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|Submission Guidelines
For Contributing Authors
The Tactical Edge welcomes submissions from current members and selected non-members. Authors should follow the following guidelines:
Please submit an original manuscript in electronic format, faxes will not be accepted. Complete contact information should be provided, including law enforcement affiliation, daytime phone and e-mail address.
All articles are peer reviewed by NTOA subject-matter experts before approval for publication.
The NTOA reserves the right to edit manuscripts. These edits could include changes to clarify the story, improve the writing, trim the length or ensure that an article meets our stylistic guidelines found in the Associated Press Stylebook and Chicago Manual of Style.
Digital photos are preferred, but color prints are acceptable. The NTOA reserves the right to crop photos. All photos must include captions keyed to photo file name.
Digital photos must be a minimum of 300 dpi resolution (600 dpi is preferred) and at least 3 x 5 inches (8 x 10 inches preferred). The size should be as close to 1mb as possible. Use a 3-megapixel or higher camera on the best-quality jpg or tif setting. Photos embedded in Word or PowerPoint files, or images copied from the Internet are unacceptable and cannot be used.
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In consideration of being published in The Tactical Edge, the submitting author(s) agrees that NTOA may reprint, reproduce and disseminate as determined by the Executive Director of the NTOA.
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The Tactical Edge publishes incident summaries for the benefit of fellow officers. Often the lessons learned in one incident will help law enforcement anticipate potential problems in future incidents. Incident summaries for The Tactical Edge may be brief or in-depth, depending on the type of incident and the lessons learned. We welcome your commentary and observations, so that others may learn from the tactics - good and bad - that were employed. This type of article does not require extensive writing experience. Often an informative article can be created from a written report. The staff of The Tactical Edge will provide editing expertise.
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You're leaving Wedding Paper Divas to see the Deal of the Day at our parent site, Tiny Prints.
You won't be able to dismiss this by usual means (escape or click button), but you can close it programatically based on user choices or actions.
"The design says that the background is black. This is partly true because the shadow behind the flowers is black, but the card itself is a deep navy. I was initially concerned because my wedding colors don't include black, but this Save the Date turned out to be exactly what I wanted. I made a few minor changes to text colors, i.e. I changed the color of "Save the Date" and "Formal invitation to follow" from the default deep pink, to the dusty lavender/lavender-grey font option, as I prefer softer colors."
"We really liked the design on this card, but the colors in our picture were making it difficult for the words to show up well. Customer service was very quick (sometimes within a couple hours) to make the changes we requested and the card looked great. I was nervous about the paper quality, but they were very sturdy and durable. And the picture came out very clear. I would definitely recommend using this product. I am 100% satisfied with my whole experience and end product."
"We were able to change the style of writing and personalize it and add some extra details on the back! The price was great (even though I over ordered,by a lot!). Delivery was extremely fast! One week from USA to Australia! Amazing stuff! Will definitely be ordering again!"
"I absolutely loved how my save the dates came out. Everyone who received them thought the magnet idea was also very creative and unique. When it came to customizing colors and editing designs, it was so easy and the staff are helpful. Every specific detail they can edit to your taste. For example, I felt there were too many swirls so they took as much as I wanted off. This came out just perfect. The quality was also worth every penny."
"my soon to be husband and I loved the design and it was sent right on the 3rd like expected. overall happy with the purchase! thanks for helping us find a great card to send for our special day <3"

subset: commoncrawl


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The Greene County Surveyor has been arrested for crimes in Perry County, confirmed Attorney General Jim Hood today.
Billy Eugene Brewer, 69, who currently serves as Greene County Surveyor, was arrested at his home in Leakesville on Thursday by investigators with the Attorney General's Consumer Protection Division. Brewer is facing four counts of false pretense and four counts fraudulent use of identity. Brewer is alleged to have performed four surveys on properties in Perry County while being unlicensed and illegally using another surveyors name and license.
Brewer was booked into the Perry County Detention Center. Bond has not yet been set, nor have any court appearances.
The case is being investigated by Bo Luckey and will be prosecuted by Special Assistant Attorneys General Patrick Beasley and Alexander Kassoff of the Attorney General's Consumer Protection Division. As with all cases, the defendant is presumed innocent until proven guilty beyond a reasonable doubt in a court of law.
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Have you been feeling tired or moody? Have you been putting on extra weight that you haven't been able to lose even with diet and exercise? Are you dreading the onset of cold weather this fall? You might have low thyroid function. And if you do, you can join an estimated 53% of America's populace who are either under medical treatment for thyroid problems are among the very many whose thyroid problems have gone undiagnosed and untreated.
Even among those who have had blood tests showing "normal" thyroid levels, there are many whose thyroid function is less-than-optimal.
Low thyroid function is responsible for a number of unpleasant symptoms, including the following –
Symptoms of Low Thyroid Function –
- Low body temperature
- Unexplained weight gain
- Fatigue and lethargy
- Hair falling out
- Constipation
- Sensitivity to cold
- Depression
- Pale, dry skin
- Muscle weakness
- Painful, stiff, swollen joints
- Menstrual problems
Why Are So Many So Sick?
In our modern society, thyroid problems are epidemic in scope. We can blame at least part of this on mercury fillings in our teeth, chlorine and fluoride in the water we drink and bathe in, and the frequent use of soft drinks such as Mountain Dew and Gatorade which contain bromine. Each of these substances can harm the thyroid and lead to numerous health problems as a result! (1)
How Do You Know If Your Thyroid Needs Help?
If you can identify when at least a few of the common symptoms of low thyroid function, then it's a good idea to check your temperature first thing in the morning 3-5 days in a row. Menstruating women should do this on days 2-4 of their period. This is called the "basal metabolic" temperature.
For the most accurate results, get a digital basal thermometer (available at most drug stores) and lay it on the nightstand for easy access first thing in the morning. Immediately upon waking, place the thermometer in your mouth and take your temperature. Stay lying down in bed and keep your eyes closed if possible, so as to capture your temperature before beginning any activity for the day.
Normal body temperature is 98.4 degrees. If your average basal temperature is below 98 degrees, you may have hypothyroid or low thyroid function.
My Experience With Overcoming Thyroid Problems
In 2002 after 4 years of suffering with Chronic Fatigue Syndrome and Fibromyalgia, low body temperature (in the 97 degree range), fatigue, and several other symptoms indicative of thyroid problems, I did something that most people might not have the luxury to do. I spoke with my doctor and asked him to allow me to try a low dose of Synthroid, the most common drug for low thyroid function, even though my thyroid levels were within the "normal" range (this is before I knew about essential oils!). I had an unusual doctor who was open-minded to trying different things, and he agreed.
Within 1 day on the Synthroid, my energy levels skyrocketed, my body temperature normalized, and I was able to go on a study abroad program in Russia for 2 months as a result!
The problem for me, however, was that the longer I was on Synthroid, the more I needed just to keep functioning. For me, it was not a long-term solution to low thyroid function.
After I came across Young Living's amazing products in 2005, I weaned off Synthroid with my doctor's support. Here's what else I did –
Natural Solutions for Low Thyroid Function
Thyromin — As soon as I learned of this amazing product, I began to take 2 of them at night before bed. The first morning after taking my first dose, I literally woke up skinnier, more energetic, and with a more normal body temperature than the day before! After a couple of years using Thyromin, I no longer needed support for my thyroid and I discontinued using it with no problem.
Enhanced with the essential oils of peppermint, spearmint, myrtle, and myrrh along with bovine glandular extracts, iodine, and other nutrients that feed the thyroid gland, Thyromin is a unique and effective supplement that is guaranteed to help with thyroid function!
To sum it up, for low thyroid function, use 1-3 Thyromin capsules each night before bed. Increase or decrease the dosage by 1 capsule until you find the dose that improves function for you. Some people with severe low thyroid issues may need to take up to 5 capsules in the morning as well as 5 before bed to start with in order to nourish and reinvigorate the thyroid gland.
For hyperthyroid issues (an overactive thyroid), take 1-2 Thyromin capsules in the morning. This also feeds the adrenal glands.
EndoFlex is a special blend of essential oils that was designed to balance the body's glands, including the thyroid. To help with thyroid function, apply 2 drops to the throat area 2x/day. EndoFlex can also be applied over the adrenal glands (low/mid-back), ovaries, pituitary (forehead area) and thymus (breastbone area) to help improve overall hormone function.
EndoFlex can help with both hypo- and hyperthyroid conditions as it helps the body to cope with imbalances in the fragile endocrine system.
Thyromin and EndoFlex can also be used with Hashimoto's Disease where the body's own immune system attacks the thyroid, leading to low thyroid function.
During the time when I overcame low thyroid function naturally, I also supplemented with B vitamins, minerals, omega-3 fatty acids, and the amino acid L-tyrosine (available at health food stores), ate an extremely healthy diet, and addressed the emotional components of my illness.
Getting my thyroid in balance coincided with regaining my health from Chronic Fatigue Syndrome/Fibromyalgia, when I began to tolerate exercise and began to function as a normal human being again for the first time in SIX years after having the stamina of a sick 80-year-old throughout much of my 20′s!
After using the Thyromin for a couple of years I went off it with no problem. Recently I began having symptoms of low thyroid function again, and found the help I needed with Thyromin.
If you have problems with your thyroid, try out the solutions I outline and keep me posted on how they work for you!
(1) http://www.thenhf.com/article.php?id=2042
Julie Behling-Hovdal is a reflexologist/holistic healer and founder of Essential Survival where she teaches people how to prepare for the #1 cause of death in the event of an economic collapse — lack of access to medicines. In 2005 Julie was able to get off 4 prescription drugs and heal from a 6-year stint of Chronic Fatigue Syndrome and fibromyalgia with products from Young Living Essential Oils. Get a free copy of her report "Fast Track Survival Medicines" at http://essentialsurvival.org/fast-track-survival-medicines/.
Statements made about the essential oils that come in the Essential Oil Survival Kit and other products offered by Essential Survival have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure or prevent any disease. Anyone suffering from disease or injury should consult with a physician.


