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Patterns of primary care and mortality among patients with schizophrenia or diabetes: a cluster analysis approach to the retrospective study of healthcare utilization
© Copeland et al; licensee BioMed Central Ltd. 2009
Received: 11 March 2009
Accepted: 26 July 2009
Published: 26 July 2009
Patients with schizophrenia have difficulty managing their medical healthcare needs, possibly resulting in delayed treatment and poor outcomes. We analyzed whether patients reduced primary care use over time, differentially by diagnosis with schizophrenia, diabetes, or both schizophrenia and diabetes. We also assessed whether such patterns of primary care use were a significant predictor of mortality over a 4-year period.
The Veterans Healthcare Administration (VA) is the largest integrated healthcare system in the United States. Administrative extracts of the VA's all-electronic medical records were studied. Patients over age 50 and diagnosed with schizophrenia in 2002 were age-matched 1:4 to diabetes patients. All patients were followed through 2005. Cluster analysis explored trajectories of primary care use. Proportional hazards regression modelled the impact of these primary care utilization trajectories on survival, controlling for demographic and clinical covariates.
Patients comprised three diagnostic groups: diabetes only (n = 188,332), schizophrenia only (n = 40,109), and schizophrenia with diabetes (Scz-DM, n = 13,025). Cluster analysis revealed four distinct trajectories of primary care use: consistent over time, increasing over time, high and decreasing, low and decreasing. Patients with schizophrenia only were likely to have low-decreasing use (73% schizophrenia-only vs 54% Scz-DM vs 52% diabetes). Increasing use was least common among schizophrenia patients (4% vs 8% Scz-DM vs 7% diabetes) and was associated with improved survival. Low-decreasing primary care, compared to consistent use, was associated with shorter survival controlling for demographics and case-mix. The observational study was limited by reliance on administrative data.
Regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For schizophrenia patients, with or without comorbid diabetes, primary care offers a survival benefit, suggesting that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
Excess mortality has been documented among patients with schizophrenia, [1] and indeed schizophrenia has been estimated in community-based studies to be associated with up to 25 years' shorter lifespan. [2] Mortality rates for all causes, natural causes, and unnatural causes are all higher than expected among schizophrenia patients relative to the general population. [3]
Medical comorbidity among aging schizophrenia patients is common, the result of poor health behaviors, medication side effects, and schizophrenia itself, in addition to the usual functional and health status declines associated with aging. [4–7] Diabetes, in particular, represents a significant medical illness among individuals with psychiatric conditions. This comorbidity affects about 20% of all VA patients with or without a serious mental illness. In 2002, nearly 670,000 veterans over age 50 received care for diabetes in the VA, including 13,000 with schizophrenia.
The benefits of primary care for patients in general and for patients with a complex chronic illness, specifically, have been well documented. Multiple studies demonstrate a relationship between availability of primary care and mortality. [8, 9] In small geographic areas where access to primary care is better, people are more likely to report improved overall health. [10] Delivery of high quality primary care is associated with a reduction in racial/ethnic health disparities for both physical and mental health. [8] Studies in both the U.S. and other countries consistently find that population health is better where there are more primary care providers. [9] Among patients with type 2 diabetes, higher levels of continuity with a primary care provider are associated with improved glucose control. [10] Furthermore, when primary care delivery is more consistent with the chronic care model, patients with diabetes have a reduction in likelihood of developing coronary heart disease. [11]
Although the delivery of primary care has documented benefit, health services use by patients with schizophrenia is frequently suboptimal. In the VA, veterans with schizophrenia are almost 40% less likely to have visited a primary care provider compared to patients without a psychiatric diagnosis over a one-year period. [12] Moreover, patients with schizophrenia are less likely to remain engaged in appropriate health care, although when mentally ill patients are "well-engaged" in care, appropriate care is more likely. [13–15] Dixon's research group noted diminished quality of care for patients with both serious mental illness (schizophrenia or major mood disorder) and diabetes, relative to patients with diabetes alone, in their study of quality indicators. [16] This is a troubling finding in view of the high level of risk factors for diabetes among VA patients with serious mental illness. Among inpatient decedents, loss of contact with the VA healthcare system for the year-long prior period was associated with increased risk of unforeseen death and was more common among patients with schizophrenia (20%) than among other decedents (8%). [17] If loss of system contact predicts subsequent increased risk of unforeseen death among inpatients, does decreased primary care put outpatients at increased risk? Seminal risk factors for mortality such as primary care utilization among the population of VA outpatients with schizophrenia should be identified to permit outreach to those patients at high risk of death.
The purpose of this study was to examine the relationships between patterns of primary care and mortality across three groups of patients: those with schizophrenia only, diabetes only, or both conditions.
Study Design
The local institutional review board approved the study prior to its commencement. Patient data for 241,508 VA patients with schizophrenia and/or diabetes were extracted from administrative sources (fiscal years 2002 – 2005) to provide measures of patient characteristics and care in the VA for this retrospective cohort study.
Patients included in the study were aged 50 or older on Oct. 1, 2001 (fiscal year 2002 runs from October 2001 through September 2002) and carried a diagnosis of schizophrenia, diabetes mellitus, or both schizophrenia and diabetes (Scz-DM). Patients were considered to have schizophrenia if they had an ICD-9 code of 295.xx (excluding latent schizophrenia 295.5x) from at least one VA inpatient stay or at least two VA outpatient visits on different dates, based on the methods of the VA's National Psychosis Registry. [18] This definition selects only patients in contact with the healthcare system at baseline, and thus may not fully include intermittent users.
Patients with schizophrenia typically have other psychiatric conditions in the medical record. Patients with schizophrenia who were also diagnosed with schizoaffective disorder or other serious mental illness, including bipolar disorder, major depressive disorder, other psychosis, and post-traumatic stress disorder (ICD-9 codes 295.7; 296.0, 296.1, 296.4–296.8; 296.2–296.3; 297–298; 309.81) but were treated primarily for schizophrenia, as described above, were retained in the sample. Patients diagnosed more frequently with a serious mental illness other than schizophrenia or schizoaffective disorder (i.e., bipolar disorder, major depressive disorder, other psychosis, or post-traumatic stress disorder) were excluded from the study. [18]
Patients were identified as having diabetes if they had an ICD-9 code of 250.xx, 357.2x, 362.0x, or 366.41 on at least two different outpatient care dates in fiscal 2002 at least 30 days apart, consistent with diagnostic validity research. [19] Diabetes-only patients were limited to those without diagnosed serious mental illness, as defined above. Because of the very large number of diabetes patients, patients diagnosed with diabetes and no serious mental illness were randomly sampled and age-matched 1 to 4 with patients with schizophrenia.
Data Sources
This study used archival data extracted from the VA's all-electronic medical record detailing patients' use of VA hospitals, extended care facilities, and outpatient clinics, as well as prescription medications, laboratory tests, and enrolment status. In the VA vital status database, date of death is based on VA, Social Security Administration, and US National Death Index records per a validated algorithm with demonstrated sensitivity of 98%. [20] The VA vital status database does not report cause of death.
Race, gender, and marital status were recoded from medical record extracts as indicators of Hispanic, black, and missing race data, female gender, and married vs divorced vs widowed vs never married at baseline. Age was calculated as of the beginning of the study period, October 1, 2001. Date of death was used to calculate survival from the beginning of the study period.
The outpatient healthcare parameter of interest, primary care, was assessed by totalling the number of days each year on which patients had primary care visits (includes geriatric primary care and women's clinic). The trajectory of primary care use was captured by a cluster analysis of the number of primary care visits per year over the four years of the study. There are several advantages to this approach compared to total counts of visits. First, this approach permits inspection of differential use of primary care within years as well as across years, in contrast with the standard approach of analyzing across years only. In addition, this allows one to group patients according to their trajectory of primary care use, rather than by total utilization. The method is further described in the Analysis section.
