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Internal Medicine 2014 News
Scientific Meeting News for April 12, 2014
Disclosing errors the right way
If a waiter told you he was sorry you thought your food was cold, then hurried off to another table, would it feel like a sincere apology? That's why it's important to choose your words carefully when disclosing medical errors to patients, one speaker said. More...
Smoking cessation more about controlling urges than quitting cold turkey
Frank T. Leone, MD, FACP, said he sees a lot of ambivalence about smoking cessation among the patients in his clinic. He advised physicians to think of smoking as a disorder of motivation not to quit. More...
Make quality metrics work for you
Quality metrics are key to achieving fame and fortune as a hospitalist, attendees learned Friday morning from Win Whitcomb, MD, a hospitalist and chief medical officer. More...
Consider country, culture when caring for Latino patients
Cultural competence can be defined as patients and doctors coming together to talk about their concerns without cultural barriers, Olveen Carrasquillo, MD, MPH, told attendees at Thursday's panel on "Special Issues in Providing Care to Hispanic and Latino Patients." More...
Breaking news
ACP launches care coordination toolkit to improve communication between primary care, subspecialists
ACP has unveiled a High Value Care Coordination Toolkit designed to enable more effective and patient-centered communication between primary care and subspecialist doctors. More...
For attendees
ACP to conduct Annual Business Meeting
All members are encouraged to attend ACP's Annual Business Meeting to be held today during Internal Medicine 2014. Current College Officers will retire from office and incoming Officers, new Regents and Governors will be introduced. More...
Session shines light on the Sunshine Act
A panel session will provide an overview of a provision of the Affordable Care Act that requires the public reporting of specified transfers of value by health care industry to physicians and teaching hospitals from the perspectives of industry, teaching hospitals, practicing physicians, and ethicists. More...
Panel to examine the role of subspecialists in the PCMH neighborhood
The literature reflects significant problems regarding communication and coordination of services between primary care and subspecialty practices—the transition between the patient-centered medical home (PCMH) and its medical "neighborhood." More...
It's not too late to submit a profile to the ACP Job Placement Center
Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. More...
Disclosing errors the right way
If a waiter told you he was sorry you thought your food was cold, then hurried off to another table, would it feel like a sincere apology?
Probably not. We know what a sincere apology feels like, and patients do, too. That's why it's important to choose your words carefully when disclosing medical errors to patients, said Wendy Levinson, MD, FACP, a professor in the department of medicine at the University of Toronto Institute of Health Policy, Management and Evaluation, in a Friday session titled "Disclosing Medical Errors to Patients: Considering Where, When and How."
In an error disclosure, patients want to hear an explicit statement that an error occurred, what happened and the implications for their health, why it happened, and how recurrences will be prevented in the future for themselves and other patients.
"And they want an apology. Not a statement of regret like, 'I'm sorry this happened to you,' but a statement such as 'I'm sorry I caused you harm,'" Dr. Levinson said.
Several groups around the world have studied the optimal way to disclose errors, she added. This work, from organizations such as the U.S. National Quality Forum, the Canadian Patient Safety Institute, and the U.K.'s National Patient Safety Agency, tends to have the following guidelines in common:
Begin by stating you regret to say there has been a mistake (or error);
- Describe the course of events, using nontechnical language;
- State the nature of the mistake, consequences, and corrective action;
- Express personal regret and apologize;
- Elicit questions or concerns and address them; and
- Plan the next step and next contact (with the patient).
"This is harder than it sounds," Dr. Levinson said. "I've run workshops with fake patients where the physicians are sweating as they practice this. I encourage you to do some role playing around error disclosure."
One tricky issue is whether and how to disclose errors made by other clinicians. Ideally, your institution should offer guidance in how to handle this situation, and you feel comfortable approaching your colleagues to discuss situations that arise.
The disclosure strategy for errors by a colleague likely will depend on the clinical situation, such as whether it involved a physician with whom you were co-managing, or a trainee, or a clinician who didn't have direct contact with the patient.
In the case of co-managing physicians, both should participate in the disclosure regardless of who made the error. In the case of a trainee error, the attending physician and the trainee both should be involved, Dr. Levinson said.
Attendings also should handle disclosure of errors made by a clinician who didn't have direct contact with the patient, although the clinician who made the error should be invited to join if desired, she said.
If the error occurred at another institution or is unrelated to current care, the disclosure should be handled by the medical director at the institution currently caring for the patient, after consultation with the clinician who made the error and/or with the outside institution, she said.
It's important to remember, too, that the actions following an apology are as important as the words used in the apology, said co-speaker Thomas Gallagher, MD, FACP, professor of medicine and of bioethics and humanities at the University of Washington School of Medicine in Seattle.
"We've often been too focused on the words we say to patients but in some respects what's more important are the broader set of actions that follow," Dr. Gallagher said.
Those actions can include institutional changes. Knowing that those are in the works can be a great comfort to patients, who often want to believe that their experience might lead to a positive change for others, he said.
Still, clinicians are often fearful about disclosing errors, he added. "They are anxious about an unpredictable, punitive response by institutions, regulators, and malpractice insurers. And [this fear] hampers efforts to learn and prevent recurrence," he said
Institutions have begun to embrace the idea that errors are their responsibility as well as the responsibility of individual clinicians, Dr. Gallagher said. "Communicating with patients after an unanticipated outcome is now seen as a broader part of how we think about high-quality health care; it isn't just about risk management," he said.
To make their disclosures high quality, institutions should be candid and transparent about unanticipated outcomes, conduct a rapid investigation, offer a full explanation, and apologize as appropriate, Dr. Gallagher said. Furthermore, where appropriate, the institution should seek to provide for the patient's and family's financial needs resulting from the error without requiring recourse to litigation.
Finally, the institution should build systematic patient safety analysis and improvement into its risk management plan, he said.
"Currently, ours is often a system of accountability that doesn't adequately service the patient's need for information, for our accepting responsibility, for timely compensation [when appropriate], and for a sense that we've learned from the mistake," said Dr. Gallagher. "We need to demonstrate to the patient and the public that learning is happening; in many ways, this is the most important thing we miss."
Smoking cessation more about controlling urges than quitting cold turkey
Frank T. Leone, MD, FACP, said he sees a lot of ambivalence about smoking cessation among the patients in his clinic.
"I want to want to quit," a patient once told him.
His reaction and advice to attendees of his "Smoking Cessation in Primary Care" at Internal Medicine 2014 on Friday morning was, "Think about smoking as a disorder of motivation: not a disorder that's a deficit of motivation to quit, but rather, as a disorder characterized by excess motivation not to quit."
Dr. Leone, who is an associate professor of medicine and director of the Comprehensive Smoking Treatment Program at the University of Pennsylvania in Philadelphia, explained how to turn patient ambivalence into action.
He explained that nicotine works on not the conscious part of a person's thinking, but the survival system of the brain located in the cortex to midbrain. Nicotine creates long-term changes in the brain, including:
- an increase in neuronal arborization as the patterns linking neurons to one another are altered,
- an increase in the density of nicotine receptors, and
- changes in gene expression.
Brain cells maintain these changes, which can result in relapses for years after quitting.
And, nicotine hijacks these brain systems to create a sense of safety and calm. Taking it away causes a negative reaction, and this is what Dr. Leone says he sees in his clinic.
"It's an uncertainty, a visceral uncertainty that stopping now is the right thing to do," he said. "So there's a conundrum. The thinking part of [the patient] says to quit, the visceral part of [the patient] says not today. And [the patient] is stuck between those 2 sides going back and forth, back and forth."
He continued, "I think of this as the cardinal sign of the illness, the same way I think of wheezing as the cardinal sign as asthma or COPD. When I see ambivalence to quit, I'm not afraid of that. I'm not repelled by that. I can't use that as my signal not to treat because it's the cardinal sign."
He offered suggestions on using drugs and devices to help patients control their urges to smoke using nicotine replacement therapy.
Nicotine patches offer a way to deliver controller medications that may reduce the frequency and intensity of the compulsions to smoke. The urges don't disappear, but they become more manageable, he said.