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Quotes & Info
|UTX > SEC Filings for UTX > Form 8-K on 28-Aug-2013
|All Recent SEC Filings
Other Events, Financial Statements and Exhibits
On August 28, 2013, United Technologies Corporation issued a press release announcing that it will exercise its rights to redeem the $294.2 million aggregate principal amount of its outstanding Goodrich 3.60% Notes due 2021.
The press release issued August 28, 2013 is furnished herewith as Exhibit No. 99.1 to this Report, and shall not be deemed filed for purposes of Section 18 of the Securities Exchange Act of 1934, as amended.
(d) Exhibits
Exhibit Number Exhibit Description Press release, dated August 28, 2013, issued by United Technologies 99.1 Corporation.


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like Wilco
If this gets as far north as Preston, I'll give it a try. Elbow doesn't exactly scream fine ales to me though.
Stella's french.
Wilco beer.
Stella's Belgian, not French.
Stella's bad too...
Interesting project, this
Digging: Interpol - El Pintor
Jupiler's the best Belgian pint anyways.
But I prefer the stronger beers, so this Elbow beer may taste not so bad (I hope)
4% isn't strong
That might be the best headline I have ever read.
Still looking forward to Amon Amarths Ragnarok beer. 8.2%? Yes please
Digging: Tiamat - Clouds
That's pretty decent. Is it a light or a darker beer?
Downed some pints of St Bernardis 10.0% and Duvelle 8.5% last night, no more cans or bottles only gonna do big things from this point forward.
I tried to post an article about a black metal beer several months ago and it got rejected.
what is this i don't even
check this one out balls
St Bernardis is delicious! Tried Bush Beer? That's a whooping 13% and it drinks itself like it's lemonade
Delve into the Avery Brewing Company. Mephistopheles-17%, Samael 15.3%, The Beast 14.9%.
Awesome scream
Hey, I know this probably seems a little out of the blue, but does anybody know if there's a place where I can buy this online? Probably sounds like a strange question but I was hoping to get a bottle for my friend for his birthday.
Any help is appreciated. Cheers.
Bands: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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Product Recall: We are voluntarily recalling fewer than 8,000 cases of regular Kraft American Singles Pasteurized Prepared Cheese Productlimited to 4 SKUs on two "Best When Used By" dates of February 20, 2015 and February 21, 2015. Click Here.
HEAT grill to medium heat.
MIX cream cheese and herbs until well blended. Roll into 4 balls; flatten each into disk on sheet of waxed paper. Refrigerate 15 min. or until firm.
COMBINE meat, Worcestershire sauce, salt and pepper. Shape into 8 thin patties. Place cream cheese disks on 4 patties; cover with remaining patties. Press edges together to seal.
HEAT oil in large skillet on medium heat. Add patties; cook 5 to 6 min. on each side or until done (160°F). Serve in rolls topped with watercress.


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Topics :: Judy Shepard
- 1 thru 4 of 4
Collins Set To Meet Matthew Shepard's Parents
By Arnie Stapleton | Friday Feb 28, 2014
For a guy who waited so long to get his chance to play basketball again, this was one game Jason Collins couldn't get through fast enough.
Gay Hate Crimes Activist Speaks in SC
Monday Oct 21, 2013
The mother of Matthew Shepard is speaking in Charleston. It's been 15 years since Shepard, who was gay, was abducted and beaten to death in Laramie, Wyo.
Slain Student's Mother Touched by Collins' Tribute
By Bob Moen | Wednesday May 1, 2013
The mother of a gay University of Wyoming student who was robbed and beaten to death in 1998 says she finds it touching that NBA veteran Jason Collins honored her son by wearing jersey No. 98.
Judy Shepard speaks at Bryant University
By Joe Siegel | Tuesday Oct 13, 2009
Judy Shepard, mother of Wyoming college student Matthew Shepard, spoke at Bryant University in Smithfield on Oct. 7. She continues to travel the country in support of her new book, The Meaning of Matthew: My Son's Murder in Laramie, and a World Transformed.
- 1 thru 4 of 4


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1.8M HDMI Cable for the Raspberry Pi
The Pi Hut
( inc. VAT )
1.8M Gold plated HDMI cable for the Raspberry Pi computer. 1080p output
> Connects your Raspberry Pi to your HDMI display unit
> Gold-plated connectors for highest signal transfer rate and resistance in corrosion.
> Fully Compatible with new HDMI 1.4 specification and HDMI 1.3b or below.
> Supports 480i, 480p, 720p, 1080i, 1080p


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The most remarkable and strangest thing we saw in the House of Physics was a force that carries news from one place to another in an instant with complete clarity and accuracy, even if the two places are far apart, because it is done with writing. The way they did it was with a disk of brass like the face of a clock, engraved with all the letters (and the vowels too, because the vowels are letters for them). This disk was firmly fixed to a stand, which had as many holes in its sides as there were letters, a hole under each letter. Across from it was another disk, lying flat, that was also marked with all the letters, with a pointer at its center. The two disks were connected by two wires that vibrated. If one person wished to talk with another, he would turn the first disk so that the needle lodged in the hole below the letter desired; the pointer on the second disk would stop at the same place. So it went until the words were complete and perfectly understood—all with the greatest speed. They claim that the force between these two disks can carry words instantly from one place to another. Even if there were thousands of hours of travel time between them, it would take just a second, that is, one-sixtieth of a minute.
This device completely staggers the senses, but one who has seen it with his own eyes will not doubt it. We tried it ourselves with a few words and could not move our eyes from one disk to the other before the pointer stood at the correct letter. They claim that they have set this up between Paris and Orléans, a distance of ninety miles, and also between the chamber where they gather to make their laws and the palace of the sultan, by means of a device hidden underground with an attendant at each end. They talk to the sultan from the chamber while he is in his palace, and he answers them, although they are a great distance apart.
On Thursday, the twenty-third day of the month, we went to the house for printing books called the "astanbā," which is another of their amazing crafts. First of all, you should know that the letters are cast in tin, thick at the bottom and narrow at the top. Some letters are single, and others are made of two letters joined together. The printer takes the letters he wants and puts them in a frame the size of the page to be printed, setting them in straight lines like writing. The letters are held tightly with a clamp that keeps them in order. Then they coat them with ink and lay a sheet of paper over them, pressing it down firmly by means of a vise. When the paper emerges, it is completely covered with writing. This is a general description of it. Now let me tell in detail about what we saw in this place.
First we entered a room with an oven where the workers cast the letters in copper molds the size of the type; the letter is engraved on the bottom of that mold, like the letter "sīn," for example. When the melted tin comes out, the letter at its head is reversed, but when they print with it, it comes out straight like any stamp. These workers cast letters in many types, both Arabic and non-Arabic. In the next room there were many workers, more than in the first; their task was to straighten and polish the letters, removing the bumps so that they would fit smoothly together in the frames. There were others who sorted the letters into compartments, one for each letter.


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JTT drives up to his house and waits until 6:01 to go inside. This makes Mary happy, I guess. I wouldn't be. I would want my boyfriend to get the Porsche. Mary smiles, and her teeth look crooked. JTT wishes his family Merry Christmas, and they're all happy to see him. Dad offers JTT the Porsche, but JTT refuses it because he knows what Christmas is really about, which is "not getting Porsches." Dad's all, "Whatchoo talkin' 'bout JTT?" Well, he would have said that if he were played by Gary Coleman. JTT asks the new wife what her sweater size is so he can buy her one, and she says that it's an eight. Don't women's sweaters have sizes like "small," "medium," and "large?" I checked my closet, and all my sweaters have sizes like that and not numbers. But that's not as important as how creepy it is that JTT is asking his stepmother about her sweater size in the first place.
Oh, and the town holiday parade is coming by the house. They see the sleigh parked in front and get mad at JTT. But he is forgiven, and then he drives his whole family and stupid Mary around in the sleigh, followed by the parade. Good thing he somehow knows the parade route. I hope this crappy sleigh ride was worth never ever riding in a Porsche, Mary, you stupid selfish bitch. A crane shot of the whole procession pans up, and the words "the end" come onto the screen. And then that stupid goddamn white ball pops up and ruins any warm feelings I might have had about this movie, which is fine because I didn't actually have any.
Oh, and the ending credits are just as bad as the opening ones. It's just like the opening with the map, but this time it stays over New York and also has flashing colored lights on the following towns: Middletown, Larchmont, Poughkeepsie, and Hampstead NY; Newark, NJ; and Norwalk and Hartford, CT. I would be happy about seeing my home state on the screen like that, except that I hate Connecticut, and also, an *NSYNC Christmas song is playing. Also, the music credits list two versions of "I'll Be Home for Christmas" and one of "I Won't Be Home for Christmas." That's just ridiculous. I only watched the credits because I thought that maybe we would see Robbie or Ian at the end of them. That did not happen, so I felt it necessary to provide you and me with some closure. Here we go: Ian dies in his locker, and Robbie dies in jail. Also, JTT and his family have an unfortunate freak sleigh accident and they all die as well, except for Dad. However, his face is so badly damaged that he requires massive plastic surgery, which makes him look like Gary Coleman. Don't we all feel better now?


