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Company Overview of CHSP DC Holding Trust
BOARD MEMBERS AFFILIATED WITH Douglas W. Vicari *
Vice President, Treasurer, and Director
*Data is at least as current as the most recent Definitive Proxy.
MOST CONNECTED PEOPLE TO Douglas W. Vicari
|John W. Hill
|71 Relationships
|Thomas D. Eckert
|50 Relationships
|Jeffrey D. Nuechterlein
|16 Relationships
|James L. Francis
|11 Relationships
|Thomas A. Natelli
|10 Relationships
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School News Nationwide 10/30 Benefit Showing of DEFIANCE Postponed
Due to emergency weather conditions, the showing of the movie DEFIANCE, featuring guest speakers Zvi Bielski (son of resistance leader Zus) and Sally Frishberg, Holocaust survivor, originally set for Symphony Space, tomorrow, Tuesday October 30th, 2012 is postponed and will be rescheduled.
All outstanding tickets will be honored at the next scheduled event. Feel free to contact firstname.lastname@example.com with questions or concerns.
School News Nationwide, a New-York based organization dedicated to developing skills and teaching tolerance to New York City public school students presents a showing of the stirring 2009 movie "Defiance," starring Daniel Craig (popular English actor featured as James Bond) and Liev Schreiber, written, produced and directed by Edward Zwick.
School News Nationwide (SNN) previously announced two guest speakers: Zvi Bielski, son of resistance leader Zus, and Sally Frishberg, a survivor from Poland.
The movie is based on Nechama Tec's stirring book "Defiance: The Bielski Partisans," relating the true story of the four Bielski brothers, Tuvia, Zus, Asael and Aron. In 1941, as Nazi forces swept through Eastern Europe, the Jewish brothers succeeded in escaping the slaughter by the Germans in their town of Belarus, during which their parents were among the victims. They hid in the forests to survive, also taking on the responsibility of looking after a large and ever-growing mass of fleeing Polish Jews from the German war machine. Their heroic efforts of finding food and weapons in these unforgiving surroundings resulted in the saving over a thousand lives.
SNN, founded and directed by Bill Tingling, partners with Holocaust Museums, public schools, universities, local police precincts, and other organizations to help youngsters become productive, constructive members of society. The program nurtures active learning with after-school classes in journalism, investigative reporting and interviewing, television and video, and other outlets that offer students a chance to learn and excel. The showing of "Defiance" is part of SNN's highly praised "Words of Bonds" Holocaust Tolerance program.
For more information, visit www.schoolnewsnationwide.org and www.wordsofbonds.org.
To see a trailer of "Defiance" click here.
About Author
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Michelle Williams
Brokeback Mountain 10 Years Later: Jake Gyllenhaal and Anne Hathaway Remember Heath Ledger and Look Back on the Oscar-Winning Film
Originally posted 07/28/2015 04:40PM
To mark the 10-year anniversary of Brokeback Mountain, Jake Gyllenhaal and Anne Hathaway shared their memories of making the Oscar-winning film, and they also remembered their late costar, Heath Ledger.
How Heath Ledger's Family Is Keeping His Spirit Alive for His Daughter
Originally posted 04/19/2015 09:30PM
It's been seven years since Heath Ledger died, but his sister Kate is working to keep the actor's memory alive for his daughter, Matilda.
Michelle Williams on Being a Single Mom in Show Business: I'm Exhausted!
Originally posted 03/03/2015 04:50PM
"It's a real luxury to have a moment when I'm not scrambling," the actress says
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Looks like awards season just got a little sweeter
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The star gives us major hair, lipstick and bag envy in her spring ad campaign
Michelle Williams Stars in Cabaret: See the Pic!
Originally posted 04/02/2014 10:45AM
Willkommen Cabaret back to Broadway!
Flashback Friday, Oscars Edition: See What the Stars Are Posting
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A roundup of the best Tweets and Instas celebrating past Academy Awards
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The almost 8-year-old wears a pink Oz, the Great and Powerful tee while walking home from school with her mother in Brooklyn
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Michelle Williams to Make Broadway Debut – in Cabaret
Originally posted 09/05/2013 08:00AM
Michelle Williams, welcome to the cabaret!
The three-time Oscar nominee is set to make her Broadway debut in the Roundabout Theater Company's revival of Cabaret, opening in April, The New York Times reports.
Williams, 32, will play the lead role of Sally Bowles, made famous by Liza Minnelli in the 1972 film, for which Minnelli won the Oscar.
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Race 32 of 36 on Sprint Cup circuit
Martinsville Speedway, Martinsville, VA
October 23, 2005 1:00 pm EDT
0.526 miles
263.00 miles
|Tony Stewart
|Was the victim of a tire failure as the leader on lap 217 in Charlotte last week and finished 25th, evaporating his 75-point lead atop the standings; is tied with Johnson in points but still holds the top spot in the standings by virtue having one more victory than the fellow Chevrolet driver; entered the "Chase" on a tear with 12 straight finishes of eighth or better, including each of his five checkered flags this season; after extending the streak to 13 with a runner-up in New Hampshire, has posted two finishes outside the top 15 in the last four races; has posted three straight finishes of 14th or worse here since running third in this event in 2003; won this event in 2000 and is fourth among "Chase" drivers with a 14.923 average finish on this track.
|Short-track specialist has 55 career wins with 25 coming on tracks measuring under one mile; seven of those victories have come here, with the most recent coming last spring in the Advance Auto Parts 500 - his only checkered flag since 2001; the 49-year-old, in his final season on the circuit, fell three spots to seventh in the standings after a late accident resulted in a 24th in Charlotte last week; has run outside the top 20 twice in the last three races after running 19th or better in 18 of the previous 19 events; ran 10th in this event last year and fifth here in April for the first of his eight top-fives this season; the 1989 series champion is excited to be coming to a track that other drivers fear: "Martinsville's been a great track for me. I always feel like when I get there, if I'm in a ditch of having a problem, Martinsville's a place where I get back on track."
|Ryan Newman
|The circuit's most prolific qualifier the last four seasons tumbled two spots to fourth in the standings despite a seventh in Charlotte last week; is just 17 points behind the leaders after arriving at Lowe's Motor Speedway 75 points behind Stewart; after being the last driver to clinch a spot in the "Chase," recorded his first victory of the season in New Hampshire; had not finished higher than 12th in the six races leading up to the "Chase" but has run seventh or better four times in five events since; has run in the top five in each of his last four starts here, including a fourth in April; has 32 poles over the last four seasons, including two on this track; hoping to continue recent run of success here: "We used to be absolutely horrible at Martinsville and that was because the driver would burn off the brakes. After we talked to him, we got him to settle down and drive the car right. We've always had fast cars there and that shows with our qualifying effort, but recently we got the package together for racing and I think we'll be better than we've ever been this time."
|Jimmie Johnson
|Entered this race 227 points off the pace last year but claimed his second straight checkered flag amid a furious rally that brought him within eight points of Busch in the closest standings finish in stock car racing history; his victory here in 2004 came amid tragedy as several members of team owner Rick Hendrick's immediate family were killed in a nearby plane crash; went on to claim an emotional victory the next week at Atlanta Motor Speedway among his six straight top-10s, including four wins, to conclude the season; is in an opposite position this season, tied for the points lead with Stewart after claiming his record fourth straight checkered flag at Charlotte last week; was his fourth victory of the season and second of the "Chase"; was runner-up to teammate Jeff Gordon in this event in 2003; expects more frustration here this week after tire issues riddled drivers in Charlotte: "I think Martinsville is a place where contact is going to come into play and tempers are going to be high a lot like at Bristol. There is a lot on the line for the 'Chase' contenders on a track where you can never get away from lapped cars and cars that you are racing. The potential there is for contact and problems. Since they resurfaced the track, it is a single-file track on the bottom. The way you make a position is by someone making a mistake or you helping them make a mistake."
|Finished 11th in Charlotte last week to climb a spot to eighth in the standings, 115 points off the pace; the "Chase" has been a microcosm of his season as he mas managed only one top-10 but has not finished lower than 16th; has only eight top-10s overalls - easily the fewest among championship-eligible drivers - but has stayed out of trouble with just five finishes outside the top 20 this season; won in Michigan on August 21 for his first victory since a dramatic triumph in Richmond to climb four spots to ninth in the standings on the eve of the inaugural "Chase"; ran sixth in this race last year as one of few bright spots in last year's 10-race championship run; under the scoring system used from 1975-2003, would have finished 15th in points last season; has five top-10s but just a 21.25 average finish in 20 career starts here.
