minute, making it ideal for universities, R&D and small-volume production applications.
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Ulta - Green With Envy and OPI - Fireflies top glaze on Flickr.
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