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CME Disclosure
R. Bruce Lydiard, Ph.D., M.D., Ralph H. Johnson VA Medical Center, Charleston, SC
Dr. Lydiard reports no competing interests.
Address correspondence to R. Bruce Lydiard, Ph.D., M.D., Ralph H. Johnson VAMC, 109 Bee Street 116, Charleston, SC 20401; e-mail: firstname.lastname@example.com.
Panic disorder (PD) is a severe, persistant and potentially disabling anxiety disorder which affects 3.5 to 5% of individuals at some point. PD is characterized by one or more unexpected panic attacks followed by worry about additional attacks and/or the implications of the attacks. If attacks are sufficiently severe or frequent, they can promote marked, sometimes debilitating behavioral changes and avoidance (agoraphobia). We know from clinical experience and clinical trial outcomes that many PD sufferers are incompletely responsive to the initial treatment. Based on accruing evidence in the literature and clinical experience, inadequate treatment appears an important factor in treatment failure. In this article, strategies for optimizing PD treatment—including sufficient intensity of treatment—will be presented. A differential diagnostic approach for clinical evaluation of unsatisfactory response of PD treatment will be outlined. Finally, potential next-step treatments for unsatisfactory PD treatment outcome will be presented.
Panic disorder (PD) is a severe and potentially disabling anxiety disorder that affects 3.5%–5% of individuals in the United States during their lives (1, 2). Panic attacks are characterized by a sudden surge of intense fear or discomfort, with at least four symptoms that occur abruptly and peak within 10 minutes (Table 1).
DSM-IV-TR Diagnostic Criteria for Panic Attacks
To meet diagnostic criteria for PD, the individual must experience recurrent unexpected panic attacks (Table 2), at least one of which is followed by ≥1 month of one or more of the following: 1) concern over having more attacks, 2) worrying about the implications of the attacks (e.g., having a heart attack, losing control or "going crazy"), and 3) significant change in behavior related to the attacks (help-seeking, fearful avoidance) (1). PD most frequently appears in the late teens or early twenties and affects women twice as often as men. A significant percentage of affected individuals exhibit fear and avoidance of situations in which they may be unable to escape or be embarrassed should another attack occur (agoraphobia) (1). The avoidance behavior can interfere with work, social, and family functioning (or all of these) and can range from mild to completely disabling. PD rarely occurs alone, but typically co-occurs with other anxiety disorders, depression and alcohol/substance abuse disorders (2–5).
DSM-IV TR Diagnostic Criteria for Panic Disorder
Comorbid agoraphobia and other psychiatric disorders represent a significant treatment challenge and appear to contribute to increasingly poor outcome as they accrue (6, 7). In the published treatment research literature, patients with comorbid disorders were typically excluded, thus limiting extrapolation of many research findings to clinical practice. Findings from the National Comorbidity Study indicated that although 96.1% of individuals with PD with agoraphobia and 61.1% of individuals with panic attacks sought treatment within the past year, a significant percentage received inadequate treatment (2).
This review will focus on the assessment and management of inadequate treatment outcome in PD. The term "treatment resistance" for PD has not been operationalized. Consequently, much of the extant literature consists of reports including small groups of patients with PD with "unsatisfactory" response to one or several treatments, often without defining the degree of improvement or the treatments received. Likewise, there has been no consensus on what constitutes "adequate treatment" with medications or psychosocial treatment such as cognitive behavior therapy (CBT), although some suggestions have been offered (8).
The initial assessment should include a thorough psychiatric history to confirm the diagnosis of PD as well as screening for comorbid psychiatric disorders (other anxiety disorders, depression, and alcohol or substance abuse). Prior treatment (if any) and outcome should be reviewed. Psychosocial and developmental history including childhood adversity, family psychiatric history, and general review of symptoms should be included. Patient safety, including suicidal behaviors' current protective factors, family history of suicide, and current psychosocial stressors should be assessed (8).
Medical history, current prescriptions and over-the-counter medications, usual caffeine intake (including soft drinks, energy drinks, tea, and coffee), and any alternative or herbal treatments that can cause anxiety should be reviewed (9, 10). The medical workup should include a complete physical examination, complete blood count, thyroid function tests, urinalysis, electrolytes, liver function tests, ECG, and, if indicated, a urine screen for abused drugs. For patients with onset of PD after age 45 or those with true vertigo, timing of anxiety clearly related to meals, loss of consciousness, amnestic episodes or panic attacks without fear, a more thorough assessment is indicated (10).
Establishing and maintaining credibility with the patient is a key strategy for successful treatment. Reviewing evidence that risk for PD can be inherited may help reduce the patient's sense of failure to manage symptoms on his or her own. Being available and encouraging questions will help foster a sense of trust. Available treatment options, including the pros and cons of each should be reviewed, noting that more than one treatment or treatment modality may be required to find the best "fit" for that individual. Significant others should be included in the education exchange whenever possible.
Many clinicians rely on clinical assessment of patients in treatment. Using validated rating tools that provide systematic assessment of PD to document severity of the illness and the clinical improvement is essential (8). For example, early treatment studies used panic attack frequency as the primary outcome variable. However, panic attack frequency is affected by many variables. For example, if one patient in treatment remained at home and had no panic attacks, while another actively entered previously avoided situations and had more panic attacks, panic attack frequency would provide a poor assessment of actual clinical progress. It has been shown that reduction in panic attack frequency correlated poorly with global outcome assessments (11). The Panic Disorder Severity Scale (PDSS) (12) is a clinically useful, validated rating scale for assessment of the status of patients with PD (13). The PDSS domains include panic attack frequency, distress related to the attacks, degree of anticipatory anxiety, phobic avoidance, and PD impairment of work and social functioning. Effective use of the PDSS and other assessments includes educating the patient about reporting of symptoms, which will enhance the assessment process. To this end, weekly visits for the first several weeks is ideal for helping patients become more "tuned in" to symptoms and reporting them more reliably. Use of validated self-rating scales for depression such as the Hospital Anxiety and Depression Scale (HADS) (14) or the Quick Inventory of Depressive Symptomatology (QUIDS) (15) can likewise supplement the clinical interview in documenting progress in treatment. Such assessments can easily be incorporated into the clinical interview without detracting from the doctor-patient relationship and can provide valuable information for patients who do not respond well to initial treatment.
The goal of treatment is to reduce symptoms associated with PD (panic attacks, phobic avoidance, anticipatory anxiety, depression, and cognitive distortion) and comorbid conditions such as depression or other anxiety disorders). This includes not only reducing symptom severity with treatment but also attention to identifying the importance of progress made (such as driving a car, shopping for groceries, and attending social functions) as important steps in the journey to recovery of full functioning. The choice of the initial treatment is guided by patient factors (preference, treatment history, and psychiatric and medical status), the orientation and expertise of the clinician, and illness severity. Either pharmacotherapy or CBT is recommended as an effective first-line monotherapy (8). Theoretically, pharmacotherapy exerts therapeutic effects by normalizing the reactivity of the amygdala and brainstem areas within the fear network to suppress panic attacks, followed in turn by decreased anticipatory anxiety and reduction in conditioned fear behaviors. CBT is predicted to work "upstream" by normalizing distorted cognitions, enhancing the ability of the higher cortical structures to exert inhibitory effects on lower brain structures, and reducing panic attacks and related learned fear responses (16) (Figure 1). Choice of initial treatment may be influenced by the most distressing panic symptoms (e.g., predominantly somatic versus cognitive symptoms). There is insufficient evidence to recommend initial treatment with combined medication and CBT versus initial monotherapy (8) or to recommend one treatment modality over another.
Theoretical Sites of Action of CBT and Antipanic Agents.
The selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), traditional monoamine oxidase inhibitors (MAOIs), and benzodiazepines (BZDs) are approximately equally efficacious in the treatment of PD (8, 17). Antidepressant monotherapy with an SSRI or SNRI is the recommended first-line treatment.
On the basis of their breadth of efficacy, tolerability, ease of administration, and safety in overdose, the SSRIs and SNRIs are recommended as the first-line treatment for PD with or without agoraphobia (8, 17). Sertraline, paroxetine, fluoxetine, fluvoxamine, citalopram, and escitalopram have been empirically shown to be effective for PD (17), as has the SNRI venlafaxine. Fluoxetine, sertraline, paroxetine, and venlafaxine are considered to be equivalent in efficacy for the treatment of PD and have received U.S. Food and Drug Administration (FDA) approval.
Imipramine (IMI) is the most well-studied TCA (18). Its desmethyl metabolite desmethylimipramine has also been shown to be effective for PD (19). Clomipramine, a TCA that is a potent inhibitor of serotonin reuptake, is effective in the treatment of PD and has a greater breadth of efficacy against other anxiety disorders than the other TCAs (20, 21). Although TCAs are as effective as SSRIs for PD, the predictable side effect burden (anticholinergic and cardiovascular) and danger in overdose limits enthusiasm for their use unless at least two first-line treatments fail.