|Kurt Busch
|Was runner-up to Jimmie Johnson last week at Lowe's Motor Speedway, making up 82 points on the top spot in the standings; still is last among the 10 championship-eligible contenders, 142 points off the pace; after posting nine top-10s in the inaugural "Chase," finished 35th and 23rd in the first two races of this year's edition to become a long shot to repeat as series champion; has sandwiched top-10s at Talladega and Charlotte around a 14th in Kansas two weeks ago; won this event in 2002 among his three top-10s in 10 career starts at this track; finished 19th here in April after running fifth in this race last year.
|Carl Edwards
|In his first full premier series season, is among five Roush Racing drivers in the "Chase"; ran 10th in last week's UAW-GM Quality 500, which was plagued by 15 cautions, for his fourth straight top-10; remained sixth in the standings but moved within 54 points of the leaders; also still in championship contention in the Busch Series and will race in that circuit's event in Memphis on Saturday before taking a charter flight to Martinsville; has struggled more than any other championship-eligible driver on this track, finishing 24th in this race last year and 38th here in April.
|Greg Biffle
|Emerged relatively unscathed from a tire-issue marred UAW-GM Quality 500 at Charlotte last week, running third to climb within 11 points of the leaders; was his second straight top-three finish and third top-five in the first five "Chase" events; tied with Tony Stewart for the circuit lead with five checkered flags and has won six races dating to last season's finale; has run sixth or better in seven of the last nine events but has not won since June 19 in Michigan; struggled to a 29th here in April and has not finished higher than 17th in five career starts on this track.
|Matt Kenseth
|The 2003 series champion encountered a tire problem on lap 63 in Charlotte and finished 26th - last among "Chase" contenders - and slipped a spot to ninth in the standings; has three top-fives during this year's 10-race run for the championship after managing just one top-10 in the inaugural "Chase," his struggles from the end of last year carried into this season as he recorded only one top-10 in the first 10 races; has produced 13 top-10s in 22 events since, including a dominating victory in Bristol - a short track similar to Martinsville - from the pole in August; ran 11th here in April and 16th in this event last year; was runner-up to Bobby Labonte in the 2002 spring race among his three top-10s in 11 career starts here.
|Mark Martin
|Four-time series runner-up is fifth in the standings, just 51 points off the pace in what was scheduled to be his final season on the circuit; the 46-year-old claimed his first checkered flag since last June two weeks ago in Kansas and followed with a fifth in Charlotte last week; has run seventh or better in all but one of the first five "Chase" events, but an early accident in Talladega relegated him to a 41st and jeopardized his chances for an elusive first title; won this race in 1992 and the spring race in 2000 among his six checkered flag on the five remaining tracks this season; expected to drive the No. 6 Ford Fusion for Roush Racing against next year before Jamie McMurray takes over in 2007; won three straight poles here, beginning with this race in 1990.


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Caregivers Support Group
3173 Members Strong and Growing!
Oct 6 in Anger Management, Caregivers, Dementia
I work as a caregiver for seniors and live with my parents helping them. They are both very hard of hearing and Dad has Lewy Body Dementia, which also includes Parkinson's symptoms. I know he cannot control most of the things he does that annoy me bu...
♥ 5
Oct 8 in Alzheimers, Caregivers, Dementia
Welcome to SG and welcome to our Dementia and Alzheimer groups October newest members: @Sknick1 - @Rmertz Also saying hello to current SG members for their support!! @ClaudiaR @JimmyG Have a good day everybody! ...
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Hotel Delle Palme
No prices found through our partners. Please contact the business directly or check some of our recommended alternatives.
- Free High-Speed Internet
- Swimming pool
- Restaurant
- TV Channel One Russia
- Wheelchair accessibility
- Bar/lounge
TripAdvisor Reviews Hotel Delle Palme Letojanni
Travel Blogs from Letojanni
Day 14 Letojanni - Mt Etna - Syracuse
... the Mediterranean has been and gone. So the tour took us to the Archeological Park where we saw a Greek Amphitheater, a limestone quarry used by the Greeks to get building materials for their temples and theaters. What had started out as a very cold morning, was now a very humid afternoon, where everyone was jostling for shade. The next part of the tour was the old town where the Greeks first colonized the ...
From Beach to Mountain and into a Cock Bar
... It was such a hot day that we relaxed over a hazelnut frappe and enjoyed the panoramic views this bar had to offer.
We returned down the mountain to refresh ourselves at my cousins friends house, where we shower and change into some neat casual clothing, before walking through the main street of Taormina. This famous town is totally geared up for the tourists and on the main drag there are boutiques and restaurants that are ...
To Shop or Not To Shop, That is the Question!
... meaning bath and al Saqquah dating back to the cult of the Syrian god "Shai al Quaaum". Could it be that my descendant are a mixture of Spanish and Arabic on my Grandfather's (Rosario Sciacca) side of the family.
In the afternoon Ottavio had spend sometime with me going over the computer.
In the evening Saro's cousin and his family arrived for a casual dinner alfresco style in their court yard.
Swimming in the Ionian Sea
After a good nights rest I woken up to a breakfast of Granita and Brioche. I believe it has been the staple diet for the whole time I have been in Sicily. The day was enjoyed relaxing by the waters of the Ionian sea and as well the frequent dips. The Mediterranean water are quite warm, but under currents which thrust into the water are freezing. After a while those shots of icy water ...
Freezing waters of Gole Alacantara
... been built since Zio Francesco (deceased), brought me here all those years ago.
The name Alancantara is of Arabic origin (al-Qanṭarah). Several thousand years ago, the river bed was blocked by lava flow from Mt Etna. As the lava cooled much more quickly by the water than it would have done otherwise, it crystallised in the form of columns. Over the next millennia, the river naturally eroded a channel through these columns, resulting ...
Other places to stay in Letojanni
Hotel OlimpoVia G. Chincherini, Letojanni | 4 star hotelfrom $114
Hotel AntaresVia G Chincherini, Letojanni | 4 star hotelfrom $118
Le TerrazzeVia G Chincherini, Letojanni | 4 star hotelfrom $120
Hotel AlbatrosVia Luigi Rizzo , Letojanni | 3 star hotelfrom $107
Hotel San PietroVia Luigi Rizzo, Letojanni | 3 star hotelfrom $88
Park Hotel SilemiVia Silemi 28, Letojanni | 4 star hotelfrom $129
- Such a beautiful view!
- Lovely Hotel
- Hotel clean and tidy - Food uninspiring
Edgewood ResortEdgewood Park Road, Alexandria Bay | 1 star hotelfrom $94
Hotel da PeppeVia Vittorio Emanuele 345, Letojanni | 3 star hotelfrom $68
Hotel San VincenzoVia Michelangelo Garufi 34B, Letojanni | 4 star hotelfrom $108
Hotel FernandaVia Roma 69, Letojanni | 3 star hotelfrom $59


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Book your room at Sheraton Old San Juan Hotel
Get an overview of this hotelWaterfront resort across from San Juan cruise-ship piers, just steps from restaurants, shops and attractions.
Modern, amid history
Located along the water in Old San Juan, this contemporary Puerto Rico resort is across from cruise-ship piers and 3 blocks from the massive Fort San Cristóbal.
Casino and café
Within walking distance of numerous galleries, shops, restaurants, and museums, this Sheraton's highlights include an on-site casino and rooftop pool.
Work and relaxation
Sheraton Old San Juan Hotel & Casino has 240 air-conditioned rooms and suites, all with flat screen TVs, cordless phones, and high-speed Internet access.Information missing or incorrect? Tell us!
Hotel Amenities
Hotel Amenities
Sheraton Old San Juan Hotel & Casino is across the street from the cruise-ship piers and 3 blocks from Fort San Cristobal.
The resort's 10,000-square-foot casino offers Caribbean stud poker, blackjack, craps, roulette, and slot machines. Guests have access to a computer in the resort's administrative office, along with tour/ticket assistance, complimentary wireless Internet access in public areas, an Internet point, multiple conference/meeting rooms, luggage storage, and photocopy, faxing, and secretarial services. A fitness center contains cardio machines. The resort's shopping arcade lies across a narrow street.
This Puerto Rico resort is smoke-free.