Loss of system contact was determined from enrolment files for each follow-up fiscal year and summarized in an indicator (yes/no) denoting loss of contact during FY03–FY05, where patients scoring 0 or "no" were seen in the VA at least once during each year, and those scoring 1 were alive but had no VA care during at least one follow-up year.
In addition to the index diagnosis, measures of other illness were derived from ICD-9 codes on inpatient and outpatient records, including the Selim comorbidity indices. The Selim physical comorbidity index counts 30 medical conditions, although we excluded diabetes which was captured separately by diagnosis group. The indices were developed with self-report data, and have been operationalized and validated in VA administrative data. [21, 22] We also counted the number of drug classes for which patients had VA prescriptions during each year, as this has been found to be a good proxy for comorbidity burden. [23] Interestingly, this measure was not highly collinear with the Selim index (variance accounted for = 28%).
Veteran priority score is assigned by the VA to veterans to determine eligibility for VA healthcare. It is associated with physical and mental health status, and it appears to be a proxy for socioeconomic status and disease severity. [24] It incorporates service-connected disability, a rating of how related a veteran's illness is to his/her military service, described in increments of 10% from 0% to 100%. The categories of VA priority status are: service-connected disability of 50% or more (category 1), service-connected disability 30% or 40% (category 2), former POWs, Purple Heart recipients, 10% or 20% disability (category 3), catastrophically disabled (category 4), very low income (category 5), special era-related status/0% service-connected disability (category 6), and non-service-connected status (categories 7, 8). [22, 25] Priority 1 patients have no co-pays for VA care or prescriptions. At the time of this study, Priority 2–6 patients had co-pays for some VA care and for VA prescriptions; Priority 7–8 had co-pays for care and prescriptions.
Descriptive frequencies and means were prepared. We used cluster analysis to identify patterns of health services utilization, logistic regression to assess the relationship between patterns of care and death, and Cox proportional hazards to analyze associations with survival in the study period.
The cluster analysis explored the possibility of different trajectories of health care use within the sample. Cluster analysis classifies respondents by the pattern or profile defined by their values on specific variables (e.g., primary care visits each year). The profiles may differ in shape or scale. A difference in shape might indicate consistent values over time (a flat line) or might indicate successively increasing values over time (a sloped line). A difference in scale might occur when one group has consistently high scores while another has consistently low scores. In this type of cluster analysis, the distance between cases (persons) is calculated based on their values on the variables of interest (number of primary care visits during each of four years), and cases that are closest together in Euclidean space, i.e., that have the most similar pattern of values, are clustered together. The cluster analysis begins by clustering the closest pair, then forms the next cluster treating the first pair as a single unit, and so on until the number of clusters reduces from the number of cases (241,466) to the number of clusters with Eigenvalues greater than 1 (in this case, 4).
We did not impose a specific structure on the shapes of the trajectories over time. Thus for each cluster, the mean slope of the trajectory each year was the difference of the mean number of primary care visits between adjacent years, which could vary across years. To handle the large dataset, we executed a preliminary clustering to produce 20 clusters (PROC FASTCLUS, which optimizes processing by not assessing Eigenvalues) followed by a standard cluster analysis of the preliminary clusters, allowing the data to dictate the number of clusters in the final analysis (those with Eigenvalues greater than 1). We then inspected the proximity coefficients and the theoretical meaningfulness of the solutions. Ward's method, which uses squared Euclidean distances as a proximity measure, identified the cluster solutions. This method maximizes within-group homogeneity and between-group heterogeneity, and does not require pre-specification of the number of clusters. [26, 27]
Logistic regression models assessed the relationship between death and patterns of care, adjusting for covariates (listed below). Logistic regression model fit was assessed by the concordance c-statistic, which ranges from 0.50 (no improvement over null) and 1.0 indicating perfect fit. Hazard ratios were estimated for primary care cluster by a Cox proportional hazards model, adjusting for covariates. Survival analysis modelled years survived from the beginning of the study period as a function of patterns of care (primary care cluster). Predictors included diagnostic group (schizophrenia, Scz-DM, diabetes), age as of October 1 2001, race, gender, marital status, loss of system contact, VA priority status, Selim physical comorbidity score, and number of medication classes prescribed in the baseline year. An interaction term of cluster by diagnosis was included to determine whether use of primary care had a differential impact on mortality over the 4-year study, for patients with schizophrenia, diabetes or both conditions.
A total of 242,898 VA patients met eligibility criteria. Patients without valid priority status were considered to be non-veterans and were excluded from the study (n = 1,390); another 42 cases were dropped for utilization more than 31 days after date of death (post-mortem bereavement counselling is offered by the VA; continued illogical use suggests error). The final sample numbered 241,466 VA patients
There were 53,134 schizophrenia patients aged ≥ 50 years with valid priority status receiving care in the VA in FY02. These patients were age-matched in a 4:1 ratio with diabetes patients (n = 188,332). During matching, it was noted that there were not enough diabetes patients aged 50–52 to match 4:1 for all schizophrenia patients; this age group matched 2.5 diabetes patients per 1 schizophrenia patient. Among patients with schizophrenia, 25% (n = 13,025) were also diagnosed with diabetes leaving 40,109 patients in the schizophrenia-only group.
Sample Characteristics of VA Patients with Diabetes, Schizophrenia, or Both Diabetes and Schizophrenia (N = 241,466)
Characteristic | Schizophrenia Only (n = 40,109) | Both Schizophrenia & Diabetes (n = 13,025) | Diabetes Only (n = 188,332) | Overall Sample (N = 241,466) |
Mean (SD) | ||||
Age (range 50–104 years) | 59.8 (9.5) | 60.4 (9.3) | 61.0 (9.5) | 60.7 (9.5) |
Age at Death (n = 34,991) | 68.1 (10.9) | 67.7 (10.4) | 68.6 (11.0) | 68.5 (10.9) |
Female | 1,359 (3.4) | 439 (3.4) | 3,429 (1.8) | 5,227 (2.2) |
Race/Ethnicity | ||||
Hispanic | 2,786 (7.0) | 1,411 (10.8) | 10,440 (5.5) | 14,637 (6.1) |
Black | 8,482 (21.2) | 3,532 (27.1) | 23,745 (12.6) | 35,759 (14.8) |
White | 24,195 (60.3) | 6,920 (53.1) | 96,084 (51.0) | 127,199 (52.7) |
Other/unknown | 4,286 (10.7) | 1,003 (7.7) | 56,451 (30.0) | 61,740 (25.6) |
Marital Status | ||||
Married | 9,806 (24.5) | 4,286 (32.9) | 117,870 (62.6) | 131,962 (55.3) |
Divorced | 11,462 (28.6) | 3,608 (27.7) | 39,351 (20.9) | 54,421 (22.8) |
Never married | 16,481 (41.1) | 4,338 (33.3) | 19,536 (10.4) | 40,355 (16.9) |
Widowed | 1,683 (4.2) | 657 (5.0) | 9,751 (5.2) | 12,091 (5.1) |
Diagnosis Group | 40,223 (16.6) | 13,057 (5.4) | 189,618 (78.1) | -- |
Diagnosis of Hypertension | 14,187 (35.4) | 8,252 (63.4) | 139,214 (73.9) | 161,653 (67.0) |
Diagnosis of Hyperlipidemia | 9,300 (23.2) | 5,590 (42.9) | 103,965 (55.2) | 118,855 (49.2) |
Diagnosis of Dementia | 1,123 (2.8) | 414 (3.2) | 1,142 (0.6) | 2,679 (1.1) |
Any Inpatient Admission over study period | 21,550 (53.7) | 8,137 (62.5) | 63,317 (33.6) | 93,004 (38.5) |
Priority Category | ||||
Category 1: 50–100% disabled | 20,705 (51.6) | 7,440 (57.1) | 55,106 (29.3) | 83,251 (34.5) |
Category 2: 30–40% disabled | 1,226 (3.1) | 467 (3.6) | 13,268 (7.1) | 14,961 (6.2) |
Category 3: 10–20% disabled, former POW, Purple Heart | 1,694 (4.2) | 707 (5.4) | 18,086 (9.6) | 20,487 (8.5) |
Category 4: Catastrophically disabled | 8,188 (20.4) | 2,248 (17.3) | 12,905 (6.9) | 23,341 (9.7) |
Category 5: Low income | 7,748 (19.3) | 2,037 (15.6) | 64,662 (34.3) | 74,447 (30.8) |
Category 6: 0% disabled, special eras | -- | -- | -- | 781 (0.3) |
Category 7–8: Non-service-connected status (copayment required) | 504 (0.2) | 117 (0.9) | 23,577 (12.5) | 24,198 (10.0) |
Missing data on race was three times more common among diabetes patients relative to schizophrenia patients (diabetes 30% vs Scz-DM 8% vs schizophrenia 11% missing race data; chi-square(2) = 8774; p < .0001). In VA databases in 2002, race was recorded by a clinical observer in inpatient records and was rarely missing, while outpatient records were characterized by high rates of missing data. Because patients with schizophrenia are likely to be hospitalized for acute psychotic exacerbations, they had more opportunity to receive a valid code on this measure.