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Image by SESConferenceSeries via Flickr
Now, I did happen to mention in a blog post about the event that Kaushik would be giving out six free copies of his newest book, "Web Analytics 2.0," to the participants who ask the most compelling questions during the webcast. So, maybe I'm partially to blame for what happened next.
His webcast was a big success. And in terms of Key Performance Indicators (KPI), his questions-per-attendee was off the chart!
But there were more questions than he had time to answer in the one-hour webcast.
Fortunately, he has taken the time and effort to tackle a small selection of the 80 questions the he could not answer in the wide ranging webinar. You'll find them on his blog, Occam's Razor, in a post entitled, "Dear Avinash: Search / SEO Metrics & Analytics Questions + Answers."
And his detailed answers are accompanied by illustrations, charts, and screen shots. So, dig in -- and dig deep.
Oh, and that's just a small sample of what you'll hear during his morning keynote at SES London 2010 as well as one of the keynotes at SES New York 2010.
This is also why I've advised industry veterans: Don't sleep in. Yes, yes, it's traditional to drink all night and sleep through the morning keynotes. But you won't want to miss Kaushik's morning keynote, "Be Awesome: Ideas for Approaching Search Analytics Differently."
If you want the KPI for hearing his keynote, then I suggest "actionable-insights-per-words-spoken." Based on his track record, Kaushik's keynotes will be off the chart.
The Original Search Marketing Event is Back!
SES Denver (Oct 16) offers an intense day of learning all the critical aspects of search engine optimization (SEO) and paid search advertising (PPC). The mission of SES remains the same as it did from the start - to help you master being found on search engines. Register today!


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Girls Gone Wild : The Search for the Hottest Girl in America Season 1 Episode 4 HDTV English | 97mins | 688x288 | 25fps | XviD | MP3 - 131kbs | 230MB Genre: DramaThe west coast bus hosts an open call in Las Vegas, and hits the jackpot with 18-year-old Katie . We know who we are, where we came from, and why we're here. Do you?
Download: http://www.ep.uplod.net/Girls_Gone_Wild__The_Search_for_the_Hottest_Girl_in_America_Season_1_Episode_4_HDTV&/file/sGsTpVjUse JDownloader to get Premium speed


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The Worst Foods for Your Skin
Generally, if you eat a healthy, balanced diet, it will show on your face. Scientists have argued for years over the link between diet and skin problems, though there are some things that everyone agrees can negatively impact your skin's appearance and aggravate existing problems. The good news? You can eat chocolate - as long as you stick to a low-dairy, low-sugar choice. But here are the types to avoid:
Dehydrating Foods
Getting enough moisture to your skin is imperative, and unfortunately our internal organs metabolize most of the water we drink before it reaches our skin. So any foods that dehydrate you are doubly bad for your skin. Stay away (as much as possible) from alcohol, caffeine, and salty snacks, deli meats, or high-sodium canned goods.
High Glycemic Foods
There's no doubt that foods with a high glycemic index like cakes, pasta, and white breads, will affect your weight. But there seems to be a link between these foods and break-outs as well. An Australian study published in the American Journal of Clinical Nutrition showed that a low-glycemic diet actually reduced acne by 50%. Some studies have linked blood-sugar problems - which can be caused by too many sugary and high glycemic foods - to acne.
Trans-Fat and Fried Foods
It's probably no surprise that these chief health offenders are also bad for your skin. Though doctors still debate the link between these and acne, they do know that these fractionated oils can damage skin's free radicals, leading to premature aging. And many do feel that they can contribute to trapping bacteria under the skin, leading to break-outs.
Not Enough Fat
While you should stay away from "bad" fats, good ones help maintain your health - and skin. The National Institutes of Health states that fat is crucial for maintaining healthy skin, so be sure to include healthy, unsaturated fats like fish and olive oil in your diet.
Food Intolerances
You may not realize that you're mildly allergic to foods like nuts, dairy, or gluten products. Reactions to these intolerances can show up on your skin, often in pigmentation problems, minor rashes, or even eczema breakouts. Consider cutting these from your diet or getting tested for sensitivities if you're having skin issues.
Dairy & Meat
Some studies have shown that cutting milk products and red meat from their diet showed skin improvement. However, these contain important vitamins and minerals, so you should speak with your doctor about how to replace these in your diet.
According to Dr. Lawrence E. Gibson, M.D., an expert from the Mayo Clinic website, "If you're interested in healthy skin, you might simply focus on a balanced diet." And it seems that this approach does indeed make the most sense. Focus on a healthy you - and your inner health will show up on your skin.
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American Journal of Clinical Nutrition
Medline (publication of the National Institutes of Health)
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02 67425333
02 67425330
For more information contact Richard on 0427 003890
Ultra Lubricants is an established Oil, Agricultural and Industrial supplier. It was established in Gunnedah NSW in 1999 and has expanded its operations to include a branch in Wee Waa in 2003 and storage depots in Moree, Tamworth and Melbourne.
Our Company's aim,
"To ensure competitive pricing and outstanding customer service at all times"
has led to Ultra Lubricants obtaining a wide market share in Australia, with customers spanning from Western Australia to the Riverina.
Ultra Lubricants products are manufactured under a quality assurance AS/NZS 9001:200
Guidelines and are subject to a yearly audit by NCSI1.
As part of our quality assurance procedures, all raw materials are supplied by quality approved organisations and the finished product is tested to strict ASTM2 standards by an independent NATA3 approved laboratory prior to release. All products supplied by Ultra Lubricants are covered under a $10M product liability insurance policy.
The product range includes a full range of Diesel and Petrol Engine Oils, Transmission, Differential and Hydraulic oils. Ultra Lubricants is also compatible with other manufacturers oils, of equivalent grades in "top up" situations. We can also provide the facility to blend specialty products, including Extreme Engineering Products and Ultra Pro Racing for motorsport.
MSDS and Specification sheets are available on request for any of our products.
1NCSI - NATA Certificate Services International
2ASTM - Australian Society for Testing Materials
3NATA - National Association of Testing Authorities
4MSDS - Material Safety Data Sheets


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Tire marks, tire marks, finish line with the fire marks
When the relay starts Im a runaway slave-master
Shittin on the past gotta spit it like a pastor
After, bash her, did it like doe like dasher, faster-motorbike faster
Iggy gotta get a bitch watch for my rapture
White bitch go, bout to blow like the wind
Penthouse too roof top at the wind
When I win, when I win I win, no when I wid em they good like shin
Got hoes on call, got hoes on call to come through take a pro-to-call
Just damagin thats my protocol
Dismantle ya, Australians on Slauson, no camera, I dont care who you are
No condom rap gotta give it to you raw
Pitchfork point better pass me the joint
Gotta twist this beat Ima sprang my joint
Straight crack rock, go to the pop-pop
Pumo jiggy rap city, no tiggy - yeah shorty do illa Im raw no digga
Whats my muthafuckin name its Iggy not Jiggy
Dont compare me to her, throw the b*tch in the ditch
Ruff ruff ho, kill the bitch I'm vick
Sewed the game up stapled up in a stitch
Click-click pow D.R.U.G.S. gang, my clique
Look at my heels LV on it, ignorant art, everybody on it
Everybody want it, 666 got a three car garage driveway be the omen
Boss like Cowen?
Hate me, Chordz 3D cant see me
Pockets better than a H3, I dont see you like mace-me, ugh
D.R.U.G.S - click oh and we on - hater
On these hoes hairs no activator, whores fuck up when he activate-her
Cuz Im goin out with my hand raised
Bout to smack, smack, smack till my hand cave
On the bitch May, honey Im paid, Ima get laid fuck yer man cave
Ya act like ya girl be real, son
Kinda spaced-out you b*tches be duckin
Better than ya girl, than the best, make the competition rest
Unless its sex no less, Ima fuck a ho game Im best
With my strap on, my vibrator, bout to Bust-a-Rhyme, no violator
Course no, Ima feel myself
Im a masturbator like uh uh uh uh-fuck me, fuck me
Now Im off beat, my head hurts, I murk shit, I gets paper
Wash my mouth, I curse like a sailor - bitch!
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Sentinel Node Biopsy (cont.)
Who Is Not a Good Candidate for Sentinel Node Biopsy?
Not all women are good candidates for sentinel node biopsy. A woman with any of the following may be a poor candidate for the procedure:
In addition, the following factors are associated with an increased risk of complications involving most surgeries (but none are specific contraindications to sentinel lymph node biopsy):
Medically Reviewed by a Doctor on 6/20/2014
Medical Author:
Leigh A Neumayer, MD, MS, FACS
Medical Editor:
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(Page 2 of 11)
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The Role of Sentinel Node Biopsy in Skin Cancer »
The incidence of malignant melanoma is increasing rapidly, at a rate of 4-8% per year. Malignant melanoma typically affects young patients (median age 45 y).