He suggested starting with a high dose to get control and then tapering it. Package inserts say to taper the patch over 8 to 10 weeks, but there are a lot of data that support treating patients longer for better patient response, he noted. While treating for 6 months is good, Dr. Leone said, doing so for 12 months works as well. Using the patch compared to placebo will increase a patient's sensation of control about twofold.
The time frame should be chosen in conjunction with the patient. "If [the patient] is still jonesing at 10 weeks, she's going to come into the office and say should I stop the patch now. That to me is an expression of a misunderstanding on [the patient's] part. She thinks she's supposed to quit, not get control."
The most common side effect of nicotine patches is local irritation, either from the nicotine itself or the adhesive used on the patch. If it's about the adhesive, the redness will be wider than the patch. If it's the nicotine, the redness will be under the patch. Either way, a little dab of hydrocortisone cream before application will cure those 2 side effects, Dr. Leone said.
Patients who smoke on the patch may ask about smoking while on the patch. In the doctor's mind, that means the patient won't smoke. More likely, it means the patient won't use the patch, Dr. Leone said. Tell the patient regardless of smoking to leave the patch on. "Smoking on the patch results in … um … how do you say it? 'Nothing,'" he said.
Patients using nicotine replacement therapies who continue to smoke change their smoking behavior. They take fewer puffs, they take smaller puffs, and their baseline nicotine levels remain the same, Dr. Leone said.
Gums and lozenges are placed next to the oral mucosa and are used instead of a cigarette when patients want to smoke. They generally increase sensation of control by about 50%. Dr. Leone advises patients to use these products like chewing tobacco, not chewing gum, because chewing releases acid to the stomach and makes the patient feel nauseated. Also, the product doesn't get absorbed and it's rendered useless, Dr. Leone said.
Inhalers aerosolize nicotine to the back of throat via a plastic tube and a liquid nicotine cartridge. There are 450 different versions of these products, which are popular with patients, in the U.S., ranging from options that allow people to mix their own cartridges to disposable units found at convenience stores to much more expensive computerized kits.
"None of them have any data on efficacy, how you use them, or how often you use them," Dr. Leone cautioned, adding that there are also no safety data about what happens when patients absorb other products they contain, such as propylene glycol, for years of use.
Two drugs started prior to quit attempts may help patients succeed, Dr. Leone said. Bupropion improves odds of sensations of control 2-fold, he said. While package labels say to start the drug 7 to 10 days before quitting, a lot of data suggest using it 4 weeks prior actually works better.
In the clinic, he tells patients to start bupropion and then "Don't quit smoking."
He added, "I've removed a total obstacle for her not using the medication, because now, it's not about her quitting, it's about how she feels on the inside, and all she has to do is take a pill."
The same is true for varenicline. While it's prescribed for 1 week prior to quitting, it could require 4 weeks to reach effect. The drug comes in a blister pack marked with an arrow indicating that patients should quit smoking on the seventh day of use. Again, he tells patients to ignore that instruction and to keep smoking until the next check-in. Data suggest that going for a total of 5 weeks helps control later urges to smoke, he said.
Contrary to lay media reports about psychiatric disturbances, varenicline simply doesn't cause them, Dr. Leone said. While the drug was associated with a 10-fold increase in sleep disorders, these can be alleviated by taking the drug with food at breakfast and dinner, and not at bedtime, he noted.
Make quality metrics work for you
Quality metrics are key to achieving fame and fortune as a hospitalist, attendees learned Friday morning from Win Whitcomb, MD, a hospitalist and chief medical officer for Remedy Partners, a health care services company in New York City that administers bundled payments.
It probably won't be celebrity-level fame and fortune—although Dr. Whitcomb did point out that both U.S. News & World Report and Consumer Reports publish hospital ratings—but measures are beginning to carry real money and the chance "to be publicly embarrassed or publicly made to look wonderful," he said.
Readmissions penalties and value-based purchasing (VBP) are scheduled to affect an increasing percentage of hospitals' Medicare payments over the next few years, and hospital-acquired conditions will attract new penalties beginning in 2015. The numbers may be small right now, but they will add up.
"By the time we get to 2017, with these 3 programs, a medium-sized hospital will have $5 million at risk," said Dr. Whitcomb.
Those numbers may frighten hospital executives, but hospitalists who provide high-value care could actually benefit, because their efforts will be essential to hospitals' financial success. "I see this as a major opportunity for hospitalists," Dr. Whitcomb said.
Hospitalists will also be involved in CMS's new effort to evaluate and reward health care efficiency. The measure, which debuts in 2015 but will actually be based on 2013 data, compares all Medicare Part A and B spending per beneficiary from 3 days prior to a hospitalization to 30 days after discharge. "It's actually a lot like a bundled payment," said Dr. Whitcomb.
Another change to quality measures is that they're going to begin affecting physician income, and not just as a trickle-down from hospital charges. Medicare's Value-Based Payment Modifier (VBPM) will raise or lower physician payments by 1% or 2%, starting with groups of 100 or more doctors in 2015 and including all doctors in 2017.
That's not a lot of money, Dr. Whitcomb noted, and the Physician Quality Reporting System (PQRS), on which the VBPM is based, has only lured 30% of physicians to participate. "It's been a hard program to participate in," said Dr. Whitcomb, who showed calculations indicating that a typical hospitalist with $450,000 in annual charges would only gain about $700 in the PQRS program.
The VBPM measures relevant to hospitalists include things like prescribing antiplatelets to patients with coronary artery disease, screening for dysphagia after stroke, and treating atrial fibrillation with warfarin. "You and I can decide whether these are our picture of what a great hospitalist is or not," said Dr. Whitcomb.
That debate is the biggest problem with quality metrics, said Dr. Whitcomb, whose talk was subtitled "The Good, the Bad and the Ugly." Critics have charged that the qualities of hospitalists that really count—including timely diagnosis and treating complicated patients—aren't measured.
And it's clear that documentation decisions have a major impact on results. For example, concern over hospital-acquired conditions will likely drive your hospital's coding experts to flag any catheter-associated infections you note, if they haven't started already. "Think about what you write in the chart," said Dr. Whitcomb advised.
Another challenge is the difficulty of measuring the performance of any individual physician, which there will be an increasing push to do. "Any outcome measure that's applied at the individual physician [level] is very tough to do," Dr. Whitcomb said.
He showed the audience an example of his own Joint Commission-required Ongoing Professional Practice Examination (OPPE) report, describing the statistics on it as "mysterious." This measurement, which compares one's resource utilization and metrics like 30-day mortality to an unspecified peer group, is meant to eventually determine physician credentialing, but how that would work is "very vague right now," he said.
Then there's patient satisfaction scoring. The HCAHPS were never meant to assess satisfaction with individual physicians, and even more targeted surveying, such as that done by Press Ganey, poses problems when hospitalists are compared to other physician specialties.
According to such surveys, "Patients are least satisfied when they are on the psychiatry inpatient service. Next to that it's us," Dr. Whitcomb said, to laughs from the audience. Patients admitted through the emergency department also have particularly low satisfaction, meaning that hospitalists are very likely to score low in across-specialty comparisons. "We really need to be compared to like physicians," he said.
Dr. Whitcomb encouraged his audience to push their hospitals for hospitalist-specific satisfaction surveying. He also suggested they investigate the metrics they're being measured on, asking questions like "If you're being measured on a process measure, is it something that affects outcomes? If it's an outcome, is the sample size big enough to be valid?" and "Is it something you have influence over?"
In answer to that last question, it may necessary to broaden your perspective to encompass new, more expansive concepts of team care, such as accountable care organizations. "I think we have to get past that thing of 'We have no control over it,'" said Dr. Whitcomb. "Maybe you do have control if you work as a team."
And, finally, whether you're evaluating, reviewing, or just complaining about quality metrics, don't forget the whole reason for their existence. "Quality metrics to me don't mean all that much if we don't move past measurement to improvement," said Dr. Whitcomb. "Isn't that the real reason why we're here? Let's not lose sight of that."
Consider country, culture when caring for Latino patients
Cultural competence can be defined as patients and doctors coming together to talk about their concerns without cultural barriers, Olveen Carrasquillo, MD, MPH, told attendees at Thursday's panel on "Special Issues in Providing Care to Hispanic and Latino Patients."
Doctors did their own version of that during the session, airing concerns related to caring for Latino patients. (The terms Hispanic and Latino are mostly interchangeable, Dr. Carrasquillo noted, although Hispanic is more prevalent in Texas and Latino in California, and the latter term is preferred by some because it has less of a colonial connotation.)
Dr. Carrasquillo, a professor of medicine at the University of Miami, started the session by offering some background on Latino demographics. Latinos are a rapidly growing ethnic group (not a race, since the definition is based on country of origin rather than skin color, he noted) in the U.S., expected to comprise 1 in 3 Americans by 2060.