- 24-hour front desk
- ATM/banking
- Babysitting or childcare
- Bar/lounge
- Breakfast available (surcharge)
- Free newspapers in lobby
- Computer station
- Conference center
- Conference space
- Conference space size (feet) - 8073
- Conference space size (meters) - 750
- Dry cleaning/laundry service
- Elevator/lift
- Express check-out
- Free WiFi
- Hair salon
- Health club
- Luggage storage
- Multilingual staff
- Number of floors - 9
- Number of meeting rooms - 10
- Outdoor pool
- Porter/bellhop
- Restaurant
- Safe-deposit box at front desk
- Self parking (surcharge)
- Smoke-free property
- Spa treatment room(s)
- Spa tub
- Television in lobby
- Total number of rooms - 240
- Tours/ticket assistance
- Valet parking (surcharge)
- Wedding services
Family Friendly Amenities
- Babysitting or childcare
- Free Wi-Fi
- Microwave (on request)
- Outdoor pool
- Refrigerator (on request)
- Rollaway/extra beds available
Available in all rooms: Free WiFi , Free wired high-speed Internet
Available in some public areas: Free WiFi
Self parking (surcharge), Valet parking (surcharge)
Room Amenities
- Air conditioning
- Blackout drapes/curtains
- Climate control
- Coffee/tea maker
- Free toiletries
- Cribs/infant beds available
- Daily housekeeping
- Designer toiletries
- Desk
- Down comforter
- Free WiFi
- Free wired high-speed Internet
- Hair dryer
- Hypo-allergenic bedding available
- In-room massage available
- In-room safe (laptop compatible)
- Iron/ironing board
- Microwave (on request)
- Pay movies
- Phone
- Pillowtop mattress
- Premium bedding
- Premium TV channels
- Private bathroom
- Refrigerator (on request)
- Rollaway/extra beds available
- Room service (limited hours)
- Satellite TV service
- Shower/tub combination
Where to Eat
Palio - This authentic Tuscan chophouse offers local selections and stunning views of San Juan Bay from the resort's second floor. Breakfast, brunch, and happy hour are also available. Closed Mondays.
Chicago Burger Company - Guests can build their own burgers at this indoor-outdoor restaurant on the scenic San Juan Bay. Menu includes certified Angus beef, salmon, and vegetarian options for lunch, dinner, and appetizers. Guests can also graba a drink at happy hour.
Sheraton Old San Juan Hotel & Casino serves a full breakfast from 6:30 to 11 AM each morning.
Nearby Things to Do
Guests can take advantage of the hotel's outdoor pool for swimming and sunning, and fitness equipment for staying in shape.
The concierge desk can assist with a range of tours and activities, from mountain climbing to snorkeling.
The recreational activities listed below are available at or near the hotel; fees may apply.
- Golfing nearby
- Snorkeling nearby
- Hiking/biking trails nearby
To make requests for specific accessibility needs, complete the "Special or Accessibility Requests" section of "Trip Preferences" when you book your hotel.
- Accessible path of travel
- Accessible bathroom
- Roll-in shower
- Accessible parking
- In-room accessibility
- Accessibility equipment for the deaf
- Braille or raised signage
Hotel Policies
Minimum check-in age is 18
Check-in time starts at 3 PM
Check-out time is 11 AM
Payment types
Children and extra beds
- Children are welcome.
- Kids stay free! Children under 16 years old stay free when using existing bedding.
- Rollaway/extra beds are available for USD 25 per night.
- Cribs (infant beds) are available.
Pets allowed, Only dogs are allowed, Maximum number of pets per room 1, Pet maximum weight in lb is 40
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
Service animals exempt from fees/restrictions
Noise-free rooms not guaranteed
- Resort fee
Optional extras
- Fee for buffet breakfast: USD 20 per person (approximately)
- Self parking fee: USD 21.40 per night
- Valet parking fee: USD 20 per night (in/out privileges)
- Early check-in fee: USD 75
- Late check-out fee: USD 75
- Refrigerator fee: USD 10 per night
- In-room microwave fee: USD 10 per night
- Rollaway bed fee: USD 25 per night
We should mention
A resort fee is included in the total price displayed. Children 16 years old and younger stay free when occupying the parent or guardian's room, using existing bedding. Only registered guests are allowed in the guestrooms. Some facilities may have restricted access. Guests can contact the property for details using the contact information on the booking confirmation.


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Some combos of the 9 may session with Aude Cassagne - She's back on her bike for one month after a two years and a half break due to her medicine studies ! Enjoy !
More Photos and videos on my page :facebook.com/MaximeCassagnePhotographies
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Seibertron.com - The Ultimate Transformers Fansite
Twitchfilm wrote:Michael Bay is planning to shoot parts of the latest installment in the Transformers franchise in Hong Kong. Reportedly, after looking at photographs of different parts of the city, he is most interested in Sham Shui Po because of its unique aesthetic. The district, situated in North West Kowloon, is one of the oldest and most densely populated areas of Hong Kong. The producers have already approached local government officials and businesses to propose the closure of sections of roads for filming.
-Kanrabat- wrote:YEah, too many Transformers are in a serious need of a good rim job.
Blast Cannon wrote:This thread is brilliant. Duragrip you are a gloriously weird sexual deviant and I love it.
Return to Transformers Live Action Film Forum
Registered users: Bing [Bot], Delicon, Delta Magnus, Emerje, Exabot [Bot], Google [Bot], Google Adsense [Bot], homicide, Insidious, Jeen0808, Majestic-12 [Bot], MSNbot Media, Rainmaker, RAR, Sabrblade, Stuartmaximus, Yahoo [Bot]


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queen Articles
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Adventure Activities in Amsterdam -- Try if You Dare
by Larissa Ovitt. Posted Sep 8th 2010 04:30 PM
Continue ReadingTravelers who are seeking more than Amsterdam's iconic windmills, homemade cheeses, and wooden shoes should take a deeper look into the thrilling experiences this charming, medieval city has to offer. We dare you to try an adventure activity in Amsterdam, Netherlands.
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Corvallis 104.3 FM • Hood River 91.9 FM • Portland 90.7 FM
Hosted by Abe Proctor and Joe Uris
Tonight we highlight two events from the transgender and allied communities. Both of these community events welcome everyone!
Our first music break is from Joan Jett's 'Androgynous'
We welcome Chloe Flora back to the show to discuss Communi-T, Portland's trans resource fair happening at the QCenter on Nov 13 from 2:30 tp 6pm.
Voters in Mississippi will decide tomorrow on a 'personhood' initiative which, if passed, would confer legal personhood upon a fertilized ovum. This would of course render abortion illegal, and any other act that interfered with said ovum's development -- like, say, a miscarriage, or the use of certain kinds of birth control -- could be considered negligent homicide or even murder.
Jan Haaken and Mike Snedecker talk about the right of assembly and how it comes into play for the Occupy movement. They consider the role of elected leaders to make discretionary calls in managing assemblies and the importance of protecting First Amendment rights, but also the potential limits on the place, time and manner of people's assemblies.
Joe Clement hosts this show and we hear:
Which US military force carried out the infamous night raids in Afghanistan? It flies more Drones than any other force and has captured, interrogated and imprisoned over a thousand alleged "terrorists". Recently it carried out the targeted assassinations of American Citizens in Yemen. You might guess the CIA but you'd be wrong. It is the JSOC, the President's personal sword. Join me, Linda Olson-Osterlund, and my returning guest William Arkin, author of Top Secret America:. The Rise of the New American Security State. He'll shine a light on this shadowy organization playing a pivotal role internationally.
Joe Clement hosts and we hear:
Civil Liberties Ten Years After 9/11: Can We Be Safe and Free?
Prison Pipeline brings a discussion of the missing link that has traditionally existed between postitive personal growth that many motivated prisoners experience during their incarceration and the reality of release. Topics include the difficulty for the ex-convict in finding service agencies and support groups in the free community to sustain and nuture those pre-social skills and dreams concieved inside prison walls.
Latest newsletter: September 2015
Past newsletters
KBOO is seeking responses to this Request for Proposal (RFP) for Strategic Planning Support! Help us build our next plan into the future!!
The next regular monthly Board meeting will be Monday, September 28th (the fourth Monday) at 6 pm at KBOO - 20 SE 8th Ave. Portland, and is open to the public
KBOO Community RadioOffice Phone: 503 231 8032Studio Phone: 503 231 8187Fax: 503 231 714520 SE 8th Avenue, Portland, OR 97214
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Magic Wand Makeup Artistry
Hair and/or makeup are essential for a perfect wedding, and our wedding beauty experts deliver professional Makeup Artist results.
West End Salon
Get exceptional Waxing results with the freelance beauty experts at West End Salon, which are only available to those in East Dennis.
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Want a gorgeous, all natural look for your wedding? Let the bridal makeover professionals at Image by Kristen help with all the services you need.
Calming Room
You have enough to do and worry about at your wedding, let Calming Room help with outstanding professional Manicures services.
John Carver Inn and Spa
East Dennis weddings are even more special and spectacular when you use Pedicures services provided by John Carver Inn and Spa freelance beauty experts.
Mary Kay Cosmetics
Let our skilled professional wedding beauticians transform your entire wedding party with Makeup Artist services available only in East Dennis.


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Waiwhenua Homestead Farmstay
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North Island just about done
... The valley feeds down to Lake Rotomahana which appears to be a favourite breeding site for black swans. It took two hours of leisurely strolling downhill to reach the lake where, thankfully, a bus was provided to return us to the car park. A short drive took us to our overnight stop at Waikite Thermal Pools campground. No sooner had we set up when a big black cloud decided to treat us to thunder , lightning and ...