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Can You Identify This Fan?
Good Questions
Q: Can anyone identify this fan? It is the closest fan to the beautiful Boffi fan...but hopefully much cheaper. I'm looking for this without the light.
Sent by Mihail
Editor: Leave your suggestions for Mihail in the comments - thanks!
• Got a question? Email yours with pic attachments here (those with pics get answered first)
6 Comments
Checkout Modern Fan Company. The blades look similar to my Ball fan.
It looks like the Fanimation Zonix fan with a woven trim around the housing and the light kit:
Modern Fan Company would be my first stop, because the fans there have that minimal, sleek look. Also remember that many times, a fan that has a light on it in the position your photo shows -- meaning straight down, not those combinations of 4 or 5 "tulip" lights that flare out -- will also come with a solid cover if you don't want to use the light. Both of my Minkas came with optional solid covers (but I like the bit of overhead light).
I got one a lot like that (with the blade ends hidden in brushed metal housing) from the local Home Depot. The blades sides have different wood stains so you can use the side that matches your furniture best. And yes, you can use a cap instead of the lite. Great buy.
My sister has that fan. She bought it at Home Depot. It only works by remote control, FYI. If I had to guess based on what I know of her budget, it was probably in the $100-$200 range.
That's the lapa from Modern Fan. See here: http://www.modernfan.com/lapa.html. Add the light, and switch the blades to maple. They discontinued the 3-blade model a while ago though.


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From Wikipedia, the free encyclopedia - View original article
Trans Executive Airlines of Hawaii is an American airline headquartered at Honolulu International Airport in Honolulu, Hawaii. The company operates cargo flights under the name Transair; and passenger charter and tour flights under the name Interisland Airways. The airline was started in 1982 by Teimour Riahi.[1] As of December 2011, the airline operated a fleet of seven Short 360 aircraft.[2]
|This article relating to a United States airline is a stub. You can help Wikipedia by expanding it.


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Fat-Free Superbowl Sunday Recipes
Alright, I admit it: I hate football.
I do love going to Superbowl parties. I look at Superbowl Sunday as an excuse to get together with friends and eat good food (and feed vegan treats to unsuspecting omni's).
I also learned early in life that it's important to see the commercials during the Superbowl because everyone talks about them at school or ...


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Reader Comments (Page 1 of 1)
Hivetyrant said...
How did you manke those noises without drooling?
I can't seem too :(
Funny that, because when I look at the weapons I think:
"Haven't I seen these somewhere before?"
Oh yeah, I have.
On Marrowgar.
Illidan/KJ get drooly-unique models. Arthas gets reworks of drops from the first boss in the instance.
I know this is QQ but, come on. The Lich King. The end boss. Reused models? Give me a break
^^ This.
It seems Blizzard really got lazy this expansion.
So, they took out attunements, is that an excuse to have 0 quests for Naxx, aside from the Saphiron heart thing?
And Ulduar just don't feel the same when the only quest comes from the healer weapon legendary chain inside.
I don't think attunements should have been removed.
I think they should've been simplified, to the point of "Do a solo'able quest chain, kill the last boss of 2-3 heroics for another chain, and do a summon-able, 10-mannable world boss."
I think that would make a fun atunement chain for naxx, and do a smaller one for OS, and let the heart be the one for Maly.
Do the same thing with ToC, UIduar and ICC and I would've been happy.
To stay on topic.
If all the bosses in a raid have to share weapon models, fine.
But just give the end boss unique looking loot.
The 2hander won't make people stop and think "Wow, that guys taken down the LK..."
It'll make people think "Hey, well atleast I know that guys competent enough to do 'Lord Marrogar must die!".


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Kate Farrish, Conn. Health I-Team Writer
Publication: theday.com
The state Department of Public Health has fined a dozen nursing homes in recent months for lapses in patient care, including the deaths of residents at homes in Bridgeport and Norwalk.
Bridgeport Manor in Bridgeport was fined $1,440 in December for failing to provide a resident with psychiatric services and adequate supervision, DPH records show. The resident was frequently observed playing with privacy curtains at the home. On Nov. 27, 2012, the resident was found with a privacy curtain wrapped around the neck and upper body and died two days later.
In February, Paradigm Healthcare Center of Norwalk was fined $1,230 in connection with the case of a mentally ill resident who choked on food that had been left on a tray on Dec. 7, 2012. The resident had "copious amounts of food obstructing the airway," sustained a brain injury and went into cardiac arrest, records show. The resident died a week later when life support was discontinued, DPH records show.
Jonathan Neagle, a court-appointed receiver, said the home was under state receivership when the incident happened. "This accident clearly was an accident, and all the policies and procedures in place have been reinforced to prevent any further incidents,'' he said.
Bridgeport Manor officials for Bridgeport Manor could not be reached for comment.
Among other citations, according to DPH records, was one issued to Bayview Health Care in Waterford. Bayview was fined $1,020 in January for a November 2012 incident in which a nurse's aide shoved a washcloth in the mouth of a resident with dementia and pinched the resident's nose three times. That aide was fired, along with another aide who witnessed the incident but did not intervene out of fear of retaliation from the first aide.
This story was reported under a partnership with the Connecticut Health I-Team (www.c-hit.org).
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1. Brandon Myers vs. DEN
Brandon Myers has been hampered by a minor shoulder injury over the last few weeks, but it surely didn't show in his 14-catch, 130-yard and a touchdown performance last week against the Browns. Myers comes off his best game in his career into a matchup against one of the easiest matchups in the league, the Denver Broncos. The Broncos have allowed a touchdown in more than half of their games this season, including one last week to Dallas Clark.
2. Owen Daniels at NE
A frustrating string of one touchdown in the last four weeks has plagued Owen Daniels owners, but things could be turning around as early as this week. On Monday night, Daniels faces a Patriots squad that has been toasted by tight ends this season. New England has allowed the second-most yards to opposing tight ends and have allowed seven touchdowns to the position this season.
3. Jimmy Graham at NYG
I'm wondering if it's a soft "J" and it's pronounced "Yimmy," because Jimmy Graham's play has been exceptionally soft over the last few weeks. In the last three weeks, Graham has only managed yardage totals of 29, 33, and 59 yards, which is significantly worse than the 94 yards he was averaging over the previous three weeks. The Giants have only allowed two scores to tight ends this season, but the bright spot is that they were on the losing end of the 18 reception, 167-yard game for Jason Witten a few weeks back. They're susceptible to allowing a big game and there's no way I'm benching Yimmy in a playoff week.
4. Martellus Bennett vs. NO
Martellus Bennett broke back into the end zone for the first time in eight weeks on Monday night. His 82 yards and a score against the Redskins could help break him back into your fantasy lineup this week too. His matchup against the Saints looks to be an easy one. New Orleans started the season by giving up only one touchdown to a tight end in the first eight games, but they've allowed four touchdowns to the position in just the last four weeks.
5. Jermaine Gresham vs. DAL
Jermaine Gresham has firmly planted himself in the top 10 rankings among tight ends. With an average of nearly 50 yards per game and five total touchdowns, he ranks in the top 10 in both categories, meaning he's pretty much an every week starter. This week he faces a hot and cold Dallas defense. In the last three weeks the Cowboys were beaten by Ben Watson for two scores and Brent Celek rocked out seven catches for 73 yards. So it's not exactly the cream of the crop who has figured out a way to beat Big D.
6. Tony Gonzalez at CAR
In his last seven games, Tony Gonzalez has scored three times, all of which came against the New Orleans Saints. Unfortunately he does not face the Saints this weekend, but a Panthers team that's been pretty decent against the pass. Carolina has not allowed more than 73 yards to any tight end this season, but has given up three touchdowns to tight ends in just the last three weeks.
7. Kyle Rudolph vs. CHI
It looks like Percy Harvin will not suit up for the Vikings again this week, leaving Kyle Rudolph as Christian Ponder's only trusted target. Since Harvin went down in the Seattle game, Rudolph has topped 50 yards and scored in each of the last three games, including a matchup with this week's opponent, da Bears. Chicago lost both Brian Urlacher and Tim Jennings to injuries this week, so this defense doesn't look nearly as fierce as it once did.
8. Heath Miller vs. SD
For the first time in five weeks, Heath Miller had a chance to do his end zone dance, with a dramatic touchdown catch as a part of a five-catch, 97-yard afternoon last weekend in Baltimore. The Chargers are the opponent this week and they're kind of a weird bunch against tight ends. In the last four weeks the Chargers have allowed a tight end to score in three games and allowed 81 total yards to the Denver tight ends in the other contest. Either way, Miller looks like he should have a nice afternoon.
9. Jason Witten at CIN
Last week against the Eagles, Jason Witten grabbed six catches for 108 yards. It was his third 100-yard game this season. Unfortunately, he didn't score… again. Witten has only scored once this season, Week 4 against the Bears, but this weekend he's got a fair shot. While the Bengals are one of the league's best defenses against wide receivers, they're only middle-of-the-pack against the tight end. Cincy has allowed the 11th most receptions to opposing tight ends, something Witten owners, and PPR players, can feel pretty good about.
10. Dennis Pitta at WAS
Dennis Pitta is about to go off. Mark my words. He did not fare well in either game against the Steelers over the last three weeks, but has scored in the two other games he's played over a four-week span. A matchup with Washington is the first in a line of great tight end matchups for Pitta, and since the Ravens need wins to keep their hold on a first round bye, they're going to throw it. The Redskins have allowed the most receptions, yards and the second-most touchdowns to tight ends this season. Slam dunk.
Other options…
11. Greg Olsen vs. ATL
12. Jacob Tamme at OAK
13. Dallas Clark vs. PHI
14. Aaron Hernandez vs. HOU
15. Marcedes Lewis vs. NYJ
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Seeing like a state: How Certain Schemes to Improve the Human Condition Have Failed (Google eBook)
Yale University Press, Feb 1, 1999 - POLITICAL SCIENCE - 463 pages
Compulsory ujamaa villages in Tanzania, collectivization in Russia, Le Corbusier's urban planning theory realized in Brasilia, the Great Leap Forward in China, agricultural "modernization" in the Tropics -- the twentieth century has been racked by grand utopian schemes that have inadvertently brought death and disruption to millions. Why do well-intentioned plans for improving the human condition go tragically awry?
In this wide-ranging and original book, James C. Scott analyzes failed cases of large-scale authoritarian plans in a variety of fields. Centrally managed social plans misfire, Scott argues, when they impose schematic visions that do violence to complex interdependencies that are not -- and cannot -- be fully understood. Further, the success of designs for social organization depends upon the recognition that local, practical knowledge is as important as formal, epistemic knowledge. The author builds a persuasive case against "development theory" and imperialistic state planning that disregards the values, desires, and objections of its subjects. He identifies and discusses four conditions common to all planning disasters: administrative ordering of nature and society by the state; a "high-modernist ideology" that places confidence in the ability of science to improve every aspect of human life; a willingness to use authoritarian state power to effect large-scale interventions; and a prostrate civil society that cannot effectively resist such plans.
"A broad-ranging, theoretically important, and empirically grounded treatment of the modern state and its propensity to simplify and make legible a society which by nature is complex and opaque. For anyone interested inlearning about this fundamental tension of modernity and about the destruction wrought in the twentieth century as a consequence of the dominant development ideology of the simplifying state, this is a must-read". -- Daniel Jonah Goldhagen, author of Hitler's Willing Executioners
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LibraryThing ReviewUser Review - margaret.pinard - LibraryThing
Great insights into social nature, urbanization, statebuilding and such. Can go on into more dense field issues, but I found the historical treatment very good. Read, Kat! Or at least flip through... Read full review
Review: Seeing Like a State: How Certain Schemes to Improve the Human Condition Have FailedUser Review - Aaron - Goodreads
I suspect I will return to this book from time to time. What Scott presents makes a tidy framework for thinking about lots of different phenomena, and I would recommend anyone add this to their own cognitive toolkit. Read full review
Selected pages
Part 2 Transforming Visions
Part 3 The Social Engineering of Rural Settlement and Production
Part 4 The Missing Link