The bad news in Latino health is that many Latinos lack insurance coverage, and the decision of many Latino-heavy states to refuse Medicaid expansion means that relatively few will gain coverage under the Affordable Care Act. "If we include the undocumented, it's about 40% to 50% of Latinos that are not going to benefit from health insurance expansion," said Dr. Carrasquillo.
The good news is that U.S. Latinos continue to live longer than their peers despite limited access to care and higher rates of some conditions, including obesity and diabetes, a phenomenon known as "the healthy Latino," Dr. Carrasquillo said.
"Hispanics have much lower death rates than blacks and even non-Hispanic whites," he said. Researchers have thoroughly examined this decades-long disparity in life expectancy and have still not found an answer, he reported.
More answers have been found, however, about the best ways to make a medical practice welcoming to Latino patients. Brendaly Rodriguez, a health communication specialist at the University of Miami, offered some general suggestions.
"It's not a checklist, because it could lead to oversimplification and thinking that all Mexicans believe [this or] that," she said. Physicians should try to learn specifically about the patients they're treating by collecting information about race, ethnicity, primary language spoken, and even the history of the patient's country of origin.
"To know about Dominicans, you need to know about the Trujillo years," Ms. Rodriguez gave as an example, referring to the dictator Rafael Trujillo, who controlled the Dominican Republic from 1930 to 1961.
She encouraged clinicians to ask open-ended questions, investigate patients' barriers to care, and use community health workers. She also strongly urged practices to use professional translators, rather than relying on friends and family (whose stake in the conversation could lead them to distort the translation) or one's own less-than-fluent language skills.
One audience member asked about learning more medical Spanish to communicate with his patients, and the panelists lauded his intentions but cautioned him not to tackle any complex conversation. "Patients greatly appreciate you making any effort to speak their language, but you really shouldn't wing it," Dr. Carrasquillo said.
Another audience member asked for any advice on improving patient satisfaction scores among Hispanic patients, who tend to rate satisfactory care at a lower number. Dr. Carrasquillo said he hasn't found a good solution yet, having seen 1 hospital instruct patients to give 5s and others lobby the measurement companies to adjust Hispanic patients' scores. "Often their anchoring point is around 3 or 4," he said.
Palliative care may be another area where clinicians notice differences in how Latino patients respond. "There's more honesty about end of life. We try less futile care," said panelist Moises Auron, MD, FACP, a hospitalist at the Cleveland Clinic. "The main thing is being very open with the patient and the family and explaining what palliative care means. When they understand it is not throwing in the towel, it is changing the context of medical care, it is very welcome."
The importance and influence of family should be a major consideration in planning end-of-life discussions, the experts agreed. Family involvement affects a number of aspects of medical care, they said, from weight loss plans (if you want a patient to exercise, make classes open to the whole family and don't give a healthy Mexican cookbook to Salvadorans) to prescriptions (an elderly patient's adherence may depend on her daughter's ability to afford medications).
But, finally, there are some differences that a physician just has to accept. One audience member asked whether she should call the FDA about her concern: "The patients are going to these Hispanic supermarkets, and the stores are selling antibiotics and other medications that are not controlled."
Dr. Carrasquillo advised that if you want to effectively engage the community it may be better not to call the authorities. "It would create high levels of community distress and you would never be able to walk into a bodega again," he said. Instead, talk to those selling the medications about your concerns and try to work together toward your mutual goal of good health for Latino patients.
Breaking news
ACP launches care coordination toolkit to improve communication between primary care, subspecialists
ACP has unveiled a High Value Care Coordination Toolkit designed to enable more effective and patient-centered communication between primary care and subspecialist doctors.
"Physicians need specific information to do their jobs effectively," said Molly Cooke, MD, MACP. "The High Value Care Coordination Toolkit facilitates clear communication between primary care and subspecialist practices so that doctors can provide seamless, coordinated, and quality care to their patients."
The toolkit was developed collaboratively through ACP's Council of Subspecialty Societies (CSS) and patient advocacy groups. CSS acts as a forum for the exchange of ideas between ACP and subspecialty organizations on matters affecting medicine in general and subspecialty societies in particular. The High Value Care Coordination Toolkit includes 5 components:
- a checklist of information to include in a generic referral to a subspecialist practice,
- a checklist of information to include in a subspecialist's response to a referral request,
- pertinent data sets reflecting specific information in addition to that found on a generic referral request to include in a referral for a number of specific common conditions to help ensure an effective and high-value engagement,
- model care coordination agreement templates between primary care and subspecialty practices and between a primary care practice and hospital care team, and
- an outline of recommendations to physicians on preparing a patient for a referral in a patient- and family-centered manner.
These resources are the latest components in ACP's High Value Care initiative, which is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.
Health care expenditures are currently 17% of the U.S. gross domestic product, and many economists consider this spending unsustainable. Up to 30%, or $765 billion, of health care costs were identified as potentially avoidable, with many of these costs attributed to unnecessary services.
For attendees
ACP to conduct Annual Business Meeting
All members are encouraged to attend ACP's Annual Business Meeting to be held today during Internal Medicine 2014. Current College Officers will retire from office and incoming Officers, new Regents and Governors will be introduced.
The meeting will be held today in Room 315 at the Orange County Convention Center from 12:45 to 1:45 p.m., with outgoing ACP President Molly Cooke, MD, MACP, presiding. Robert A. Gluckman, MD, FACP, will present the Annual Report of the Treasurer.
A key feature of the meeting is the presentation of ACP's priorities for 2014-2015 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.
Session shines light on the Sunshine Act
A provision of the Affordable Care Act requires the public reporting of specified transfers of value by health care industry to physicians and teaching hospitals. A panel session today, "Shining Light on the Sunshine Act: Everything You Need to Know," will provide an overview of this provision from the perspectives of industry, teaching hospitals, practicing physicians, and ethical perspectives, including how this provision can affect internists and how to make sure the information reported is accurate.
Data collection for 2013 began on Aug. 1, 2013, and is scheduled for public reporting on Sept. 31. 2014. While physicians have no formal obligations regarding this legislation, they will have the right to review and dispute any industry-reported information prior to public display.
The session is scheduled from 11:15 a.m. to 12:45 p.m. in room 311 EH. Speakers will include Aaron S. Kesselheim, MD, JD, MPH (Harvard); Pamela L. Mason, BS, CCMEP, FACME (AstraZeneca); and Frederick G. Savage, JD (Johns Hopkins).
Panel to examine the role of subspecialists in the PCMH neighborhood
The literature reflects significant problems regarding communication and coordination of services between primary care and subspecialty practices—the transition between the patient-centered medical home (PCMH) and its medical "neighborhood." In a panel session today titled "The Role of Subspecialists in the PCMH Neighborhood," experienced clinicians will focus on several ongoing approaches of addressing this issue and facilitating more effective and efficient referral engagements, including:
- the development of a care coordination toolkit through a collaboration of members of ACP's Council of Subspecialty Societies and patient advocates,
- the use of and physician attitudes regarding "preconsultation" exchanges, and
- the use of e-consultations and e-referrals as a complement and alternative to traditional face-to-face consultations.
The panel is scheduled from 2:15 p.m. to 3:45 p.m. today in room 311 EH. Speakers include Deidra C. Crews, MD, ScM, FASN; David C. Kendrick, MD, MPH, ACP Member; and Justin L. Sewell, MD, MPH, FACP.
It's not too late to submit a profile to the ACP Job Placement Center
Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile.
All physicians who submit a Job Seeker's Profile (limit, 1 mini-CV per physician) will be eligible for a drawing for a $100 Amazon gift card on April 12. Winners will be contacted by e-mail.
The Job Placement Center, located in the Exhibit Hall, Booth 1075, provides physicians with tools to assist in job searches, as well as the opportunity to meet with potential employers.
Submit your profile online today.
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ACP Internist Weekly
From the February 14, 2017 edition
- Nonpharmacologic treatment first for low-back pain, ACP guideline recommends
- Women with breast cancer at high mutation risk report barriers to genetic testing in recent survey
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text: Welcome to Sleepdoctorradio.com! You will find this website useful if you are a fan of the "sleep doctor", Michael Breus or simply have an interest in sleep disorders. Please feel free to browse our informative articles to find additional information on the man himself or the disorders that he treats.