Taupo to Napier
From Rotorua, we headed south to Taupo, the weather not so good, overcast, windy and cold. We arrived in Taupo and went straight to the i-site in order to find out about the Tongariro Crossing, one of the great walks over an alpine volcano. Unfortunately it was a no go. There had been a recent heavy snow fall and it was -7. We are not geared for that kind of weather or have the experience, so we stayed the night in a motel and had a thermal bath. We decided to ...
The recipe for a great road trip
... to tie in with it.
A huge cruise ship was in town. Shops vied for the passengers trade, selling 1930s memorabilia at 'special rates' to the cruise ship passengers! I'm not sure if there were many takers however of elbow length gloves or 1930s wigs!
We ended the day camping down the coast in Hastings, appropriately beside a pebble beach. A nice spot, looking out at the sea, the sun setting behind us. If every day was like this (or even just this warm) we'd be ...
Earthquakes and Art Deco
... don't like wine so I drank them and ended up very sloshed and not feeling too good- never again.
The next day we left Napier after popping into the British Car Museum which is really a rather large private collection and I mean large as he has over 360 British cars some piled on top of each other. It was really lovely in a ramshackle way with old British cars doing what they do best, rusting and leaking oil. After this we drove over to the west coast to visit yet another car ...
The Rotorua Taupo Napier Blog!
... Rotorua. We had spent a weekend here back in early May and decided it was worth a couple more days. Unfortunately it rained buckets for three of the four days we spent there; fortunately we chose a hostel that has geothermal heating so being forced to stay indoors, relax, and enjoy the hot spa pool was no difficulty.
The day we left Rotorua was sunny and we took the opportunity to take in the views and ...
Other places to stay in Hastings
Hawthorne House1420 Railway Road South, Hastings | B&Bfrom $232
Cardoness Lodge2543, roys hill road, s.h. 50, Hastings | B&Bfrom $252


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Q&A | The Truth About Pink Slime
Deborah Blum, Pulitzer Prize-winning science writer and professor of journalism at the University of Wisconsin-Madison gives us a break down on the beef byproduct known as pink slime.
Last week, New York City education officials pledged to make sure so-called pink slime is out of school lunches by September. Today, the company that makes pink slime has suspended operations at three of four plants where the ingredient is made, saying they'll work to address recent public concern about the product.
What is exactly is pink slime?
Pink slime is sort of a term that was coined by a U.S. Department of Agriculture scientist who really hated this stuff. The official name is fine, leanly textured beef, and it's kind of scraps. … it's just these tiny little bits and pieces of scrap meat that don't fit in the official cuts. And it's spun off, the fats removed, and you have this kind of … fine ooze of tiny, tiny bits of meat. That is then put through a tube and puffed with ammonia. There's like a puff of ammonia gas. And the ammonia is there … and that kills bacteria. … . …"
How widespread is its use? Is it just in beef?
The astonishing thing when you look at it: it's in cereal, it's in chocolate, it's in bread. It's a widely used technique to kill bacteria because in the end I think our food companies have decided that a little ammonia is not as bad as a lot of food poisoning.
Is pink slime unhealthy?
Part of it is that the company, Beef Products, Inc., that just halted production in a number of factories, made a real strong pitch to the USDA to not mention this was in beef. … When people started realizing that the government and the company had kind of been complicit in hiding this, then I think you got this huge reaction tied to the fact you were talking about ooze. … Health wise, you know, it's not that bad.
Are there unintended consequences of removing pink slime?
There's some research that shows that [pink slime] … is slightly less nutritious than regular beef because there's more insoluble fiber in it. I am not an expert on what beef and soluble fiber is – I take that to be finely textured gristle. … So there's some chance you're not getting quite as much meat nutrition. … The regular ground beef is going to be higher in fat because … you were getting a lower fat product.


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From MAMORU OSHII, the world-acclaimed director of Ghost in the Shell comes an award-winning story of an exciting but endless war with heroes too young to understand the meaning of their battles. A group of eternally young fighter pilots known as Kildren experience the sudden loss of innocence as they battle the enemy in astonishing dogfights above the clouds. With his only childhood memory consisting of intense flight training, the fearless teenage pilot Yuichi's dogfights coexist with his struggle to find his missing past. When his beautiful, young female commander Suito is reluctant to discuss the fate of the pilot that Yuichi is replacing - or the strangely perfect condition of that pilot's former aircraft - Yuichi's curiosity becomes heightened.
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The film starts out with a young adults as an experienced fighter pilot. We later find out they are "Kildren" and stay young forever. Read morePublished 2 months ago by The Movie Guy
Great scenic air scenes and battles. However the overall plot and characters majorly lacked depth. It was a very melancholy undertone throughout the entire movie. Read morePublished 5 months ago by Jeffery Martinez
This is sub-titled in English; nowhere in the information on the Amazon web site or on my Roku display was this mentioned, no way to know until you've already paid for it. Read morePublished 6 months ago by Eric jacobson
an exceptional animation and movie. should have run an hour longer.Published 6 months ago by James Burr Jr
Let me just state right up front, not only is this my favorite movie but this is my personal pick for the best motion picture of the 2000s. Why? Read morePublished 7 months ago by Daniel Smith


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HELL - If you don't think there is a HELL!!! THINK AGAIN!!
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What point would you see in god creating humans if he knew so many would end up in hell then?
Anonymous Coward 35814087
First of all
, when God (YHWH) made Adam, He made him good. Adam had the freedom to choose to obey or disobey God. Adam is the one who rebelled. God did not make him rebel and God is not responsible for Adam's rebellion. It would be like a parent having a child knowing that the child would eventually disobey the parent. Does this mean that the parent is responsible for the child's rebellion when it occurs because the parent knew it would happen? Of course not. Furthermore, if the parent has more children, does he/she not know that some children may very well turn out good and others bad? Should the parents then not have children because some of them might turn out bad? The skeptic, if he is consistent, would urge parents not to have any children at all lest some of them turn out bad.
The skeptic might say, "But God knows for a fact who will be bad and good. Why allow the people going to hell to be born in the first place?" But, if this is the case and if God arranged it that no "bad" people were born, then we would all go to hell. You see, Jesus is the only way to be forgiven of our sins. His sacrifice on the cross was necessary in order to make it possible for us to be saved because everyone, "good" and "bad" has sinned. If there were no "bad" people born, then there wouldn't be any "bad" people around who would have sent Jesus to the cross. If that never happened, then we wouldn't be saved from our sins because Jesus would never have been unjustly condemned and His sacrifice would never have happened.
if someone says that it is wrong for God to allow someone to be born and who will go to hell, then would he rather have God remove our freedom to rebel against Him so that no one can be blamed for sin? If the critic says he only wants those people born who go to heaven, then how are they truly free and how would that fulfill the ultimate plan of God to sacrifice His Son for the redemption of mankind?
God could have reasons for sending people to hell that we cannot understand.
God is just and always does what is right. Therefore, sending people to hell is the right thing to do, especially when we understand that God is eternally holy and those who sin against God incur an infinite offense because the infinite God is the one who is offended.
Finally, the Bible simply tells us that people will go to hell. They go there because they are not covered by the sacrifice of Christ. Whether they are created or not does not affect the fact that sinners must be punished; otherwise, the holiness and righteousness of God mean nothing.
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NASA About To Make An'Amazing' Announcement About Pluto
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Scientists Finally Prove That Life After Death Exists
Native Americans Now Have Full Legalization of Marijuana On Reservation Lands
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How did these three inmates beat three Harvard students in a debate?
Underground City Of Giants Discovered In The Grand Canyon
Behold a Pale Gun Confiscation Agenda
Electromagnetic Pulse: One Day We Will Wake Up In An America Without Electricity And Society Will Totally Break Down
Obama Preparing More Executive Actions on Gun Control
Matt Drudge Drops Bombshell Warning in Surprise Interview — "I had a Supreme Court Justice say to me it's over"
Aliens Exist: Here Is The PROOF
Moon Landing A Hoax? Here's 10 Reasons Why
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WATCH: Fire ants form life rafts out of their own bodies in order to survive historic flooding in South Carolina.
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This Mind-Blowing Video About The Universe Is The Reason You Won't Sleep Tonight
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Like a salmon swimming upstream...
... day he is still a famous artist, because he was just that good. You need a solid week for the Sistine chapel alone, and it doesn't help you cant take pictures to remember it (because fun fact: a Japanese camera company owns the rights to the images in the chapel). I generally like to think that Bernini is my favorite artist, but holy crow is Michelangelo impressive. Think about it: the guy considered himself purely a sculptor, but upon threat of excommunication he learned how to ...
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We need a person skilled in MS Access to design a form that will collect 13 pieces of data of which six are variables used in four formulas to compose a report complete with bar graph. We use MS Access 2003.