text: The Maine Center for Public Interest Reporting will keep citizens informed about their government and their public servants through high-quality, independent investigative reporting that is published by media outlets across the state. In recent years, most newspaper and broadcast news outlets in Maine have reduced newsroom staffs through layoffs, early retirements and attrition. One of the first victims is in-depth journalism — stories which often take one or more reporters "off the street" for weeks or even months.


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Reader Comments (Page 1 of 1)
You were lucky. We lived for three months in a paper bag in a septic tank. We used to have to get up at six in the morning, clean the paper bag, eat a crust of stale bread, go to work down t' mill, fourteen hours a day, week-in week-out, for sixpence a week, and when we got home our Dad would thrash us to sleep wi' his belt.
kittytrainer said...
I think counseling might help you with your problem......
Well we had it tough. We used to have to get up out of the shoebox at twelve o'clock at night, and LICK the road clean with our tongues. We had half a handful of freezing cold gravel, worked twenty-four hours a day at the mill for fourpence every six years, and when we got home, our Dad would slice us in two with a bread knife.
EaterOfBirds said...
its not 'quite' funny even. the original is hilarious beyond hilarity. man i have to dig out the holy grail and watch it now.
''on second thought, let us not go to camelot. it is a silly place''
Right. I had to get up in the morning at ten o'clock at night, half an hour before I went to bed, drink a cup of sulphuric acid, work twenty-nine hours a day down mill, and pay mill owner for permission to come to work, and when we got home, our Dad and our mother would kill us, and dance about on our graves singing 'Hallelujah.'
And you try and tell the young people of today that ..... they won't believe you.


text:
Happy 4/13, everyone!
This blog is going to be discontinued as of today! Basically, there's just too much uncertainty and I don't want to freak anyone out without reason. If we ever get an official end date (which I personally doubt) or if it becomes obvious that the comic will probably end on a certain date, then I'll probably continue this. Until then, I bid you all goodbye, and I'll still be available for questions, if anyone wishes.
sighs i know, it kind of got out of hand. i'm actually just thinking about discontinuing this blog, i would leave it up, just not update it any more (unless we did actually receive an official end date, which i doubt) i would also love to tell everyone who was freaking out that i could possibly be wrong, but it's impossible, there's almost 4000 notes. i figure if i discontinue the blog, at least i could avoid freaking any additional people out? i'm honestly not sure what to do anymore, if you have ideas or thoughts, i'd love to hear them.
Quite honestly, it's mostly an assumption, based on a few things: one, we know for a fact that Homestuck IS ending sometime this year. Second, that would mean it ends on April 13th of 2013, so it would be a double 413. It has to end at some point, so why not the fourth 4/13? Finally, I just have this weird instinct that it'll end on that day. I could very well be wrong! And if I do end up being wrong, I'll be sure to issue a formal apology, but we'll cross that bridge when April comes.
As of today, January 16th 2013, there are only 87 days left in Homestuck.
Ask box is open! Questions, comments, concerns, I'm here to answer.
I've seen this a lot in the reblogs of the previous post, so I though I would address this quickly: I am not completely certain that Homestuck will be ending on April 13, 2013 HOWEVER all signs that I can think of are pointing towards that date for the end date. Please do not be angry if that turns out to be wrong, however I don't think it will be. Thank you, carry on scrolling.
As of today, January 15th 2013, there are only 88 days left in Homestuck.
As of today, January 14th 2013, there are only 89 days left in Homestuck.


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By Lawrence Fine, Author of the FineSoccer Coaching Bible.
Welcome to the FineSoccer Drills Newsletter. Today's featured activity works on defensive shape and balance with an emphasis on high pressure.
Start with a 10 x 20 yard area (10 yards deep and 20 yards wide) with 3 attacking players starting on an endline and 2 defenders. One of the attacking players has a ball.
The attacking players are trying to take the ball over the opposite end line. The defenders are using high pressure to prevent the attackers from getting Continue reading