subset: commoncrawl


text:
Breast cancer is the most common malignancy among women in the United States and many other parts of the world. Genetic factors play an important role in the etiology of breast cancer. Recent genome-wide association studies (GWAS) have identified multiple genetic susceptibility loci for breast cancer. However, these newly- identified genetic factors, along with high-penetrance susceptibility genes reported previously (such as the BRCA1 and BRCA2 genes), explain only a small fraction of genetic variation for breast cancer. In this application, we propose two novel projects that will significantly advance our understanding of the genetic basis for breast cancer and the methodology used for genetic epidemiologic research. The first project is a GWAS based on the newly-established Asia Breast Cancer Consortium and will include over 27,000 cases and controls recruited from 11 studies conducted among Asian women living in various parts of the world. Through analyzing GWA scan data from 3,500 cases and 3,500 controls, we will identify and evaluate the top 8,500 SNPs in an independent set of 3,500 cases and 3,500 controls and then validate approximately the top 100 SNPs in 6,700 cases and 6,700 controls. In the second project, we will sequence eight GWAS-mapped regions in 3,000 cases and 3,000 controls with the goal of identifying additional genetic risk variants, particularly low- frequency variants, for breast cancer in these regions. We will select up to 180 promising SNPs for replication in an independent set of 2,500 cases and 2,500 controls and then select the top 30 SNPs for further evaluation in another independent set of 2,500 cases and 2,500 controls. This is the only well-powered GWAS conducted in Asian women, and thus is the only existing GWAS capable of discovering genetic variants for breast cancer that are unlikely or more difficult to identify in other GWAS. The proposed sequencing project represents a new model for future genetic association studies. These two newly-proposed projects will be built upon several well- conducted, NCI-funded studies to generate substantial novel information that will help to not only understand breast cancer biology and genetics, but also to improve risk assessment models and identify high-risk women for cost-efficient prevention of breast cancer.
Genetic factors play a major role in the etiology of breast cancers, yet only a small number of cases are explained by genetic factors identified thus far. The large epidemiologic study we propose will comprehensively evaluate genetic markers in relation to breast cancer risk. This study will generate valuable results for the identification of high-risk women for the primary and secondary prevention of breast cancer.
|Wen, Wanqing; Zheng, Wei; Okada, Yukinori et al. (2014) Meta-analysis of genome-wide association studies in East Asian-ancestry populations identifies four new loci for body mass index. Hum Mol Genet 23:5492-504
|Agarwal, D; Pineda, S; Michailidou, K et al. (2014) FGF receptor genes and breast cancer susceptibility: results from the Breast Cancer Association Consortium. Br J Cancer 110:1088-100
|Zhang, Yanfeng; Long, Jirong; Lu, Wei et al. (2014) Rare coding variants and breast cancer risk: evaluation of susceptibility Loci identified in genome-wide association studies. Cancer Epidemiol Biomarkers Prev 23:622-8
|Zhang, Ben; Jia, Wei-Hua; Matsuo, Keitaro et al. (2014) Genome-wide association study identifies a new SMAD7 risk variant associated with colorectal cancer risk in East Asians. Int J Cancer 135:948-55
|Milne, Roger L; Burwinkel, Barbara; Michailidou, Kyriaki et al. (2014) Common non-synonymous SNPs associated with breast cancer susceptibility: findings from the Breast Cancer Association Consortium. Hum Mol Genet 23:6096-111
|Cai, Qiuyin; Zhang, Ben; Sung, Hyuna et al. (2014) Genome-wide association analysis in East Asians identifies breast cancer susceptibility loci at 1q32.1, 5q14.3 and 15q26.1. Nat Genet 46:886-90
|Zhang, Ben; Jia, Wei-Hua; Matsuda, Koichi et al. (2014) Large-scale genetic study in East Asians identifies six new loci associated with colorectal cancer risk. Nat Genet 46:533-42
|Long, Jirong; Delahanty, Ryan J; Li, Guoliang et al. (2013) A common deletion in the APOBEC3 genes and breast cancer risk. J Natl Cancer Inst 105:573-9
|Shi, Jiajun; Sung, Hyuna; Zhang, Ben et al. (2013) New breast cancer risk variant discovered at 10q25 in East Asian women. Cancer Epidemiol Biomarkers Prev 22:1297-303
|Jia, Wei-Hua; Zhang, Ben; Matsuo, Keitaro et al. (2013) Genome-wide association analyses in East Asians identify new susceptibility loci for colorectal cancer. Nat Genet 45:191-6
Showing the most recent 10 out of 13 publications


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KIMT News 3- The current presidential election has garnered a lot of attention; on the Republican side, 17 candidates emerged allowing for many options for early primary and caucus states. On the Democratic side, Former Secretary of State Hillary Clinton and Vermont Senator Bernie Sanders have been locked in almost a virtual tie in New Hampshire and Iowa. In order to move forward to the National Convention candidates need to gain enough delegates, but the number of candidates on the Republican side, as well as the tight race on the Democratic side, makes this hard to do.
Experts are now talking about a possible Brokered Convention or Contested Convention as a way to alleviate these issues. According to our political analyst, Bennett Smith, a Contested Convention can happen before a single vote occurs in the National Convention. A Brokered Convention happens after the National Convention and candidates still don't have enough support, which also allows for pledged delegates to support other candidates.
"This could make for a very interesting race," says Smith. "On the Republican side, I can see a 3 candidate race, but if they don't get the 1,237 delegates needed, the pledged delegates for candidates who have dropped out now can support another candidate. Another interesting fact about the Republican side is the "threshold". Many of the up coming states require a certain percentage of delegates to qualify as a way to reduce the number of candidates."
"On the Democratic side, this will have a huge effect because of how close the race is," says Bennett. "If we go into one of these conventions pledged delegates could jump on to one of the other candidates changing the race completely."
Smith also says many of the upcoming states will have a huge impact on the number of delegates candidates will have, while most states before March 14 allow candidates to win a certain number of delegates, others, like Florida and Ohio, are winner-take-all.


