text:
White Paper
July 15, 2009
by Jeffrey S. Flier, MD
Dean of the Faculty of Medicine
Harvard Medical School, Harvard University
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1. Introduction
2. Diverse arenas relevant to financial COI should be examined and understood independently
3. Education and COI
4. Transparency, public disclosure and other operational issues
5. How to view industry in the context of COI at HMS
6. How will HMS address COI going forward?
7. A future academic agenda regarding COI in biomedicine
8. Conclusion
9. Footnotes
1. Introduction
Harvard Medical School educates physicians and scientists to assume leadership roles in society and to conduct research to improve human health. It should come as no surprise that the integrity of our faculty in the conduct of their clinical, research, and teaching missions is of paramount importance to the School. One potential challenge to our integrity arises from financial conflicts of interest, a topic that is receiving substantial attention in the press and in national oversight and legislative bodies. HMS is actively working to define the problem and address it responsibly, by conducting a thorough review of its Policy on Conflicts of Interest and Commitment. This policy has been in effect with periodic modifications since 1990.
However, what is sometimes seen as a single problem or issue is revealed upon further analysis to be a complex amalgam of different issues, each with distinct characteristics. Failure to take note of these complexities can result in discussions of conflict of interest topics that are less informative than they could be, sometimes diminishing rather than enhancing the public's understanding of the subject. With this in mind, I offer this statement as a starting point to frame some of the issues around financial conflict of interest for discussion within the HMS community and beyond.
Who are the HMS faculty and why might they want to interact with industry? The faculty of HMS are approximately 10,500 members employed by Harvard University or its affiliated academic health centers/institutes. Their goals are to pursue fulfilling careers by conducting innovative research and providing high quality medical education and patient care to benefit the sick and suffering. Our faculty represent an unparalleled source of knowledge and expertise that can be deployed to enhance therapeutic discovery and development. Collaboration with industry can be an important means to accomplish this, and many faculty desire to participate in that process. Despite the potential benefits, some believe that relationships between HMS faculty and industry represent a nearly insoluble problem. Those holding this view assert that such interactions can be so injurious to the public health and welfare as to warrant their prohibition and see many risks with few benefits. Others view these risks as limited and emphasize the benefits. Some go as far as to say that such interactions are required if HMS and its faculty are to have maximal opportunity to improve human health through the discovery, evaluation and eventual introduction and use of new drugs and devices. Although nearly all agree that both benefits and risks exist, the balance of the two is the subject of vigorous debate.
Risks do exist and must be managed. Some relationships among our institutions, our faculty and industry create issues that require scrutiny, analysis, institutional guidance, and, in specific cases, prohibition. These issues include both the risk of faculty diluting their effort and commitment to the school or to the institutes and hospitals that are their primary employers, and the risk that financial inducements could cause some faculty to breach accepted standards of professional conduct, reducing the public's confidence in the endeavors of HMS faculty as a whole.
A conflict of interest (COI), which for purposes of this discussion is defined as a situation in which there is a conflict between the private interests and the official responsibilities of a person in a position of trust (Merriam Webster Online), can present challenges to fulfilling one's duties impartially. Conflicts of interest of all kinds are widespread and inherent to the human experience. Moreover, most conflicts of interest, including financial conflicts, exist without unethical or improper acts resulting from them. One reason for this is that medicine and research have professional codes of ethics in place, and these are largely internalized and adhered to by most. At HMS, we have a proud history of unwavering commitment to these high professional standards of ethical conduct. In fact, our policies and practices that address scientific integrity and professional conflicts of interest have existed long before these topics have come under sharp scrutiny at other academic medical institutions.1 Nonetheless, as a leader in this area, we must continue to take these risks and potential for harm extremely seriously. We will periodically update and clarify our expectations for faculty behavior, as we are currently doing.
Our faculty in context. I have interacted with hundreds of physicians and scientists, as both a faculty member and academic leader, and have been extraordinarily impressed by the high ethical standards of my colleagues. Nonetheless, ethical failures do arise, as they do in all professions. Questionable or overtly unethical behavior on the part of our faculty appears historically to have been caused less by financial inducements than through other motivations, including competitiveness, hubris, sloppiness and, occasionally, antisocial behavior. In most cases, we manage deviations from accepted norms through prevailing social, professional and ethical codes of conduct, supplemented where necessary by institutional rules and, increasingly, by laws. Regarding our faculty, the question is not whether financial interests are appropriate, since such interests are ubiquitous in all professions, but what is the nature of the conflicts that arise from those interests. We should clarify the diverse contexts in which financial conflicts confront our faculty and institutions. The goal is to identify the harms that these conflicts might impose, so that we can promulgate appropriate responses based upon reasoned study and objective evidence. At the same time, we should seek to understand the real risk of harm that could arise as unintended consequences of institutional or legislative responses to COI.
2. Diverse arenas relevant to financial COI should be examined and understood independently.
There is a tendency to conflate disparate issues under the rubric of COI. I will first try to deconstruct some of the diverse issues that can appropriately be considered to fall within the sphere of financial COI.
Sponsored research and COI. Industry sponsorship of faculty research at HMS or the affiliated institutes and hospitals is an important element when considering the types of financial relationships that universities, academic medical centers and faculty may form with industry. In the past, it has proven useful to distinguish basic, laboratory-centered research from research involving human subjects, although the separation of these spheres sometimes blurs. The existing HMS Policy was initially drafted largely to address financial COI in sponsored research, rather than in education and clinical care.
Sponsored research agreements provide funds to support laboratory research when the research question is of interest to the faculty member as part of his or her academic program, and is also of interest to a company. Such sponsored research is conducted under an explicit written agreement developed between the company and the institution (HMS or one of its affiliates), with input from the faculty member. The HMS Statement on Research Sponsored by Industry demands and requires freedom for the faculty member to design and conduct his or her own research, and, perhaps most importantly, freedom to publish the results. HMS does not approve sponsored research agreements that allow a company to control or suppress the direction of the research or the data produced.
All sponsored research agreements are entered into by our institutions and HMS faculty with the primary goal of obtaining funding for ongoing academic research to pursue new knowledge, not because of the remote possibility of future financial gain from product royalties or other income streams. In the rare event that sponsored research does produce such revenue to the institution, the proceeds are typically divided among the institution, the investigators (PIs) and their labs by a distribution formula in place at each institution.
NIH funds the vast majority of our sponsored research, and non-profit foundations fund a much smaller but still significant fraction. Why should sponsorship of research by companies be desired, when NIH and other funding sources exist? Most faculty, even the best funded, have some ideas and projects that will not be funded by organizations like NIH, for a wide variety of reasons independent of the quality and importance of the proposed work. In this light, industry-sponsored research is another important means for faculty to support their research aspirations. Industry-sponsored research can also provide faculty access to unique reagents and tools possessed by the company and can create stimulating interactions with company scientists who may possess unique skills and knowledge. Interactions with companies may provide stimulating intellectual engagement with areas of biotech or pharmaceutical science and development that would otherwise not be available. Many faculty who have research interactions with industry believe that such interactions facilitate their ability to have a greater impact on the future health of their patients through discovery, which is an important motivation and professional benefit. Finally, Congress and the government through the Bayh Dole Act actually direct universities to have certain relations with industry in order that inventions that arise through federal funding benefit the public.
For the most part, there is broad support for industry-sponsored basic research agreements, although some have expressed concerns. Some propose that industry-sponsored research is less meritorious than research funded by NIH or foundations and might thereby dilute the quality of the faculty research effort. However, we normally allow such research decisions to be made by faculty, in full light of their research interests and career goals and aspirations. Others believe that the academy should only pursue scholarly research and that "applied research," or research with the goal of developing a practical application, is more suited to industry or less elite academic settings. This view has been much less prevalent in recent years, though some adherents remain. Some are concerned that basic research funded by industry is more likely to be manipulated and dishonest, though evidence to support such a belief is lacking, and, in fact, the evidence suggests that precisely the opposite may be the case. It would be useful if a thoughtful evaluation of these issues, relying on empirical evidence, could be obtained.
Clinical research and COI. Agreements for sponsored research involving human subjects are also common in medical schools and hospitals. The issues are largely the same as those for basic research, with one exception: the researchers have direct interaction with patients. There is, therefore, a concern that a faculty member's financial interest in the outcome of the research may negatively affect patient welfare and standard of care. Generally, if there is no personal outside financial interest on the part of the faculty member, there is limited concern about the propriety of such a sponsored clinical research agreement. It should be remembered, however, that a researcher's desire for recognition, grant funding and promotion are sources of potential bias and COI quite apart from outside financial involvement, and these are not typically identified within our COI framework. The research itself is reviewed by an Institutional Review Board (IRB) and is conducted under IRB oversight. The IRB process should be one important locus where financial interests are assessed. If agreements between academia and industry for sponsored clinical research were not possible, then company-sponsored clinical research would rarely be overseen or led by academic physicians, who have much to add to the process.
When the physician conducting the clinical research on a technology owned or contractually obligated to a company has a simultaneous personal financial relationship (whether from consulting income, stock ownership or any other payment) with that company, further issues do arise. The concern here is that such a financial connection might consciously or unconsciously induce the physician to make decisions that might not be in the best interest of the study subject, or alternatively, create the appearance that such an outcome was possible, thereby potentially undermining trust in the profession. Responding to this concern, current HMS rules limit the amount of financial interest in such cases to a de minimus amount, with no exceptions. Many other peer institutions do allow the possibility of greater financial relationships while conducting clinical research under specific oversight plans.
One counterargument to our current prohibition beyond the allowed de minimus might be that for some types of research, such as investigator-developed devices, the character and complexity of the research is such that only the "inventor" may be capable of doing the initial studies. If so, exceptions to the prohibition, allowing greater financial interest with strict oversight, might offer society and human health a greater benefit than an outright ban of the practice would. A true risk/benefit analysis of allowing versus limiting such situations has never been established and is a worthy subject for study. In addition, the selection of a specific de minimus level may seem arbitrary, as there are no empirical data on which to base a decision about the most appropriate level. Further evidence-based analysis of this policy question may be desirable.
Faculty consulting activity and COI. Traditionally, academic institutions permit faculty to spend a portion of their time on outside activities, for which they may be remunerated directly, apart from their institutional salary. Current HMS policy permits this unless the faculty member is engaged in clinical research on the company's products and he or she has more than the permitted de minimus financial interest (see above). Faculty may pursue private activities, such as writing and publishing books and monographs and working as consultants for non-profit organizations or for-profit companies in areas of their expertise or interest. Consulting may provide stimulating and useful experiences. Such outside activities may also translate into richer educational opportunities for our students. With additional experience outside the academic walls, faculty members may become better equipped to teach students about subjects to which they would not otherwise be exposed—be it the specifics of a medical or scientific subspecialty or simply the practicalities of the medical business. Although some believe that faculty should be content to limit their faculty and professional experiences exclusively to academia, others are not convinced that such a view is realistic or appropriate.
Are there negative consequences that could arise from consulting activities? Excessive pursuit of outside activities could lead some faculty to fail to fulfill their primary obligations. The HMS COI policy limits income from consulting to a de minimus amount in cases where a faculty consults for and conducts research sponsored by the same company, which discourages these potential negative consequences.
Finally, specific financial relationships between faculty and companies, while portrayed as "consulting," may more accurately be described as payments to faculty as part of a marketing strategy, with the goal of increasing product sales. While faculty consulting activities that fully educate health care professionals about the risks and benefits of a particular therapy to advance the public's health should be beyond reproach, other interactions raise legitimate questions about the appropriate role of the faculty as educator versus paid agent of a company promoting its commercial interests. In extreme instances, consulting payments may mask bribery or kickbacks for use of products. The latter relationships are clearly a very serious issue, already illegal under existing statutes, and merit unequivocal and severe institutional response.
Authorship and COI. Independent of the COI policy and its management, HMS has long prohibited our faculty members from engaging in guest authorship, the practice of attributing authorship in a scientific journal article, abstract, poster or other work to an individual who had no role in the planning or conduct of the research reported. As our Authorship Guidelines, adopted in 1999, state, "Everyone who is listed as an author should have made a substantial, direct, intellectual contribution to the work," and "Honorary or guest authorship is not acceptable." Other HMS Integrity in Science Policies rightly call the practice of honorary or ghost authorship "deplorable."2
Misconduct versus COI. Also independent of the COI policy and its management, HMS has a clearly defined policy addressing faculty misconduct that is taken extremely seriously and strictly enforced. Many of the behaviors that are discussed as possible adverse outcomes from industry relationships—for example manipulation, suppression or falsification of research data—fall squarely within the faculty misconduct policy. Our institutional remedies for these behaviors are clear and decisive.
3. Education and COI.
The existing HMS policy on COI does not explicitly address education as it relates to financial interests, apart from requiring that financial interests be disclosed in papers and public talks where appropriate (see HMS COI Policy, Section II(e)). It is, therefore, timely to focus attention on this issue in the context of HMS's review of its Policy on Conflicts of Interest and Commitment. Because distinct issues arise during the different phases of medical education, it may be helpful to examine these distinct phases of the education process as relates to COI.
At the outset, one overarching principle must be stated: HMS requires its teaching faculty to be excellent educators, based on their ability to transmit information and concepts objectively and rigorously, along with other skills as educators. HMS can and should be proud of its great and continuing success in the education arena, and the School continues to strive so that this remains the case.
Preclinical medical education and COI. By and large, the teaching of HMS medical students during their first two years is under the direct control of the school. This phase of the curriculum is heavily weighted to basic science, normal physiology and disease mechanisms, much of which has little to do with therapeutics. In addition, these students are years from treating a patient or making independent therapeutic decisions. Nonetheless, pharmaceutical and sales representatives have long been prohibited from coming to the HMS campus to interact with students. Perhaps for these reasons, this phase of education has historically generated minimal concerns on the part of HMS about the potential of bias due to faculty interactions with pharmaceutical companies.
In thinking about the potential for financially induced bias in the preclinical curriculum, we should examine how the curriculum is developed and assessed at HMS. The content of the curriculum is determined under the leadership of the dean for medical education, working with a curriculum committee composed of faculty with major and often passionate interest in teaching and course content, and with course directors, lecturers and tutorial leaders chosen for their expertise and excellence as teachers.
Although HMS now compensates most hospital-based preclinical teachers by contributing an hourly stipend to help fund their salaries, faculty rarely, if ever, engage in teaching at HMS to enrich themselves financially. Why, then, do HMS faculty teach? In the vast majority of cases, faculty teach out of dedication to the educational process and the students. Although we need to acknowledge the possibility that our faculty could theoretically seek to teach preclinical students for the purpose of biasing them toward treatments that might financially benefit the faculty, or a company that they might have consulted for, the possibility of such an unethical practice seems quite remote.
Stimulated by requests from some students who were concerned about potential faculty bias, HMS now requires preclinical lecturers to disclose financial relationships potentially relevant to their lectures. While such disclosures have long been the standard for lectures in the clinical arena due to continuing medical education (CME) accreditation requirements, this was not previously done at HMS for preclinical lectures. Time will tell whether this proves to be useful to the students, and if so, in what ways.
Should our choice of lecturers or tutors be influenced by whether the faculty member has financial associations requiring disclosure? Those who perceive a great threat of faculty bias from financial interests might recommend that such faculty be removed from teaching roles. Many of our most renowned faculty, however, are sought after as consultants by industry. If we allowed only those faculty without financial interests in industry to teach future physicians and scientists, those students may well be deprived of valuable learning experiences through contact with some of our most accomplished faculty. This topic could be a worthwhile subject for future surveys of students and faculty and for academic study. Do preclinical faculty members with industry consulting or sponsored research give biased presentations with adverse educational consequences, with or without disclosure? There would appear to be no data bearing on this question, and it would be in our interest to obtain such data.