The traditional nonselective MAOIs such as phenelzine and tranylcypromine have not been studied in DSM-defined PD but are effective in individuals with phobic avoidance with panic attacks (22, 23). These agents are rarely used because of their side effects, potential danger after tyramine ingestion or overdose, and dietary restrictions. For the rare patient whose PD is unresponsive to other treatments, judicious use by an experienced psychopharmacologist may be beneficial (17, 24). The selective MAO-A selegiline has not been studied in PD; moclobemide (unavailable in the United States) is of questionable use as a treatment for PD (17).
There are insufficient data to recommend mirtazapine or nefazodone (which also has a small risk for hepatic damage) (17). Mixed results were seen in open-label studies of bupropion, and it is not recommended (25, 26) as a first-line treatment. Bupropion may be coprescribed to address depression or sexual side effects of antidepressant treatment (27).
The most well-studied BZDs are alprazolam and clonazepam (18, 28). Other less well-studied BZDs including lorazepam and diazepam are also effective for PD (8, 29). Alprazolam is effective and well-tolerated, reducing panic attack frequency and severity within the first several days of treatment. A practical disadvantage is that several daily doses are necessary and "interdose rebound" between doses can be bothersome for some patients (30). Clonazepam is more potent, has a longer elimination half-life and efficacy equal to alprazolam (28), and is also FDA-approved. It has the clinical advantage of requiring only one or two daily doses, and its slow elimination reduces discontinuation effects.
Daily administration of BZDs invariably results in the development of physiological dependence and the appearance of withdrawal upon discontinuation. It is important to distinguish between "addiction" (nonmedical use) and physiological dependence (iatrogenic). This confusion promotes the largely unfounded concern over the abuse potential of BZDs (31). In anxious patients without a history of substance abuse, it is rare (32). The evidence indicates that long-term use is associated with a decrease in daily dosage (33, 34). Unwanted effects of BZDs include sedation, ataxia, fatigue, and subjective memory difficulty. The latter concern—memory disruption—remains controversial (35) despite evidence to the contrary (31, 36).
The evidence for efficacy of anticonvulsants in the treatment of PD is limited to one multicenter, placebo-controlled study of gabapentin, in which secondary but not primary outcome measures provided some support for a benefit in PD (37). The use of sodium valproate (VPA) is limited to open studies (38) and has been reported to be helpful for patients with comorbid bipolar disorder and PD (39) and those with the additional complication of alcohol abuse (40, 41). Evidence for use of other anticonvulsants such as tiagabine, vigabatrin, and levetiracetam is limited to open-label reports for PD (8, 42).
Buspirone, a nonbenzodiazepine anxiolytic, is ineffective as monotherapy for PD (43). Standard neuroleptics have no role in the treatment of PD. There are reports suggesting beneficial effects from the second-generation antipsychotics olanzapine (44, 45) and risperidone (46) in treatment-resistant PD. There is no evidence to support long-term treatment (47).
CBT is as effective as pharmacotherapy for PD in acute treatment (48). The standard components of CBT for PD include cognitive-restructuring interventions, exposure, and arousal reduction. CBT has been shown to significantly increase the likelihood of successful BZD discontinuation (49). It is generally provided in 12–16 weekly sessions (48). Some studies have reported that patients with PD with comorbidity respond well to PD-focused CBT (50, 51), although others reported less benefit in patients with comorbid conditions (52).
Approximately three-quarters of apparent PD treatment failures are due to inadequate dosage and/or duration of treatment with antipanic medication (53–55). The "recommended" dosage for antipanic medications is derived from fixed-dose studies completed during the process of obtaining FDA approval. For example, the "target dose" listed for paroxetine is 40 mg daily, even though many patients receiving lower doses benefitted. For sertraline, there is a range of recommended therapeutic doses of 50–200 mg daily. This was based on the lack of statistical differences between drug groups (50, 100, or 200 mg daily) in pivotal clinical trials. Because there is no information about dosages higher than those studied during drug development, there are no official recommendations for higher doses. Clinical experience indicates that the optimal dose for some patients with PD can be higher than the "recommended" dose or range and must be determined by gradually advancing the dose until a full therapeutic effect or limiting side effects occur.
SSRI/SNRI- and TCA-induced activation is common during initiation of treatment. This should be explained before initiation of treatment. Advising the patient that this reaction is not dangerous and may even suggest that the diagnosis of panic disorder is correct may help shift the perception of this side effect to a more positive experience. For patients who experience activation from even small initial doses, reducing the dose by dissolving capsules in fruit juice to administer a tolerable dose of a few milligrams can be accomplished, with very gradual dose adjustments as tolerated.
TCAs should be reserved for patients with a poor response to at least two first-line agents. Empirical data for the TCAs is limited to imipramine. Mavissakalian and Perel (56) reported that patients whose daily oral IMI dose was at or above a threshold of approximately 150 mg orally showed better rates of response than those taking lower doses. These investigators also reported that patients who achieved steady-state plasma concentrations of (IMI + desipramine combined) in the 125–150 ng/ml range experienced an optimal balance between benefits and side effects reported at higher doses (57). For more severely ill patients with comorbid depression, higher doses or levels may be necessary. In addition to targeting plasma levels, TCA levels can also be useful in confirming compliance.
For most patients, doses of alprazolam in the range of 1.5 to 6 mg daily are sufficient, but clinical experience suggests that some may require higher doses (8–10 mg) (58, 59). A dose-finding study in patients with uncomplicated PD comparing several dosages of clonazepam versus placebo suggested that the "optimal" dose for clonazepam is approximately 2–4 mg daily (again, higher doses may be required by some patients). For clinical use, clonazepam is about twice as potent as alprazolam (28).
When there is inadequate response, compliance with treatment is unclear, or if an individual patient appears to require much higher levels than expected, plasma levels of BZDs may be clinically useful. Fixed-dose studies of alprazolam show that each oral dose of 1 mg is associated with 10 ng/ml at steady-state plasma levels. Maximal clinical improvement with a tolerable side effect burden appeared to be in the 20–60 ng/ml range (correlating with a 2–6 mg daily alprazolam dose) (58).
Adequately intense treatment also requires an appropriate duration of treatment at an effective dose. The available information from the published literature indicates that for uncomplicated PD, improvement in panic attack frequency is usually observable within 4–6 weeks for antidepressants and for BZDs often within the first week but may take several weeks for some patients. For more patients with comorbid conditions, the response may be slower, and the observation for response should be accordingly longer (8–12 weeks).
There is wide variation in the dosage required for successful treatment of PD, especially for patients with considerable comorbidity. When it appears that further benefit at a given dose is unlikely, a systematic dose increase with observation at appropriate (8- to 12-week) intervals can avoid adverse effects and optimize benefit. Table 3 shows recommendations based on the published literature (8). In this author's experience, higher dosages may be necessary. If the upper limit of the dosage range shown is reached and there is a clinically significant partial response with tolerable side effects and no evidence of toxicity or misuse of the medication, gradual increases in the dose and observation for further improvement and continued tolerability of side effects is a reasonable strategy. For example, doses of alprazolam up to 10 mg may be required for some patients. The psychiatrist can address medico-legal concerns by documenting (when possible with rating scales) the rationale for prescribing higher dosages and the fact that risks and benefits have been discussed and the patient understands and agrees. If the psychiatrist or patient has significant concerns about higher dosages, referral for consultation to a psychiatrist with expertise in anxiety disorders can help reassure the patient and the clinician.
Dosage Ranges for Antipanic Medications*
Although manualized treatments have substantially standardized CBT, treatment "dose" is less easily defined and would depend on the number of sessions, the specific CBT protocol, and the skill of the individual therapist. The number of CBT sessions suggested by experts as adequate should be at least 12 weekly sessions (60). Effective CBT in some published studies can be accomplished in as few as 5 sessions (61).
Attention to the domain(s) of PD that remain inadequately improved offers a systematic method for assessing unsatisfactory outcome of the initial PD treatment. Attention to potential contributors to persistent panic attacks, nonpanic anxiety, comorbid anxiety or mood disorders, residual phobia and other factors that may interfere with improvement, as shown in Table 4, is helpful for planning the next step in treatment.
Differential Diagnosis for Inadequate Treatment Response in Panic Disorder
If unexpected panic attacks have diminished but still persist, and pharmacotherapy has been optimized in dose and duration, adding a BZD or CBT is a reasonable next step. For attacks that are stimulus-bound, consider other anxiety disorders such social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), or obsessive-compulsive disorder (OCD), each of which can be associated with panic attacks (62, 63). Disorder-specific CBT with exposure for the specific disorder(s) should be added to treatment. If there has been no change in unexpected attacks, switching to a different SSRI or SNRI is suggested.