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Private tented camp, Serengeti
Safari by 4WD vehicle from a private camp in a secluded section of the Serengeti, far from the lodges. We camp in a vast, private, Masai-owned wilderness where the great herds roam freely.
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The Ultimate Safari Experience: Lake Manyara, Ngorogoro, and the Serengeti
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Discovery Channel
Soon after Napoleon took the French throne, a slave revolt broke out in French-controlled Haiti, which cost the French 55,000 soldiers and drained their national coffers. Napoleon needed to recuperate funds to prepare for war in Europe. At the same time, U.S. president Thomas Jefferson saw French control over New Orleans as an obstacle to America's westward expansion. James Monroe was sent to France as an envoy with the authority to buy New Orleans for $3 million. Surprisingly, Napoleon offered the entire Louisiana Territory. On April 30, 1803, the Louisiana Territory was sold to the United States for $15 million. The Louisiana Purchase doubled the size of the United States.
Actually, after Napoleon agreed to sell the Louisiana Territory, he did have second thoughts; as was his opinion, the U.S. was getting a much better deal. Robert Livingston urged Congress to quickly ratify the treaty before Napoleon would pull out. Napoleon agreed in the first place because he planned to use the money from the sale to fight a war with England, and he had little interest in sending his armies across the Atlantic to fight the British or Dutch for relatively empty land. France had originally wanted Louisiana in order to turn Saint Domingue, Haiti, into a profitable colony. When this plan didn't work out, Napoleon decided that the money from the Louisiana Territory would be more useful than keeping the land.
Painting of French soldiers firing guns to salute raising of U.S. flag after official completion of Louisiana Purchase. (William C. Shrout//Time Life Pictures/Getty Images)
How did the slave trade in Europe and America stop?
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2 x 70g pouches satisfy the daily requirements of an average weight cat, pregnant and lactating queens may need more.
Fresh drinking water should be made available at all times, serve at room temperature
Country of Origin
MPM Products Ltd.,
Package Type
Carton Box
Recycling Information
Carton box recyclable
Allergen Information
Contains Fish, Contains Shellfish
Chicken & Prawn with Brown Rice
Chicken 55%, Prawn 20%, Chicken Broth 21%, Brown Rice 4%.
Additives: None.
Mackerel, Tuna & Sea Bream
Mackerel Flake 45%, Fish Broth 24%, Tuna White Meat 20%, Sea Bream 10%, Rice 1%.
Additives: None.
Chicken & Brown Rice
Chicken 75%, Chicken Broth 21%, Brown Rice 4%.
Additives: None.
Pacific Tuna & Whitebait
Tuna 65%, Fish Broth 24%, Whitebait 10%, Rice 1%.
Additives: None.
Nutritional Data
|Typical Values
|per pack
Customer Reviews
29 March 2014
1 of 1 found this review helpful.
I've tried just about every pouch there is and this is the only one he will eat, very good quality, no rubbish in them, brilliant!
12 February 2014
2 of 2 found this review helpful.
Worth every penny
Encore cat food is great. It looks like proper food and our cat loves the texture of the tins and the pouches - not so keen on the pots and hates the pates, though. We have switched to it because of the absence of fillers and she is thriving on it.
01 January 2014
2 of 2 found this review helpful.
goes down a treat
He scoffs this in no time, by which I deduce it must be tasty!
24 November 2012
2 of 2 found this review helpful.
At last, food the cat will eat!
I thought I'd try this on my cats as I'm sick of wasting cat food & throwing it away or it making them sick. They tucked into it heartily, with the fussiest one licking the bowl clean. Certainly worth the extra few pennies if they like it and it doesn't make a reappearance!!
29 January 2012
2 of 2 found this review helpful.
Excellent Cat Food
After giving our cat the free sample pouch that was in my shopping one week it felt cruel not to purchase it on a more regular basis! It is expense but as it doesn't dry out when left our cat likes to leave food in her bowl to go back to later so I am throwing less away. And it smells better, which is a big plus.
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text:
Poison ring, inspired by the sea. Like most of my jewellery it is pressure proof up to 6.8 miles depth.
The "triger" of the poison ring lies on the next finger, so you can open it without anyone noticeing it...
The ring itself was carved from plexi glass (acrylic glass). The rim and the lid are fabricated from silver, on the top there is an olivin (peridot).
The rim is connected to the plexi base by glue and 5 bolts.
Weight: 22.1 gramm
The diameter of the dome is 25.5 mm. The hight of the whole ring is 50 mm
Material Used
plexiglass, sterling silver, peridot