Promoting critical thinking by our students. In addition to teaching of curricular information, much of which is forgotten and relearned in a new form as understanding evolves, perhaps our greatest challenge is to help our students become critical thinkers. Students need to be exposed to the entire range of biomedical research, including the research undertaken by our broad and diverse faculty, in order to learn these critical thinking skills. During their long professional careers, students will be continually exposed to reports and claims of uncertain or unknown validity from patients, colleagues, professional organizations, companies and government. Their capacity to act independently, with integrity and in the best interests of their patients, will require that they learn how to judge for themselves which sources of information they can trust. If the ability of our students to discern trustworthy information is a problem within the relatively cloistered domain of the HMS curriculum, it will be a far greater problem once they enter the "real world."
Hospital based education of medical students and COI. The third and fourth years of HMS education are primarily conducted at our affiliated hospitals, which are independent corporate entities linked to Harvard via affiliation agreements. HMS is responsible for this educational effort, in extremely close collaboration with numerous HMS faculty and educational leaders who, in addition to holding HMS faculty appointments, are employees of the hospitals. Some hospital-based education is also carried out by house officers who are not HMS faculty. HMS has an obligation to ensure that our students are properly educated at each site and that attention is paid to appropriate principles of ethical behavior.
How should HMS approach the oversight of education of our students at the hospitals and what rules should be established to prevent faculty financial COI from diminishing the quality of their education? Although further research is necessary to understand the potential harm, if any, to our students arising from faculty financial conflicts during the course of clerkships and electives, some faculty and students are concerned about this possibility. In our upcoming deliberations, HMS will need to consider the manner in which financial interests of faculty might be disclosed (and, if necessary, managed) related to the many informal and formal teaching rounds that take place on the wards (as opposed to lectures, which tend to be covered by the disclosure requirements of CME certifying agencies).
While the actual adverse effects on faculty and students of the "pens, pads and pizzas" sometimes provided by companies to the ward teams is uncertain, prohibiting such gifts, as well as gifts of meals and travel, may be useful to reduce even the appearance of gratuitous industry influence. In addition, a version of such restrictions is now a matter of law in Massachusetts.
As students read journals and magazines, or even watch TV, they will be exposed to advertising and detailing by pharma and device companies, as will their patients. As faculty responsible for their education, it might be argued that our goal should include teaching students how to read and interpret such materials, as opposed to simply sheltering them from these materials or advising them not to read or watch them. Likewise, though we want to discourage gratuitous student contact with pharma detailing reps, and such contacts are prohibited on the HMS quad, it may sometimes be useful for students to hear their presentations, and under the tutelage of faculty, learn how to critically judge these and respond to them.
Finally, on a more philosophical level, it is important to note that the truth of an assertion reflects the details of the assertion itself, and is independent of the identity and interests of the person or organization from whom the assertion derives. Or, stated more concretely, some statements by financially non-conflicted but otherwise biased or misinformed faculty will be erroneous, while others from pharma reps will be entirely accurate. While the ratio of the former to the latter is hopefully very low, it is the accuracy of the statement and not the source that ultimately matters.
CME and COI. Continuing medical education primarily targets practicing physicians, and state licensing board requirements that include certification of participation in a certain number and type of CME courses ensure that these educational events will be numerous. Typically, these requirements will conform to guidelines by accrediting agencies such as the American Council on Continuing Medical Education (ACCME), which require financial disclosure by faculty and provide protections to ensure separation of content and sponsorship. The HMS Department of Continuing Education (DCE) is run by a dean for CME, and this department organizes and certifies hundreds of courses and conferences each year, all within accepted ACCME guidelines for financial disclosure and relationships with industry. The vast majority of our HMS CME courses are supported by tuition, with only a small fraction of revenues deriving from industry under ACCME guidelines. All new courses undergo rigorous analysis and review by a committee of senior faculty before being approved.
What are the major questions that we now face regarding CME and COI? First, we must ask whether it is appropriate for accredited HMS CME courses to receive funding from industry sources. At one end of the spectrum are those who assert that the answer is no. No matter how it might be done, these people argue that, as for-profit entities, companies would only provide funds if it served their interests, and their interests will always be counter to values that we support. Further, they assert that HMS and the hospitals should have adequate resources to accomplish all reasonable CME goals without seeking additional revenues. Let us examine this viewpoint.
Although every hospital-based medical educator would wish it not so, the funds to support hospital lecture series and CME programs are always limited. In many hospitals, with financial margins and hospital profits decreasing and expected to decrease further, funds to invite outside speakers and develop and run courses are in short supply from internal sources. Some clinical divisions in the hospitals lack revenues to fund such educational activities, and in the absence of unrestricted educational grants from companies, there might be inadequate funds to bring in experts from other cities and pay them honoraria.
While lack of funds should not by itself justify the acceptance of industry funds, the key issue is whether the industry funding brings with it influence over the content or is truly unrestricted. Efforts by companies to influence the content of academic, hospital-based presentations that they fund would, to the extent that it occurs, raise serious concerns. The HMS Committee reviewing our COI policy will likely consider in what ways industry support for CME, if permitted, can be managed so as to benefit our educational programs while preventing inappropriate influence over content.
Paying faculty to give CME lectures. Another question relates to the practice of our faculty lecturing at a variety of venues, generally on topics involving therapeutics, with honoraria paid by one or more companies. For example, industry may pay a faculty member to deliver a lecture because of his or her status as an expert, with the imprimatur of a Harvard appointment an additional gain from a marketing perspective. An occasional company-sponsored lecture by a faculty member would likely arouse limited concern, if the faculty member disclosed the association, was exclusively responsible for the material presented and was, of course, prepared to defend its accuracy. Under Harvard policy, payments for such lectures are permitted but must be disclosed, whether coming directly from the company or through an intermediary. If the faculty member also conducted research on the therapy, the current HMS Policy would apply, including the prohibitions on receiving more than de minimus financial payments.
A more vexing problem can arise when a faculty member gives a very large number of such industry-sponsored lectures, even more so if the content of the lecture is provided by or substantially influenced by the sponsoring company. This circumstance raises several issues for consideration by HMS. 1) When might we consider that a faculty member is spending too much time on these outside activities given his or her full-time status? 2) Can a faculty member, by virtue of the large number of lectures, cross the line between balanced academic pursuit and explicit promotion on behalf of the company? 3) If the latter, would the activity be inherently inappropriate, or would it be necessary to examine the details and veracity of what is actually being promoted? 4) In a case of real and explicit industry promotion, should the faculty member be allowed to use his or her Harvard faculty status in publicity associated with the activity?
4. Transparency, public disclosure and other operational issues.
In our current policy, faculty disclosures are submitted to the school, and HMS and representatives at each of the affiliates fully resolve any reports that indicate prohibited activity. The disclosures are otherwise confidential. Over the past several years, there has been a major interest in the possibility of providing elements of this information to the public. Some members of industry and some academic health centers have expressed their intention to publicly post information on payments to faculty and institutions, ideally in a form that makes clear the distinct purpose for the payments (e.g., sponsored research, consulting, lecturing or expense reimbursement). Whether this change in sentiment toward public disclosure will be reflected in changes in the HMS policy is now under discussion.
Implementation of such public disclosures may be more complex than some expect, and the implications of such disclosures are far from clear. But this direction does seem to be gaining favor. Whatever happens with public disclosure, it is likely that information about our faculty's financial interests already collected through their disclosures to HMS (not just potential violations), should be made more accessible to key institutional leadership in useful formats to permit the identification of potentially problematic patterns of outside activity. HMS strives to ensure that 100 percent of its faculty members complete the submission of their disclosure forms and that any identified conflicts with the current policy are resolved. However, HMS does not currently have an active auditing and monitoring program to assess the accuracy of COI disclosures. The benefit of some form of audit sampling is clear, and is being discussed by the COI committee. Finally, it is exceptionally important that new disclosure rules and forms be as clear and free of ambiguity as possible.
5. How to view industry in the context of COI at HMS?
In considering academic–industrial relations in the context of biomedicine, we confront varying views of the ethics and goals of for-profit biopharmaceutical and device companies (BPDC) with which we collaborate. Depending on one's views in this regard, the preferred contour and extent of the interactions will vary. Just as it was important to examine distinct domains of medical education and research in the foregoing discussion, it might be useful to treat BPDC as a complex ecosystem with distinct elements, rather than as a monolithic entity with a singular identity.
For-profit versus not-for-profit. Does the fact that BPDCs are for-profit, while medical schools and hospitals are not, create a serious barrier to collaboration between these kinds of organizations in the service of important values? Although interactions between these "worlds" are possible and productive in other segments of our economy, some argue that there are special problems in the intersection of biomedicine and BPDCs. It is true that the mission and professional ethics of physicians are an essential and revered tenet of the profession, and the oath to act always on behalf of our patients' interests has no precise analogue in the industrial sphere. However, for-profit businesses and their employees are not inherently unethical in their goals and behavior, nor are physicians and not-for-profit organizations and their employees necessarily ethical. High ethical standards should be expected from people and organizations regardless of their profession or tax status. Greed unchecked by values, leading to dishonest or otherwise objectionable and immoral behavior, is unfortunately part of the human condition, and is found in some physicians and scientists in both for-profit companies and not-for-profits, in government and even in religious organizations. We must devise approaches, both private and governmental, to limit such behaviors and protect us from them when they occur.
It may be useful to distinguish between those elements of BPDCs that focus on discovery and development and those that deal with marketing and sales. When HMS faculty interact with BPDCs they are most often dealing with company scientists and physicians, many of whom have spent time in academia. The main currency in such interactions is data and truth, and although perspectives on some issues may differ between those inside and outside industry, the cultural divide is often not very wide. As more and more faculty, including those at high levels of accomplishment and recognition, have moved from academia to industry, and others have moved in the opposite direction, the divide continues to narrow.
Not surprisingly, the core goals of marketing and sales divisions of BPDCs are focused on profit, rather than science and medical value. How may we be protected from potentially dishonest marketing efforts? The fact that companies marketing drugs are under substantial legal and regulatory oversight provides one substantial, if not fully adequate, bulwark against bad behavior. Nonetheless, there are many examples of marketing and sales organizations seeking to influence physician prescribing behavior through techniques that rely on gifting and other inappropriate financial inducements. There is evidence from many quarters that companies, even those with longstanding records and reputations for ethical behavior, have made serious mistakes that led to questions about their internal standards and corporate culture.
Having said this, not all marketing activities are dishonest or illegitimate. A substantial portion of explicit BPDC marketing is accurate and consistent with FDA guidelines, and may be useful to some practitioners along with many other sources of information. Certainly, the existence of unquestioned financial interest on the part of the marketer should cause medical professionals to be cautious in accepting any presentation at face value. On the other hand, viewing all marketing information as erroneous and all such personnel as persona non grata may not be appropriate.
The emerging opportunity. It is increasingly evident that the pharmaceutical industry has been less successful than expected in recent years at developing breakthrough treatments based on the torrent of new information that bioscience has produced. Both within and outside industry, many people recognize this problem and are seeking a new model of academia-industry collaboration to achieve greater success at discovery and development of new treatments while fully protecting academic values and those of the medical profession. As many breakthrough drug classes go off patent, and the pipeline has insufficient replacements, the profitability of the industry will likely fall and the motivations for industry to partner with academia in new ways to accelerate progress will likely increase. From this perspective, it may be desirable to create a culture that is open to creative new approaches to collaboration on scientific development, rather than one that seeks to make novel interactions more difficult.
6. How will HMS address COI going forward?
HMS is now conducting a thorough and comprehensive review of its COI policy, involving our faculty from the HMS preclinical departments and affiliated hospitals and our students. This review will define our current state, identify the current challenges, take testimony from individuals and groups representing distinct perspectives, and propose a revision of the policy going forward. And this time, since Harvard University is simultaneously undertaking a University-wide review of this topic, our policy will be fully consistent with emerging University standards.
Although the final recommendations will not be clear until the process is complete, it is certain that we will address education in a way not previously considered in the policy, and we will identify ways to make the policy more explicit in several areas. We will likely expand the transparency of disclosures and find approaches to enhance the way that information is used by our leadership. Finally, we will work hard to synergize and make as seamless as we can the policies of HMS with those of our affiliates.
7. A future academic agenda regarding COI in biomedicine.
In the course of my consideration of these issues, it has become apparent that there are major knowledge gaps in this area. As a result, many differences of opinion are not easily resolved by consulting scholarly discussion and analysis. Since COI issues lie at the critical interface between research, education, patient care and the public, I believe that HMS should play a leadership role in defining and elaborating an academic agenda for this field in the future. The field of inquiry is broad and interdisciplinary. It will involve expertise from the worlds of research, education and clinical medicine, as well as philosophy, law, business and public policy. Some of the insights will arise from convening the right people to address focused issues in a new way. Others will require objective study and the acquisition of data from the real world. I commit HMS to advancing this agenda over the course of the next several years.
8. Conclusion.
Over the course of a 31-year career on the faculty of HMS, and now as dean of the faculty of medicine, I have observed and had to deal with a certain number of transgressions of ethical norms. Nonetheless, I have repeatedly been struck by the fact that our faculty is remarkable for their dedication to ethical patient care, unbiased education on many levels and pathbreaking research. Interactions with industry have provided many members of our faculty with opportunities to extend their research and expand their horizons. The preponderance of these activities are not only defensible but praiseworthy and important to maintain.
There are, however, increasing concerns about some kinds of financial relationships between faculty and industry. Many, but not all, of these relationships emerge from marketing efforts of pharma and device companies. These range from small gifts and meals provided to physicians; to lecture programs in which faculty may subtly evolve from being academicians compensated to present their views on a topic of interest into roles as paid spokespersons for a particular product; to behaviors that have the appearance or reality of being explicit payoffs and bribes. The foregoing activities range from being unseemly but potentially harmless, to being inappropriate for a full-time academic and subject to review, to being criminal, and we must address them in a manner that takes account of their actual status. In their zeal to market, pharmaceutical companies have too often overstepped lines that demarcate reasonable and appropriate marketing, which is their right, from dishonest and otherwise unethical behavior, which is not. Leaders of this industry, who have been chastened both by negative publicity and some major court settlements, are becoming aware of this fact. Our academic leaders have a responsibility to work with industry, and in particular the scientific leaders within industry who have often moved there from academia, to rein in practices that we can all agree are inappropriate. Similar considerations apply in determining the appropriateness of non-marketing relationships between faculty and industry.
Having said that, it would be a mistake of enormous consequence if attention to these important concerns were to create a false conclusion regarding the many important ways in which academia and industry could work together productively and ethically for the benefit of human health. I hope that I have at least begun the process of providing a framework for discussion as we deliberate on the best policy for the future.
9. Footnotes.
1 When HMS originally adopted the Policy on Conflicts of Interest and Commitment in 1990, it was one of a select group of medical schools to have a comprehensive policy of this kind. Since that time, HMS has periodically reviewed the policy to ensure that it appropriately evolves with the continually changing medical field. In addition, HMS has throughout the years adopted and revised several other policies and procedures addressing scientific integrity in various forms, including:
- Principles and Procedures for Dealing with Allegations of Faculty Misconduct
- Faculty of Medicine Statement on Research Sponsored by Industry
- Guidelines for Investigators in Scientific Research
- Guidelines for Investigators in Clinical Research
- Authorship Guidelines
- Guidelines for Editors and Authors of Medical Textbooks
- Guidelines for Attribution of Credit and Disposition of Research Products
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2 See the:


text:
I'll never forget the first time I slipped while driving a slot-head wood screw using my Yankee push drill. The bit drilled a 1/4-inch hole right through my thumb. It was the mid-1970s, when I was still banging in finish nails by hand, and having sore–and injured–fingers was part of the job.
Impact drivers get their name from the pounding action of the hammer connected to the motor against the anvil attached to the bit holder.
Credit: Photo: by dotfordot.com
My fingers started to heal in the early 1980s, about the same time the first cordless drills came out. I thought I had died and gone to 9.6-volt heaven–but the best was yet to come when, some 20 years later, I got my first cordless impact driver. I haven't let go of that tool since.
If you don't know about impact drivers, let me tell you about one of the greatest tools that's ever been invented next to the nail gun, table saw, and power miter saw. Just like an auto mechanic's pneumatic impact wrench, the rotation of the impact driver delivers hammering force, adding a lot of torque without a lot of reaction force. Inside the tool, attached to the back of the bit holder is a two-lugged gear called the anvil. A drive gear with two matching lugs (the hammer) repeatedly strikes the lugs of the anvil when the torque needed to turn the bit exceeds the torque of the tool's rotational force alone. Similar to the blows per minute of a rotary hammer, impact drivers are measured in impacts per minute.
Put simply, an impact driver runs like a very fast drill until you need more torque to drive a screw. Then the hammer hits the anvil about 50 times per second and drives the screw with hundreds of little hits. Finish carpenters' 12-volt drill/drivers ramp up to about 250 inch-pounds of torque, while early impact drivers topped out at about 700 inch-pounds. But some new lithium-ion impact drivers approach 1,500 inch-pounds–a huge difference. You'll rarely strip the head of a screw with an impact driver, but you can shear one off easily.
The Tools
We set out to test the latest 18-volt lithium-ion impact drivers, but we made a few exceptions to round out the field. All but the Bosch are LI-powered, but a few different voltages and tool configurations are in the mix. The 14.4-volt tools include the Hilti SID144-A and Panasonic's EY7540LN2L and EY7542LN2L combination impact/clutch-controlled driver. The 18-volt tools are the Bosch 23618, DeWalt DC827KL, Hitachi WH18DL, Makita BTD141 and BTD142HW compact, Milwaukee 0881-22, Ridgid R8823, and Ryobi P230. The Craftsman 320.28128 is the only 20-volt tool.
Flexible Fuel. The Bosch is limited to nicad batteries, but many of the drivers also can be powered by their brand's nicad or NiMH batteries of the same voltage, including the DeWalt, Hitachi, Milwaukee, Ridgid, and Ryobi. The Ridgid can even use 24-volt LI batteries. Makita's compact model is smaller because it has a half-sized battery with reduced runtime but full 18-volt power. Hitachi just introduced a similar compact version, but it was too late for our test.
Similarities. Functionally, these tools are very similar. All have variable speed triggers, automatic brakes, through-handle direction switches with lockoff position, and headlights. Impact drivers have 1/4-inch hex bit holders that hang on to bits with a ball-bearing detent system for a vibration-proof grip and quick bit changes.
Combination Tool. Panasonic's EY7542LN2L is an impact driver with a separate, nonimpact driver mode controlled by clutch settings. This tool saves you from having to keep a separate drill on hand for drilling holes, as an impact driver is probably one of the worst tools to use with a drill bit. This tool also is safest for driving soft brass screws or steel screws against hardware.
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subset: commoncrawl