The form will be used to collect information at a convention where a user will come up to our computer and type in the data to generate the report. After inputting the last piece of data on the form we would like to have a check box that would say: "Print Report Now? __Y or __N". After the report is printed, the screen would default back to last user and say: "Would you like to put in new data?" If yes, screen keeps user's info and allows overwrite of data. If the answer is no, the screen would reset for a new user. If a user comes back later to input new data, we would like to easily pull up the user's previous info for an overwrite.
We want all the data to be collected in the database throughout the show in order to easily identify which organizations and which individuals ...
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from £306 /night help Price for guests, Nights
from £306 /night help Price for guests, Nights
Estimated nightly price based on a weekly stay. Excludes fees (if applicable). Enter your dates to see the total cost.
Villa / 4 bedrooms / sleeps 8 Home 1374887
Availability Your dates are available
Villa / 4 bedrooms / sleeps 8
|Key Info
Gentle waves, white sandy beaches, lush greenery and pristine clear waters define this Pearl of the Andaman. Indulge your senses, tee off on the greens while your kids enjoy the activities. Enjoy true peace, calm and rejuvenation in the comfort of your own luxurious villa.
Surrounded by a lush tropical setting, LHV150 villa Phuket is a tranquil getaway within Laguna Phuket, Asia's finest destination resort. It is a holiday paradise spanning 1,000 acres of tropical park along an eight kilometre stretch of pristine beach at Bang Tao Bay, Phuket.
The villa is family friendly and ideal for family reunions. Facilities and activities include spas, restaurants, water sports, jungle tours, golf and Phuket's best beaches. The villa has convenient access to Phuket's best attractions.
Whether you are travelling with friends or holidaying with family, LHV150 Phuket offers ample opportunities for fun and relaxation.
|Sleeps up to 8, 4 bedrooms
|Will consider
|Long term lets (over 1 month)
|Family friendly
|Great for children of all ages
|No pets allowed, No smoking at this property
Features and Facilities
|Jacuzzi or hot tub
|Private outdoor pool (unheated)
|Air conditioning, TV, Safe, Satellite TV, Wi-Fi available
|Kettle, Toaster, Iron, Hair dryer
|Clothes dryer, Dishwasher, Cooker, Microwave, Fridge, Freezer, Washing machine
|4 bedrooms, 3 bathrooms of which 2 Family bathrooms and 1 En suites
|1 Sofa beds, Double beds (3), Single beds (2), Dining seats for 8, Lounge seats for 8
|Linen provided, Towels provided, High chair
|Private outdoor pool (unheated), Balcony or terrace, Private garden
|Parking, Not suitable for wheelchair users
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Calendar last updated:07 Oct 2015
Based in Thailand
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Coast Lori lee lace maxi dress
Item No.58607_01318306
Item No.58607_01318306
A truly stunning maxi gown perfect for any extra special occasion. The Lori Lee Lace Maxi Dress features lace bodice lined with a soft slip for a demure and feminine allure. The waist is cinched with a lustrous waist tie embellished with faux gems for an opulent aesthetic. The back of the dress features a graceful keyhole detail and the skirt is fully lined for party perfect movement. Dress length from underarm to hem is 128cm/50.5 inches. Height of model shown: 5ft 9inches/175cm. Model wears: UK size 10.
UK Home Delivery Free (UK orders over £30) or £3.49
Delivered within 4 working days
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Subject to exceptions, Debenhams is happy to exchange or refund your purchase within 28 days of delivery. Please check here for more details on our returns policy and exceptions.


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For example, pre-ordering from Amazon will earn you Batman (for use in a two-on-two arena battle mode) and an exclusive in-game item, the Amazonian Gauntlets (get it?). Walmart pre-orders also come with the arena mode Batman character, plus Joker's Trick Pistol. There are unique DC Comics-inspired armaments available from eight different retailers in all.
In addition, pre-ordering the collector's edition will entitle you to a Batman figurine and two more weapons. You can browse all the available options at SOE's pre-order site. And if you can't wait for your pre-ordered copy to arrive, sign up for the open beta now.
Buy from $270
- Key specs
- Reviews • 18
- Prices
- Discussions
- Game format Optical disc, Downloadable
- Online features Multiplayer, Voice chat, Video chat, Store, Browser
- Drive capacity 250 GB
- Controller type Wired, Wireless
- Motion controls Accelerometer, Gyroscopic
- Video outputs HDMI (v1.3), RCA / composite
- Released 2012-09-25


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You don't hear much about potassium—but you should. It's important for muscle strength, nerve functioning, and a healthy cardiovascular system, says Janet Brill, Ph.D., R.D., a Philadelphia-based nutritionist. The nutrient's in lots of delicious foods (think: melon, avocados, bananas, and white beans). But even if you get the recommended 4,700 mg per day, you still might have a deficiency. Why? The more sodium you consume, the more potassium your body excretes, says Brill. Tip-offs that you need more can be hard to notice, but if you experience any of these signs and can't figure out what's behind them, check in with your doc to have your potassium levels tested.
1 / 9
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Copyright © 2015 Rodale Inc.


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multiple mines in multiple countries moving alot of earth-this is the mining buisness after all, so it's inevitable to have mother nature or mechanical issues or,labor, or govt's or ,human error or p,m prices or dollar or ,market conditions or or or or cause some sort of flucuation- so big deal mother nature throws a ground condition exaggerated by some human error and bolivia has a power outage in 3rd and some lower grade ,all these issues are short term and fixable , add some christmas inventory overhang which can be sold for more next quarter- all short term fixable and just the mining buisness, you then balance them off against against success of rochestor wth its increases and huge kensinton contribution and we still produced record 18million oz's silver and next year 18/19.5 and 250,000oz gold -
yep...edmund...all of the above...
more fun to be doing it...than to be invested in it or managing it...for many...anyway...
a move to Chicago says a lot about the top folks...
so does continued under performing on expectations...
good luck and skill...I hope they do well for their employees and
for the communities within which they operate...and continue to
do well for you, stahlz, vicaritas, and the rest of the real investors
and long speculators...and if you can play the cycles well,
and try to be truthful about that, you too...
Thanks Geo
I was on the phone with Edmund twice this morning .
I dropped my ask price down to 20 cents on the 24 Calls and they took them as fast as I put it in ..
40 bucks is 40 bucks as Edmund said .
I drank my 1st Johnny Walker "BLUE "last evening .at someone's house.
They wanted to crack open a bottle so I obliged .
Exceptionally smooth .
I drank it out of a snifter which was more than a shot and straight up
Not worth the money for me to buy a bottle but I felt compelled to taste a bit as it was offered graciously from somebody who can certainly afford it .
Then we went to dinner and I dropped it back to "Black" .on the rocks .which my palette had no problem accepting .as they were buying us dinner too .
I didn't even drink the Gold which is actually a good buy @only a few bucks more than black .
Again they can afford it but I didn't want to come up as a pig .
It just so happens I was bought my first drink of Johnny Gold by an orthodontist when It first came out but I had just met him at this bar where we were having an after dinner drink.and we got talking about Johnny Walker which he also likes to drink and he insisted I try it.
That was years ago and at that time I was not even aware they started making Gold .
When I learned he was an Orthodontist I took him up on his offer , figuring he could afford it .
I wasn't in Rome that night but I did as the Roman's supposedly do
.Never afraid to learn !
nice mundane spin. scorecard = 2 buck stock. management fails again.


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Massachusetts approves 2-month tax amnesty program - 0 Comments
BOSTON — A tax amnesty sponsored by House Republicans could help Massachusetts collect millions in overdue tax revenues.
The program, signed into law by Gov. Deval Patrick, is available to taxpayers who failed to file a timely tax return or underreported their income.
Taxpayers who failed to pay any outstanding tax liability or failed to pay the proper amount on a required estimated tax payment are also eligible.
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September 2011
Layoffs Watch '11: Deutsche Bank Has No Idea What You're Talking About
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Goldman Takes A Dark View (WSJ) In a 54-page report sent to hundreds of Goldman's […]


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Use of robotics in oncologic surgery is increasing; however, reports of safety and efficacy are from highly experienced surgeons and centers. We performed a population-based analysis to compare laparoscopic hysterectomy and robotic hysterectomy for endometrial cancer.
The Perspective database was used to identify women who underwent a minimally invasive hysterectomy for endometrial cancer from 2008 to 2010. Morbidity, mortality, and cost were evaluated using multivariable logistic and linear regression models.