Antidepressant intolerance is sometimes overlooked by the clinician, and should be considered in the differential diagnosis as a potential cause of persistent anxiety. Comorbid anxiety disorders such as SAD, generalized anxiety disorder, or PTSD can contribute to persistent nonpanic. If the patient is receiving an intermediate half-life BZD such as alprazolam or lorazepam, and anxiety worsens before the next scheduled dose or in the morning several hours after the bedtime dose, gradually changing to a longer-acting agent such as clonazepam may be effective. Review current medications and any new medications, including alternative or herbal remedies that the patient may not have reported. Previously undetected alcohol and/or substance abuse can worsen PD and interfere with treatment (64, 65). A controlled study that combined CBT and an SSRI plus relapse prevention for individuals with PD and alcohol dependence reduced anxiety symptoms. However, there was no apparent advantage over psychosocial treatment alone on subsequent relapse rates (66).
Unrecognized depression should be considered in the initial evaluation of inadequate response to treatment. When depression and PD coexist, both disorders are more severe, more persistent, and less likely to respond to standard treatments (6, 67, 68). If there is a partial response to the initial antidepressant treatment, increased treatment intensity is indicated.
For patients with depression that does not respond to aggressive pharmacotherapy with at least two first-line antidepressants or CBT, using imipramine with targeted plasma levels is a reasonable consideration. For some patients, improvement can subsequently be maintained with gradual switching to an SSRI or SNRI and tapering imipramine.
There is significant co-occurrence of PD and bipolar disorder (9, 69–71). The coexistence of PD and bipolar disorder predicts poor prognosis for both conditions (72, 73). Comorbid bipolar II disorder can be overlooked during the initial evaluation, as these patients often fail to identify and report periods of hypomania as problematic. In addition, a positive family history for cyclic mood changes can help increase the index of suspicion. Because antidepressant treatment may cause mood instability, reduction or discontinuation of antidepressant treatment should be considered, and a mood stabilizer should be added. Limited data suggest that VPA treatment (38) may be a good choice. VPA has been reported to be beneficial in patients with comorbid PD and bipolar disorder, including a subgroup further complicated by alcohol abuse (40, 41, 74). Short-term atypical neuroleptics have been reported to be beneficial for some patients (75, 76). The risk of treatment must be considered in the context of the severity of illness and functional impairment of the individual patient.
The differential diagnosis for residual avoidance includes evaluation of whether there was insufficient exposure for agoraphobia or if there may be a concurrent anxiety disorder with related avoidance (SAD, PTSD, or OCD). If avoidance is being driven by a comorbid anxiety disorder, disorder-specific CBT should be added. If social avoidance due to demoralization or social withdrawal due to depressed mood appears to be promoting avoidance, more aggressive treatment of depression is indicated.
New onset or worsening of preexisting psychosocial stress can exacerbate PD and interfere with treatment. Reassessment should include asking about new problems, interpersonal difficulties, and occupational or family stressors. Noncompliance with treatment is not infrequent and can result from lack of sufficient patient understanding of the principles of treatment, including compliance with medication administration or behavioral changes prescribed is not frequent. Some patients or significant others may require refresher information sessions about the nature of the illness and/or the requirements for adequate treatment.
Practical strategies that make clinical sense to be considered include other interventions, which may also contribute to clinical progress for many patients. One such strategy is to increase the frequency of patient visits, which may strengthen the doctor-patient relationship, provide more confidence in the clinician and promote a sense of caring for and dedication to the progress of the patient. Another strategy that may be useful is a recommendation to initiate or return to a regular exercise regimen, which is known to improve stress tolerance. Yoga or meditation exercises may be useful. Such activities can both promote a sense of well-being and enhance the patient's sense of mastery and confidence.
If the issues of diagnosis, treatment intensity, and other factors noted above have been addressed, and an unsatisfactory response is apparent, it makes sense to modify the treatment. The options are to augment the initial treatment or switch to a different treatment. The empirical literature in this area is very limited. The majority of published studies reporting beneficial effects from treatment changes included patient samples that have not been carefully characterized. There is only one published study to date that prospectively studied SSRI treatment resistance and used state-of-the-art methods. Unfortunately, the results of the study were inconclusive because of a small sample size (77). However, it did support the concept that increasing the dose of the initial treatment, supplementing pharmacotherapy with CBT, or augmenting with a BZD provided similar but small increases in remission. Although not as illuminating as would be hoped, the study is a model for future research, which includes a sufficiently large sample size and adequate statistical power.
Several augmentation strategies have been reported to improve inadequate response in PD, but none has been intensively studied. There is substantial clinical experience that addition of a BZD at this point can be beneficial. Pindolol, a β-adrenergic agonist with 5HT1a agonist properties, which was useful as an augmenting agent in resistant depression, has been shown in one small controlled study to benefit patients who had not responded to 20 mg of fluoxetine for 8 weeks (78) although the initial dose (79) and duration of SSRI treatment in that study may have been inadequate. One case series reported that combining an SSRI with TCAs was helpful for patients with PD that was unresponsive to either an SSRI or a TCA (80). There are limited uncontrolled data supporting the utility of mirtazapine for PD as an augmenting strategy (8, 81). Uncontrolled reports have suggested the utility of addition of atypical neuroleptics in treatment-resistant PD (44, 46). However, this practice should be considered only for very severely ill patients and those with treatment-resistant PD. Repetitive transcranial magnetic stimulation as an augmentation treatment was shown to be beneficial in a small group of patients with PD that was unresponsive to SSRIs (82), although this approach is probably not practical or widely available. Finally, addition of CBT to augment inadequately effective drug treatment for PD has been shown to be an effective strategy (83–85).
There are only limited data regarding the addition of pharmacotherapy for partial responders to CBT. Clomipramine augmentation of unsuccessful behavioral treatment for hospitalized patients has been reported to be effective (20). For outpatients who were inadequately responsive to CBT, adding the SSRI paroxetine has been shown to be an effective strategy (86).
The literature on combined treatments has generally suggested a slight advantage for combined medication and psychotherapy over either monotherapy alone so long as medication is continued. After treatment discontinuation, combined treatments were comparable to psychotherapy alone and slightly better than medication alone (87, 88). A few studies in which clonazepam was combined initially with an SSRI and then tapered after a few weeks showed faster onset of the combination (89, 90).
If the initial treatment fails to show clinically significant benefit, switching treatments is indicated. For pharmacotherapy, switching to a different first-line treatment (a different SSRI or an SNRI) is recommended. After two SSRIs or an SSRI and an SNRI, second-line pharmacotherapy such as TCAs or benzodiazepines is a reasonable next step (8). When treatment is switched from one SSRI or SNRI antidepressant to another, it is common practice to add the second agent and increase the dose with gradual up-titration to a moderate dose treatment and then gradual down-titration of the initial agent. Careful additional upward titration during or after the process of cross-titration can avoid SSRI discontinuation symptoms. The process usually takes several weeks and requires careful observation.
For patients who are considered appropriate and willing to follow a low tyramine diet, the older MAOIs may be beneficial. There is no empirical basis beyond the older published literature, but one recent report suggested benefits from phenelzine after other treatments were unhelpful (24). Use of these older MAOIs should be completed by psychiatrists who are familiar with them and the management their side effects. Introducing these agents requires tapering and discontinuation of other antidepressants for at least 2 weeks before initiation of treatment.
With the exception of one controlled study of psychodynamic psychotherapy for PD (91), there is no alternative to individual or group CBT that has been empirically shown to be effective for PD. Other approaches that enhance treatment adherence, provide more information, or otherwise support the individual should be made on the basis of the psychiatrist's knowledge of the patient.
Treatment of PD has evolved and improved substantially as our understanding of the neurobiology and neurobiological substrates of anxiety have expanded. The optimal treatment must still be individualized for each patient. A systematic, differential diagnostic approach to the evaluation and optimal treatment of PD has been presented. As research provides more information on optimizing treatment, additional advances in providing relief for the many individuals who experience PD will be made. Undertreatment of PD remains a major problem. The most important of the identified factors for promoting adequate treatment of PD is insufficient intensity of treatment.
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The Municipal Library of Nuremberg (Stadtbibliothek im Bildungscampus Nürnberg) is housing as a permanent loan from the Jewish Community of Nuremberg (Israelitische Kultusgemeinde Nürnberg) a remarkable collection of looted books.
The collection of about 9,000 prints was forcibly taken from persecuted Jews, freemasons, priests and other groups victimised by the Nazis between 1933 to 1945. This collection, today known as the 'Collection IKG / Sammlung IKG' (Sammlung der Israelitischen Kultusgemeinde), was found at the end of the Second World War in the editorial offices of the infamous anti-Semitic periodical 'Der Stürmer' with some material in the private residence of Julius Streicher at Cadolzburg near Fürth.