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Last Updated on 4 Dec. 2009,
Total: 14 Knowledge Base Tips
Modifing the Pairwise Master Key (PMK) and Preauthentication settings for better roaming... Read More
How to encrypt files easily from Windows Explorer... Read More
Want to right-click on a .msi file and select Run As? Here's how!... Read More
To enhance security you can prevent users from using the RunAs command... Read More
This article continues the discussion of FSRM notifications by taking a detailed look at the New-FsrmFmjNotification cmdlet... Read More
As we explained in the Part 1 of this article series, although you have designed an Active Directory Health check procedure that includes important Active Directory health check items to be checked and keep you informed of any failures or misconfigurations, but there are a few health check items that many Active Directory admins forget to include... Read More
Tip explains how to get manually created replication connection objects in an Active Directory Forest... Read More
Tip explains how you can check object replication status Active Directory forest... Read More


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Asus Unveils ZenFone 2 Laser Smartphone
Starting at $199 with 16GB of storage, the ZenFone 2 Laser is a GSM phone that features an octa-core processor and a 13MP main camera.Asus has announced its ZenFone 2 Laser smartphone, the latest model in its ZenFone lineup, featuring a 5.5-inch 1080p Full HD display, 16GB or 32GB of built-in storage, and dual SIM slots for travelers. The ZenFone 2 Laser, which was unveiled Nov. 2, also includes an octa-core Qualcomm Snapdragon 615 processor that consists of a quad-core 1.7GHz ARM Cortex A53 CPU and a quad-core 1.0GHz ARM Cortex A53 CPU, Adreno 405 graphics, 3GB of memory and an SDXC memory card slot that holds cards of up to 128GB. The smartphone, which will be available in November, is priced at $199 for a 16GB model and $249 for a 32GB model. The phone's touch-screen display is protected by Corning Gorilla Glass 4 and can be operated even while wearing gloves, according to Asus.
Also built into the handset is an auto-focus, 13-megapixel PixelMaster rear-facing main camera that has a wide-angle F/2.0 lens built with five elements, as well as dual LED flash that helps the camera capture images in low light. Plus, the phone has a 5-megapixel, F/2.0 wide-angle front-facing camera and is capable of Full HD video recording and playback.
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Tomorrow: Our 10 Best Wintery Restaurants
Check back here tomorrow for our picks for the 10 best wintery restaurants in the city: Places that have an increasing appeal as the temperature plummets. We're thinking of wood-burning ovens, hearty, insulating food, fireplaces, and dishes warm with spice (though, yes, we know that technically chiles cool you down). Do you have a favorite spot that takes the chill out of your bones? Let us know in the comments.
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Our weekly guide to New York dining includes food news and reviews, as well as dining events and interviews with chefs and restaurant owners.
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Newegg.com - A great place to buy computers, computer parts, electronics, software, accessories, and DVDs online. With great prices, fast shipping, and top-rated customer service - once you know, you Newegg.
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Showing Results: Most Recent
This review is from: WD 3TB My Book Desktop External Hard Drive - USB 3.0 - WDBFJK0030HBK-NESN
Pros: Low power consumption
Price can be cheaper than buying the drive inside by itself
Whisper quiet
No bright lights
Good ventilation holes
Sleek enclosure design
Cons: No fan to dissipate heat
Drive inside is only 5400 RPM
Plug to wall takes up too much room
Other Thoughts: I've only had this for less than a week but so far I'm quite happy with my purchase. I've loaded it up about half full and so far everything is working very well. Even though it doesn't have a fan it doesn't get too hot. A different enclosure I have without a fan the drive gets so hot I fear it might damage it, this is not the case with this. At best I can feel a slight warms when touching the enclosure or feeling the vents for heat. The drive inside is WD WD30EZRX which spins at only 5400 RPM but only takes up 6W of power on load which is partly why no fan is needed. It is whisper quiet because of the good enclosure design. At arms length away you will not be able to notice that it's on except for the light which is a nice soft white. The power plug does not have a power brick in the middle so the plug to the wall is a bit of a brick, not oversized but I'd rather the brick be in the middle of the cord to free up space on the wall outlet. I purchased this for cheaper than it costs for the drive inside. Packaged software that it comes with is good but as I'll be using it for a NAS I have not used it too much. Excellent buy so far. Gave 4 eggs for the cons though I suppose it would have been more expensive had it fixed those issues.READ FULL REVIEW
This review is from: TRENDnet TEW-652BRP 802.11b/g/n Wireless N Home Router up to 300Mbps/ 10/100 Mbps Ethernet Port x4
Pros: My parents have been using this for a few years now and they've experienced no significant issues. They just use it for browsing mostly.
Cons: I wouldn't recommend it for gaming.READ FULL REVIEW
This review is from: Asus VE228H 21.5" Full HD HDMI LED BackLight LCD Monitor w/Speakers ASCR 10,000,000:1
Pros: Bright colors
Good sound quality
Lots of inputs / outputs
Good response rate
Cons: Nothing I can think of
Other Thoughts: I've had this for almost 1.5 years and this thing is still great! It's perhaps not as good as monitors that are double this price, I paid $159 for this Nov 2010, but for the price it is great. The sound is what you would expect from 2W speakers and it has audio in, audio out, hdmi, dvi and all that you would expect out of a gaming monitor. No dead spots or always on spots after 1.5 years so far. Looking forward to it lasting much longer.READ FULL REVIEW


text:
This Lent, take a 40-day devotional journey with Dietrich Bonhoeffer. Click here to sign up.
9:1 After these things had been done. That is, four and a half months after arrival (7:9; 10:9).
the officials approached me and said. Ezra had come to teach the law (7:10 note) and now some of the leaders came to him to report certain sins. Possibly they were responding to his teaching.
have not separated themselves. The point was the difference of religion, not race, as the following verses indicate (vv. 10–12; 4:3 note).
the peoples of the lands. Of those listed, only the Ammonites, Moabites, and Egyptians were present in the days of Ezra. The others were in the land during the Conquest under Joshua, and the mention of them could have brought to mind the original prohibitions against intermarriage (Ex. 34:10–16; Deut. 7:1–4).
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The BC Humanist Association is proud to host political scientist Edwin Hodge who will be speaking about hate speech on the internet. This topic is especially pertinent given the federal government's recent repeal of Section 13 of the Canada Human Rights Act that regulated hate speech on the internet.
His abstract:
The Internet has been something of a double edged sword for most of its existence. While offering people all over the world access to information they might never have seen otherwise, modern communications technology also proved to be a boon to racist organizations desperate to get their message out. To a great extent, their attempts have been successful; there are now more than 1000 known hate groups present in the United States, and their numbers continue to grow. These groups are religious, secular, white supremacist, black supremacist, anti-Semitic, anti-government, and many other flavours besides, with the vast majority hewing to one form of explicit (and violent) white supremacy or another. How has their message been adapted to fit into the digital age? How do they recruit? Who are their leaders, and who joins their causes? How does one counter an idea that can spread around the world in the blink of an eye? How can a person recognize racist speech – especially when it has been specifically tailored to appear non-racist?
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text: Imagine being able to consume 250,000 calories daily without gaining weight. If you had the metabolism of a shrew you could. And while most of us can't hold our breath for more than a few minutes, the Weddell seal can remain underwater for a full 75 minutes! Through many amazing examples this audio discusses the mechanisms humans and other creatures have evolved to gauge their need for food, gather water and oxygen, circulate blood, regulate body temperature, respond to stressful situations, and maintain other survival needs.


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Newegg.com - A great place to buy computers, computer parts, electronics, software, accessories, and DVDs online. With great prices, fast shipping, and top-rated customer service - once you know, you Newegg.
If you are reading this message, Please click this link to reload this page.(Do not use your browser's "Refresh" button). Please email us if you're running the latest version of your browser and you still see this message.
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Showing Results: Most Recent
This review is from: GeIL Black Dragon 8GB (2 x 4GB) 240-Pin DDR3 SDRAM DDR3 1333 (PC3 10666) Desktop Memory Model GB38GB1333C9DC
Pros: Was cheap and worked like RAM should. Passed memtest with flying colors and even has a pretty cool design.
Cons: I was just looking to pick up another 8 gigs for an overhaul of my wife's desktop and it's discontinued...what a shame.
Other Thoughts: I guess I should have bought at least 32 gigs worth while it was for sale.READ FULL REVIEW
This review is from: GIGABYTE GA-H61M-DS2 LGA 1155 Intel H61 Micro ATX Intel Motherboard
Pros: Solid board for the price, though I did not purchase through newegg. Booted first time and ran like a champ. Initially paired it with a Pentium G860 which handled everything great except some of the more demanding games of today.
Cons: I looked at the cpu's this board supported on the gigabyte website and decided to go with an i5 3570 (non-K). I saw that it needed a bios update to do so, which is no big deal. What I didn't realize is there are 3, yes 3 revisions to this board. I had rev 1.0 which will NOT IN ANY WAY support the i5 3570 (non-K) ivy bridge part.
Also, whoever designed the SATA layout needs to be publicly shamed. It's not a problem if you use a small GPU or onboad graphics, but my GTX 560 covers ALL FOUR PORTS. Luckily I had a couple of low profile 90* SATA connectors laying around and it was more of an annoyance than a show-stopping problem.
Other Thoughts: If you think you may upgrade to a different cpu, CHECK YOUR REVISION NUMBER!!! I had to buy a new motherboad since I couldn't send the CPU back because I already used it. Guess you live and learn. I'm temped to give it only 3 eggs simply for asanine placement of the SATA ports and horrible revisioning, but those have noting to do with how well the board performed.READ FULL REVIEW
This review is from: ZOTAC GeForce GTX 560 (Fermi) DirectX 11 ZT-50708-10M 1GB 256-Bit GDDR5 PCI Express 2.0 x16 HDCP Ready SLI Support Video Card
Pros: Played all of the games i like maxed out.
Cons: Purchased on October 20th, 2012. Card then commited suicide while playing Fallout: New Vegas on January 21, 2013. Heard a pop, then no video at all. Could smell it and the fan won't even come on.
Other Thoughts: Zotac just lost a customer. The rebate took longer than stated and would have never come if I had left them alone. Now I fear I'll be stuck with Intel video for the next month while they take their sweet time on the RMA, not to mention this card was discontinued a couple of weeks after I got it. I new it was too good to be true. A GTX 560 for $114 after rebate. Guess I've learned my lesson.READ FULL REVIEW