We identified 2,464 women, including 1,027 (41.7%) who underwent laparoscopic hysterectomy and 1,437 (58.3%) who underwent robotic hysterectomy. Women treated at larger hospitals, nonteaching hospitals, and centers outside of the northeast were more likely to undergo a robotic hysterectomy procedure, whereas black women, those without insurance, and women in rural areas were less likely to undergo a robotic hysterectomy procedure (P < .05 for all). The overall complication rate was 9.8% for laparoscopic hysterectomy versus 8.1% for robotic hysterectomy (P = .13). The adjusted odds ratio (OR) for any morbidity for robotic hysterectomy was 0.76 (95% CI, 0.56 to 1.03). After adjusting for patient, surgeon, and hospital characteristics, there were no significant differences in the rates of intraoperative complications (OR, 0.68; 95% CI, 0.42 to 1.08), surgical site complications (OR, 1.49; 95% CI, 0.81 to 2.73), medical complications (OR, 0.64; 95% CI, 0.40 to 1.01), or prolonged hospitalization (OR, 0.85; 95% CI, 0.64 to 1.14) between the procedures. The mean cost for robotic hysterectomy was $10,618 versus $8,996 for laparoscopic hysterectomy (P < .001). In a multivariable model, robotic hysterectomy was significantly more costly ($1,291; 95% CI, $985 to $1,597).
Despite claims of decreased complications with robotic hysterectomy, we found similar morbidity but increased cost compared with laparoscopic hysterectomy. Comparative long-term efficacy data are needed to justify its widespread use.
Hysterectomy is the standard of care for endometrial cancer. The procedure is traditionally performed through a laparotomy and has been associated with substantial perioperative morbidity. In the 1990s, laparoscopic hysterectomy for endometrial cancer was introduced. Compared with open hysterectomy, the laparoscopic procedure is associated with lower morbidity and shorter hospital stays and has become the preferred treatment option for many surgeons.1
In the last decade, robotic surgery has emerged as an alternative minimally invasive surgical strategy for a number of cancers. Although initially used for radical prostatectomy, robotically assisted surgery has now been adopted for a wide range of procedures including hysterectomy.2 Robotic assistance affords many advantages including three-dimensional visualization, increased freedom of instrument movement, and enhanced ergonomics and surgeon comfort.2,3
Despite the potential benefits of robotic hysterectomy, studies comparing it with laparoscopic hysterectomy have been small in size, nonrandomized, and limited to highly experienced surgeons and centers.4–11 In one of the largest studies to date that included 103 robotic hysterectomies, median blood loss and operative times were lower for robotic compared with laparoscopic hysterectomy.5 Although these studies are informative and demonstrate the feasibility of the procedure, its safety and efficacy in the community may be far different.
The use of robotic surgery is increasing.2 Although a variety of factors influence the uptake of new technologies, marketing often plays a significant role.12,13 Previous work has shown that many new surgical technologies are adopted when only minimal data are available.12,14–16 This is problematic not only because these technologies may not improve clinical outcomes, but also because they are frequently associated with increased cost.3,17,18 The goal of our analysis was to compare the perioperative morbidity, resource utilization, and cost of laparoscopic and robotic hysterectomy in a large cohort of women with endometrial cancer treated throughout the United States.
The Perspective database (Premier, Charlotte, NC) was used. Perspective is a voluntary, fee-supported database originally developed to measure resource utilization and quality of care (Appendix, online only). Perspective samples more than 500 acute care hospitals throughout the United States that contribute data on inpatient admissions.19 In addition to demographics, disease characteristics, and procedures, the database collects information on all billed services. The Perspective database is validated and has been used in a number of outcomes studies.20,21 In 2006, Perspective recorded approximately 5.5 million hospital discharges, which represent approximately 15% of nationwide hospitalizations.19,21
Our analysis included women who underwent a minimally invasive hysterectomy for endometrial cancer (International Classification of Diseases, Ninth Revision [ICD-9] codes 182.0 to 182.8) between October 2008 and March 2010. Patients were stratified into the following two groups based on the type of hysterectomy performed: laparoscopic (ICD-9 code 68.41 or 68.51) or robotic (ICD-9 code 17.42 or 17.44). Women who underwent either a laparoscopically assisted vaginal hysterectomy (ICD-9 code 68.51) or a total laparoscopic hysterectomy (ICD-9 code 68.51) were included. Patients who had ICD-9 codes for both a robotically assisted and a laparoscopic procedure were included in the robotic hysterectomy cohort. Performance of lymphadenectomy was noted for each patient and defined through identification of any ICD-9 code for nodal sampling.
Demographic data analyzed included age (< v ≥ 60 years of age), race (white, black, or other), marital status (married, single, or unknown), and insurance status (Medicare, Medicaid, commercial, self-pay, or unknown). The hospitals in which patients were treated were characterized based on location (urban or rural), region of the country (northeast, midwest, west, or south), size (< 400, 400 to 600, and > 600 beds), and teaching status (teaching or nonteaching). Risk adjustment for comorbid conditions was performed using the Charlson comorbidity index.22 The ICD-9 coding to define the Charlson index as reported by Deyo et al23 was used.
For each surgeon and hospital, we determined the total number of laparoscopic and robotic hysterectomies performed during the study period. Because not all physicians and hospitals contributed data for the entire study period, we calculated annualized procedure volumes. The annualized procedure volume was estimated by dividing the total number of patients who underwent a procedure by the number of years a given surgeon or hospital contributed at least one procedure. The volumes were then divided to create three approximately equal tertiles of surgeon and hospital volume (low, intermediate, and high).24,25 Separate volume estimates were determined for laparoscopic and robotic procedures.
The primary outcome of the study was perioperative morbidity. Secondary outcomes included individual complications, rates of transfusion and reoperation, mortality, and resource utilization. Perioperative morbidity was classified into the following categories: intraoperative complications (bladder injury, ureteral injury, intestinal injury, vascular injury, and other operative injury), surgical site complications (wound complications, abscess, hemorrhage, and bowel obstruction), and medical complications (venous thromboembolism, myocardial infarction, cardiopulmonary arrest, acute renal failure, respiratory failure, cerebrovascular accident, bacteremia/sepsis, shock, and pneumonia). A composite score of overall morbidity was determined based on the occurrence of any one of the complications. For each cohort, we calculated the rates of transfusion and reoperation. Rates of readmission were calculated by determining the number of patients who were readmitted to the same facility within 60 days of the initial surgery for any of the complications previously described.
We also examined a number of process measures and utilization metrics. Patients who required more than 2 days of inpatient care after the procedure were considered to have a prolonged hospitalization. The Perspective database includes an itemized, data-stamped log of all items that are billed to a patient, including drugs, laboratory and radiologic tests, and therapeutic services. Within the Perspectives database, approximately three quarters of hospitals submit direct cost data taken from internal accounting systems. The remaining institutions provide estimates based on Medicare cost to charge ratios.19,21,26 Cost data from the Perspective database have been used in a number of outcomes studies.19,21,26 Cost data from the index admission were examined. The discharge status of each patient was noted. Women who were transferred from an acute care hospital to a skilled nursing facility, nursing home, or an acute or subacute rehabilitation center were considered to have a nonroutine discharge. Readmission for any of the morbidities described earlier was also examined. Perioperative mortality was defined as death during the primary hospitalization.
Frequency distributions between categorical variables were compared using χ2 tests, whereas continuous variables were compared with one-way analysis of variance. The association between the outcomes of interest and the type of procedure performed was assessed using multivariable logistic regression models that included patient, surgeon, and hospital characteristics. Results are reported with odds ratios (ORs) and 95% CIs. Cost estimates more than three standard deviations from the mean were removed, and the remaining cost data were assessed using linear regression models including the variables described earlier. The analysis of the secondary end points was exploratory, and the 95% CIs for these estimates are not adjusted for multiplicity. All analyses were performed with STATA version 11.0 (STATA, College Station, TX) and SAS version 9.2 (SAS Institute, Cary, NC). All statistical tests were two-sided.
A total of 2,464 women who underwent minimally invasive hysterectomy for endometrial cancer were identified. The cohort included 1,027 patients (41.7%) who had a laparoscopic hysterectomy and 1,437 patients (58.3%) who underwent a robotic procedure. The clinical and demographic characteristics of the cohort are listed in Table 1.
Use of robotic surgery increased with time (Fig 1). In October 2008, 46.2% of the minimally invasive hysterectomies for endometrial cancer were robotic. This increased to 58.2% in June 2009 and to 61.1% in March 2010. In a multivariable model, single women (OR, 1.27; 95% CI, 1.02 to 1.58), women treated at large hospitals (OR, 2.89; 95% CI, 2.21 to 3.78), women treated at nonteaching hospitals (OR, 1.28; 95% CI, 1.04 to 1.59), and women operated on at centers outside the northeast were more likely to undergo a robotic procedure (Table 2). Black women (OR, 0.46; 95% CI, 0.32 to 0.67), women without insurance (OR, 0.56; 95% CI, 0.34 to 0.94), and women residing in rural areas (OR, 0.50; 95% CI, 0.32 to 0.94) were less likely to undergo robotic hysterectomy.