In the search for the previous owners of these books, the Municipal Library of Nuremberg has published a list of 1,390 names of individuals or statutory corporations and institutions from 300 towns all over Europe. A noteworthy number of books has already been restituted - on a pro bono basis - to their former owners or legal successors from Austria, Canada, France, Germany, Great Britain, Israel, Switzerland and the United States of America.
Readers are invited to search the lists below, which are sorted according to names and to places:
Die aktuelle Suchliste der Vorbesitzer sortiert nach Namen / the current search-list sorted by names:
Die aktuelle Suchliste der Vorbesitzer sortiert nach Orten / the current search-list sorted by places:
Weitere Informationen zur Sammlung der Israelitischen Kultusgemeinde unter / Read more about the Collection IKG: http://www.nuernberg.de/internet/stadtbibliothek/sammlungikg.html?pk_campaign=stadtbibliothek&pk_kwd=altbestaende_sammlungikg.html

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Wüsthof Precision 2-Piece Chef's Knife Set
- Summary
The bold lines and dynamic silhouette of the Wüsthof Precision collection not only make these stunning knives a joy to look at but a pleasure to use. Williams-Sonoma worked closely with legendary German knife-maker Wüsthof to bring you a kitchen knife like no other—from the blade's advanced ceramic coating to the seamless transition from handle to bolster to blade. The satisfying heft of the high-carbon-steel blade and the unbeatable balance of the double-bolster design deliver elite-level performance.
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2-piece set includes:
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- 8" chef's knife: 8"-long blade.
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- It is not advisable to use any knife but a meat cleaver to cut through bone, as other blades can be easily damaged.
- Hand-wash with warm water and a mild detergent. Rinse and dry immediately.
- Maintain the knife's cutting edge by regularly using a honing steel.
- Sharpen as needed. With regular use and honing, your knife should not need sharpening more than once or twice a year.
- Sharpen knife at home using a whetstone or knife sharpener, or have it sharpened by a professional.
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text: Yamaha SPM-K30 Wall-Mount Bracket for compatible Yamaha Digital Sound Projectors Zoom Front Photos Videos Item #: 022SPMK30 Review Summary 2 people say In Stock Free Crutchfield lifetime tech support Free Shipping Your price $79.99 each Add to cart + Add to wishlist Email me alerts for this product $71.99 Open Box Buy this item and earn up to 80 Rewards points See more offers and ways to save Special Financing Available x By buying this product you'll earn up to 80 Rewards points. When you sign up for a Crutchfield account, you'll be enrolled in Crutchfield Rewards. You'll earn one point for every dollar you spend on gear from us. You can turn your points into Rewards Cards that you can use toward future purchases. You can sign up for an account now, or after you complete your purchase (you'll get credit for the points either way). Sign up for a Crutchfield account Overview Details Customer Reviews Q&A Articles & Videos Our take on the Yamaha SPM-K30 Wall-Mount Bracket by Ralph Graves See more info on this item Highlights:for use with YSP-5100, YSP-4100, YSP-4000, YSP-3050, and YSP-3000 Yamaha Digital Sound Projectorshardware included to attach bracket to speakerwarranty: 1 yearOur 60-day money-back guarantee Hands-on research from the Crutchfield Labs (what are the Labs?) What's in the box? | In-depth notes Product Research What's in the box? Download owner's manual Left large mount bracket Right large mount bracket 4 Small wall mount brackets 2 Safety wires Six 6mm machine screws with a lock-washer and flat-washer attached to each one Ten 4mm machine screws with a lock-washer and flat-washer attached to each one Four 6mm flat-washers Instruction Manual (English/Spanish/French) Our Product Research Team At Crutchfield, you'll get detailed, accurate information that's hard to find elsewhere. That's because we have our own in-house Product Research team — they open the box, verify contents, check the owner's manual, and record dimensions, features and specs. We stay on top of new products and technologies to help people make informed choices. Features Overview: The Yamaha SPM-K30 Wall Mount Bracket is designed to mount the Yamaha Digital Sound Projectors, models YSP-4000, YSP-3000, YSP-900 and YSP-800 to your wall. The SPM-K30 Wall Mount Bracket comes supplied with two sets of adapter plates so it can be used with any of the Yamaha Digital Sound Projectors. The Type-A adapter plates are used for the YSP-800 and YSP-900, while the Type-B adapter plates are used for the YSP-4000 and YSP-3000. Hardware is supplied to secure the bracket to the Yamaha Digital Sound Projectors and two safety wires are supplied to keep your Digital Sound Projector in place. However, wall-mounting screws are not provided. The dimensions after assembling the SPM-K30 vary depending on the type of Digital Sound Projector being mounted. Wall Bracket Dimensions For YSP-800/900 Installation: Width = 26.75", Height = 4.415", Depth = 0.635" Wall Bracket Dimension For YSP-3000 Installation: Width = 27.5625", Height = 4.415", Depth = 0.635" Wall Bracket Dimension For YSP-4000 Installation: Width = 28.75", Height = 4.415", Depth = 0.635" Review this product Submit a review and then enter to win a $500 rewards card Yamaha SPM-K30 Wall-Mount Bracket Reviews Average Customer Review: 2 people say: Review this product: Thanks for taking the time to share your experiences about this product. Please be sure to focus your comments on the product itself. Read our Review Guidelines for more information. Review title * Email Your email won't be visible. Please use the email address that is associated with your order. Display name (e.g., JohnD) Your review will be signed using the display name and location * Your location (e.g., Charlottesville, VA) * Your rating Click on a star to rate the overall product on a scale of 1-5 1500 characters left * Your review Attach a YouTube Review Crutchfield Video Review Guidelines Only submit videos that you made or are authorized to use. Do not submit videos that contain music, video or visuals that are copyrighted and belong to someone else. Please see our Review Guidelines for more information. Submit the URL of your YouTube™ video review or product demonstration. e.g., "http://www.youtube.com/v/o79TWHh598U" 500 characters left Pros 500 characters left Cons * Agree to Terms By checking this box you agree your review becomes the property of Crutchfield, that you are over 18 years of age, that you own or have owned this product, and that you are located within the United States or its territories. Please see our Review Guidelines for more information. We reserve the right (but are not obligated to) review all submissions and edit or remove any review in any manner which we deem necessary. Your review should be posted within seven days. Filter by rating: 5 Star: (0) 4 Star: (0) 3 Star: (0) 2 Star: (0) 1 Star: (0) 5 out of 5 Yamaha SPM-K30 Wall-Mount Bracket Written By Anonymous, Charleston, WV on Sunday, July 08, 2012 Crutchfield Customer Review (What's this?) Perfect! Was this review helpful? Yes | No 5 out of 5 Yamaha SPM-K30 Wall Mount Written By Robert, Trumbull, CT on Wednesday, June 17, 2009 Crutchfield Customer Review (What's this?) I purchased a Yamaha SPM-K30 Wall Mount for a Yamaha YSP-800. It worked perfectly. Instructions were clear and all parts included. I could not be more satisfied. I installed it under a flat panal TV which is wall mounted and it looks like the YSP-800 is part of the TV. 6 out of 6 people found this helpful Was this review helpful? Yes | No For a more in-depth review and enhanced detailed information on the Yamaha SPM-K30 Wall-Mount Bracket, please visit the Crutchfield website product page (/ISEO-rccbcspd/p_022SPMK30/Yamaha-SPM-K30-Wall-Mount-Bracket.html ). × Front Searches related to the Yamaha SPM-K30 Wall-Mount Bracket for compatible Yamaha Digital Sound Projectors Yamaha Yamaha Speaker Wall Mounts Best Speaker Wall Mounts Speaker Wall Mounts under $100 Yamaha SPM-K30 Wall-Mount Bracket reviews


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Has had any experience with these sights?? It seems a decent price as long as the bidding does not go bonkers.
Advice on any other brands would be most welcomed
Has had any experience with these sights?? It seems a decent price as long as the bidding does not go bonkers.
Advice on any other brands would be most welcomed
I have no personal experience with Spott Hog. I know from other forums that they have reported quality customer service and quality products. Depending on what your gonna use it for and the distance .29 pins are alright. I prefer .19's. I use a Sword 3rd plane with extension bar with 6 .19 pins. I can swap them out if I want with thinner or thicker pins. It all depends on the distance you'll be shooting at. A thick pin will cover up the X or vitals at longer distances. My two cents.