Among patients diagnosed with schizophrenia, 34% were also diagnosed with schizoaffective disorder, post-traumatic stress disorder (7%), bipolar disorder (4%), major depression (3%) or other psychosis (3%) on two or more occasions in the baseline year.
The Selim physical comorbidity score, minus diabetes, averaged 2.3 (SD = 1.6; range 0–15) for patients with diabetes alone, 2.1 (SD = 1.6; range 0–11) for patients with both index conditions, but 1.4 (SD = 1.5; range 0–13) for patients with schizophrenia alone. The average number of medication classes for which patients received prescriptions in the baseline year was 6.4 (SD = 4.5; range 0–33) for schizophrenia-only patients, 10.0 (SD = 5.3; range 0–36) for both conditions, 8.7 (SD = 4.7; range 0–42) for diabetes-only.
Cluster Profiles
Mortality Models
An unadjusted model of mortality during the three years of follow-up estimated increased relative odds of death associated with membership in Low-decreasing primary care use compared to the Consistent-use cluster (OR = 3.8, 95% CI 3.7–4.0). Compared to patients with Consistent primary care use, patients in the Increasing-use trajectory had lower relative odds of death (OR = 0.50, CI95 .45–.55) while those with High-decreasing use had increased odds of death (OR = 2.5, CI95 2.3–2.6). The unadjusted model had a poor fit as assessed by the C-statistic of 0.64.
Characteristics Associated with Decreased Survival among VA Patients with Diabetes, Schizophrenia, or Both Diabetes and Schizophrenia (N = 241,466)
Parameter | Hazard Ratio | Pr > ChiSq |
Age in Decades (range 5–10) | 1.72 | <.0001 |
Female | 0.69 | <.0001 |
Married | 0.74 | <.0001 |
Black | 0.99 | 0.5030 |
Hispanic | 1.00 | 0.9348 |
Missing Data on Race | 0.73 | <.0001 |
Vietnam Era | 1.05 | 0.0023 |
Priority Status – Referent: Priority 1 | ||
Priority Status 2 | 0.93 | 0.0046 |
Priority Status 3 | 0.96 | 0.0496 |
Priority Status 4 | 1.36 | <.0001 |
Priority Status 5 | 1.01 | 0.5910 |
Priority Status 6 | 0.95 | 0.6357 |
Priority Status 7 | 0.79 | <.0001 |
Priority Status 8 | 0.74 | 0.0582 |
Selim Physical Comorbidity Score (range 0–15) | 1.10 | <.0001 |
Number of Medication Classes at Baseline (range 0–42) | 1.07 | <.0001 |
Loss of System Contact During Study Period | 1.17 | <.0001 |
Primary Care Trajectory by Diagnosis Subgroups – Referent: Consistent Care – Diabetes Only | ||
Increasing Primary Care – Schizophrenia | 0.26 | <.0001 |
Consistent Primary Care – Schizophrenia | 0.95 | 0.2781 |
Low-Decreasing Primary Care – Schizophrenia | 4.20 | <.0001 |
High-Decreasing Primary Care – Schizophrenia | 1.31 | 0.0002 |
Increasing Primary Care – Schizophrenia with Diabetes | 0.48 | <.0001 |
Consistent Primary Care – Schizophrenia with Diabetes | 1.01 | 0.8176 |
Low-Decreasing Primary Care – Schizophrenia with Diabetes | 5.01 | <.0001 |
High-Decreasing Primary Care – Schizophrenia with Diabetes | 1.44 | <.0001 |
Increasing Primary Care – Diabetes Only | 0.38 | <.0001 |
Low-Decreasing Primary Care – Diabetes Only | 3.85 | <.0001 |
High-Decreasing Primary Care – Diabetes Only | 1.59 | <.0001 |
Our cluster analysis approach to varying trajectories of primary care use allowed us to examine administrative data on a large sample of patients to distinguish important subgroups of patients for their differential risk of mortality. Survival was associated with patients' trajectory of primary care use, with differential effects by diagnosis group (schizophrenia only, diabetes only, both schizophrenia and diabetes). Overall, the interaction effect of diagnosis by primary care trajectory was primarily due to significantly greater hazard ratios in the low-decreasing cluster. Therefore, a pattern of primary care use that was either consistent over time or high-decreasing over time would be most likely to achieve optimal outcomes for patients with schizophrenia. Conversely, effective intervention with patients with low-decreasing primary care should have the best chance of reducing premature mortality, especially for patients with schizophrenia only as that group appears to be over-represented in the trajectory.
Why would decreasing use of primary care be associated with higher risk of mortality? Starfield and Shi, in their review of the benefits of primary care, postulate 6 mechanisms that may account for the beneficial effects of primary care: 1) increased access to health care services created by primary care for relatively deprived population groups, such as those with schizophrenia; 2) enhancement by primary care of overall quality of health care delivered to the patient; 3) impact of primary care on prevention; 4) impact of primary care on early management of health problems; 5) accumulated contribution of primary care characteristics such as care coordination to more appropriate care, for example, continuity of primary care and coordination of care are associated with better control of risk factors for cardiovascular disease such as blood pressure and lipid levels, especially for patients with diabetes; [11] and 6) the role of primary care in reducing unnecessary care that may lead to harm. [9] While schizophrenia-only patients in this study did not have diabetes, they frequently had comorbid hypertension or hyperlipidemia and were at risk from diabetogenic medications. [28]
Patients with decreasing primary care use may have substituted inpatient for outpatient care. In the VA, inpatients may still receive care in the outpatient clinics, because both types of care are provided in the larger facilities, making it difficult to disentangle these measures, but inpatient days did show a small negative correlation with primary care visits (r = -0.03 to r = -0.04). Thus, acutely ill patients requiring hospitalization could account for some of the shortened survival noted in this trajectory.
A limitation of this study is its reliance on VA administrative data; out-of-system health care use was not captured and qualitative data was not available. The scope of the study precluded chart review of the electronic medical records from which the administrative data were extracted. VA patients are predominantly male, reflecting enlistment practices of the armed services, but they also tend to be poorer and sicker than US residents in general, characteristics shared with low-income populations in general, such as Medicaid patients. Another limitation of the study is its bias against intermittent users of VA healthcare services, because inclusion in the cohort required at least two outpatient visits in the baseline year. Potentially a fifth trajectory of primary care exists in which intermittent users variably use primary care; our study is unable to address these possibilities. We know that a fairly large percent of VA patients, especially older individuals, utilize out of system providers (primarily through Medicare, the federal healthcare insurance program available to US residents over age 65), and this study was unable to examine such utilization. However, seriously mentally ill patients have been documented to remain within the VA for their care more often than other veterans. [29]
The relative value of psychiatric care vs primary care may be of interest, as these two forms of care may covary or may diverge, depending on the patient. We noted a modest positive correlation of psychiatric with primary care (r = .02 to r = .09). An in-depth exploration of this covariance may yield valuable insight.