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Required Reading
- The Russia Story: Everything Donald Trump Doesn't Want You to Know
- Secession Planning in California: CALEXIT is Russia's Ultimate Objective
- From Lance Armstrong to Trump: The Rise & Fall of the Deified Narcissist
- Participation Trophy Politics
- Reading Malcolm X in Texas
- Dah, Donald: Russian Blood Money and the FBI's Case Against Trump
- Tiny Crowds, Tiny Hands vs. Huge Crowds, Huge Hearts
- 5 Tips for Surviving as Female
- Playing the Donald Trump Game
- Like a Heart Floating in Formaldehyde: A Letter to the President-Elect
- What Are the Odds of Donald Trump Serving All Four Years of His Term?
- The Unbearable Hopelessness of Trump (and Being)
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- Song Beneath the Song: "The Reflex" by Duran Duran
Tag Archives: Braid
If My Cat's A Gamer, Then So Are You
Samuel Sattin explains why video games, even the most violent ones, are not more harmful to society than actual guns. Continue reading
Posted in Popular Culture Tagged Assasins Creed, Borderlands, Braid, cats, Evan Narcisse, God of War, Infamous, Journey, Kotaku, Mario Kart, Portal, Republicans, Uncharted, Video Games 1 Comment


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"Small Strokes Fell Great Oaks" (explained)
Peter "Johnson" Strokes, (alias Small Strokes, alias Tiny Strides, alias Little Lagurski), was so small that he was often mistaken for an oddly shaped fire hydrant. Because of the unfortunant attention paid to him by a number of neighborhood dogs, his dry cleaning bill was atrocious.
The sense of the remainder of this saying is still obscure. One theory proposes that it has been altered from "leg gets soaked", however, this is purely conjecture.
© Copyright 2017 brucek. All rights reserved.
Status: Finished
Genre: Humor
Hey, I really liked ths, very quirky.
All I can say besides great, is, "What a pisser!"
Haha! Mike nailed it!
Well done, my friend!
Script / Humor
Miscellaneous / Humor
Poem / Poetry
Shelves: 7
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You'll feel like a green goddess (or god) when you treat yourself to one of these amazing sandwiches! Nutty pesto, creamy avocado, and melty vegan cheese come together between two pieces of bread to create the grilled sandwich of your dreams.
Green Goddess Griller [Vegan]
This Recipe is :
For the Pesto:
- 1/3 cup basil, chopped
- 1/4 cup pine nuts
- 1-2 garlic cloves
- 1 cup kale, chopped
- 1/4 cup extra virgin olive oil
- Salt and pepper, to taste
For the Sandwich:
- Spelt bread
- 1/2 avocado, sliced
- 1/2 cup spinach
- Your favorite vegan cheese
- 1-2 tablespoons coconut butter
- To make the pesto, add all ingredients to a blender and run until combined.
- Spread pesto sauce on both slices of bread.
- On one slice of bread, add cheese, avocado, and spinach.
- Top with the other piece of bread pressing it gently together.
- In a small fry pan, heat up coconut butter.
- Cook sandwich on both sides for four to five minutes, or until golden.
- Cut sandwich in half or in quarters.
AvocadoBasilCheesy Recipes (Vegan)Spelt


text:
MBAs tackle strategy projects in India
As a Foster MBA student, getting a job and achieving financial independence is usually expected and the path to find a job is relatively clear.... Read More
Technology Management MBA Application Tips – GMAT Scores
Achieving a good score on the Graduate Management Admissions Test (GMAT) is a concern for applicants to the Technology Management MBA Program. Tracy Gojdics, TMMBA... Read More
The TMMBA ROI Series: Part 1
Ally Wewers, TMMBA Admissions & Recruiting Coordinator Return on Investment (ROI) for an MBA degree is a common topic when talking with TMMBA students and... Read More
From senior advancement officer to senior engagement director
Sally Collins, EMBA 2012, enrolled in the Executive MBA Program to prepare herself for an executive director role in a non-profit organization. But midway through... Read More
The art of failing
This event was hosted by Neal Dempsey, the Foster School's visiting 2013-2014 Edward V. Fritzky Chair in Leadership. Failure is part of life. In fact,... Read More
YEOC students take on inequity in higher ed and business: The November and December sessions
For one Saturday a month, 145 high school students from across Washington State converge on the UW campus for their monthly YEOC session. YEOC, which... Read More
Tech specialist needed to speak the language of business
Anumeha Anumeha, EMBA 2015, had eight years of experience in information technology, but her job responsibilities increasingly brought her into contact with clients, vendors and... Read More
Journey to the French Atlantic Coast
Written by Nashua Springberry, Foster undergraduate An amazing thing about Nantes is its close proximity to the beach. It happens to be a quick 45... Read More
A day of "Chateauing" in France
Written by Nashua Springberry, Foster Undergraduate A great part about going to Audencia is the International Connection Team (commonly referred to as the IC Team).... Read More
CISB student profile: Robby Ryan
Robby Ryan is a senior at the University of Washington Michael G. Foster School of Business, pursuing an option in finance and a minor in... Read More


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I received many MTBs last year. While trying to verify their identity, I
noticed some that were close but not exactly like the checklist description.
I'd appreciate seeing any photos you might have of the following:
BUENITA (A. White, 1963)
BROWN CROWN (W. Welch, 1963)
BIT O'AFTON (D. Guild, 1970)
BLACK LADY (Rawdon, 79)
Chuck Bunnell
Lafayette, IN
Region 6
Zone 5a-5b
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Jeremiah 23:1-6New International Version (NIV)
The Righteous Branch
23 "Woe to the shepherds who are destroying and scattering the sheep of my pasture!" declares the Lord. 2 Therefore this is what the Lord, the God of Israel, says to the shepherds who tend my people: "Because you have scattered my flock and driven them away and have not bestowed care on them, I will bestow punishment on you for the evil you have done," declares the Lord. 3 "I myself will gather the remnant of my flock out of all the countries where I have driven them and will bring them back to their pasture, where they will be fruitful and increase in number. 4 I will place shepherds over them who will tend them, and they will no longer be afraid or terrified, nor will any be missing," declares the Lord.
5 "The days are coming," declares the Lord,
Cross references:
New International Version (NIV)
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text:
Simple website (PHP) - End My Argument
This project received 26 bids from talented freelancers with an average bid price of $485 CAD.Get free quotes for a project like this
Project Budget$250 - $750 CAD
Total Bids26
Project Description
Users can create an account to write about an argument they are currently having with someone. After creating the account, they can post their argument with two simple possible solutions or two pictures.
For example the user would write :
My wife and I wants to go to the movies next Friday night, she wants to see X, I want to see Y. Which one should we go see?
and then provide two answers:
Another example:
I do not know which of these two shirts I should buy, which one should I choose?
- Picture 1
- Picture 2
- A logged in user should be able to see all the questions they have previously asked (some sort of profile page)
- After all information has been provided, other users (logged in or not) can answer with what they think is the right answer. (the same user should not be able to vote twice on the same question)
- After answering, users should also be able to comment on the question.
- On the main page, we should be able to see ''HOT'' questions (popular), new questions and random questions.
- Users should be able to share the questions on Facebook, Twitter or Google+.
Skills Required
Looking to make some money?
- Set your budget and the timeframe
- Outline your proposal
- Get paid for your work
Hire Freelancers who also bid on this project
Looking for work?
Work on projects like this and make money from home!Sign Up Now
- Forbes
- The New York Times
- Time
- Wall Street Journal
- Times Online