text:
Effect of Physician Ownership of Specialty Hospitals and Ambulatory Surgery Centers on Frequency of Use of Outpatient Orthopedic Surgery
Arch Surg. 2010;145(8):732-738. doi:10.1001/archsurg.2010.149
Background Physician-owned specialty hospitals and ambulatorysurgery centers have become commonplace in many markets throughoutthe United States. Little is known about whether the financialincentives linked to ownership affect frequency of outpatientsurgery.
Background Physician-owned specialty hospitals and ambulatorysurgery centers have become commonplace in many markets throughoutthe United States. Little is known about whether the financialincentives linked to ownership affect frequency of outpatientsurgery.
Objective To evaluate if financial incentives linked tophysician ownership influence frequency of outpatient orthopedicsurgical procedures.
Design and Setting We analyzed 5 years of claims datafrom a large private insurer in Idaho to compare frequency byorthopedic surgeon owners and nonowners of surgical proceduresthat could be performed in either ambulatory surgery centersor hospital outpatient surgery departments.
Main Outcome Measure Frequency of use, calculated as numberof patients treated with the specific diagnoses who receivedthe surgical procedure of interest divided by the number ofpatients with such diagnoses treated by each physician.
Results Age- and sex-adjusted odds ratios indicate thatthe likelihood of having carpal tunnel repair was 54% to 129%higher for patients of surgeon owners compared with surgeonnonowners. For rotator cuff repair, the adjusted odds ratiosof having surgery were 33% to 100% higher for patients treatedby physician owners. The age- and sex-adjusted probability ofarthroscopic surgery was 27% to 78% higher for patients of surgeonowners compared with surgeon nonowners.
Conclusion The consistent finding of higher use ratesby physician owners across time clearly suggests that financialincentives linked to ownership of either specialty hospitalsor ambulatory surgery centers influence physicians' practicepatterns.
Under existing federal law, it is illegal for physicians torefer Medicare and Medicaid patients to designated health careentities in which the physician has an ownership interest. Abouthalf the states have enacted similar prohibitions that applyto privately insured persons.1 The federal law and most stateself-referral bans do not apply to "whole" hospitals and ambulatorysurgery centers (ASCs).1-2 The whole-hospital exception wasbased on the presumption that because general hospitals offera wide array of services, any referrals made by an individualphysician investor would produce little personal economic gain.1 The ASCs (freestanding facilities that provide surgical proceduresthat do not require an overnight stay) were exempt from theself-referral prohibitions because they were viewed as an extensionof the physician's practice. In fact, the federal safe-harborguidelines require that physician owners of multispecialty ASCsperform at least one-third of their outpatient surgical proceduresat the facility in which they have a financial stake. This safe-harborguideline does not apply to single-specialty ASCs.3
The exceptions to federal and state self-referral prohibitionsare one factor that has fostered the growth of specialty hospitalsand ASCs that involve referring physician investors.1-4 Theseso-called limited-service facilities have grown most rapidlyin states with less stringent regulatory environments. Specialtyhospitals have become increasingly common in about a dozen statesthat do not regulate the development of new hospitals or expansionsof existing facilities.2, 4-5 In contrast, the growth of ASCshas been more widespread because many state certificate-of-needlaws have provisions that exempt ASCs.2-3 Other factors thathave contributed to the growth of both types of facilities includephysicians' desires to have greater involvement in managementdecisions, uninterrupted operating room schedules, and the potentialto improve efficiency and quality that may result from specialization.Moreover, physician owners share in any profits that resultfrom facility fees and ancillary procedures performed at theASC or specialty hospital. Thus, ownership provides an avenuefor physicians to supplement the income they generate from theprovision of direct patient care.2, 4-5 Although proponentstout the advantages physician-owned facilities provide (ie,more efficient management and scheduling of patients), criticsmaintain that ownership of specialty hospitals or ASCs representsan inherent conflict of interest for referring physician investors.2, 4-7 As owners, physicians have financial incentives to referless-sick patients and those with good insurance to their ownhospital or ASC. These financial incentives may result in increasedutilization of profitable procedures and services, some of whichmay not be medically necessary. Because increased utilizationis the driving force behind escalating health insurance premiums,such trends are likely to result in greater numbers of uninsuredand underinsured persons. Such practices also may weaken theability of competing general hospitals to provide safety netservices.2, 6-7
Nearly all prior research on physician-owned specialty hospitalsis based on site visits and/or market-level analyses of Medicareinpatient claims.4-11 Existing evidence based on inpatient proceduresprovides an incomplete picture because inpatient proceduresaccount for only 20% of the services rendered at physician-ownedspine, orthopedic, or surgical facilities.4 Although ASCs aregeographically distributed throughout the United States, researchdocumenting their effects on use of outpatient surgery is limited.12-19 Previous research provides limited insight about whetherpatients who are treated by physician owners of ASCs or specialtyhospitals are more likely to undergo outpatient surgical procedurescompared with patients with the same clinical conditions whoseek care from physician nonowners. To my knowledge, only 1study to date has examined whether physician ownership of specialtyhospitals influences the frequency of use of inpatient and outpatientsurgery, but the analysis was restricted to workers' compensationcases that involved back or spine injuries.20 The present studyaddresses this significant gap in knowledge. I analyzed claimsdata from a large private insurer in Idaho to compare frequency(referral rates) by physician owners and physician nonownersof specific outpatient orthopedic surgical procedures that couldbe performed in either ASCs or hospital outpatient surgery departments.
Data Source
Using data from state records and the insurer, I identifiedthe freestanding ASCs, specialty hospitals, and full-servicecommunity hospitals located in Idaho. I compiled a databasecontaining the incorporation date, location, ownership, andcontact information for each facility. Nearly all of the growthin ASC availability had occurred since the mid-1990s. I alsocontacted each facility to obtain additional information onthe types of surgical procedures performed, the number of operatingrooms, and more details on physician investors for those facilitieswith incomplete ownership records. With further assistance fromstate documents on corporate filings and detailed physicianrecords from the insurer, I was able to identify the physicianowners of each ASC and specialty hospital in Idaho. I was alsoable to identify the date each physician-owned facility becameoperational, thus enabling us to accurately classify each physicianby ownership status for each year.
The frequency-of-use comparisons are based on analyses of medicalclaims data for the years 2003 through 2007 from the large privateinsurer. The claims contain detailed information on each patientencounter, including the physician who performed the service,location, type of claim (professional or facility), and taxidentification number; patient characteristics such as age,sex, and diagnoses; and details regarding the types of servicesreceived and type of coverage: deductible, copayments, amountbilled, and amount reimbursed. In 2003, the insurer providedhealth insurance coverage (indemnity and preferred providerorganization plans) for approximately 228 000 individuals.By 2007 it had covered an estimated 326 000 individuals,so the insurer's market share was about 40%.
I restricted the analysis to procedures performed at facilitieslocated in Idaho. Services performed by out-of-state physicianswere excluded because they account for a small share of allclaims and do not directly compete with in-state physicians.The insurer uses a fee schedule to determine the amount it willpay for each procedure. Although the deductibles vary acrossplan types, the insurer pays 80% of the allowed fee for outpatientsurgery and the patient is responsible for the remaining 20%.This cost-sharing arrangement applies to both the professionalfee paid to the surgeon and the facility fee paid to the hospitalor ASC. No enrollee was required to obtain plan approval beforeundergoing outpatient surgery. Individuals with Medicare supplementalcoverage and those enrolled in Medicare health maintenance organizationswere excluded from the analysis, but about 2% of patients wereenrolled in a preferred provider organization Medicare Advantageplan.
Calculating Frequency of Use For Specific Surgical Procedures
I constructed frequency-of-use indicators for common outpatientsurgical procedures performed by orthopedic surgeons: carpaltunnel repair, rotator cuff repair, and arthroscopic surgeryof the knee. I developed the following algorithm to constructthese indicators.
Step 1
I identified for both orthopedic surgeon owners and nonownersthe most commonly reported diagnoses associated with each surgicalprocedure of interest (Table 1).
Step 2
For each orthopedic surgeon owner and nonowner, I identifiedall office visits of patients with these diagnoses that occurredwithin the 90-day period that preceded the surgical procedureof interest.
Step 3
For each orthopedic surgeon owner and nonowner, I identifiedall patients with these diagnoses who had office visits butdid not undergo the surgical procedure of interest.
Step 4
I constructed frequency-of-use indicators; that is, the percentageof patients who received the surgical procedure of interest.The numerator is the number of patients who received the surgicalprocedure of interest performed by orthopedic surgeon owners(or nonowners) in each given year. The denominator is the sumof (1) patients who had an office visit with the designateddiagnoses followed by the surgical procedure, (2) patients whohad an office visit with the designated diagnoses but no surgery,and (3) patients who had no office visit with an orthopedicsurgeon owner or nonowner but who underwent the surgical procedurefor the designated diagnoses (these cases were infrequent butwere included to obtain accurate counts of the number of proceduresperformed).
In calculating the frequency-of-use indicators, I addressedpotential concerns to obtain accurate rates of use. First, toensure that the orthopedic surgeons performed the proceduresof interest on a regular basis, I eliminated cases associatedwith orthopedic surgeons who did not perform a minimum numberof the surgical procedures of interest in a given year. Theminimum was 5 for carpal tunnel repair, 1 for rotator cuff repair,and 5 for arthroscopic surgery of the knee. Although I droppedonly a handful of physicians from each group, I also conductedsensitivity analyses by including these low-volume physicians.Second, I identified overlap cases, in which the office visitwith the orthopedic surgeon owner or nonowner occurred in Novemberor December but the surgery was performed in the following year.Each overlap case was assigned to the year the surgery was performed,but it was excluded from the denominator for the preceding yearwhen the office visit occurred. Third, I excluded cases withpatients who had an initial office visit with an orthopedicsurgeon owner or nonowner during the fourth quarter of 2007(October-December) but did not subsequently undergo surgeryin 2007. These exclusions were made to allow for the possibilitythat these patients may have had surgery in 2008. Their inclusionin the denominator would be a source of potential bias in calculatingfrequency of use. Finally, I conducted sensitivity analysesusing 60- and 120-day windows.
I stratified the frequency-of-use rates for each surgical procedureby ownership status and year. The null hypothesis assumes thatthere were no differences in the frequency of surgery performedby physician owners vs nonowners during a given year. I evaluatedthe null hypothesis for each surgical procedure by year (2003-2007)using a 2-tailed test of differences between proportions (P < .001).Statistically significant year-specific differences are highlightedin yellow on the figures (Figures 1, 2, and 3), depicting thecomparisons. I also estimated a series of logistic regressionmodels to predict the probability that a patient underwent thesurgical procedure of interest in a given year, while controllingfor physician ownership, age, and sex.
The health care marketplace in Idaho has undergone a dramatictransformation since 1995. Although the number of communityhospitals remained stable at 37, 4 specialty hospitals ownedsolely by referring physicians entered the Idaho market. In1995, 8 ASCs were located in Idaho and all but 1 were ownedby referring physicians. By 2005, there was a 5-fold increasein the number of ASCs. Idaho currently has 42 ASCs, 39 of whichare owned entirely by referring physicians. Physician-ownedlimited-service facilities account for 25% to 47% of the operatingroom capacity in the 6 regions of the state. About 25% of bothowners and nonowners were practicing in the Boise area. Theremainder in both groups, however, were geographically distributedthroughout Idaho. Moreover, Idaho has no medical school andonly 1 family practice residency program, so surgical proceduresperformed by nonowners are not concentrated in teaching institutions.
Table 2 reports the number of patients treated by orthopedicsurgeon owners and nonowners through office visits and/or surgeryby year and procedure type. The mean ages of men and women whounderwent surgery performed by owners and nonowners were similarfor carpal tunnel repair (48-56 years). For owner and nonownerphysicians, women represented 65% to 73% of patients who hadcarpal tunnel repair. The age range of patients who underwentrotator cuff repair was similar for owners and nonowners; menwere aged 53 to 58 years and women were aged 54 to 58 years.Between 36% and 50% of patients who had rotator cuff repairperformed by nonowners were women, whereas women accounted for40% to 46% of such procedures performed by physician owners.For patients who had arthroscopic surgery of the knee, thosetreated by owners were somewhat younger (aged 38-45 years formen and aged 41-45 years for women) than those treated by nonowners(aged 42-47 years for men and aged 45-50 years for women). Approximately48% to 52% of patients who had arthroscopic surgery performedby nonowner physicians were women, compared with 44% to 46%for knee surgery performed by owners.
As shown in Figure 1, the frequency of carpal tunnel repairfor patients treated by owners was significantly higher thanthe rate for patients treated by nonowners (P < .001).In 2003, the frequency of use by owners was 33.1% compared with24.2% for nonowners, a difference of nearly 9 percentage points(P < .001). By 2007, this difference had widenedto 15.6 percentage points: 32.8% for owners vs 17.2% for nonowners.Age- and sex-adjusted odds ratios (Table 3) show that the oddsof having carpal tunnel repair were 54% to 129% higher for patientsof owners relative to nonowners (P < .001).
Figure 2 depicts frequency-of-use comparisons for rotator cuffrepair. In 2003-2004, there were no differences in frequencyof use by ownership status. During the period 2005-2007, frequencyof rotator cuff repair for patients treated by owners was 4.6to 8.8 percentage points higher compared with nonowners (P < .001).Adjusted odds ratios (Table 3) indicate that the likelihoodof undergoing rotator cuff repair during the period 2005-2007was 33% to 100% higher for patients treated by owners comparedwith those treated by nonowners (P < .001).
Figure 3 presents comparisons for arthroscopic surgery of theknee. In 2003, differences between owners and nonowners werenot significant. This pattern changed in 2004, when the frequencyof use was 33.2% for owners compared with 24.5% for nonowners,a difference of close to 9 percentage points (P < .001).The difference widened further to nearly 13 percentage pointsin 2005 (P < .001). In 2006-2007, the differencesin frequency of use between owners and nonowners had narrowedsomewhat but remained statistically significant, at 7.8 and5.5 percentage points, respectively (P < .001).Adjusted odds ratios (Table 3) show that during the period 2004-2007,patients treated by owners were 27% to 78% more likely to undergoknee surgery compared with those treated by nonowners (P < .001).
Since 2000, specialty hospitals and ASCs that involve referringphysician investors have grown rapidly in several markets throughoutthe country. Whereas the pros and cons of physician ownershipof limited-service facilities have been the subject of extensivedebate among advocates and critics, the most controversial issuerelates to the practice of physician self-referral.2, 6-7,21 Three recent studies based on Medicare inpatient claims foundthat when a physician-owned specialty hospital enters the market,there is subsequently an increase in the use of procedures ofinterest.5, 8-9 Other evidence indicates that specialty hospitalstreat primarily low-acuity cases within specific diagnosis relatedgroups as well as those with few comorbid conditions.4-5,10-11 Furthermore, relative to general hospitals, specialty facilitiestreat small percentages of Medicaid patients and negligiblenumbers of uninsured patients and are less likely to provideemergency care.4, 10 Prior research on ASCs is composed of casestudies,12-13 trend analyses documenting their growth,14 comparisonsof the patient mix treated in freestanding ASCs and hospitaloutpatient surgery departments,15-16 and comparisons of annualsurgical caseloads treated by owners vs nonowners.17-19 Existingevidence, therefore, provides limited insight into whether thefinancial incentives associated with ownership of specialtyhospitals or ASCs influence the frequency of use for outpatientsurgical procedures.
This study analyzed 5 years of claims data from a large privateinsurer in Idaho to provide new evidence on this issue. Theanalyses evaluated the relationship between physician ownershipand frequency of use for 3 common outpatient surgical procedures:carpal tunnel repair, rotator cuff repair, and arthroscopicsurgery of the knee. The health care marketplace in Idaho isan appropriate laboratory to investigate these issues for severalreasons. First, the state has almost equal numbers of physician-ownedASCs and competing general hospitals, along with 4 physician-ownedspecialty hospitals. Nearly all of these facilities were establishedbefore 2003, so the findings reflect a somewhat steady-statepicture of the effects of physician ownership on frequency ofuse of outpatient surgical procedures. Second, I was able toaccurately classify orthopedic surgeons as either owners ornonowners because the insurer requires physicians and facilitiesto report ownership and financial relationships. Finally, Idahois an attractive marketplace for specialty hospitals and ASCsto locate because it has no state certificate-of-need laws andfavorable reimbursement rates due to the absence of capitatedmanaged care plans.
With few exceptions during the 5-year period, frequency of usefor each of the orthopedic procedures examined was significantlyhigher for physician owners compared with physician nonowners.The age- and sex-adjusted probability of undergoing carpal tunnelrepair was 54% to 129% higher for owners compared with nonowners.The age- and sex-adjusted likelihood of rotator cuff repairwas 33% to 100% higher if the patient was treated by a physicianowner. Age- and sex-adjusted odds ratios indicate that the likelihoodof having arthroscopic surgery was 27% to 78% higher for patientsof owners compared with nonowners. Moreover, the results weresimilar when I altered the episode window to 60 or 120 days.The consistent finding of higher adjusted use rates by physicianowners across time clearly suggests that financial incentiveslinked to ownership of specialty hospitals or ASCs influencephysicians' practice patterns.
I also investigated factors other than financial incentivesthat might account for the higher referral rates that characterizeorthopedic surgeon owners. One consideration relates to thepatient mix. Patients treated by physician owners might be healthierand therefore more likely to tolerate surgery. Alternatively,they may have more severe orthopedic problems, implying thatsurgery is warranted. Although such issues about patient mixcannot be addressed with claims data, it is important to recognizethat information on physician ownership is generally not disclosedto patients. Considering the absence of full disclosure, thereis no reason why healthier patients or those with more severeorthopedic injuries should be predisposed to seek care fromphysician owners rather than physician nonowners. A second possibleexplanation is that patients of physician owners may be enrolledin health insurance plans that require less cost sharing, andas a consequence these patients may be more prone to consentto elective surgery. This explanation, however, cannot accountfor the differences in use rates that exist between owners andnonowners because a 20% cost-sharing rate is applied to boththe professional and facility payments for outpatient surgicalprocedures. A third possible explanation is patient preferences.Although I have no data on patient choice, I contend that thisconsideration would be dominated by financial incentives linkedto physician ownership. I conducted analyses to evaluate thehypothesis that physician owners work primarily in their ownfacility, whereas nonowners perform surgery in nonowner facilities.For arthroscopic surgery of the knee, I found that physicianowners perform 75% to 84% of these procedures in the ASC orspecialty hospital in which they have a financial stake. Thereverse characterizes the practice patterns of physician nonowners.Consistent with expectations, nonowners perform between 77%and 81% of these procedures in nonowner facilities. The otherprocedures showed similar patterns.
Although the results reported in this article provide new insightson how financial incentives affect physicians' practice patterns,the study has some limitations. First, the analyses are basedon claims records from a large private insurer in Idaho. Thus,one consideration is whether similar patterns would be evidentin other markets with a high concentration of physician-ownedspecialty hospitals and ASCs. Several studies have found higheruse rates for inpatient procedures in markets with establishedphysician-owned specialty hospitals,5, 8-9 so it seems likelythat analyses of outpatient surgical procedures would exhibithigher use rates as well. A related question is whether thefindings are applicable to patients with other types of generousinsurance. A recently published study comparing frequency ofuse of inpatient and outpatient procedures used to treat injuredworkers by physician owners and nonowners suggests that similarresults are evident among patients with other generous insurancecoverage.20 A third limitation is my inability to ascertainwhether the higher frequency-of-use rates that characterizephysician owners represent surgery that has little marginalbenefit to patients who receive it. A recent study by Kirkleyet al22 published in the New England Journal of Medicine suggeststhat this may be the case for at least 1 of the procedures examinedin our article: arthroscopic surgery of the knee. The authorsfound that arthroscopic surgery of the knee for the treatmentof osteoarthritis yielded no improvement in outcomes comparedwith patients who received only physical and medical therapy.These procedures are estimated to cost about $5000 per case,which is 2 to 3 times higher than a course of physical and medicaltherapy. If a substantial proportion of the increased frequencyof surgery by physician owners is performed in marginal cases,then a share of the greater expenditures associated with self-referralrepresent inefficient spending.
In conclusion, these findings documenting the effects of physicianself-referral on frequency of use of elective surgical proceduresperformed on well-insured individuals should be of concern tofederal and state legislators, third-party payers, employers,and patients. The increased utilization that characterizes physicianself-referral arrangements will continue to lead to higher healthinsurance premiums, which in turn is likely to result in moreuninsured and underinsured persons.
Correspondence: Jean M. Mitchell, PhD, Georgetown Public PolicyInstitute, Georgetown University, 3520 Prospect St NW, Room423, Washington, DC 20007 (email@example.com ).
Correspondence: Jean M. Mitchell, PhD, Georgetown Public PolicyInstitute, Georgetown University, 3520 Prospect St NW, Room423, Washington, DC 20007 (email@example.com ).
Accepted for Publication: April 28, 2009.
Financial Disclosure: None reported.
Funding/Support: Research support was provided through an unrestrictededucational research contract between the Idaho Hospital Associationand Georgetown University.
Author Affiliation: Georgetown Public Policy Institute, Georgetown University, Washington, DC.