Other protective factors for these patients were continued contact with the healthcare system, being married, being younger, and female gender. Loss of system contact was shown in previous research to be associated with unforeseen inpatient death and again in this study of outpatients. This study reinforces the value of at least annually using the VA healthcare system, so as to allow clinicians to review treatment recommendations, including adherence to psychotropic medications, monitoring blood glucose and blood pressure, and screening for new problems. Therefore, outreach to patients who have been out of contact for more than 12 months seems warranted, [30] in addition to maintaining consistent or higher levels of primary care.
Older VA patients have a variety of risk factors for premature death, including comorbidity burden and sub-optimal use of health care services. Life might be extended by the timely treatment of comorbid physical disease. While research supports an inverse association between primary care and mortality, assessing patterns of primary care use in a cohort of patients offers the potential to illuminate which patients require outreach, and what patterns of care may be necessary to improve patient outcomes.
This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (IIR 05-326; PI: Copeland). This work was completed with the additional support of the VERDICT Research Program at the South Texas Veterans Health Care System, San Antonio, TX, the University of Texas Health Science Center at San Antonio, and the Serious Mental Illness Treatment Research & Evaluation Center, VA Ann Arbor Healthcare System, Ann Arbor, MI. LAC is funded by Merit Review Entry Program grant MRP-05-145 from the VA Health Services Research and Development program. CPW, VAL, ALM, MV and JEZ are co-investigators on grant VA HSRD IIR-05-326 [Copeland-PI]. The authors gratefully acknowledge the contributions of Brandon J Hosek in extracting, aggregating, and managing the data.
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- Selim AJ, Fincke G, Ren XS, Lee A, Rogers WH, Miller DR, Skinner KM, Linzer M, Kazis LE: Comorbidity assessments based on patient report: results from the Veterans Health Study. Journal of Ambulatory Care Management. 2004, 27 (3): 281-295.View ArticlePubMedGoogle Scholar
- Pugh MJ, Copeland LA, Zeber JE, Cramer JA, Amuan ME, Cavazos JE, Kazis LE: The impact of epilepsy on health status among younger and older adults. Epilepsia. 2005, 46 (11): 1820-1827. 10.1111/j.1528-1167.2005.00291.x.View ArticlePubMedGoogle Scholar
- Schneeweiss S, Seeger JD, Maclure M, Wang PS, Avorn J, Glynn RJ: Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data. American Journal of Epidemiology. 2001, 154 (9): 854-864. 10.1093/aje/154.9.854.View ArticlePubMedGoogle Scholar
- Kazis LE, Miller DR, Clark J, Skinner K, Lee A, Rogers W, Spiro Ar, Payne S, Fincke G, Selim A, et al: Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Archives of Internal Medicine. 1998, 158 (6): 626-632. 10.1001/archinte.158.6.626.View ArticlePubMedGoogle Scholar
- Shen Y, Hendricks A, Zhang S, Kazis LE: VHA enrollees' health care coverage and use of care. Med Care Res Rev. 2003, 60 (2): 253-267. 10.1177/1077558703060002007.View ArticlePubMedGoogle Scholar
- Aldenderfer MS, Blashfield RK: Cluster Analysis. Volume 07-044. 1984, Newbury Park CA: Sage PublicationsView ArticleGoogle Scholar
- Everitt BS: Cluster Analysis. 1980, London: Heineman Educational Books Ltd, SecondGoogle Scholar
- Lambert MT, Copeland LA, Sampson N, Duffy SA: New-onset type-2 diabetes associated with atypical antipsychotic medications. Progress in Neuro-psychopharmacology & Biological Psychiatry. 2006, 30 (5): 919-923. 10.1016/j.pnpbp.2006.02.007.View ArticleGoogle Scholar
- Rosenheck R, Fontana A: Utilization of mental health services by minority veterans of the Vietnam era. J Nerv Ment Dis. 1994, 182 (12): 685-691.View ArticlePubMedGoogle Scholar
- McCarthy JF, Blow FC, Valenstein M, Fischer EP, Owen RR, Barry KL, Hudson TJ, Ignacio RV: Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers. Health Services Research. 2007, 42 (3 Pt 1): 1042-1060. 10.1111/j.1475-6773.2006.00642.x.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/9/127/prepub
Pre-publication history
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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"VERY HAPPY with the services I have received! Sandy is Great. I was quoted from a different automotive shop stating I needed $2500 worth of work which didn't include the possible head gasket repair. I took it to Cheshire Auto for a second opinion, by referral, and didn't have much hope for the Jeep, but the only thing the other auto shop got right was that my latch assembly was broken and needed replace (which I could tell because the rear window wouldn't close). They definitely treat all customer with the respect that ALL automotive companies should, whether your a man or women! This is one Automotive shop that I would HIGHLY recommend, because they won't charge you for something that you don't need."
— Google Review
"This Automative shop is the definition of AMAZING! The friendliest people you ever met. They treat you like family when you walk in the door. Gregg is so nice and he will take care of you! He definitely helped me out In a time of need and from that I will forever be a loyal customer, and will always refer anyone I know to Cheshire! I witnessed him treat everyone who walked through the door like a friend. He is someone you can totally trust with your vehicle, hes definitely one the best! Great service and great care!!"
— Yelp Review
"A rare find, absolutely honest, skilled and reliable! Amazing professionalism."
— Google Review
"Since I drive an old car, I'm always on the lookout for a good mechanic, and these guys are my go-to for KC and the surrounding area. It's a local place - they fix it fast, they don't overcharge, and they'll make sure the job gets done so you're not right back in the shop. Great service all around."
— Google Review
"Finally, a mechanic that backs up his work! My intake valve gasket went bad, and he not only quoted me the lowest price, but finished the work in the amount of time he said he would. About a week and a half later, a hose blew, and I had to have the car towed. He fixed the hose and took care of the tow bill! EXCELLENT customer service! I will definately be taking my cars back to him!"
— Yahoo Review
"I've been meaning to thank you for your work on our 2008 Cadillac. I can't remember the last time we had no oil leaking onto the garage floor, or onto anyone's driveway.... Hallelujah... and you have save us a TON of money from what the dealer wanted to fix the continuous leak, for which we are forever grateful. Also, I don't know what else you've done with the car, but it certainly sounds better and seems to run more smoothly. So you've made magic, saved us money, and made us feel like "well, OK, this car doesn't seem so bad"... We appreciate your time and TLE, and thank you greatly. I've given your cards to a couple of people, so maybe your talents can shine on them also. Thanks again, and we will be back.... we have two cars! "
— Google Review

subset: commoncrawl


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Disney opens 'distinctly Chinese' Shanghai park
Shanghai Disneyland gives the Hollywood giant a chance to burnish the brand behind "Frozen" in the world's most populous film market.
Shanghai Disneyland gives the Hollywood giant a chance to burnish the brand behind "Frozen" in the world's most populous film market.
Murphy spent much of the time speaking about the shooting at Newtown, Connecticut's Sandy Hook Elementary School in December 2012.
"There's nothing in this case to indicate that there was anything extraordinary" in terms of neglect by the parents, an Orange County sherif…
HEAT ADVISORY: Hot, hazy and humid weather persists into the weekend.
Monday may be the official start to summer, but you can't tell that by stepping outside.
Jessica Cabello, 21, and Janet Munoz, 24, were crossing the street when they were hit by a car driven by Dean G. Lackey, 51
The Royals won their fifth game in a row on Wednesday night to complete a three-game sweep of the Cleveland Indians.