Rates of intraoperative complications (4.0% for laparoscopic v 3.0% for robotic; P = .18) and surgical site complications (1.8% for laparoscopic v 2.9% for robotic; P = .08) were similar for the two procedures, whereas medical complications (4.9% for laparoscopic v 2.9% for robotic; P = .01) were more common among women who underwent laparoscopic hysterectomy (Table 3). Prolonged length of stay (> 2 days) was noted in 11.4% of women who underwent laparoscopy compared with 9.9% of women who had a robotic procedure (P = .23). Although reoperation was more common in patients who underwent laparoscopy versus robotic hysterectomy (0.8% v 0.2%, respectively; P = .04), there were no differences in transfusion requirements, readmission, or rates of conversion to open laparotomy (P > .05 for all).
After adjusting for patient, surgeon, and hospital characteristics, there were no statistically significant differences in the rates of intraoperative complications (OR, 0.68; 95% CI, 0.42 to 1.08), surgical site complications (OR, 1.49; 95% CI, 0.81 to 2.73), medical complications (OR, 0.64; 95% CI, 0.40 to 1.01), or prolonged hospitalization (OR, 0.85; 95% CI, 0.64 to 1.14) between the cohorts (Table 4). The overall complication rate was 9.8% in women who underwent laparoscopic hysterectomy compared with 8.1% for women who underwent a robotic procedure (P = .13). The adjusted OR for any morbidity for robotic compared with laparoscopic hysterectomy was 0.76 (95% CI, 0.56 to 1.03). Perioperative mortality was noted in 0.2% of laparoscopic and 0.1% of robotic surgeries (P = .74).
The mean cost for laparoscopic hysterectomy was $8,996 compared with $10,618 for robotic hysterectomy (P < .001; Table 3). In a multivariable model adjusted for patient characteristics, surgeon factors, and hospital characteristics, the cost for robotic surgery was $1,291 (95% CI, $985 to $1,597) higher than laparoscopic hysterectomy (Table 5). Hospital costs were also greater in single women, patients treated at teaching hospital, patients who underwent lymphadenectomy, and patients with the most comorbidities (P < .05 for all). Hospital costs were lower for patients treated by high-volume surgeons and patients operated on at intermediate-volume centers (P < .05 for both). These results did not change significantly when the cost variable was log-transformed. Separate models of cost for robotic and laparoscopic hysterectomy are also presented in Table 5. To examine whether the cost of robotic hysterectomy decreased with surgical volume, we developed separate models for low- and high-volume surgeons. For low-volume surgeons, the cost of robotic hysterectomy was $1,488 (95% CI, $938 to $2,038) higher than for a laparoscopic procedure; for high-volume surgeons, robotic hysterectomy was $818 (95% CI, $239 to $1,397) more costly than laparoscopy. In our cohort, if all 1,680 minimally invasive hysterectomies performed in 2009 were done robotically, direct hospital costs would have been increased by more than $2,000,000.
Our findings suggest that robotic hysterectomy offers little short-term benefit over a laparoscopic procedure for women with endometrial cancer. Perioperative morbidity was similar for the two procedures, whereas resource utilization is significantly higher for robotic hysterectomy. Robotic hysterectomy is associated with substantially higher direct hospital costs.
To date, there have been no randomized trials comparing laparoscopic and robotic hysterectomy for endometrial cancer. A recent systematic review of uncontrolled case series of robotic hysterectomy for endometrial cancer that identified 589 procedures found no differences in intraoperative or postoperative complications rates, transfusion requirements, rates of conversion to laparotomy, operative times, or length of stay between women who underwent laparoscopy and women who had a robotically assisted hysterectomy. However, compared with laparoscopy, robotic hysterectomy was associated with clinically insignificant lower blood loss (mean, 182 v 92 mL, respectively). Lymph node yield, a measure of surgical quality, was similar for the two modalities.27 Most of the reports included in this review were from surgeons and centers that possess significant expertise in robotic surgery.4–11 In our population-based analysis, there were no significant differences in the morbidity of robotic and laparoscopic surgery after adjusting for patient, physician, and systems characteristics.
A major concern surrounding the use of robotic surgery is the economic viability of the technology. A single-institution series of 110 patients with endometrial cancer noted that laparoscopic and robotic surgery had similar costs and that both modalities were significantly less costly than open hysterectomy.7 In contrast, a decision model found that laparoscopic hysterectomy was the least expensive treatment from both a hospital and societal perspective.3 In addition to the price of the robot, which ranges from $1 million to $2.25 million, an annual service contract of $140,000 is required, and disposable instruments cost $1,500 to $2,000 per case.13,28 Modeling studies of endometrial cancer have suggested that even if the purchase price of the robot is excluded and the price of disposable instruments is substantially reduced, laparoscopic hysterectomy remains the most economically advantageous.3 A recent analysis of 20 types of robotically assisted procedures noted that the addition of the robot added on average $1,600, or 6% of the total procedure cost.17 In our multivariable model, use of the robot increased direct hospital costs by nearly $1,300, more than 14% of the total hospital cost of a laparoscopic procedure.
Our data are remarkable in that by 2010, more than 60% of all minimally invasive hysterectomies for endometrial cancer were performed robotically despite the limited available data. A number of factors including perceptions, characteristics of early users, and contextual factors have been shown to drive innovation of a new technology.12 For surgical innovations, several studies have demonstrated that the introduction of a new technique often increases aggregate use of a surgical procedure.17,28–30 The introduction of robotic prostatectomy in the United States between 2005 and 2008 was associated with a 60% increase in the number of prostatectomies performed despite a decreasing incidence of prostate cancer.17 Although technologic innovation cannot follow the same developmental process as that of new drugs, there is increasing recognition that more formal regulation is needed.31 The Balliol Collaboration's Innovation, Development, Exploration, Assessment, and Long-Term Study (IDEAL) model proposed that new surgical techniques should evolve from a concept through safety exploration followed by randomized trials before widespread implementation.14,16,31,32 The US Food and Drug Administration is currently revising its regulatory process for medical devices after substantial public criticism.33
We identified a number of disparities in the use of robotic hysterectomy as the technology diffused into practice. Black women were 54% less likely than white women to undergo a robotic procedure, whereas uninsured patients were 44% less likely to have a robotic hysterectomy than patients with commercial insurance. The hospital setting in which patients received care also had a strong impact on the allocation of care. Women treated at large facilities and at nonteaching hospitals were more likely to undergo robotic surgery, whereas women treated at rural hospitals were 50% less likely to undergo a robotic hysterectomy. These disparities mirror those seen with the introduction of laparoscopy for a number of different procedures.34–36
We recognize several important limitations in our study. Because the primary purpose of claims data is for billing, complications are often under-reported. To minimize this bias, we focused our analysis on major perioperative complications that are likely to generate a claim. Any under-reporting of complications would have been equally likely in both cohorts. Although the Perspective database contains a sample of women from throughout the United States, our findings may not be generalizable to the entire US health care system. Perspective lacks data on tumor characteristics such as histology, grade, stage, and depth of invasion that impact treatment. Although we included only patients who underwent minimally invasive surgery, and the indications are the same for both procedures, some degree of procedure selection likely occurred based on tumor characteristics. We cannot exclude the possibility that some patients' procedures were misclassified. However, even during the early months of the study, the relative number of patients who underwent robotic surgery was high, suggesting that ICD-9 coding for robotic surgery was well recognized. With any new procedure, a learning curve exists for physicians, and this is certainly true for robotic surgery.11 We attempted to account for this by including surgical volume as a covariate in our analysis, but we recognize that costs may be lower as surgeons become more familiar with the technology and operative times decrease. Our costing data are based on a nationwide sample of directly reported hospital costs or estimates. Certainly wide variations in cost exist based on whether acquisition and maintenance costs are included and whether costs of disposable instruments are included; however, we feel that, if anything, our costs are likely to underestimate the true costs. A number of factors, including lymphadenectomy, which was more common in the robotic hysterectomy group, also had a strong influence on cost. Finally, it should be recognized that both procedures were associated with low overall morbidity, limiting our power to detect statistically significant differences between groups. Although there were no statistically significant differences in morbidity, there was a trend toward fewer medical complications in the robotic hysterectomy group.
Our findings raise questions as to the role of robotic surgery in the treatment of endometrial cancer. Robotic technology initially gained widespread utilization in urology.2 Because laparoscopic prostatectomy is technically demanding and not routinely performed, robotics introduced a minimally invasive surgical option for prostatectomy.2 In contrast, laparoscopic hysterectomy is well described, technically feasible, and now taught in most training programs.1 However, despite the availability of laparoscopic hysterectomy, a 2008 survey demonstrated that only 8% of gynecologic oncologists used the procedure in more than 50% of their patients.37 Even though laparoscopy is less costly, surgeon preferences for robotics may allow some women to undergo a minimally invasive procedure who may otherwise have undergone laparotomy. Proponents of robotic hysterectomy also argue that robotic capabilities allow surgeons to perform more technically challenging procedures without resorting to laparotomy.3,27 Although difficult to measure, this may be an important advantage of robotics. Finally, further data are needed to compare the oncologic outcomes of robotic and laparoscopic hysterectomy and to compare quality of life after the procedures.