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DICKINSON COUNTY, Kan. (WIBW) -- Enterprise officials are considering not having a police department anymore and contracting with the Dickinson County Sheriff's Department.
It's not because the city can't afford a police force but when their police chief left for another job, officials started to weigh their options and see where they could save money.
"This just gives us an opportunity to see what would be best at this time," said Mayor Tom Decker about the talks.
It would save the town about $20,000 a year. In exchange, sheriff's deputies would patrol less than half the amount of time Enterprise police do.
"Our police department usually puts in over 470 hours a month and the talks have been to get 200 hours a month from the sheriff's department which that would come to around $88,000 a year. Our police budget is $107,000 a year. And we're not doing it because we can't afford to have the police department. I guess it's just since the chief left, it's just something we can discuss and look at doing," explained Decker.
The towns of Solomon and Hope have contracts with the Dickinson County Sheriff's Department. Decker says Enterprise officials have conferred with leaders from both towns to discuss the pros and cons.
"The Dickinson County Sheriff's Department has two deputies that are on the road most of the time, 24/7. I think Dickinson County is 875 miles square so the two deputies patrol that 24 hours a day," Decker said.
Some residents in the town of 855 support the move while others have expressed concerns over response times.
Cherise Achi, longtime Enterprise resident, told WIBW: "There are pros and cons to everything. The pro here would be to save money for the city but at the same time, it's nice to have a cop here. If something happens, one is here immediately instead of having to wait for the sheriff's deputy to come from Abilene or wherever he is in the county. Growing up here, it was always a nice thought to have someone in town at all times to be on the safe side- not that much happens here but I think they should keep it the way it is."
"Usually if something happens, the Enterprise police respond first and then the Dickinson County Sheriff comes in after that and it takes 5-10 minutes to come from Abilene so if it's a real dire emergency, you have to wait that extra time for the sheriff's deputy to come,"
LaRae Miller, also longtime Enterprise resident, thinks the change would be cost efficient.
"I feel bad for the police officers that would lose their jobs because of the economy but sheriff's deputies are driving through here all the time and I just think it would be a good idea. I think it would be more cost efficient," she said.
An open city meeting will be held January 26th at 1 PM in the basement of the library for citizens to share their thoughts on the matter.
"I personally want to hear what the citizens have to say about it. They're the ones paying for it. We've had law enforcement in this town for a long time. It's what they want and what they're comfortable with," Decker said.
Officials plan to come to a decision in February.
In the meantime, Enterprise leaders are also conducting interviews with applicants for police chief. The town does have an acting chief for the time being.