The Train Robbers and Stockade had their game suspended in the 6th inning due to inclement weather on Wednesday night.
Sporting Kansas City advanced to the Round of 16 in the U.S. Open Cup on Wednesday night.
The website Gawker on Wednesday published what it said appears to be the Democratic National Committee's anti-Donald Trump playbook.
The father of a woman killed in the Paris massacre is suing Google, Facebook and Twitter, claiming the companies provided "material support"…
Alligators are not uncommon in Florida, however, unprovoked attacks on humans are uncommon and deadly attacks are extremely rare.
Friends say a man's behavior turned uncharacteristically strange and threatening in the days before he allegedly plowed into nine bicyclists…
Three first-term Democrats, led by Sen. Chris Murphy, filibustered in the Senate Wednesday to force a vote on gun reform legislation.
More and more, people who want to get in touch with small businesses are using texts or online chats rather than emails or phone calls.
A $3.5 million gift from a KU alumna and her late husband will be split evenly between the university's law school and Kansas Athletics.
A month-long investigation into a residential burglary in Milford, Kan. has led to formal criminal charges being filed against three people.
As hot as it already is and with temperatures expected to keep reaching the triple digits, here's a couple of tips to keeping your AC from c…


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We will engage New Yorkers in compassionate, value-driven conversations about advance care planning, so they may live with the comfort of knowing their choices will be honored by loved ones and healthcare professionals.
Guided by Jewish values, we envision a community that embraces advance care planning as a natural part of life, where end of life decisions are known, respected and honored.
Photo by Angelica Ciccone
In his best-selling book Being Mortal, Atul Gawande writes, "Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need." He urges us "to refashion our conversations in ways that transform the possibilities for the last chapters of everyone's lives."
In response, JCC Manhattan has embarked upon an advance care planning initiative to enable individuals in the Jewish community to think about, plan for, and take steps to ensure that when the time comes, their end-of-life wishes will be respected and honored. Made possible through a generous grant from Plaza Jewish Community Chapel, What Matters: Caring Conversations About End of Life is a collaboration between JCC Manhattan, The New Jewish Home, and the Center for Pastoral Education at the Jewish Theological Seminary.
This initiative builds upon Respecting Choices, a program with proven success nationwide. In La Crosse, WI, where it began, 96 percent of the residents had an advance care plan; the national average is 25 percent.
This effort will heighten awareness about the importance of completing advance care directives and enable individuals to thoughtfully consider and document their end-of-life preferences—with opportunities to engage Jewish values as part of the process.
Five pilot sites have been designated for the first phase of this program: JCC Manhattan, Congregation B'nai Jeshurun, Central Synagogue, Kehilat Rayim Ahuvim, and the New Jewish Home.
This initiative will create opportunities for people to connect, grow, and learn. In the words of JCC Manhattan Executive Director Rabbi Joy Levitt, "Thinking about the end of our lives provides us with an extraordinary opportunity to speak with those whom we love about that which matters most—our hopes, our values, what makes us happy, what makes us feel safe."
For more information, or to schedule a conversation, please contact firstname.lastname@example.com or one of the following congregations or organizations:
Central Synagogue Rabbi Marion Lev Cohen 123 East 55th Street NY, NY 10022 (212) 838-5122 ext. 1013 firstname.lastname@example.com
Congregation B'nai Jeshurun Rabbi Sarit Horwitz 270 W. 89th Street NY NY 10024 Phone: 212-787-7600 x261. email@example.com or firstname.lastname@example.com
JCC Manhattan Rabbi Brian Fink 334 Amsterdam Avenue NY NY 10023 646.505.4408 firstname.lastname@example.com or email@example.com
Kehilat Rayim Ahuvim Dr. Michelle Friedman 205 West End Avenue Suite 1A NY NY 10023 email@example.com
The New Jewish Home Tammy Marshall 120 West 106th Street NY, NY 10025 Phone- 212-870-4663 firstname.lastname@example.com
Park Avenue Synagogue 50 East 87th Street, New York, NY 10128 (212) 369-2600 ext. 121 Rabbi Neil Zuckerman firstname.lastname@example.com
West End Synagogue 190 Amsterdam Avenue, New York, NY 10023 (212) 579-0777 ext. 305 Janet Rosenberg firstname.lastname@example.com
DOROT 171 West 85th Street, New York, NY 10024 212-769-2850 Wendy Handler firstname.lastname@example.com
Lincoln Square Synagogue 180 Amsterdam Ave, New York, NY 10023 (212) 874-6100 Rachel Neumark Herlands Sarah Robinson firstname.lastname@example.com
Sage Voices: A diverse group of rabbis and religious leaders speak to end of life issues and how they integrate Jewish tradition into their own teaching and care for others.
Made possible through a generous grant from:
In collaboration with:
For more information about What Matters, e-mail us by clicking here.


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It's been over 20 years since the last time I was here. Even though they have moved down the street, their fares haven't. Nice place to relax and enjoy cold treats.
Can a gluten free person get a good meal at this restaurant?
Is this restaurant good for dinner?
Does this restaurant offer outdoor seating?
Is this restaurant good for dining on a budget?
Is this restaurant good for large groups?
Is this primarily a coffee shop?
Does this restaurant offer takeout or food to go?
Is this restaurant wheelchair accessible?
Are the prices at this restaurant low or inexpensive?
Is this restaurant good for brunch?
Thanks for helping!
Share another experience before you go.It's been over 20 years since the last time I was here. Even though they have moved down the street, their fares haven't. Nice place to relax and enjoy cold treats.
Hands down the best ice cream in Saskatoon. Tucked away in a pretty neighborhood, this 50s diner-style ice cream parlor is a fabulous treat! They must have at least 24 flavors of ice cream and they change it up all the time.
Great selection of flavours and treats. The Dog's Breakfast is something fun for the family to share!
I LOVE LOVE LOVE this place!!! Everytime we have been, the lineup is out the door and down the stairs. Very 50s atmosphere inside and amazing ice cream. Sadly I now have lactose intolerance so please enjoy on my behalf!
Unique flavours and classics too service is always fantastic Lines can be long at peak times after dinner but we usually get through within 20 minutes ... it gives the kids extra time to change their selection 100 times before it's our turn.
The Owner is rude, and doesn't know how to treat his employees. Always a lack of flavours or out of something, due to owners incompetence. Yes the ice cream is delicious(when it's there) and there is amazing service. The owner just needs to step his game up if he wants to keep his employees.
A great location to go and treat yourself on a warm day (or a cool one too!). Ice cream is great, there are so many flavours, and it is one of the only places I can find a good maple walnut sundae!
Delight your taste buds with a cornucopia of flavors and variety at this awesome ice cream parlour! Exotic flavors will be sure to tempt the finer palettes .....always a fun visit filled with delicious ice cream concoctions !
We went to Homestead today with our kids. When you first walk in, you look up and see a giant chalkboard behind the counter that holds their menu, and there are tons of options. All the standards are there, like cones and sundaes, as well as unique items like whoopsie pies and a giant ice cream challenge, if you dare.... More
One night during a summer festival nearby, we walked to Homestead for some gourmet ice cream. Known for unique, home-made ice creams, we were excited to see what flavors they'd come up with. Understaffed, nasty washrooms and a limited selection of ice cream made this a experience that was inconsistent with previous visits. I'm hoping that this was an unfortunately-timed... More
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Congress hears testimony on location-based services and online privacy
A hearing in the House of Representatives on online privacy and location-based services suggests that geolocation data might be treated as personally identifiable information.
Wednesday's joint House of Representatives hearing on "The Collection and Use of Location Information for Commercial...
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Purposes" produced one clear result: Congress has woken up to the fact that technology, particularly location-based services, has outpaced online privacy law.