text:
VALPARAISO | Most Porter County taxpayers are unlikely to notice much of a difference in their residential property assessments when notices are mailed out during the first week of October.
Among the exceptions are higher-end properties, which have taken a bigger hit in values than more affordable homes, said Tim Jorczak, director of commercial operations at the Porter County assessor's office.
This trend is likely the reason Ogden Dunes experienced the largest overall drop in assessed values, Assessor Jon Snyder said.
Portage also experienced a downward trend, with the biggest drop among homes valued between $125,000 and $175,000, according to figures provided by Snyder.
Slight upward trends are found among condominiums in Center Township, homes valued at less than $275,000 in Liberty Township, and much of Union, Boone and Pine townships.
The trends are based on residential property sales during 2009, 2010 and the first part of this year, Snyder said.
The county's overall real property assessment shrank by just more than 1 percent, he said.
Figures were not available for area commercial properties, but Snyder said he is hearing the assessments are down elsewhere around the state.
Among the reasons statewide that the rocky real estate market has not had more of an effect on residential assessments is that while parcels are taking longer to sell, they generally are selling for pretty close to their assessed values, said Amanda Stanley, assistant director of communications at the Indiana Department of Local Government Finance.
Snyder said individual parcels likely will see increases in value if improvements have taken place, such as an addition or the installation of a pool, shed or barn.
Assessor's office workers are in the process of visiting each property in the county looking for any changes as part of the general reassessment, he said. While the general reassessment will not affect tax bills until 2013, the effect of some of the parcel improvements that have been discovered already could begin showing up as part of this year's assessments.
Anyone who disagrees with the upcoming assessments will have 45 days from the date of the notice to contact the assessor's office to either discuss a potential change or file an appeal, Snyder said. He intends to offer an online appeal process for the first time this year.


text:
Maiden Voyage: Mother-daughter pioneers
The colonization of the American West, particularly prior to the completion of the railroad in 1869, included thousands of Mormon immigrants settling in Utah. Within a fifteen year period in the mid-nineteenth century, ten women from one ancestral line traveled there in mother-daughter pairs. United by religious faith, these women left comforts and family behind in England, Denmark, and Vermont to embark on brave transatlantic and transcontinental journeys.
Anita Wells
Mother-led voyages
Two of the five pairs consisted of mothers with young daughters: Bertha and Mary Jacobsen from Denmark, and Elizabeth and Annie Scarborough from England.
Daughter-led voyages
Three of the five pairs of women consisted of older mothers traveling in conjunction with their adult daughters: Clarissa and Sylvia Eastman from Vermont, and Rebecca and Emma Rogers and Jane and Annie Thorne, from England.
Family history sources
A brief list of family records consulted