I've got a Real Deal on one bow and a HoggIt in it's box. Without going into a whole lot of detail have no fear about their quality. The Real Deal comes with 5 pins and these can be changed out very easily for different sizes if you wish. There is a wire positioned in the vertical center of the guard to help with vertical alignment. Nice feature if you have eyes young enough to see it. Their fibers aren't the brightest when compared to a lot of wrapped sights today, but they should do you well if you get it. One thing nice about the sight is that by loosening a locking screw you can gang adjust for both vertical and horizontal. It's not what I'd call micro adjust as there are no click stops. I like to refer to it as infinite adjustment.
As for customer service. I couldn't tell you. As with most quality products I doubt that you'll ever be in need of repairs. I doubt that that price is going to be stagnant. Stateside price is about $130 so that's probably about $100 Euro.
If You're Not Living on the Edge You're Taking Up Too Much Space
Martin Gold Plus Staff Shooter
Alien Mafia
PSAA Life member, UBP Life member
PADI AOW Diver


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Main Content
You've been a NASCAR fan for as long as you can remember – show off your die-hard fanaticism with the Simple Established 1948 T-shirt from The Game. It features distressed "NASCAR Est. 1948" lettering surrounding two checkered flags.
- 100% Cotton
- Distressed screen print graphics
- Imported
- Officially licensed NASCAR product
- Rib-knit collar
- Tagless
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Manufacturer direct items are shipped directly from the manufacturer. These items are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite number, and/or designs. Some options may be limited by league rules.


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Quality Management Publications
New Imperative: Driving Performance, Connecting to Value
September 2014 | Conference KeyNotes
Companies increasingly view health care as an important investment and want a greater return: they are still keenly interested in lowering costs but are also demanding better performance and value from providers.
How Can Companies Make the Value of Intangibles More, Well, Tangible?
June 2014 | Executive Action Report
There is a critical need to develop better standards for measuring, reporting, benchmarking, and analyzing intangible investments.
Connect, Converse, Create: How Companies Can Generate Value through Internal Social Collaboration
March 2014 | Research Report
This report explores why internal social collaboration (ISC) is necessary in the modern workplace, and examines how organizations can increase its adoption and engineer ISC for success.
Avoiding the Digital Desert
November 2013 | Executive Action Report
Globally, technology developments are taking place at an unprecedented and ever-increasing pace, but, in many respects, European policies and attitudes seem frozen in time.
2013 Succession Management Conference KeyNotes Report
November 2013 | Conference KeyNotes
Succession management should be integrated into every phase of strategic planning, not isolated as an HR activity. If not, the organization may not take it seriously.
Changing Chinese Supply Chain
November 2013 | Executive Action Report
This report presents detailed information about managing supply chains in China and the characteristics of a successful risk management program.
Brave New World: Recruiting Talent in the Digital Age
October 2013 | Research Report
To be effective, online talent acquisition needs to be aligned with and integrated into your company's overall brand and social marketing objectives and practices.
When Innovation Isn't: By pursuing breakthroughs less indiscriminately, we may just get more of them.
October 2013 | The Conference Board Review
The first step to bridging the innovation gap is to cease labeling every new initiative as "innovation."
Who's in Charge Here? Bossless organizations can teach you how to be a better boss.
October 2013 | The Conference Board Review
Bossless companies, with minimal internal management structure, have a great deal to teach managers in conventional organizations.
How Teleworking Works Best: A Practical Guide for Managing Teleworkers
October 2013 | Executive Action Report
Successful managers of teleworkers are those who have learned to manage the work and not the workers, quantify deliverables and not hours at a desk, and communicate regularly and mindfully with all workers.
Local Content Requirements and Strategic Workforce Planning
October 2013 | Executive Action Report
Meeting local content requirements abroad is key to a sustainable multinational business model, and HR professionals should be part of their organization's localization efforts. Strategic workforce planning can help.
Managing Contractors and Ensuring Safety in Emerging Markets
May 2013 | Council Perspectives
Although emerging markets beckon with new business opportunities, they also present major health and safety challenges that foreign investors need to clearly understand.
2013 Customer Experience Leadership Conference KeyNotes Report
April 2013 | Conference KeyNotes
Social media may have changed the retail experience, but digital technology has given companies tools for coping with and capitalizing on that change.
Globalization Revisited: Who Will Get the New Wave of Knowledge Process Jobs?
April 2013 | Executive Action Report
Offshoring is no longer the best or the only answer for management of knowledge process jobs, and many companies are investigating nearshore and onshore alternatives as the global competition for knowledge jobs intensifies.
Leveraging Corporate Security for Business Growth and Improved Performance: The Transformative Effect of 9/11
September 2012 | Council Perspectives
Security has become a core function, embedded in disciplines like finance, law, human resources, quality, supply chain, marketing, and operations.
When the Debt Incurred in a Cash Merger Causes the Target to Fail: Protecting Target Directors
September 2012 | Director Notes
This report describes the potential liability directors may face if they approve a cash merger financed in substantial part through borrowing and the target company fails. It also offers steps directors can consider to help mitigate that risk.
Do Your Customers Trust You?
July 2012 | The Conference Board Review
Q&A with Don Peppers and Martha Rogers, authors of "Extreme Trust: Honesty as a Competitive Advantage."
Water Worries: How Incorporating Long-Term Risk into Strategic Planning Pays Off
June 2012 | Council Perspectives
How companies manage risk, opportunity, and scarcity today will determine the long-term value they create for stakeholders and society, and the world's dwindling water resources are a pivotal case in point.
2012 Customer Experience Leadership Conference KeyNotes Report
May 2012 | Conference KeyNotes
In an increasingly connected world, companies are in danger of overlooking the secret ingredient that makes for a good customer experience—the personal touch.
2011 Customer Loyalty Conference KeyNotes Report
March 2012 | Conference KeyNotes
The keys to having loyal customers include knowing your customers personally, knowing what they want, and delivering it to them, sometimes before they even realize they want it.
2011 Corporate Security, Business Continuity, and Crisis Management Conference KeyNotes Report
December 2011 | Conference KeyNotes
Companies need to expect and prepare for the unexpected. Risk mitigation and crisis planning are ongoing processes should include anticipating potential threats and practicing how to deal with certain crises.
First Customers
July 2011 | The Conference Board Review
In a new market, you need to secure a foothold. World domination can come later.
Answering the 2011 CEO Challenge:
Accelerating Growth through Quality
June 2011 | Council Perspectives
This Council Perspective examines the role the quality function can play in meeting the top challenges identified in the latest edition of The Conference Board CEO Challenge™, an annual survey of top executives.
Converging Physical and Information Security
Risk Management
February 2011 | Executive Action Report
Traditionally, physical and information security have operated in their own silos with separate teams and different risks, processes, and budgets. But risks and threats are evolving and becoming interdependent. As new technologies are adopted in the workp
Investing in CSR to Enhance Customer Value
February 2011 | Director Notes
This report, which is based on the analysis of 163 articles from the most relevant empirical literature on the subject, offers a number of practical recommendations to business leaders embarking in CSR programs for their companies.
Connecting to Customers
February 2011 | The Conference Board Review
Corporate leaders too often keep their distance from the people that are the most important.
Supply Chain Benchmarking: Process and Methodology
June 2010 | Council Perspectives
Supply chain operations within an organization should be constantly reviewed to identify where improvements can be made.
Answering the CEO Challenge: How Quality Can Drive Profitable Growth across the Organization
April 2010 | Council Perspectives
Results of The Conference Board 2010 CEO Challenge survey point to an increased global focus on corporate reputation for quality, one of the original drivers of the quality management movement.
Reengaging Lost Customers
February 2010 | Executive Action Report
What can be done to win back customers that have proven loyal in the past and who may account for a significant portion of profits? A Mid-market Conversation Starter.
Solving the Customer's Price Issues.
February 2010 | Executive Action Report
This Mid-Market Conversation Starter gives you a couple of new perspectives from which to think about solving customer price issues.
A Leadership Prescription for the Future of Quality
May 2009 | Research Report
This report, created by The Conference Board Quality Council, looks at the future role of quality throughout the enterprise.
A Leadership Prescription for the Future of Quality
May 2009 | Council Perspectives
This report, created by The Conference Board Quality Council, looks at the future role of quality throughout the enterprise.
Clicking With Customers
May 2009 | The Conference Board Review
There's a difference between online presence and online marketing.
Restoring Quality
May 2009 | The Conference Board Review
Subir Chowdhury implores America to change its mindset.
Security Metrics as a Management Tool
April 2008 | Executive Action Report
Traditionally viewed as a cost, security is not merely risk avoidance. It lets companies measure and manage risk and adds value by, e.g., enabling firms to operate in new markets.
Business Benefits of Security: Making the Case in Mid-Market Companies
April 2007 | Executive Action Report
Mid-market companies are coming to the realization that security is best viewed as an investment that increases business value, rather than an expense to be minimized.