"Location-based applications and services are springing up each day like wildfire," said Rep. Bobby Rush (D-Ill.), chair of the Subcommittee on Commerce, Trade and Consumer Protection, after the joint hearing with the Subcommittee on Communications, Technology and the Internet. "Yesterday, there was Facebook, and in the not-too-distance future we will be encountering something more akin to a 'Placebook.'"
More data privacy resources
GPS devices, geolocation data create privacy, security risks
Survey shows privacy policy success lies in collaboration with IT
Should geolocation data be included in an online privacy law, enterprise security officers could need to treat such data as personally identifiable information and protect it accordingly. Communications, Technology and the Internet subcommittee chair Rep. Rick Boucher (D-Va.) said that he expects geolocation and consumer privacy to be a part of a larger privacy bill that he's working on. That declaration came after a morning of testimony in which privacy advocates, researchers and industry representatives testified to the explosion in location-based services and associated geolocation data.
Rep. Doris Matsui (D-Calif.) observed that according to one estimate, use of location-based services is expected to reach 80 million users in the United States. "In today's economy, information is everything to everyone," she said, adding that while such services provided through mobile devices are an inherent part of that, "privacy policies and disclosures should be clear and transparent. The scope of information collected should be clear, including what it is used for and how long it is retained."
Michael Altschul, senior vice president and general counsel at CTIA, the Wireless Association, testified that, "technology has now overtaken our static assumptions. The move towards open platforms like iPhone and Google Android, adoption of smartphones with their own GPS capabilities and usage of GPS devices have combined to make a carrier-based approach to location-based services no longer sufficient for current guidelines."
A tension between protecting consumers and preserving innovation in this sector was clear. Rep. Ed Whitfield (R-Ky.) cited the utility of global positioning systems for navigation or the use of geolocation data by emergency services to find people in distress. "The rapid progression of technology is both awe inspiring and bewildering," said Rep. Kathy Castor (D-Fla.). "We need to protect consumer privacy. The law has not kept pace with this increased need."
Bridging the "regulatory gap"
With respect to that lag, Rep. Cliff Stearns (D-Fla.) pointed out that a key provision of the Communications Act of 1934 states that wireless carriers are generally prohibited from using location-based information. Application providers are not so governed. Given the explosion of mobile applications that use geolocation data, this has created a lack of regulatory oversight. That "regulatory gap" is particularly acute because of the growth of technologies that can locate a consumer without the use of a telecommunication carrier's technology.
"Increasingly, location-based services do not touch a wireless carrier," testified Altschul, "regardless of whether an application runs with the carrier's knowledge or not." For instance, John Morris, general counsel for the Center for Democracy & Technology and director of its Internet Standards, Technology and Policy Project, said that geolocation data can be collected through Wi-Fi networks by Skyhook Wireless without the carrier or consumer's knowledge and consent.
"Research suggests consumers are concerned, but most services don't tell them how or where they'll be used," said Lorrie Cranor, associate professor of computer science at Carnegie Mellon University. "Better controls are needed. As the website PleaseRobMe.com reveals, users may not think through the consequences of making their location data public."
Yesterday, there was Facebook, and in the not-too-distant future we will be encountering something more akin to a 'Placebook.'Rep. Bobby Rush,
Buzz, a new social network based on Google's Gmail system, was mentioned in the testimony of Anne Collier, co-director of ConnectSafely.org. Collier referenced Altimeter Group founder Charlene Li's post on Google Buzz, online privacy and kids, observing that "it's time to update privacy law, but it needs to coordinate with COPPA [the Children's Online Privacy Protection Act]. The law shouldn't just refer to a single technology."
Who should regulate location-based technology? Morris testified that "jurisdiction of privacy should rest with the FTC. Our position is that the Internet in general should not have an agency with broad jurisdiction." He cited Section 230 of the Telecommunications Act of 1996, which set a policy of allowing the Internet to grow without regulation.
"The writing is on the wall that there will be baseline privacy legislation introduced," said Morris after the hearing. "It will require location be treated as sensitive data, like medical data. You'll need to do more than just post a disclosure statement."
Morris recommended that security and compliance officers practice data minimization to manage risks posed by breaches of consumer's location data. "Business models should be built to only gather what they need," he said. "If there's no reason for that information to be retained and tracked, don't do it."
Let us know what you think about the story; email Alexander B. Howard, Associate Site Editor or @reply to @digiphile on Twitter. Follow @ITCompliance for compliance news throughout the week.
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I am a Corona commercial,
sun grilled with a lime slice.
Each wave a current event,
each sunset seen through a longneck,
fish eye view of a golden world.
Never let a wave pass by,
nod to all the ladies - all shapes and sizes.
The sweat of congeniality
calling for a cordial,
each cordial calling for a companion.
Close your eyes - test the other senses,
hear the surf
taste the hops
touch the foam
smell the salt,
pass the time - grilln' the lime.
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Integrate & Simulate
Data Management
AVL Solutions for Test Data Management increase the efficiency and quality during the test operation for locally and globally networked test facilities. One of the major challenges dealing with data management in automotive testing is the massive increase of data from different testing domains: More data is produced in less time. On the other hand, cost efficient development and manufacturing require increasing productivity of the test field.
Products & Services
Individual AVL PUMA testbeds are ideally networked within a test facility. Parameters and results are stored centrally in an ASAM-ODS compliant database.
AVL SANTORIN COMPACT™ is managing all result data in test fields with stand alone test beds from different suppliers.
AVL SANTORIN MX 2™ is an intelligent, ASAM-ODS based data management solution for engineers in the area of product validation and verification that provides maximum protection against the unstoppable explosion of data - ready for "Big Data". Further, AVL SANTORIN MX 2™ is a proud member of the AVL Team SUITE™.
AVL TFMS 1™ is the premier test lifecycle management solution for automobile development. Further, AVL TFMS 1™ is a proud member of the AVL Team SUITETM.


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Sign Up Here!
"Just Trust Me." – Jesus
Ivy Beckwith
A couple of weeks ago at the United Church of Christ's Thirtieth General Synod I led a workshop for the youth and their leaders on the concept of Bible storying.
Be the Church
Rev. Holly MillerShank
Advent and Lent are always some of the busiest seasons within the life of the church
Good Summer Reads
Dr. Kimberly Whitney
It happened earlier in the spring. Progressive blogspots emblazoned the news: N.Y. Times Reading List achieves a full Euro Quota! My heart sank. But Facebook book posts with alternative reading lists began to spark and kindle across collegial lines.
Do the "Dones" call us just to be?
On a recent, beautiful morning in May, I felt such gratitude for belonging to the United Church of Christ. On that Friday morning, I joined other national staff in a peaceful walk to pray first in front of the Justice Center in downtown Cleveland, and then on the steps of City Hall.
Unexpected Places
Patrick G. Duggan
No, this is not a plug for General Synod 30 (but it could be!).
Finding Peace
Cameron Trimble
Someone asked me this week, "How do I find peace? I just feel so unmoored, so adrift but drowning in busyness. I can't pack anymore things into my day, but I feel so unsatisfied with my life." I am hearing this a lot these days.
'Bringing Wood to the Fire'
David Schoen
Bishop Yvette Flunder spoke her now well-known phrase "Bring wood to the fire" in a discussion several years ago with national staff and others on starting new churches.
A Challenge to the Church
Rev. Beth Long-Higgins
Things aren't so different for the church. How will the church be responsive to the needs of older populations the world over?
Say 'Yes'
Ivy Beckwith
About 15 years ago, I spent a delightful evening in Denver with a group of seminary professors. They were not the reason the evening was delightful. The evening was enjoyable because we attended a performance by a local improv group. This was my first experience with improv and I found it intriguing and very funny.
Love Goes All the Way
J. Bennett Guess
If I speak like I know everything, like the world revolves around me, but I don't love, I am nothing but a fool at a microphone.