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6 Beloved Organizations (Started For Terrifying Reasons)
#3. The Rhodes Scholarship
Question: What do Bill Clinton, Kris Kristofferson and feminist writer Naomi Wolf have in common, besides the obvious fact that they have "I's" in their first names, "O's" in their last names and were all born in even-numbered years?
Oh, and aside from the fact that they've all gotten laid in the Oval Office.
Answer: They were all Rhodes scholars, chosen to participate in one of the world's most prestigious postgraduate programs. Also, they all have luscious, touchable hair.
Ever since 1902, the Rhodes Trust has selected the brightest minds in the world to do postgraduate work at Oxford University in England. Winners enjoy the benefits of free tuition, a monthly stipend to cover all their living expenses and a ready-made excuse for avoiding combat in Southeast Asia.
Who'd want to do that?
Its Sinister Origins
The Rhodes Scholarship was originally intended to be a secret network of British ruling elites, indoctrinated to advance the Queen's cause all over the world, ultimately even recovering the United States for the mother country.
It was one thing for Cecil Rhodes to be a racist imperialist: you wouldn't expect anything less from a white Victorian-era diamond magnate. The fact that he seized a million miles of African land, named a country after himself and declared that all Englishmen had "won first prize in the lottery of life" without batting a beady little eye shouldn't even faze hardened Cracked readers such as ourselves.
Observe how he casually smothers a midget in this picture.
So, in his mind, this fund wasn't just some gesture of international goodwill. In fact, Cecil Rhodes wouldn't have known "international goodwill" if it sneaked up and frenched him in the ear. In the first draft of his will, Rhodes set up a fund for:
... the establishment, promotion and development of a Secret Society, the true aim and object whereof shall be for the extension of British rule throughout the world ... especially the occupation by British settlers of the entire Continent of Africa ... the ultimate recovery of the United States of America as an integral part of the British Empire ...
They'll try again one day, readers. The British aren't to be trusted.
Fortunately, Rhodes' advisers who weren't insane convinced Rhodes to re-imagine the scholarship as a way to indoctrinate Colonials and get them on the side of the crown, then send them back into the world thoroughly Anglicized. And that's how the scholarship ultimately ended up. Which is a good thing, because toad-in-the-hole sounds disgusting.
#2. Ballet Schools
When ballet began, it wasn't so much an art form as it was a royal party dance for Renaissance-era courtiers. Kind of like the electric slide, but exclusively for aristocrats. The dance form actually wasn't accessible to commoners for the first few hundred years of its history, not until King Louis XIV established the world's first ballet school, the Academie Royale de la Danse, in 1661. And that school eventually became the Paris Opera Ballet School, which is still in operation as one of the world's most prestigious ballet schools.
They won't let you eat popcorn shrimp during a recital or nothing.
But somewhere in that transition from courtly, mannered dancing among nobility to the disciplined art form we know today, something pretty repulsive happened.
Its Sinister Origins
They were whores.
Girls recruited to study at the Paris Opera Ballet School weren't just sweet little bun-headed cutie pies in tutus. They were called the "little rats." And they were prostitutes in training.
Which was why the enterprising managers of the Paris Opera recruited the poorest, most desperate girls they could find to populate the ranks. Girls such as 14-year-old Marie van Goethem, who was the model for this statue by the artist Edgar Degas:
Cute, right? Not when you find out that the relationship between Degas and the girl was "debated" and that she was only one of many petits rats expected to entertain and keep company with patrons of the opera. By bringing in desperate girls whose parents were practically their pimps, the school opened up a whole world of patronage:
In the 1830s, however, the backstage of the Paris Opera became a privileged venue of sexual assignation, officially countenanced and abetted ... the theater's enterprising management dangled before the elect of its paying public a commodity of indisputable rarity and cachet -- its female corps of dancers.
Marie herself ended up getting kicked out of the ballet at age 17 and apparently went into full-time ho'ing, along with her sisters, with her mom as her pimp. But had she stayed in the ballet corps, the only difference probably would have been that she would have had the protection of the clients who favored her, and that she would have kept dancing. That's about it. One writer of the time put it this way:
Most of the dancers first saw the light of day in a concierge's lodge.
"Voulez-vous coucher avec moi (ce soir)?"
#1. The Greatest Show on Earth
We all love a good circus. What's not to love about painted men in unnaturally colored afros, psychedelic hobo clothes and clearly oversized shoes degrading themselves to small children for applause and affection? Or elephants trained to walk like people and balance 10,000-pound bodies on precarious stools for our amusement?
In other words, a totally safe place for children.
And for many of us, our first circus experience was with the Greatest Show on Earth, the Ringling Bros. and Barnum & Bailey circus. Since the merger of America's two biggest circuses in 1919, millions of spectators have enjoyed the circusy stylings of clowns, acrobats, tightrope walker and caged-motorcycle-sphere-of-death-riders alike.
What could possibly be sinister about a circus?
Its Sinister Origins
P.T. Barnum started his empire with one singular act: the exhibition of a blind, paralyzed, withered slave lady who claimed she was once George Washington's mammy.
Before there was Ringling Bros. and Barnum & Bailey, there was just P.T. Barnum, a guy who bought another human to put her on display for paying customers. Unlike his later attractions Jo-Jo the Dog-Faced Boy, the Siamese Twins and Tom Thumb, Joice Heth was not exactly a willing collaborator just making the best of a physical disability -- she was an old lady on death's door, reportedly weighing only 46 pounds when she was purchased. As an exhibit, all Heth had to do was sing some Negro spirituals and tell stories of nursing the Father of Our Country.
Exploitation? This man?
It was all bullshit, of course. Heth wasn't 161 years old, as everyone found out when she died. BECAUSE BARNUM HAD HER PUBLICLY AUTOPSIED and charged people admittance to get in on the show. Which they did, willingly. Because how often do you get a chance to watch a physician cut into the body of a 80ish-year-old cripple who pretended to suckle the first president of the United States? It was a bargain, really.
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DENVER � Marijuana-driving standards are becoming routine debates around the Colorado Capitol, with a drugged-driving bill headed to the state Legislature for the third time in the last two years.
Gov. John Hickenlooper said it�s �common sense� to have blood-level marijuana limits for drivers as an analogy to existing blood-alcohol limits. Hickenlooper added a marijuana-limit driving standard to a special session to begin Monday to address civil unions for same-sex couples.
The marijuana-driving bill has stumped Colorado lawmakers before, and it may do so again. Marijuana activists who decry the proposed blood limit as unfair and a bad predictor of driver impairment say they�re going to renew efforts to stop the bill.
The measure would set a limit of 5 nanograms of THC, the psychoactive ingredient in marijuana, per milliliter of blood. It�s already illegal to drive while impaired by marijuana or any drug, but police say a nanogram limit would help law enforcement by setting a testable blood level to go along with officer observations about whether a driver is impaired. State toxicologists have said the 5 nanogram limit is more than fair as a standard for impairment.
But some marijuana activists point out that pot, unlike alcohol, is stored in body fat, so blood THC limits can remain elevated in some patients when they�re not high. They say the blood limit sets a standard that could be unfairly applied, and they�ve packed legislative hearing rooms testifying against the plan.
Last year, lawmakers couldn�t agree on a blood limit. Instead, they sent the question to a task force, but it couldn�t decide on a fair standard, either. The measure returned to the Legislature this year. It passed the Democratic Senate, where it failed last year, and was headed for approval in the Republican House.
But the marijuana measure fell victim to a late-night standoff over a civil-unions measure also pending in the House, killing it for the year.
Marijuana activists rejoiced � until Hickenlooper announced Thursday that marijuana DUI standards would be added to the special session call.
The governor said that the standards make sense, comparing drugged driving to drinking and driving.
�Why on Earth would Hickenlooper choose this bill as one that has to be an emergency right now?� asked Jackie Edwards, a 59-year-old medical-marijuana patient in Englewood who suffers from fibromyalgia and lung cancer and has testified against the driving standard.
Edwards calls it unnecessary: �I know when not to drive,� she said.
Hickenlooper pointed out that it�s currently illegal for drivers to have any amount of THC in their blood, and that the controversy is overblown.
�Right now there is no tolerance, right? If you have any THC, you shouldn�t be driving. So why not set a standard where we really think that ability is impaired?� he said.
A lawmaker who opposes the measure also downplayed the prospect for noisy debate over it. House Democratic Leader Mark Ferrandino said the marijuana DUI standard simply fell victim to a political meltdown over civil unions.
�It was moving through the process. It was likely to pass,� he said of the marijuana bill.