Navigating Risk — The Business Case for Security
October 2006 | Research Report
Making the business case for investment in security is easiest in companies with the most to lose—large global operations, critical infrastructure industries— but security can add value to every company.
Philanthropy at Mid-Market Firms: It Pays to Be Creative
September 2006 | Executive Action Report
A creative approach to philanthropy can help those in need as well as the bottom-line by improving corporate image and improving employee morale.
Role of U.S. Corporate Boards in Enterprise Risk Management
June 2006 | Research Report
Evolving legal developments make a robust ERM oversight process more important than ever for directors, who acknowledge in increasing numbers that overseeing risk is part of their role.
Threat, Vulnerability, and Consequence: A Framework for Managing Security
June 2006 | Executive Action Report
Risk management is the intellectual core of the security field. Analyzing security in terms of risk helps companies translate issues of physical protection and data integrity into relevant management concepts.
Making the Business Case for Security
June 2006 | Executive Action Report
With their function traditionally seen as a cost center, security directors are being asked to present metrics to establish a business case for undertaking security expenditures.
Safety, Health and Environmental Management Excellence Yields Business Benefit
May 2006 | Executive Action Report
This report highlights the Environmental Health & Safety programs of two recent winners of The Robert W. Campbell Award.
A Strategic Approach to Security: Compliance, Certification, and Competitive Advantage
February 2006 | Executive Action Report
While regulatory initiatives have transformed corporate security programs, companies can add value by integrating security into a comprehensive risk management framework.
Defining Corporate Governance Best Practices to Add Firm Value
September 2005 | Executive Action Report
European family-controlled public companies tend to perform less well in the stock market than their American counterparts. Would best practices followed by family firms in the United States be helpful examples for similar enterprises in Europe?
How Smaller Companies Earn Customer Loyalty
August 2005 | Executive Action Report
How do you develop customer loyalty? How do you measure it? How do you profit from it?
Corporate Security Measures and Practices
March 2005 | Research Report
This piece encapsulates information from a series of reports regarding security issues, which were originally published by The Conference Board in 2003 and 2004.
Security in Mid-Market Companies: Tackling the Challenge
November 2004 | Executive Action Report
Will the most important incentive for smaller companies to upgrade their security operations come from standards imposed by major corporations rather than those imposed by the government?
Cops, Geeks, and Bean Counters: The Clashing Cultures of Corporate Security
September 2004 | Executive Action Report
Bridging the clash of cultures and creating a common frame of reference is essential if companies are to manage their total security needs in an effective manner.
Security Practices ... Security in Mid-Market Companies: The View From the Top
July 2004 | Executive Action Report
Is corporate security an expense that should be minimized or an investment that increases business value?
Managing Customer Data for Strategic Advantage
December 2003 | Research Report
This report presents the findings of a recent survey of 45 companies on the goals, effectiveness, and importance of their customer data management programs.
Managing Corporate Security in Mid-Markets
September 2003 | Executive Action Report
Smaller companies find security spending more burdensome when expressed as a percentage of annual sales, and they are less likely to believe their security spending is adequate.
Sustaining Customer Care in a Rapidly Changing Business World: A Snapshot of Practices
September 2003 | Research Report
This study attempts to gauge the fast-changing technologies and approaches taken in maximizing customer and, hence, corporate value.
Corporate Security Management: Organization and Spending Since 9/11
July 2003 | Research Report
This comprehensive study reveals business spending patterns since the attacks of September 11, 2001.
Managing Corporate Security: Patterns of Organization
July 2003 | Executive Action Report
Corporate America has been slow to adapt to the realization brought on by the attacks of September 11, 2001 that greater coordination of the security function is needed.
Managing Corporate Security: Patterns of Spending
July 2003 | Executive Action Report
Two years following the attacks of September 11, there has been sharp increases in security spending, mainly in insurance and risk management.
Security Today: The New Global Context
January 2003 | Executive Action Report
The most difficult aspect of the global security challenge is in understanding how to bring prosperity to poor countries. Government and international programs need to rethink their approaches to the incentive and market structures that drive prosperity.
Branding on Site: Customer Relationships in the Digital Marketplace
December 2001 | Research Report
Done in collaboration with a Working Group of branding / marketing executives from 12 U.S. companies, this study examines how major firms are adjusting their branding strategies to embrace the Web as a new communications channel.
Corporate Security in a Time of Crisis: Bioterrorism
November 2001 | Executive Action Report
Deals with mailroom procedures and the risk of bioterrism.
Corporate Security in a Time of Crisis: Concerns for International Business Travelers
November 2001 | Executive Action Report
Addresses current security issues in business travel and emergency evacuation from overseas locations.
Corporate Security in a Time of Crisis: Management Challenges
November 2001 | Executive Action Report
Assists senior executives in becoming conversant with current security issues, including how to integrate it in the management process, the question of cost, protection procedures and contingency plans, and supply chain and product security.
Corporate Security in a Time of Crisis: Online Security Resources
November 2001 | Executive Action Report
Lists Web resources for current security issues, including management challenges, bioterrorism, protecting IT, and concerns for international business travelers.
Corporate Security in a Time of Crisis: Protecting IT
November 2001 | Executive Action Report
Discusses ensuring IT security, and IT recovery and response procedures.
Customer Relationship Management: New Ways of Keeping the Customer Satisfied
August 2001 | Research Report
This report examines planning and implementation practices for Customer Relationship Management and pinpoints keys to success among B2C and B2B practitioners across a range of industries.
Why All the Uncertainty, Fear and Doubt? Are Mergers and Acquisitions Bad for Workers?
June 2001 | Research Report
This study examines the effects of ownership changes on employment, wages, and plant closing for the entire U.S. manufacturing sector for the period 1977-1987.
Post-Merger Integration: A Human Resources Perspective
September 2000 | Research Report
Employees in both acquiring and acquired companies are the least visible constituency in the merger process, raising questions about assertions by top management that people are their most important assets.
Employee Communication During Mergers
June 2000 | Research Report
During a merger, the new strategic directions, business priorities, organization dynamics, and values combine with employees' strong personal concerns to create an enormous demand for accurate and timely information.
Speed: Linking Innovation, Process and Time to Market
May 2000 | Research Report
How can companies leverage the networking opportunities afforded by web links to employees, customers, suppliers, and other partners, to work smarter, move faster, and gain competitive advantage?
Valuing People in the Change Process
March 2000 | Research Report
Business leaders must wear many hats to manage change well; they must know if employees are change-oreinted and anticipate and prepare for the next big change.
Implementing a Post-Merger Integration
January 2000 | Research Report
Executives and business experts discuss some of the global trends in M&A and share their experiences in developing a strategic context for M&A integration, creating a corporate culture, and measuring integration success.
Post-Merger Organization Handbook
June 1999 | Research Report
Your company's just been merged. Now how do you blend your staffs, operations, and resources to make it work? The answers are here.
Understanding Productivity Growth: Entry, Survival, and the Competitive Process
February 1999 | Research Report
Do new plants outperform old plants? According to analysis in this report, the answer is yes.
Continuing Search For Performance Excellence
December 1998 | Research Report
Learn from the experiences of companies who've instituted performance-excellence initiatives, and take a look at the future in this field.
Investing in Profitable Customer Relationships
October 1997 | Research Report
Companies are discovering that loyal customers are profitable customers. The challenge is deiciding which customers and products to invest in when looking to increase loyalty.
Total Quality Journey
June 1997 | Research Report
Executives who attended The Regional Malcolm Baldridge Award conferences say the feedback they receive is worth more than winning.


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Life Below 14th Street
So this is a story about a guy in NYC. Some parts of the story are amazing, some hilarious, others confusing, some interesting, but always honest. Like any good story it has a lot of characters. It usually involves a lot of different passions. That means this story involves you as much as it does me.
Welcome to life below 14th street.


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FM stands for Future Ministry and 300 represents our equipment need of $300,000. A gift to the FM 300 capital campaign helps us to improve the vehicle, by which the Gospel message is delivered. Friend, this is the most important message of all time! Our equipment must be fully functional and of the highest quality to deliver the Gospel every day, both near and far.
Here on our website, we have pictures, prices and descriptions of the needed equipment (check the links at the bottom of this page). If God prompts you to be part of the Future Ministry 300 campaign at WEEC, you can designate a onetime gift to help with the purchase of equipment. Every donation that is marked for FM 300 will be used solely for that purpose and is tax deductible. If you already support our ministry's operations budget, we ask that you consider an FM 300 gift over and above your regular offerings.
You may use your credit or debit card here to make a contribution:
Alternatively, you can send a check to:
Springfield, Ohio 45504.
If you have any questions about this campaign or how you can be a part of God's provision for the need, call Kevin Boggs (Strong Tower Christian Media – Director of Development) at 1-877-493-3236.