Our study demonstrates that both robotic hysterectomy and laparoscopic hysterectomy are well tolerated and associated with similar morbidity profiles. Despite the rapid uptake of robotic hysterectomy, there seems to be little short-term benefit for the procedure. Compared with laparoscopic hysterectomy, robotic procedures are associated with substantially greater direct hospital costs. Our findings highlight the potential pitfalls of the rapid uptake of new technology before the availability of rigorous data to demonstrate efficacy and cost effectiveness. Defining the comparative effectiveness for new technologies and surgical approaches is necessary before rapid dissemination.
The Perspective database (Premier, Charlotte, NC; http://www.premierinc.com) is a voluntary, fee-supported database originally developed to measure resource utilization and quality of care. The Perspective database is the largest inpatient drug utilization database in the United States. Perspective samples more than 500 acute care hospitals throughout the United States that contribute data on inpatient hospital admissions. Perspective contains a representative sample of acute care hospitals throughout the United States. Participating hospitals are drawn from all regions of the United States. Similar to the makeup of hospitals in general, the hospitals sampled by Perspective are predominately midsized, nonteaching facilities more frequently found in metropolitan areas. There is a larger representation of hospitals from the southern United States. All discharges from a given hospital are recorded in the Perspective database. We used data on patients treated from the last quarter of 2008 through the first quarter of 2010.
The Perspective database contains clinical and demographic information and International Classification of Diseases, Ninth Revision, codes for all primary and secondary diagnoses. In addition, Perspective collects data on all billed services. The Perspective database contains an itemized log all of all services charged to a patient including drugs and medications, laboratory, radiologic, and other diagnostic tests, and therapeutic services. Each participating institution submits electronic updates on a quarterly basis. The data are audited regularly to ensure quality and integrity.
All data are entered by trained hospital-level data abstractors. The data are entered into an electronic decision support system and then extracted by Premier via a secure site. On receiving data from participating hospitals, Premier undertakes an extensive data validation and correction process that includes more than 95 quality assurance checks. Data are imported into Premier's engine, where the mapping, error correcting, and quality analysis take place.
Perspectives records hospital costs for each patient visit. Within the Perspectives database, approximately three quarters of hospitals submit direct cost data taken from internal accounting systems. The remaining institutions provide estimates based on Medicare cost to charge ratios. The costing data from Perspectives has been validated in a number of studies that have examined costs and trends in resource utilization.
The Perspective database contains more than 45 million inpatient discharges. To place this into context, in 2006 Perspective recorded approximately 5.5 million hospital discharges, which represent approximately 15% of nationwide hospitalizations. Over the last decade, the Perspective database has been extensively validated and used for a number of studies that have examined resource utilization, quality, and outcomes.
See accompanying editorial on page 767
Supported by Grant No. R01 CA134964 from the National Cancer Institute, Bethesda, MD (D.L.H.).
Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
Although all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: William M. Burke, Intuitive Surgical Research Funding: None Expert Testimony: None Other Remuneration: None
Conception and design: Jason D. Wright, William M. Burke,Dawn L. Hershman
Financial support: Jason D. Wright
Administrative support: Jason D. Wright
Collection and assembly of data: Jason D. Wright, Abigail S. Charles, Dawn L. Hershman
Data analysis and interpretation: All authors
Manuscript writing: All authors
Final approval of manuscript: All authors
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's Canada Institute for Scientific and Technical Information in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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In-depth info by local experts for job seekers and workers.
How to tap the hidden job market (hint: network)
You've been looking for a job for what seems like forever. And here we are looking at Labor Day weekend.
But this is good news, because many companies step up their hiring in September. Managers come back after summer vacations and realize that they need to get people in place before the end of the year, or that they need to allocate staffing budgets before they run out come December. Everyone sits up and gets busy after Labor Day.
In theory, you've been networking, interviewing and researching all summer long so you will be well-positioned to snap up one of these juicy new openings.
What's that, you say? You've been on vacation? All the more reason for you to get going.
You've probably read a million job-hunting tips, so I am going to limit my suggestions to only one. (Seriously.) And that is: Identify and go after job openings before they are advertised or posted.
It's often called the "hidden job market," and learning how to tap it is the best thing you can ever do for your career. It can be summed up in one word: network.
You've heard this one before, too; but yes, it really is "who you know." And the more people you know, the greater your chance of hearing about, or being referred to, a job. Here's your post-Labor Day game plan in a nutshell:
- Identify companies where you'd like to work.
- Learn as much as you can about these companies; use Google News Alerts to keep up to date on when they open a new branch, get new funding or merge with another company.
- Devise ways of meeting people who work at those companies; join professional or trade associations, attend conferences, ask members of your existing network for referrals.
- Get to know those people; tell them you are interested in working for their company, and why.
- Keep in touch with them. Be the person they think of first when they have a position to fill.
This job-hunting system will serve you your whole career. Bonus tip: You are allowed to contact potential employers directly, without a referral or an existing job posting. So be bold!
Work Life Blog | Topics: career change, job search, networking, self-promotionMore in
More from Work Life Blog
- October 8 - 1:00 AM Deciding to be a better decision-maker
- October 6 - 1:00 AM Remember your local library for career tools
- October 5 - 1:00 AM Want a promotion? Follow these 6 steps
- October 1 - 1:00 AM How to ask for a raise
- September 29 - 1:00 AM Taming the job-interview jitters
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- Twitter: @NWjobs
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Blog contributors
Karen Burns is the author of The Amazing Adventures of Working Girl, a career guide based on her 59 jobs over 40 years in 22 cities.
Randy Woods Writes about job-search tools, networking techniques and other tips to help you land your dream job.
Lisa Quast is a certified career coach, mentor, business consultant, former corporate executive and author based in the Seattle area.
Kristen Fife is a senior recruiter, career mentor, blogger and resume consultant.
Michelle Goodman is the author of "My So-Called Freelance Life" and "The Anti 9-to-5 Guide."
Matt Youngquist is the president of Career Horizons, a career counseling firm.
Natalie Singer is a Seattle writer, editor and small-business owner.


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Thirteen months after he was cut, DeAngelo Hall still can't believe he's not wearing an Oakland Raiders uniform.
So if the two-time Pro Bowl cornerback is unable to play for the Washington Redskins on Sunday in Oakland, the absence will pain him more than the sprained knee that sidelined him the past two games and in practice Wednesday.
"It was definitely a shocker," said Hall, whom the Raiders gave a seven-year, $70 million contract to leave Atlanta. "Coach [Tom] Cable made the statement that they had someone better behind me. I took a little offense to that. When I saw the schedule, I had this one circled, along with the Atlanta game."
Hall also is hampered by back spasms he suffered while standing on the sideline during Sunday's overtime loss to New Orleans. But he hopes to play against Oakland — not just to face his old team but also because of the Raiders' offensive style.
"Their receivers will do one thing, and that's run deep," he said. "I love to just get into a track meet. I'm faster than all of 'em. Even at 80 percent me, [I] can keep up with some of those guys. I feel like I can run straight ahead. It's the cutting that kind of bothers me, but these guys ain't doing a lot of cutting. They running full-speed right at you. Some of them run full-speed, [get] wide open and still can't catch."
On Wednesday, Cable called Hall "a very, very talented guy" and blamed his release on a failure to adjust to the Raiders' reliance on man-to-man coverage. Cable also noted that he wasn't the head coach when Hall signed.
Nnamdi Asomugha, the Raiders' Pro Bowl cornerback, criticized Hall's release when it happened and said he still believes his former partner wasn't given a chance to transition to Oakland's scheme.
"DeAngelo's a playmaker," he said. "He wants to be free to go out and make plays and do what he does best. When you come here, you have to understand that you're going to be in man-to-man [more than] 90 percent of the game. It was definitely something he wasn't used to. It took some adjusting for him, and he never really got that full chance to adjust to that change."
Hall defended his ability to play man-to-man coverage and said he wishes he hadn't been so eager to leave Atlanta. But he believes even the ugly experience with the Raiders ultimately was beneficial.
"I probably should have did my due diligence, but… I just ran to the first people that opened up their arms to me," he said.
The UFL boost
New kicker Graham Gano said playing in the United Football League helped him more than working out on his own to prepare for NFL tryouts.
"That was very beneficial for everybody that played in the league, to get some experience and get some game film out there and show the coaches you can play some ball," said Gano, who was 13-for-16 for Las Vegas.
Gano kicked a 33-yard field goal in overtime to win the UFL title game.