text:
The day I met you
Was the day I found me
At first it seemed impossible
To tolerate your presence
Then it seemed unthinkable
To live without your love
You've shown me a world
I've only seen in my dreams
You've made me feel feelings
I never knew were inside me
You've inspired me more
Than the sun and the stars
Whenever I'm down
You lift me up
When I feel plain
You tell me I'm glowing
When I am sad
You fill me with laughter
With words you uplift,
Encourage and strengthen me
Through faith you remind me
That I am God's child
Every action you take
Proves your love is my answer
Your eyes are the stars
They dazzle me daily
Your smile is the sun
It shines through you brightly
Your kiss is the rain
It comes from the heavens
You are my everything
I am your girl
You are my better half
I am your lady
You are my charming prince
And I am your princess
© Copyright 2017 Corinne Smith. All rights reserved.
Status: Finished
Genre: Romance
That was a poem from the heart and you can tell that who ever that was too is an insperation on ur life!!!Keep writing poems ur truley good at it!
Terrific I love it
oh so warm and beautiful!! This is certainly a delightful special loving card!!! Great work! Take a look at my romance stories when you have the time. Thanks so much!!
Book / Romance
Book / Other
Book / Other
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Paste the link to Youtube video in the following entry:
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text:
Enter Our Photo Contest »
It's time to show off your garden filled with American Meadows products!
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|Associated SKUs
1WF3 (Bag of 3)
1FARIS3 (Bag of 3) - Out of stock.
|Common Name
|Jack in the Pulpit
|Botanical Name
|Arisaema triphyllum
|4, 5, 6, 7, 8
|Light Requirements
|Half Sun / Half Shade, Full Shade
|Flower Color
|Mature Height
|20-24" tall
|Estimated Mature Spread
|12-18" wide
|Bloom Time
|Early spring
|Planting Depth
|Plant so that the top of the root is 1" below the soil line.
|Ships As
|Bare Root
|Foliage Color
|Large greenish, hooded, tropical-looking bloom with upright spadix (the "Jack") inside. Often streaked with white or brown. Brilliant cluster of holly-red berries follows the flower.
|Planting Time
|Soil Type
|Loamy Soil, Moist/Wet Soil
|Soil Moisture
|Average, Moist/Wet, Well Draining
|Deer Resistant, Native
|Yes - Learn More
|Ships to Hawaii, Alaska & Canada
Shipping begins in late March based on ground temperatures, warmest zones first.
As soon as your order is placed you will receive an order confirmation email that will include your shipping information. We ship perennials and spring-planted bulbs at the proper planting time for your hardiness zone. Perennials and spring-planted bulb orders will arrive separately from seeds. If your order requires more than one shipment, there is no additional shipping charge. See our shipping information page for approximate ship dates and more detailed information. If you need express shipping or have any questions, please call Customer Service toll-free at (877) 309-7333 or contact us by email.
You will receive a second email the day your order ships telling you how it has been sent. Your order is scheduled to arrive at your door, fresh and ready to plant, usually within 3-5 days of leaving our warehouse, depending on your shipping address. We pack our plants to withstand up to 10 days in transit, in the event transit is delayed. We cannot guarantee arrival on a specific day. Please make sure to open your package upon receipt and follow the instructions included.
REVIEW SNAPSHOT®by PowerReviews
Best Uses
Reviewed by 7 customers
Best Uses
Comments about American Meadows Jack in the Pulpit:
These grew. Out of the 3 planted, 2 made jacks. So I hope next year will be good.
Comments about American Meadows Jack in the Pulpit:
Bulbs did not produce plants. No signs of life whatsoever. We've had adequate rainfall and bulbs were located in an area that is shaded except very early in the morning.
Comments about American Meadows Jack in the Pulpit:
Planted them, late in the season but healthy enough to see them next Spring
Comments about American Meadows Jack in the Pulpit:
The Jack in the Pulpit, Red and Pained Trillium arrived in great shape, and came up and did very well after we planted them in the nearby woods. I am expecting bloom maybe next year.
Best Uses
Comments about American Meadows Jack in the Pulpit:
These are terrible, out of the 12 I purchased, only two came up and petered out after about 4 inches and one bloom.
Comments about American Meadows Jack in the Pulpit:
I purchased these last year and the first ones did not make it; AM replaced them and they did okay as far as coming up, only one had a pulpit and to me that means I have hope. This is my first experience with growing them in pots in Florida.
Best Uses
Comments about American Meadows Jack in the Pulpit:
The plants are not vigorous growers. Hopefully, after a few years, they will resemble the Jack-in-the-Pulpits out in the woods.
Regular Price: $26.98
Sale $17.49
To determine if a plant is sufficiently cold hardy, the USDA created numbered zones indicating winter low temperatures; the lower the zone number the colder the winter.
Enter your Zip Code to find your USDA Planting Zone
You will still be able to shop AmericanMeadows.com, but some functionality may not work unless you update to a modern browser. Update My Browser
Please wait...


text:
Our Multi-Arts Camps provide an enriching week for your child to experience the fun, stimulation, and joy of making art and friends in our state-of-the-art studios. Campers will work on age-appropriate projects in a variety of media including drawing, painting, clay, sculpture, collage, printmaking, textiles and more! Multi-Arts Camps are offered without duplication of projects, so campers can enroll in multiple sessions for something new and exciting each week. Dress for mess and bring a bag lunch. All art supplies are included.
Dates: Each week in June
Times: 9 a.m. – 4 p.m.
Ages: Group A: Ages 5-7 Group B: Ages 8-10
Tuition: $325 per week
Sibling discount: First child pays full tuition. $25 discount applies to each additional sibling. Enter code "Sibling" at checkout.
Our Special Topics Camps focus on a specific media, project or theme throughout the week. Each week provides a chance to learn something new and exciting! Dress for mess and bring a bag lunch. All art supplies are included unless otherwise noted.
Dates and times: Each week in June,
9 a.m. – 4 p.m.
Ages: 11 – 13
Tuition: $325 per week
Sibling discount: First child pays full tuition. $25 discount applies to each additional sibling. Enter code "Sibling" at checkout.
June 6 – 10
Explore the basics of comic design by creating single, double and multi-panel comics. We will practice developing characters, creating storyboards, and finding humor in everyday observations. You'll draw and laugh your way through this camp while learning to put a comical spin on your art!
June 13 -17
Learn how to take beautiful, creative digital photos! Camera handling skills, composition, lighting and basic editing will all be covered through a variety of creative shooting assignments. Campers should bring their own digital camera (any type welcome; smartphone cameras are discouraged).
June 20 – 24
Create your own mixed media sketchbook to document your personal stories, experiences, adventures, and thoughts. Techniques addressed will be pen and ink drawing, watercolor painting, collage, photo transfer, and on-site sketching. You'll walk away having learned important habits for long-term creative practice and expression!
June 27 – July 1
Spend the day creating unique ceramic pieces using both hand-building and wheel-throwing techniques. Campers will learn the basic techniques of this ancient medium as well as deeper knowledge of the form through hours of hands-on experience. Perfect for beginners and as well as experienced artists!
Financial need based scholarships are available.
Please contact [email protected] with any questions.