Thank you for helping us to equip both stations to operate with much greater efficiency and stewardship, which will in turn enhance our ability to share the greatest story ever told!


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Man's own dog helps police bust him on drug charge
PRATTVILLE, Ala. (AP) — Police in central Alabama say a man's own dog helped officers bust him on a drug charge. Full Story
(Jordan Strauss/Jordan Strauss/Invision/AP)
A distant father-daughter duo in 'Interstellar'
LOS ANGELES (AP) — Jessica Chastain doesn't even feel comfortable saying her character's name. The Oscar-nominated actress quickly attempts to course correct when she realizes she's speaking liberally about Murph, the astrophysicist she's portraying in "Interstellar," one of the most closely guarded and anticipated films of 2014. Full Story
Anna Cardwell upset over molester Mark McDaniel being around her young sisters.


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(Source: jennafifi)
I'm just a girl. Standing in front of the world. Asking it to listen to her.
I am: a graduate student of psychology, a Sigma Kappa, a scrapbooker, a blogger, a journal writer, OCD, a perfectionist, a romantic, a part time free lance writer
I like: art, music, fashion, anything related to Sigma Kappa, photographs, cooking, alone time, reading, creating, coffee, chocolate, and LOVE my family, friends, boyfriend and kittens Bellatrix and Nymphadora <3
I hate: mustard, putting away clothes, dirty rooms, procrastinating, being late


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Someone's in the Kitchen with Sarah: Kathleen Boggs
Salisbury resident Kathleen Boggs doesn't like to waste time in the kitchen. She prefers to get in and get out.
"I like easy," she said.
That was evident when I visited her home last Thursday.
She was flying around the kitchen, opening cans and chopping vegetables at warp speed.
There was rarely a moment when we were just standing around.
She likely learned speed was of the essence when she began cooking for her large Michigan family growing up.
"When I was 4 years old it was a rule that I had to make one meal a week," she said. "There were nine people in my family and back in those days, it was maybe opening a can of soup and making sandwiches.
"It was insisted upon every week that I made one meal and I just fell in line."
The oldest of seven children, Boggs learned many of the tricks she uses in the kitchen now from her mother.
"Something my mother taught me is nobody likes to clean up the mess after they get done cooking, so I keep a dishpan of soapy water to wash things off as I cook," she said.
During our visit, Boggs showed me how to make chicken enchiladas, a recipe she got from her step-granddaughter.
It seemed simple enough and turns out it was.
The first step was just opening up several cans of green chilies and dumping them into the bottom of a metal pan. We topped that with a thick layer of chicken.
Boggs boiled three chicken breasts the night before and I shredded it before placing it on top.
Then, we mixed together equal parts sour cream and cream of chicken soup. Boggs used canned soup for simplicity sake, but she typically makes her own sodium-free concoction.
Next, I spread the mixture in the pan and top with cheese.
The last step is frying up some tortillas and placing them on top.
Boggs dipped each tortilla in hot canola oil for a few seconds before flipping it over. We cut up the tortillas into halves and quarters before frying them. The smallest pieces were placed in the corners, while the larger ones filled the inside of the dish.
Then we just popped it into the oven and waited.
From the garden
While the enchiladas cooked, Boggs and I worked on a salad.
Of course, the first step was getting the lettuce ready.
We washed it, and then Boggs showed me how to prepare it the "right way" by tearing off pieces.
Then she showed me the quick way, cutting it with a large knife.
"Always learn it the right way first, and then you can take the shortcut," she said.
We chopped tomatoes, radishes, bell peppers, celery and onions.
She showed me an easy way to fancy up cucumber slices by first taking a fork and running it down the side of the cucumber all the way around.
"Doesn't that look nice?" she asked.
Boggs also taught me a quick way to get the smell of onion off my hands by adding a little salt to my hands while washing them.
Although most of the vegetables are store-bought this time of year, Boggs grows her own during the warmer months.
She and husband Tony have a multi-acre garden behind their Bringle Ferry Road home. They grow corn, cabbage, broccoli, cauliflower, mixed greens, carrots, radishes, peppers and more.
Boggs said they had more than 200 tomato plants last year and eight long rows of okra.
"I grow just about everything I can," she said. "I freeze it, I dry it, I give it away."
Boggs said she isn't above using her washing machine to clean green beans for canning.
The couple has already started this year's garden. During my visit, I saw seedlings sprouting near a window in their living room.
"My husband doesn't know how to stop growing," Boggs said. "I'm surprised he hasn't planted the driveway."
Boggs said the couple don't sell their bounty. Instead they share it.
She takes vegetables by the bucketful to Genevieve's Salon of Beauty, where she works as a hairdresser.
"We've got enough for all of Salisbury," she said. "Tony has always said there are a lot of hungry people out there, so we share.
"We have never had to replace our well and I'm sure it's the Lord blessing us because we give it away all the time."
Waste not
Boggs hardly ever throws out food.
If she notices fruit nearing the end of life, she blends it up and pours it into a popsicle mold before popping it into the freezer.
"If I want something sweet, I have one of them," she said.
Boggs said she typically places a paper towel on top of a salad and puts on a lid before flipping it upside down in the refrigerator.
"That way the moisture is absorbed into the paper towel and it stays fresh for at least a week," she said.
Carrots and radishes usually go in water in the fridge, a trick to make them last longer, Boggs said.
Boggs said there were always plenty of mouths to feed at her house growing up, so they never worried about wasting food.
"My dad would call and say "Hey put some more beans on, the Boy Scouts are coming,' " she said. "Our house was the bus stop too, so if another kid's mom didn't have time to make them breakfast they walked in, grabbed a plate and sat down."
Saturday was "bake day" at Boggs' grandmother's house.
"Everybody in town knew to stop by grandma's, and everybody called her grandma," she said. "The town I grew up in in Michigan still doesn't have a stop light."
Getting creative
Boggs said she loves looking at recipe books for inspiration.
"I never follow them, but it gives me ideas," she said. "If you're a good cook, you have to know how to improvise."
Boggs cut sugar out of her diet after being diagnosed with diabetes. Her husband has had multiple heart attacks, so they've also eliminated salt from their diet.
Cayenne pepper, garlic and onions are common ingredients found in her kitchen.
"Those are the staples that I've got to have," she said.
As we finished chopping up vegetables for the salad, Boggs took the enchiladas out of the oven.
"Whenever you cook anything, you should let it rest for 10 minutes," she said.
We chatted while we waited for it to cool.
I have to confess that I didn't try the dish, but photographer Jon Lakey and videographer Andy Morrissey did.
They agreed it was delicious.
The truth is I don't like cheese. I've never eaten it, not even as a child.
I'm almost embarrassed to tell people that because they are typically appalled, but Boggs didn't seem to mind.
Here's hoping future kitchen hosts are just as understanding.
View more photos online.
Contact reporter Sarah Campbell at 704-797-7683.
Twitter: twitter.com/postlifestyles
Facebook: facebook.com/Sarah.SalisburyPost


text:
I have a martin moab 09.When I draw the bow the string come to the right of the idler,its normal??or its cam lean??
I have a martin moab 09.When I draw the bow the string come to the right of the idler,its normal??or its cam lean??
It's hard to tell from that outstanding pic.
(Were you taking the pic, while holding the bow at full draw at the same time?)
It looks to me, like you are just severely torquing the grip.
my cheetah does that too, just to the left of the idler. shoots fine so ive quit worring about it.
I have the same problem with my 09 cheetah and I have heard of many other people with 09 cheetahs that have had this problem and has caused issues. For me it was cocked enough that my string has came off my idler wheel twice. I called martin and they said that since mine is leaning left I would have to get the bow in a press and twist the top right cable string to tighten the right side and it should bring the string to the middle of the idler wheel.
I am aware this is an old thread but the CCS will always pull the string in that direction off the front of the idler wheel. As far as I have been informed that should not cause any major issues as that is on the draw cycle. There is more of an issue if you have the lean off the rear of the cam which could ride off on the firing cycle.
The only small issue with the draw cycle is the string can get chewed, I have seen some bows where they have served that part of the string. I have also heard that some people will fit 1/8 inch washer on the front bolt between the riser & the CCS arm. According to them it removes some of the lean & helps to reduce string fray.
Personally I would like to speak to Martin before making such a design change.
Testing testing


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Murari's Kirtan Valley Govardhana Puja Oct. 30
Friday, 21 October 2011 / Published in Message Board / 1,507 views
Chanting – Music – Feast
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Mark Your Calendar:
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Krsna would love to see you!!!!!!
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Divine Madness: Art Deco Diamond Earrings
Rose cut diamonds have a little secret all their own. These gems are flat back and as a result show their beauty where it counts – in the diameter giving the visual appearance of a much larger diamond. This dictum is "apparent" in these Art Deco platinum earrings.