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Dati bibliografici
Titolo: THE AMERICANS: The National Experience
Casa editrice: The Easton Press 1992
Data di pubblicazione: 1992
Legatura: Hardcover
Reprint Leather. Hardcover. Gilt decorated covers and gilt page edges. 517pp. As new condition. No dust jacket, as issued. All page edges gilt.Embossed gilt decorations.Gilt lettering on spine and cover.A lovely collectible copy.Notes from History laid in.Book is as described - NO defects or marks of any kind. ISBN: Codice inventario libreria J1148437
Metodi di pagamento
La libreria accetta i seguenti metodi di pagamento:
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Libreria AbeBooks dal: 28 agosto 1996
Valutazione libreria:
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Libreria AbeBooks dal 1996
Pennsylvania Residents please add 6% PA Sales tax to total including shipping. All books are guaranteed and may be returned within 30 days of purchase date for a full refund of the purchase price.
Orders usually ship same or next business day. Shipping costs are based on books weighing 2.2 LB, or 1 KG. If your book order is heavy or oversized, we may contact you to let you know extra shipping is required especially on international orders.


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Watkins College of Art is accepting applications for the Director of Enrollment Management. Watkins College is a regionally and nationally accredited, non-profit, independent college of the visual arts located in Nashville, Tennessee.
The director will oversee the activities of the offices of admissions, student life, financial aid, and the registrar, although the primary focus of the position will be admissions.
Working closely with the office of communication, the director will lead the development and management of all facets of prospective undergraduate and graduate student recruitment, (including transfer students). S/he will develop comprehensive, strategic, annual and multi-year recruitment programming, which reflects the goals of the college's strategic plan, with particular attention to graduate and international recruitment.
Working with faculty, staff, and other stakeholders the director will develop creative recruitment and promotional initiatives, inside and outside the college.
Primary responsibilities:
- Manage the admissions funnel from prospect through enrollment with regard to a variety of metrics including overall goals, department goals, institutional support, etc.
- Direct oversight of admissions office and personnel.
- Coordinate the activities of financial aid, student life, and the registrar to support retention efforts.
- Create a strategic lead generation/recruitment plan that may include name purchases, SEOs, travel, social media, on- and off-campus events and visits, electronic and print publications, etc.
- Create and implement a plan for engaging key influencers such as guidance counselors, high school art teachers, parents, and alumni.
- Ensure all compliance and data integrity.
- Represent admissions on appropriate college committees.
- Engage in continuously reflective, analytically rigorous, and technically sophisticated dialogues with senior leadership about enrollment realities, forecasts, and possibilities.
Minimum Qualifications:
- Degree in communication, fine art, marketing, or related field (graduate degree preferred).
- Experience in admission/enrollment management demonstrating progressive levels of responsibility and success.
- Substantial knowledge of the field of visual arts.
To apply:
- A resume or cv that demonstrates qualifications for the position.
- A letter of application that articulates the candidate's vision for the position.
- Names and addresses of three references, including one from a supervisor and one from a direct-report subordinate.
- Salary expectations.
All materials should be submitted electronically to: firstname.lastname@example.com
Review of candidates will begin immediately, with a start date early in the spring term of 2017.
Watkins College adheres to EEO guidelines and does not discriminate on the basis of race, color, religion, creed, national or ethnic origin, sex, sexual orientation, age, or disability in hiring and employment policies and encourages candidates of diverse backgrounds to apply.


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I love that. What pattern did you use? Was it difficult to get your center points to line up? It looks very good.
Printable View
very pretty
Love this as I love the colors, great job.
It looks wonderful! I really like that pattern!! :)
Oh how pretty, and yes it does make you think of watermelon.
very nice table topper


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Hi Everyone! Just wanted to pass this information along in case no one knows about it. Well on Foodnetwork, starting June 12, 2005 at 10:00 p.m. Eastern and Pacific time, they are having a classic wedding cake show. I will list the other days and times, but you might want to check your local channel TV for the timings and listings in your area. The other dates and times are as follows:
June 13, 2005 at 2:00 a.m. Eastern & Pacific time
June 16, 2005 at 9:00 p.m. Eastern & Pacific Time
June 17, 2005 at 1:00 a.m. Eastern & Pacific Time
June 19, 2005 at 3:00 p.m. Eastern & Pacific Time
I thought this would be of an interest to all the cake decorators out there. Happy Baking!
Quote by @%username% on %date%


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This Gif entitled Don't look at Raya's boobs was created from the youtube video 3 years ago. It uses 18 frames per second and is displayed at 640px resolution. This animated image plays for 2 seconds, was built with high quality and an estimated weight of 5.29 MB for download. This animation was originally created from the Reading Mean Comments About My New Haircut! video from 05:17 to 05:19.
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You are here: Home / Archives for Michael Solano-Mullings
Renowned poet Nikki Giovanni discusses her views on censorship, voter suppression in the upcoming presidential elections, the tribute she's organizing to celebrate Toni Morrison's legacy, and offers a message to young black poets.
World Class Web Hosting® provided as a public service by pair Networks®. Learn more at www.pair.com.


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2017 Pre-Eco Endurance Challenge by Halifax Orienteering Club This is the second annual pre-E2C event hosted by the Halifax Orienteering Club (HOC) on 22 April, two weekends before the E2C. It is a great way to tune up for the E2C and you will be competing in a beautiful part of the province! The event will be held in Wentworth with registration at the Wentworth Hostel. There will be a 2 hour and a 4 hour event and the courses … Continue reading
Welcome to the 2017 event!
February 26, 2017
International Competitors
Welcome to the 2017 event! If you are a potential participant from outside North America, you may need a visa or other official documentation in order to travel to Canada. Our event is registered with Citizenship and Immigration Canada; the Immigration, Refugees and Citizenship Canada Special Event Code for this event is 17ECOE. Should you require a visa to visit Canada, you will need to contact the visa office responsible for your place of residence to obtain information and to … Continue reading
January 01, 2017
Registered Teams
As of March 23rd, there are 30 teams and 74 participants registered for the 2017 E2C. Registered teams: Public Competitive 8hr Attack Squirrels – B.Fiander, B.Kennedy (NS) Boreal Transplants – R.McIver, A.Westwood (NS) Eastern Marsh Sharks – S.Turner, M.Theriault (NS) Fast Like Wind – O.Kuzmovych, I.Hordii (Ukraine) Green Peppers – L.Brown, K.Mosher (NS) Low Flying Zippers – R.Eddolls, J.Allen (NS) Portland Estates Coyotes – S.Hennessey, D.Hogg, F.Legare, J.Leahy, T.Dikaios (NS) [PLEDGE] Shackleton – P.Bottomley, M.Bottomley (NS) Ukrainian Hunters – M.Marynchenko, O.Nedilska, M.Diakun … Continue reading
December 19, 2016
Storm the Mountain Adventure Challenge 2017!
Our fellow Search and Rescue volunteers at Pugwash Ground Search and Rescue invite you to participate in their 3rd annual "Storm the Mountain Adventure Challenge" (SMAC) taking place in Wentworth (Cumberland County) on February 4, 2017. SMAC is an eco-endurance challenge aimed at those who simply like winter fun events or those who are skilled in orienteering. It is also a great lead-up to our very own E2C in May! Proceeds will be used to upgrade the PGSAR facility and … Continue reading
May 17, 2016
2016 Maps
Maps from the 2016 E2C were as follows: 2016 Competition Map 2016 Competition Map Back
April 22, 2016
E2C 2016 – registration location
For 2016, race-day registration will be held at the Goffs Volunteer fire Department, 2040 Old Guysborough Rd. A map of the location can be found here: https://goo.gl/maps/GN5dm3U9d9v Take Exit #5A off Hwy102 (Aerotech Business Park) Follow Aerotech Drive for 1km Turn LEFT onto Pratt & Whitney Drive and continue for 250m Turn RIGHT onto Old Guysborough Road/Hwy 212 Continue down Old Guysborough Road for 5.8km, following along the side of the airport The Fire Hall will be on your LEFT, immediately after the junction with Oldham Road and opposite the Airlane golf club. *IMPORTANT NOTE* … Continue reading


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Writer and photographer Bob Friel's blog about the outlaws, outcasts and all-around extraordinary characters he's met while chasing adventure stories around the world, including the saga of Colton Harris-Moore, the "Barefoot Bandit."