text: Fair Advantage premiere shampoo is a conditioning shampoo that reduces static and aids in moisturizing to help in prevention of hair and coat breakage. Fair Advantage adds body, volume and fullness with a vibrant shine. Eliminates dryness, static flyaway and frizzies, Fair Advantage deep cleans without overstripping the coat and it rinses squeaky clean.


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I have an axe with a damaged handle that needs replacing, but I don't know how to do it. What tools and techniques should I use to get the job done?
You'll have a couple choices when replacing the handle, you can either get a good Hickory replacement handle like this,
or a Fiberglass handle like this.
Comparing handle types is beyond the scope of this answer.
Either way the repair starts the same way, by removing the old axe head. This will likely be the most difficult part of the job, as the handle was installed to not come out. You may be able to drill out enough of the material, so the handle will easily slide out. You could also try removing the metal and wood wedges (reverse of install) to remove the head, but sometimes the wooden wedge is glued in so you may not be able to remove it. If the old handle was fiberglass, it may be easier to purchase a new axe. Removing the old epoxy can be difficult, and time consuming.
Once you have the old handle removed, the installation of the new one is slightly different depending on the handle you've chosen.
Installing a Hickory (wood) handle:
It's best to buy a replacement handle that includes everything you'll need to install it, which will likely come with a notch already cut in the top of the handle (so you won't have to cut this yourself). If you can only find a handle with a wooden wedge and no metal wedges, the metal wedges are available separately.
Installing a Fiberglass handle:
When purchasing a fiberglass handle, try to find one that includes the epoxy. If you can only find handles, the epoxy kits are available separately.
When installing a fiberglass handle, you'll have to make sure the hole in the axe head is clean. You can use sand paper, or a small round file to clean the hole before installation.
Standard guidance seems to be:
I've only done this once but it was good fun. Get the wedges in solidly to avoid the axe head flying off, though:-)


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One of the ways to acquire the "Battle Scarred" achievement is to "Promote a multiplayer character to the Galaxy at War". What does this mean?
Once your multiplayer character reaches level 20, you can choose to "Promote" them. It's a bit comparable to the Call of Duty series' "Prestige" system, in that your multiplayer level for that class is then reset to 1, and you level up again to repeat the process.
Promoting imports them into your single-player game as a "War Asset" worth 75 points, which goes towards increasing your Total Military Strength. In addition, playing the Multiplayer maps will add to your Galactic Readiness multiplier. This functionality is what BioWare designed in order to have multiplayer affect your single-player game.
Promoting also adds 10 to your N7 multiplayer rating.
Promoting also gives you 10 rating to your N7 number and 75 points to your war assets, to add to the first response.
There are pros and cons to promoting a character. However what promotion does is taking that character and converting them to War Assets.
Sure the cons are more based off if you prefer the look and weapons kit you had but is a non issue if you have it memorized. After a character gets promoted you'll need to redo your kit and armor appearance.
To clarify, it WILL NOT relock Armor Appearances. You WILL however have to change them back to the colors you once had. It WILL NOT reset weapons and mods back to level I. You WILL however have to reequip the weapon and mods of your choice.
You can promote a character an infinite number of times to gain an infinite permanent War Asset bonus to ALL Shepherds.
Once a single class reaches level 20, you can promote them. The first time you do this will earn you the Battle Scarred Achievement. If you haven't reached level 60 ether, getting them to level 20 will result in another achievement.
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text:
Do we have to tithe? Why does God need us to tithe? What are the results of NOT tithing?
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closed as too broad by Mr. Bultitude, Nathaniel, curiousdannii, Lee Woofenden, bruised reed Feb 19 at 14:38
There are either too many possible answers, or good answers would be too long for this format. Please add details to narrow the answer set or to isolate an issue that can be answered in a few paragraphs.If this question can be reworded to fit the rules in the help center, please edit the question.
The strongest words with respect to the benefits of paying tithing, and the consequences for not doing so, can be found in Malachi 3: 8-12:
However, it appears that in the Christian period, just as with many other provisions of the Law, tithing was superseded by a higher law. Towards the end of both Acts 2 and Acts 4 it explains that the Christian community had all things in common, consecrating not a tithe (tenth) of their belongings but instead everything they owned to the general welfare of the church in order to do away with poverty. (It's worth noting that, while there are many obvious differences and incompatibilities between Christianity and communism, Karl Marx's famous "from each according to his ability, to each according to his need" was inspired by this part of Acts.)
The location of the chapter break between Acts 4 and Acts 5 is unfortunate, as Acts 5 begins with a direct continuation of the discussion of the treatment of the consecration of property that Acts 4 ended with. Here we see the story of a man and his wife who sold their property and gave part of the money to the Apostles, but kept back part of it to enrich themselves. Apparently the Lord takes this very seriously, (Galatians 6: 7--God is not mocked,) as He struck both of them dead when they tried to reaffirm their lie when questioned by Peter!
I'm not aware of any church today that practices this doctrine of total consecration, but the principle is still there. At the very least, a true believer should be willing to give up all that he posesses if it is needed to further the Lord's cause. (See Matthew 13: 44-46, Luke 18: 18-25, and especially Luke 18: 29-30 for the Savior's own words on this matter. See also Luke 12: 34/Matthew 6: 21--"Where your treasure is, there will your heart be also." The entire point of the Gospel is to improve our hearts and turn them towards heaven instead of the things of this world.)
I take 'why do we have to tithe' a step further:
Matthew 6:24 (NIV)
By requiring the tithe, God is teaching us to put our trust in Him over money. So HAVE TO should be WANT TO.
I know this question has an accepted answer but it seems that one scripture has been missed:
In the words of Jesus "These you ought to have done, without leaving the others undone." In the NIV translation it says
One argument for not tithing is that it is a jewish law and we are not bound by it any more. While it is true we are not bound by the law tithing came before and was made into law.
(also read Genesis 14:20)


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Top Green Gifts for Kids
Give your child the gift of green this year! Teach them about saving the environment with these gifts that are both fun and eco-friendly. Check out our ideas for green gifts for teens, men, and women, too!
1 of 11
Eco Stars Recycled Crayons
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Jeremy joined the sports medicine team in the fall of 2013 and now enters his second year at Charlotte. He serves as Associate Head Athletic Trainer working with Men's Basketball and oversees the SAC athletic training room.
Prior to coming to Charlotte he spent two years in Des Moines, Iowa as Head Athletic Trainer, travel coordinator, and equipment manager with the NBA-Development League's Iowa Energy. In the offseason he worked with the Energy's team physicians at Capital Orthopaedics and Sports Medicine. During the 2012 season, he provided coverage for the NBA Development League All Star East team as well as the NBA Celebrity All Star games in 2012.
Prior to his time in Iowa, Jeremy spent one year as Assistant Athletic Trainer at Tulane University working with men's basketball and women's tennis. He has additional collegiate experience at The Citadel, where, he worked as a Graduate Assistant Athletic Trainer covering men's basketball and assisting with football. While there, he earned a Masters of Science degree in health, sport and exercise science.
The Kansas City Missouri native earned his Bachelor of Science in Education with emphasis in Athletic Training from The University of Kansas in 2008.
|Associate Head Athletic Trainer
|Kansas City, Mo.
|Alma Mater:
|Graduating Year:
|1 Year