text:
|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|Kathey Marsden <kmarsdende...@sbcglobal.net>
|Re: Question about using URLClassLoader and Derby
|Mon, 14 Nov 2005 18:58:21 GMT
email@example.com wrote: >BTW, where would your application run? I am assuming it is outside of >any managed environment like application server. > > > Well, probably the farthest I might take a practical implementation myself is to make some upgrade tests for Derby, but I want to provide an example of how to load Derby in a ClassLoader so that a component that embeds Derby can run in any environment without interference or interfering others. For example, lets say my component was something that you could embed in your application to add a dictionary capability. I'd like you to use my component, be able to use Derby however you want to, and be able to run in any environment at all without even knowing that I use Derby. I also want to make sure the dictionary API always uses the derby jars that I shipped and used for my QA. I think the System properties can create a problem for application servers too that might want to allow connection to different versions of Derby. Kathey
|View raw message


text:
Although I have never met Phyllis Davenport in person, and we "virtually met" only a few weeks ago, she has played a big role in my life.
Phyllis wrote the book that got me hooked on sentence diagramming. The book is called Rex Barks: Diagramming Sentences Made Easy, and I cannot say enough good things about it.
It is written in a logical order, it gives clear information, and it offers great exercises along with an answer key.
1. Where did you learn to diagram sentences?
My grandfather taught me to read out of a phonics book about the three little pigs when I was four or five years old. I got the decoding device established in my head.
Later I spent four years in a plumbing-free country school where there was lots of basic ed drilled into me.
Then I spent four deadly years in a private girls' school where Miss Chalfant made us diagram till my head tried to explode, but it didn't, and the logic and beauty of our language hung on.
2. How did you get the idea to write Rex Barks?
I was teaching in a school system that suddenly chose to abandon a solid English curriculum and go to 9-week thematic units.
Since the great Warriner's Grammar and Composition books were "old," they were carted off.
So there I was, trying to teach the stuff they told me to teach AND what I knew they needed. I began to wonder what I could produce to replace Warriner.
3. How long did it take you to create Rex Barks? What was the process like?
In three weeks during the summer I pounded it out on a standard typewriter.
I got a publish-it-yourself paperback that said give a commercial artist $50 to design a cover, rent a Selectric typewriter, and produce the copy.
Of course, I couldn't do the diagrams on the typewriter. The original has a distinctly home-made quality.
4. How was your book received after you published it?
September came, and I took a copy to my department head, with three questions.
Is it OK to use it with my students at my own expense?
If a student loses it, may I charge the $3 price?
If a student wants to buy one, may I sell it to him?
Yes, it can be a supplementary material. No. No.
I found a little bookstore nearby willing to carry it, but I don't know if my students bought any.
Thank you, Phyllis Davenport, for creating this great resource, and for being so darn cool!
Read the interview with Phyllis Davenport? Read more interviews.


text:
Places to Visit in Cannon Beach - Cannon Beach Sightseeing
About Cannon Beach
One of the most trendy, coveted, coastal communities in the state of Oregon is Cannon Beach. The scenic beauty of the rock cropping monoliths on-and-offshore, including the famed "Haystack" rock, will make your beach strolls and photographs unlike none other. Cannon Beach is nine miles wide and has the most pristine beach I've ever seen…in many areas, not even a sign of sea debris—just miles of smooth sandy beach…with the occasional dune. You can fly a kite, watch sea creatures in the tide-pools or just relax on the beach.Cannon Beach was named for a cannon that was discovered on the beach from an old Navy schooner that wrecked while attempting to leave the Columbia River in the mid 1800s. However, the first recordings of the area date as far back as 1806 when William Clark, of the Lewis and Clark expedition set foot. As a matter of fact, there is a viewpoint called "Clark's Point" which can be accessed by hiking a trail from Indian Beach in the Ecola State Park. There is a vibrant art scene in Cannon Beach, with a number of wonderful galleries and culinary choices. And, the city is certainly setup for strolling; visitors will enjoy the quaint bookstores, shops and bistros.
Best Time To Visit
Best time to visit Cannon Beach is from October to February
Cannon Beach
How To Reach
Book a Package Tour
The Ocean Lodge
The first thing I noticed when I arrived at The Ocean Lodge in Cannon Beach, OR (besides the obvious beach-side proximity) was the inviting fragrant scent of wood burning in a large stone fireplace located in the lobby—nothing like the affection of a real-wood fireplace. The next thing I noticed were the wonderfully distressed spruce hardwood floors and the finished structural wood beams…really makes you feel like you're in a true, ol' style "Beach Lodge." It's not really until you get to your room and look out the balcony windows that you are taken aback by the unbelievable view (as was in my case, not all rooms have ocean views). What makes this ocean view different than others you may have born witness too, is the nonstop flood of waves—not just one after another, but almost one on top of another. And then, there are the large "haystack" monument rock formations that pepper the shallow waters just off the beach that make for an unusual and breathtaking view. Cannon Beach has some of the most pristine and expansive sandy beaches you'll come across. I also noticed the welcomingly odd void of any sort of sea debris…it's just mocha smooth sand. The rooms at The Ocean Lodge are comfortable with amenities that include a gas fireplace, whirlpool tub, lots of DVDs, small kitchenette (fridge, microwave, utensils and a coffee pot) and bathrobes, or housecoats as my Canadian friend likes to call them. While the rooms are nice, I was a bit surprised by the use of modest/common building materials (in the rooms themselves), as the common areas are more luxurious—perhaps that was by design to add to the casual atmosphere.
0 Hotels found


text:
Contour & Guaranteed Fit Program & Quiksilver Accessories
Showing 1 - 9 items
Can't decide which skate is right for you?Here at Inlineskates.com, we want you to feel confident in your inline skate purchase and ensure you find the perfect fitting skate every time.With that goal in mind, we created the Guaranteed Fit Program for I... Read More
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The Final 2 Hat from Quiksilver will be the Final hat you ever purchase. This hat is so awesome and comes in a Flexfit with a low profile design that will fit comfortably on your head. Flexfit 6-panel, Slightly Curved Brim, Low Profile Design, Mou... Read More
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Get some laid back style with the Quiksilver Destril Trucker Hat. This Cotton front panel has a breathable mesh back for that old school trucker look. The adjustable snap back closure and squared off brim give you some nice style for your dome. 100%... Read More
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Keep your dome protected from the sun with the Quiksilver Pierside Hat. This bush hat sticks out all over for maximum coverage from the sun. An adjustable chin strap allows you to get a secure fit if the wind is to pick up and a Quiksilver logo adds ... Read More
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Keep your dome protected from the sun with the Quiksilver Pierside Slim Hat. This bush hat sticks out all over for maximum coverage from the sun. An adjustable chin strap allows you to get a secure fit if the wind is to pick up and a Quiksilver logo ... Read More
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Add some style to your head with the Quiksilver Foamblast Hat. This 5 panel foam front hat with cool Quiksilver logo and old school mesh backed trucker look will have you looking stylish. 100% Polyester, 5 Panel Foam Trucker Design, Curved Brim, S... Read More
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Reg. $129.95
Upgrade your fall and winter wardrobe with the Quiksilver Into The Wild Zip-Up Fleece Hoodie. Made of a polyester/wool blend with a high-pile fleece interior, this hoodie is soft and warm for all your cold weather activities. It features a full zip-up ... Read More
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Add some style to your head with the Quiksilver Snap Addict Hat. This foam panel hat features the Quiksilver logo on the front and a classic mesh back with snapback closure for an old school trucker style cap. Foam Front, Flat Visor, ... Read More
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Protect your dome in the Bushmaster Hat from Quiksilver. This wide brimmed hat features an adjustable chin strap for customization. Mountain wave and front embroidery brings a touch of style while keeping your face and neck out of the sun's harmful ray... Read More
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text:
HUGO BOSS Round Bracelet Watch, 44mm
Product not available
Have questions?
Chat with us or call 1.888.282.6060.
HideDetails & Care
A stark, industrial dial tops a cool watch set on a brushed steel bracelet.
- Tri-fold buckle closure.
- Approx. band length: 220mm.
- Approx. band width: 22mm.
- Approx. case diameter: 44mm.
- Water-resistant to 3 ATM (30 meters).
- Stainless steel/mineral crystal.
- By Hugo Boss; imported.