A pair of rose cut diamond drops, each measuring 8 mm in diameter have an estimated weight of .85 and .80 carats (I-J color range; SI2 clarity for clear inclusions mostly on the edges) respectively. However, due to the manner in which the diamonds were cut, the gems are visually perceived to be about 1.8 carats each!
Each of these glorious ladies is suspended from a line set with three (3) accent diamonds – five (5) old European cuts and one (1) old single cut which bring the total estimated diamond weight to 1.06 and 1.01 carats for the pair. Please note the mille grain detailing and fine azuring of the earrings.
Date: Circa 1920.
Measurements: ¾ of an inch (1.9 cm) in length by 3/8 of an inch (0.9 cm) in width. Weight of 2.4 grams (1.5 dwt) for the pair including ear nuts.
Condition: Very good; one diamond with edge wear and 2 edge chips almost under the bezel only visible with a loupe.
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Kathy Padgett Baker
member for 10 years, 2 months, 10 days
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I have had people e-mail me a few times asking me to remove tokens I have left for their loved ones, because they didn't want me to increase my 'count' at their expense. If I've left a flower for someone you loved, please take a moment to read this.
I DO NOT keep count, Find-a-Grave does that. If you think that way, look how long I've been a member, look how many tokens I've left, and do the math. I'm not able to be on here very often but when I do, I try to send a silent message to at least one person that they were acknowledged that day, even if by a stranger.
If I left something, it's because you left something on one of my memorials, and I'm reciprocating; because I know someone who knew your loved one, and am leaving a remembrance; or - in the case of the people who have written to me - I try to leave flowers for people who have none. It hurts my heart to see a grave with no flowers in life, and I hate the thought of someone having a memorial on here but not being remembered any other way.
I usually don't leave a message with tokens, because I don't really know what to say, and because I don't want to sound trite. The saying is "A picture is worth a thousand words" and another, "It's the thought that counts."
Born and raised in Summerville Georgia, maiden name Padgett, I married and moved to Rome in 2006. My husband and I have one furbaby, Fancy. I am a homemaker now, "medically retired" from the workforce due to Fibromyalgia and a few other problems.
I always loved looking at old tombstones, and that developed into a general love of cemeteries.
I believe everyone deserves to be remembered, and I get especially sad seeing memorials that have no flowers. Those are the people I search out, so I can let them know that they aren't forgotten.
Thanks to everyone who leaves a remembrance on my memorials. Your thoughtfulness is much appreciated.
Please also visit the pages I have sponsored, to let the family and friends know that their loved ones are remembered and honored.
Oct. 20, 2012: Thank you to everyone who has left positive messages for me about leaving tokens for people I don't know. I'm the kind of person who cries over obviously forgotten graves, I can't afford to place flowers on the real graves that break my heart, so I try to make up for it by leaving tokens here. I appreciate all the encouragement, and apologize for not answering everyone directly. May God shine blessings down upon you all!
January 12, 2013
So apparently somebody joined Find a Grave in October and has decided to become the memorial police, looking for duplicate listings and reporting them to TPTB. I've gotten one e-mail so far telling me that my listing of Manuel Padilla is a duplicate and that FaG might want to "Memorials * and * are duplicates. They should be merged and the newer memorial deleted. You might also want to consider making this one a "Famous Person""
Wow, they've been online less than 4 months, have added almost 1400 memorials and manage a few more than they've added, and they're taking the time to police the site to find memorials they don't agree with. And DUH - wow, it never dawned on me to submit a memorial of a famous person as FAMOUS. WOW! Why didn't I think of that?!?! Of COURSE I can do that on my own, just by waving my magic wand! TPTB at FaG have nothing to do with it of course.
Yeah, I'm a little ill right now, people like this just really irk me. So anyway, for those who have left tokens for Manuel Padilla on the memorial I created, just wanted to let you know that if you try to return to leave others, you might be redirected to a different listing. If you have it in a Virtual Cemetery, you might need to change it soon. Since the e-mail that was sent to FaG was sent to me and the manager of the other memorial (a month newer than the one I listed, with no bio and only 6 tokens) it's out of my hands. Just a heads-up on the situation.
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Linda Wayman
RE: Find A Grave Memorial# 132777389q
Kathy, when I transferred the memorial to you I lost the option to remove it. There is no place for me to click to remove it. You will have to contact F-A-G and have it removed.
Added by
Linda Wayman
on Oct 26, 2014 5:38 PM
J Reece
I was glad to transfer your Aunt's memorial to you. May God bless.
Joann Reece
Added by
J Reece
on Oct 08, 2014 5:19 PM
Ryan Middleton
Did you know my father Samuel Middleton?
Added by
Ryan Middleton
on Jan 09, 2014 9:50 PM
Ryan Middleton
Did you know my father Samuel Middleton?
Added by
Ryan Middleton
on Jan 09, 2014 9:50 PM
Gracie Watson
Hi Kathy,
I hope you don't mind but I uploaded a couple photos. We visit Savannah each winter and it has become a tradition to leave an angel or toy on Gracie Watson's grave each year. Of course listening to all the stories is very interesting. I wish they would do more to preserve all the grand monuments in Bonaventure and Laurel Grove cemeteries. Especially Gracie's
Added by
on Oct 26, 2013 7:55 PM
I agree
I totally agree with your comments regarding Find A Grave.
There are a few that "deem it their duty" to tell everyone what they are doing wrong, while they, themselves, do whatever they choose.
I commend you for also leaving flowers on memorials that have no flowers, as I try to do the same thing whenever I find the time.
Bless you for your kindness!
Added by
on Oct 13, 2013 4:11 PM
Cathy Charese Pelham
Thank you so much
Thsnk you for the recognition of my dear parents. I live far away due to my job but I love and miss them. I'm crying as I write. Thanks for caring. Love to you. Charese.
Added by
Cathy Charese Pelham
on Jul 14, 2013 9:30 PM
faye mathis
Thank you
Kathy, thank you so very much for the token left for my son. He was my best friend and my heart and soul.
Faye Mathis
Added by
faye mathis
on Jul 11, 2013 9:57 PM
faye mathis
Thank you
Kathy, thank you so very much for the token left for my son. He was my best friend and my heart and soul.
Faye Mathis
Added by
faye mathis
on Jul 11, 2013 9:57 PM
Shannon M.
RE: Officer Eldridge
It was my pleasure...sad story. Poor man had no one. I plan on placing flowers on his grave for a long time comig.
Added by
Shannon M.
on May 02, 2013 9:32 AM
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Public Works Means Taxes
Recorded during the 2008 Mises University, Jeffrey Tucker interviews leading Austrian Economists on the topic of Henry Hazlitt's classic book "Economics in One Lesson." (Interview 3 of 12) [17:30]
Public Works Means Taxes Various Artists Economics in One Lesson
From: Economics in One Lesson , Thursday, October 02, 2008 by Jeffrey M. Herbener
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From high chair to 'my chair'
Stylish, safe & easy to clean - all the essentials covered!
lobster portable high chair
universal travel bag
wriggle wrapper
The poppy ™ high chair is HOT! because:
Written by: Shannon D
Wednesday November 27 2013
We received our Phil & Ted's Poppy high chair yesterday and gave it a try this morning. Our daughter loves it and so do we. So much easier to move to different rooms, put her in it and then place the tray on. Plus it's easier to clean it all down again afterwards. We are looking forward to also taking it travelling with us and using it as a chair on the front veranda.
Written by: MumofOne
Friday November 15 2013
One of the best purchases i've made in terms of baby items. I was originally reserved when looking at this highchair because of the size of the seat. Our son is HUGE! Tall, wide, and heavy. Im happy to say he fit well then (at 4.5 months) and still has plenty of room now at 10 months.
So easy to clean, love that you can shorten the legs to he can have a picnic lunch with his older cousins.
4 Stars because the straps are terrible, I don't even bother and my husband always trips on the legs.
Written by: N Urminsky
Monday September 16 2013
Bought for our second who is exclusively self feeding awesome but super messy. The poppy is super easy to clean, no extra places for food to get stuck and obviously very comfortable. The tray goes on and off easily and of course it is spectacular to look at.
The big con is most definitely the straps, I have given up using the shoulder straps as I cannot get them on and off, initially left them attached and slid them tighter and looser which was a pain. Please P&T fix this :-)!
Written by: Karen
Monday August 19 2013
My favourite things about this high chair is being able to reduce the length of the legs. At this height, I can feed my little girl from the couch after running around after her all day! The colours are awesome - she loves her bright pink chair! and it's so easy to clean. My only negative is the harness straps - I find it easier just to use the passive harness and tray to keep her secure. 10/10 from my family though!
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