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The Honorable James R. Zazzali, Chief Justice of the Supreme Court of New Jersey, will deliver the convocation address at the May 25 commencement for Rutgers School of Law–Newark. The Juris Doctor degree will be conferred on approximately 260 graduates. The ceremony will begin at 10 am at the New Jersey Performing Arts Center (NJPAC) following a bagpiper-led procession of commencement participants from the Law School building.
Zazzali is the seventh Chief Justice to lead the New Jersey Supreme Court since the 1947 Constitution. He was nominated by Gov. Jon S. Corzine and sworn into office in October 2006. He was first named to the Court by Gov. Christine Todd Whitman in May 2000.
A graduate of Georgetown Law Center, Zazzali clerked with the Honorable Lawrence A. Whipple. He served as chief of the Appeals Division of the Office of the Essex County Prosecutor, general counsel to the New Jersey Sports and Exposition Authority, receiver for Bloomfield College, chairman of the New Jersey State Commission of Investigation, vice-chairman of the Disciplinary Review Board, and as New Jersey Attorney General. He was appointed by the U.S. District Court as Special Master for the county jails in Essex, Monmouth, and Bergen counties. He also served, at the request of the U.S. State Department, on delegations to the United Nations conferences. He practiced law in Newark and Trenton in the firm founded by his late father and his brother – Zazzali, Fagella & Nowak.
Other speakers at the ceremony will include Marvin Chirelstein, Visiting Alan V. Lowenstein Professor in Corporate and Business Law, as the faculty speaker and Antonio Gutiérrez, Class of 2007, as the student speaker. | Read Story


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Bb Learn - Grade Center
The Grade Center in Blackboard Learn
There are many features and options for customization within the Blackboard Learn Grade Center. We are going to explore a small group of the most commonly used ones.
In this scenario, you will:
- Create a Column
- Delete a Column
- Change Column Organization
- Enter, Change or Delete a Grade
- Clear an Attempt
Log in to Blackboard Learn
To log in to Blackboard Learn (if you are not already logged in), follow these steps:
- Go to bblearn.nau.edu.
- Click the Log in to Bb Learn link.
- On the Central Authentication Service page, in the UserID field type your University login ID, and in the Password field, type your password.
(NOTE: If you have already authenticated through CAS from some other campus website, you might not have to complete this step or the next. Instead, you automatically will be routed to the Blackboard Learn My Bb Learn tab.)
- Click the Login button.
Navigate to the Correct Course
After you have logged in, make sure you are on the My BbLearn tab, and then from the My Courses block, select a listed course.
Enter the Grade Center
- From the left navigation menu, in the Course Management menu, click the Grade Center link. When the sub-menu appears, select Full Grade Center.
- The Full Grade Center appears, with a list of all the students on your roster.
Create a Column
Columns are automatically added to the Grade Center for work done in Discussions, Assignments, and Tests. Work that is not automatically graded can be recorded in the Grade Center by creating a Grade Column. To create a Grade Column, select the Create Column button, name the column, enter the number of points the column will be worth and click the Submit button.
Delete a ColumnTo delete a column, find it in the Grade Center, select the Action Menu to the right of its name (in this example, Quiz 1), and select Delete Column from the pull-down menu.
Change Column Organization
- To move a column to the left or right in the Grade Center, click the Manage button and select Column Organization.
- Grade Column titles will appear in a vertical list. Drag the crosshair icon of the column you want to move and drop the item at its desired location.
Enter, Change or Delete a Grade
To enter, change, or delete a grade in Bb Learn, scroll down in the Grade Center to the student who's grade you want to change. Scroll across to the correct Grade Column. Click in the cell and type a new grade. Click OK to accept the grade change.
Clear an Attempt
Users may be allowed to take a Test multiple times. If multiple attempts are allowed it is noted at the top of the Test. The Instructor may also set a limit on the number of attempts - which will also be noted at the top. A link to take the Test again appears if the Test is re-opened. The Instructor determines if one or more of the test attempt scores are recorded in the Grade Center.
- To clear an attempt, giving a student more chances, find the student's score in the Grade Center, click on the Action Menu beside the score, and select View Grade Details.
- Where the student's current grade is displayed, click on the View Attempts button.
- Click the Clear Attempt button to clear this student's attempt.


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I was wondering how I might capture or create audio which sounds like it's being heard first-person. For example, there's a scene in Being John Malkovich where the viewer sees through Malcovich's perspective, he takes a bite of toast and the chewing noises sound as if they're being heard by Malcovich himself. Is a shotgun mic and a quiet sound booth all you need to accomplish this effect? What about swallowing or breathing noises? Would some sort of contact microphone (not sure what the term for such a device would actually be) be more effective? Would selling the effect require additional signal processing?
migrated from avp.stackexchange.com Jan 24 '14 at 12:01
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I haven't seen that movie, but one way to achieve this effect is with a binaural microphone. you would have to record and add breathing and swallowing noises later, as I am sure they did in the movie. Be warned, while binaural recordings work amazing well on headphones, they do not fair so well on speakers. This is why they tend to be used more for research than for actual music recording.
I've also heard of a trick where people attach small omni microphones to their head near each ear (like to their glasses or something). Maybe you could add contact mikes (usually piezo microphones) to capture the sounds of swallowing and breathing on a separate track.


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Hey guys I found this tilemill to develop WebGIS application using MapBox. I wanted to know how is it better than OpenLayers and if I have to develop which would be a better options to go for, as I will be developing a complete GIS Architecture.
I tried to explain the relevant details of your interest below. I want to say briefly, if you want to build great application what you're looking for is that OpenLayers.
i hope it helps you...


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THE PARTY Considered by many to be the party that kicks off the North Shore summer social season, more than 600 garden lovers attended the annual Chicago Botanic Garden's Antiques & Garden Preview Evening under tents at the Garden. THE HIGHLIGHTS Stunning indoor display gardens interpreting the theme "Color in the Garden: An Artist's View" were donated by five Chicago area designers, including Craig Bergmann Landscape Design and Mariani Landscape. Jewell Events prepared delicious bites presented in a garden theme on green food carts for guests as they shopped an exquisite array of antiques from 120 American and European exhibitors. In attendance were preview evening co-chairs Kimberly and Randy Burt, Peggy and Jack Crowe, Kathy and Chris Deveny, and Kate and J.T. Fitzgerald. Design industry veteran and Garden Fair honorary chair and lecturer Michael S. Smith also attended the preview party. THE BOTTOM LINE The event raised $250,000 to benefit the Garden's conservation, education and research programs. Photography courtesy of Chicago Botanic Garden


text: Draw Tifa Lockheart from Final Fantasy VII. This tutorial will show you a few basics on drawing the popular Final Fantasy character. When it comes to friends in danger, Tifa will do anything to protect them. Quite frankly, she can pack one heck of a punch! The tutorial is laid out nice and simple for an easy drawing experience. If you found that this tutorial was simple, please leave a comment! I hope you'll enjoy this cool tutorial to learn "how to draw Tifa Lockheart, step by step". Thanks folks!


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Academic Technology provides faculty with a supportive environment for learning how to effectively integrate technology into the curriculum. We help faculty use technology to develop best practices that improve teaching and learning through workshops, demonstrations, online resources, and evaluation of technology. Our partnership with CELT's instructional consultant ensures that pedagogy is at the forefront of what we do
Jenny Darrow, Director of Academic Technology
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5 Video Game Adaptations That Missed the Point of the Movie
#2. Doctor Who: Dalek Attack, In Which the Doctor Murders Everyone
In Doctor Who: Dalek Attack, the Doctor has to fight Davros, who has an evil-sounding name, and that's all we need to know. Hey, if you didn't want your kid to eventually be murdered by a man with a strong jawline and a penchant for puns, you shouldn't have named him shit like "Davros" to begin with.
Also, stop breeding. You're pretty ugly.
So Davros is a dick, and now it's up to the good Doctor, our charming protagonist who solves every problem using only his wit, love, pluck and a screwdriver, to deal with this crisis the way he does best ...
How the Game Missed the Point
... by strapping himself onto a flying Segway and arbitrarily laser-blasting and grenade-chucking his way through an army of aliens.
You probably thought we were kidding about the Segway.
For those of you not intimately familiar with the show, the entire point of the character is that he's a pacifist action hero. His defining character trait is to avoid violence at all costs. Hell, some of the biggest problems the Doctor's ever faced could have been completely avoided if he had just shot his enemy in the face, and yet he's at his happiest when everybody lives. The show is out to prove that you can have fun, be entertained and beat the bad guy without losing your collective humanity.
By way of contrast, here's the Doctor straight up murdering a guy.
But hey, why draw up decades of awesome mythology (this show's been around for a while) for your game when lasers are a thing, and can go through other things that used to be alive? Even though you could easily go around enemies or, since the Doctor in the game has infinite health, just ignore them, the levels place endless living beings right in your path, forcing you, the Doctor, to callously mow them down without a thought.
Somewhere, K-9 is downloading tragic_disappointment.exe.
Seconds later, the Doctor shoots him dead.
#1. The Hunt for Red October: Just Blow Up Goddamn Everything
As badly as the last two items on the list botched their source material's anti-violence message, The Hunt for Red October somehow takes it to a whole other, apocalyptic level.
Nobody gets to see Montana.
In the film, Sean Connery plays a Russian submarine captain who has decided to defect because he believes the Red October, a prototype stealth sub carrying nukes, was built with the intention of starting a war -- a war he wants to avoid at all costs. Connery really stretched his acting chops here, both in pretending that he didn't want to solve every problem with his penis and/or karate chops, and in almost thinking about trying to disguise his Scottish accent a little maybe (but not really).
"I'm doing thish for freedom and Mom'sh apple piesh."
Connery's character has to contend with both the Russian military, which wants to stop the October from falling into American hands, and the U.S. as well, because the Russians have misled them into believing that Connery is actually a rogue soldier out to nuke Washington, D.C.
The situation is a powder keg, so the goal of basically every character in the movie is to prevent war. And they are successful: In the end, Connery isn't killed and everything is resolved peacefully. Only one submarine actually fires a torpedo in the whole movie, and that submarine ends up blowing itself up.
How the Game Missed the Point
By now you can guess that for the official movie tie-in game, the designers decided that we needed way more explosions, because there just weren't buttons for "terse dialogue" and "beards." So as with Platoon and Doctor Who, the result is a game where every problem is solved in exactly one way: killing the shit out of it. In the first level, you navigate the Red October through a gigantic underwater military labyrinth, nuking absolutely everything you see. Underwater laser cannons? Explode that shit! Other submarines? BOOM! Dolphins? BLA-DOW!
Screw you, wall!
The SNES version is somehow worse, where the Red October's defection starts by basically sinking the entire Soviet sub fleet. The first level has the player obliterating about 25 subs, which would mean killing about 4,000 of the defecting Soviet captain's friends and comrades.
"I never liked you, Steve!"
Then the level ends, and a new mission objective comes onto the screen:
Wait, what? OK, so apparently you made it safely to America, and now are a mercenary boat for hire? That's what the rest of the SNES version of the game is like -- sailing all over the world, using your secret super submarine to explode every vessel in the seven seas. Until the final level, where you are told:
Wait, we're supporting the rebels, right? This game is set in 1984, at the height of the Cold War ...
... and by this point you've destroyed a trillion dollars' worth of Soviet naval vessels. You're certainly not going to show up and offer help to your former government. So, you're there on behalf of the insurgents, and you proceed to destroy a fucking Soviet aircraft carrier:
Er ....
That's the end of the game. So ... how do you think the Soviet government of 1984 would have reacted to Ronald Reagan ordering a former Soviet sub to go destroy one of their carriers and the 1,500 crew on board?
Yes, a movie about a desperate attempt to prevent World War III gets turned into a game where your actions almost certainly trigger it. The message is clear: America, this is what happens when you trust a Russian.
J.F. Sargent is the managing editor of PCulpa.com. He also teaches poetry to youth that have been charged as adults in Washington, D.C. jails, and you can read his students' work here.
For more on video game failures, check out The 15 Most Annoying Video Game Characters (From Otherwise Great Games) and 8 Horribly Misguided 'Futuristic' Video Game Controllers.
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Let $\mathbb{F}_2$ denotes the free group generated by a,b, denote this group by $G$. Then consider the von Neumann algebra $L(G)$ generated by the family $\{L_{x_g} : g \in G\}$, here, with $g \in G$, we denote by $x_g$ the function on $G$ that takes the value 1 at g and 0 at other elements of $G$. Then, note that we have the following relations:
$(L_{x_g})^*=L_{(x_g)^{-1}} , L_{x_g}L_{x_h}=L_{x_g*x_h}=L_{x_{gh}}$, then, for any $ A \in L(G),$we can set $ A=\sum_{g \in g}\mu_g L_{x_g},$ with $\mu_g \in \mathbb{C}.$
When we calculate $ ||Ax_{h}||^2 $, we find that $ \sum_{g \in G}|\mu_g|^2 < \infty.$
Then, is this condition sufficient for $ A \in L(G) $? Or some stronger condition is necessary? Like $ \sum_{g \in G}|\mu_g| < \infty,$ or something else?


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Jackson Lab an example of wise spending
It was hailed as a great step forward for Connecticut's biotechnology industry. Passed in October 2011, S.B. 1401 established the Connecticut Bioscience Collaboration Program. The focal point was the Jackson Laboratory for Genomic Medicine, specifically its relocation to Connecticut from Maine and the subsequent construction of a research facility. The building will be at the University of Connecticut Health Center campus in Farmington. Jackson Laboratory's business objective is to develop person- alized medicine through genomics, with treatments tailored for individual patients based on their genetic makeup.
The legislation approved $291 million in state spending over 10 years. Funding includes $192 million to build the research center, and another $99 million to subsidize research operations during this period. Because of financing over 20 years, an additional $153 million will be spent on interest. The center will create 300 direct positions within 10 years. Many more jobs are expected to be created through spinoff companies and increased economic activity through retail operations. Genomic medicine is a growth industry that shows no signs of slowing.
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The following well known identity, where $\tau(n)$ denotes the number of divisors of $n$ appears in many number theory texts $$ \sum_{k=1}^n \tau(k) = \sum_{d=1}^n \lfloor n/d \rfloor, $$ and follows from the observation that "one out of d" integers in $\{1,2,\ldots,n\}$ are multiples of $d$ and then summing along rows $d$ as well as along columns $k$ the indicator function $1\{~ d~\mathrm{divides}~k~\}$.
Is there a good approximation, or are there any identities related to the following sum, preferably containing arithmetic functions? $$ \sum_{d=1}^n \lfloor n/d \rfloor^2 $$


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I am stuck with this problem. I posted an earlier problem with a square, where rotation with i of 90 degrees was possible. This one is a rhombus, how should I proceed?
Given ABCD is a rhombus with AC = 2BD, and b = 3 + i, d = 1 - 3i. Find a and c.
Thanks for your help.


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Love Your Body and Accentuate the Positive!
What do you love about your body and why? Do you automatically think to yourself, "Uh, nothing?" I don't know about you, but whenever I try to come up with a list of good things about myself it takes a lot of thought and time. Now, if you were to ask me what I would like to improve about my body, I could give you a list of ten things in no time flat.
Why is this? Why is it so easy for us to be self-deprecating (no matter if we are in the best or worst shape of our lives)? Yet when we are asked to name a positive or two, we really have to stop and think. And I mean really stop and think for a while, maybe even a day or two.


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The Boot Scootin' Bash and 5k Dash April Fundraiser:
This fundraiser is one of two held each year to involve our community and raise funds to support our program. We are proud to announce that this will be our 7th Annual Boot Scootin' Bash and 5k Dash April 27, 2013. We begin the day by opening our silent auction at 7:30am. Our auction consists of items we've secured through donation from our active parents or local businesses. We receive anything from movie tickets and dining gift certificates, to veterinary baskets complete with a free round of annual shots and flee, tick, and heartworm medications.
The 5k race begins at 8:00am sharp and this year we will be lucky enough to have a 1968 Corvette Convertible as our pace car for the race, graciously provided by Charles Ward who is also a member of the Beyond Boundaries board. We have both walkers and runners, both competitive and non-competitive participants and are looking to increase involvement in this fun and healthy activity.
While the race is coming to a close we begin our rider demonstrations at 8:30am. Our riders are clients that are seen for hippotherapy at our facility that volunteer to ride during our demonstrations. It's a great way to involve our friends around whom our program is focused! Both the clients and the parents enjoy participating and it gives the audience a sense of what happens during an actual hippotherapy session. It promotes overall education and awareness regarding this very specialized therapeutic tool.
Throughout the event we feature free lunch and snacks provided by Arvest Bank, Subway, and Tropical Smoothie Jacksonville. We also host booths for other community based organizations and local businesses such as Easy Runner and Sherwood Jazzercise. Our event also includes various activities for children including Home Depot's Kid's Corner. The event is free, and there is an Option A $20.00 registration fee for our 5k participants which includes a runner's gift bag and cotton race shirt. We also offer a $25.00 Option B registration that includes the registration fee, runner's gift bag and an Under Armour t-shirt. We take this opportunity to host this event at our equine facility to raise awareness regarding our program and facilitate overall community outreach. We are honored to receive support from our community.