Wednesday, January 25, 2012
Jailhouse Rock
5 comments:
- AnonymousJanuary 25, 2012 at 7:48 AM
I agree with you, Bob; it won't do much damage to him in court. His judge is in an intelligent man. And absolutely NOTHING in these emails contradicts anything he has written in his Letter of responsibility regarding his remorse, his desire to change his life, and the likelihood of his rehabilitation. It is also very telling that the prosecutors were unable to find a SINGLE line where Colton expressed anything else but remorse towards his victims. You know they would have jumped on it.
Here's my take on it, for what it's worth: When you're awaiting sentencing in prison, where shame and humiliation is the name of the game, you have to hang on with all your might to your self-esteem, and hide your vulnerability as much as possible...until the lights turn off. When the stress keeps growing every day, private correspondence to friends is a space where one, in theory, should be able to vent frustrations, express all kinds of opinions, be mad, sad, happy or silly. These excerpts from his emails were certainly handpicked beyond belief. By his own account, Nov-Dec 2011 was the most difficult and most stressful time of his whole life, and unsurprisingly, almost all of these email quotes are from that time.
I am a polite, generally law-abiding citizen, and I've used terms that are way, way more insulting than Colton's "swine" and "vermin" to describe the cops and media in my private conversations with friends. What do you expect him to say? "The police has hounded me for pretty much my whole life. I think the police is... unkind." "The media slanders me any chance they get, post extremely private reports and documents about me. The media is... not very nice." Also, how can anyone read a line that essentially says, "I have no equal, save perhaps for the Wright Brothers!" and be unable to see the playfulness, the deadpan sense of humor, the possible inside-joke? Also, sometimes, boasting can be soothing; a defense mechanism to hide your pain. He's 20 years old, FFS.
I have no doubt that his supporters will keep supporting him, and his detractors will keep spitting venom. These "damning evidences" won't change anything to anything.
-N. - AnonymousJanuary 25, 2012 at 1:35 PM
He had email in prison? ...still trying to figure out how he even got internet access in the first place!
ReplyDelete Hi Bob,
I've been piecing together, through the handy-dandy internet, what happened in Colton's federal sentencing hearing yesterday so now I have a couple questions for you, our resident expert.
You've informed us in previous posts that the State of Washington permits as much as 30% reduction in sentence for good behavior. Since Colton will be serving his concurrent federal sentence in a Washington State facility, can the 30% also apply to his federal time? Or do potentially less lenient federal guidelines still apply to his 6 1/2 US years?
I also read, but only in one article, that Judge Jones is allowing Colt's time served already in SeaTac to count toward his federal sentence. Do you know if that's accurate? If it is, then my calculations suggest that by the time Colt gets to Washington prison he'll actually only have about 4 3/4 years left on his federal time, which would be fairly close to the approximately 4 1/2 years of Washington time he'd have to serve if he takes advantage of the state's time- off-for-good-behavior policy.
I also saw somewhere that there will be yet another hearing to determine a final total of the restitution payment Colton will be assessed. Do you know anything about that and how that whole process works?
I was interested to hear that Colton, for the first time, spoke (and at some length) in court yesterday...that his mom was there, also for the first time. I can't help but think how nerve-wracking that must have been for him. The stress was probably relieved a bit by not having cameras in the courtroom (it looked like the cameras in Coupeville caused him almost physical pain), but still it must have been an extraordinarily difficult day for the kid. I wonder if speaking yesterday was his idea or a suggestion from his lawyers.
Finally, one last question. I've heard about a fund being established to help pay for some of Colton's counseling expenses over the next few years. In fact, you might have mentioned that a few posts ago--I'm losing track. Can you tell us anything more about what services he may be able to get through the state Department of Corrections, and what he may be allowed to get outside of the system while he's in jail?
As always, thank you for being a great source of reliable factual information about Colton, and an equally valuable source of reasoned, rational opinions.
NedWe're getting into legal high calculus at this point.
Washington State allows up to 40% credit for "good behavior." But then we have the 7 federal crimes, and mix in all the "truth in sentencing" legislation, which, however, usually applies only to certain crimes. My calculations including both state and federal time, have had Colt walking out of state prison free, on probation, around his 26th birthday.
John Henry Browne said yesterday, though, that he estimates that if Colt behaves himself, he'll be out in 4.5 years when he'll be about 25 and a half. John Henry is a top flight defense attorney (and plays one on TV) so I have to believe he's got this figured out.
The feds have said the total time is up to the Bureau of Corrections, but I believe what they're saying is that you don't count your "good behavior" chickens until they've hatched and spent their time in the pen following the rules and not getting into any more trouble.
There will be one more hearing for the judge to fix the restitution amount. There have been a lot of figures on that front as well. In the federal plea, Colt took responsibility for $1.4 million in costs and agreed to pay back just under $1million. The state added around $292,000, for a total of $1.3. The court system is nothing is not deliberate, though, so apparently the federal judge needs to delve into the payback plan one more time.
Yes, there is a fund set up for Colt. I'll be discussing that in a later post. Briefly: the fund was set up to pay for a special program of therapy designed to help Colt with what the forensic psychologist, Dr Richard Adler, diagnoses as PTSD as well as the persistent effects of Fetal Alcohol Spectrum Disorder.


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1 Emerald Court is located in Tewksbury, MA. At this time, the property has an estimated value of $430,500 and yearly taxes of $5,874. This condo has 2 bedrooms, 3½ bathrooms, and approximately 1,959 sqft of living space. The property was built in 2003. Similar condos nearby have 2 bedrooms, 3 baths and sell for around $425,000.
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For the Spring 2017 schedule information go to http://calendar.missouri.edu/search/events?search=Saturday+Morning+Science
Humans and Animals Together: Wellness for both ends of the lead
Dr. Rebecca Johnson, Professor of Nursing and Professor of Veterinary Medicine, MU
Humans and animals have lived closely together over thousands of years. This symbiotic relationship was originally rooted in benefits to humans and animals through providing/finding food sources, warmth, and protection. Over time animals—particularly companion animals—have come to play more interactive roles in the lives of people. The gradually evolving science of human-animal interaction (HAI) is showing strong evidence that these roles are physically, emotionally, and socially beneficial for people and companion animals. This presentation will explore the myriad wellness outcomes of HAI for not only people, but for the animals that they keep company with.
10:30 a.m., July 30, 2016
Monsanto Auditorium
Bond Life Sciences Center
Saturday Morning Science is run by volunteers with financial donations from


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gone to the crusher
gone to the crusher
cluster is part of the swap Wil. I'll trade you for your mk2......
deal pending for wheels. BUMP
the 20th emblems have been spoken for.
they aren't gone as of yet, but they have been spoken for. Meaning another party has right of first refusal to one or both.
The other party may only want one badge, thus the second one would be obtainable. Not for $5 though. Especially not $5 shipped to Rockford.
What are you looking for it if it's available?
Sent from my HTC Desire using Tapatalk
$25 shipped, if it would be going to Rockford.
some additional items added to 'the list'
"slow as molasis"
Pass side door is all you if you need it (minus the door card) I have a few different ecus so I can likely provide one for you as well
yes I was referrring to the interior door trim panel. I do have another GTI with the same color interior panel so I/m sure I can accomodate you.
"slow as molasis"
PM Sent
IG: @Dubbeanswell if you take your original offset, subtract all the numbers from it and get drunk, you'll have a damn good time at WBTB. problem solved, BBS RS
-STG "whatever" is soooo 2002
-LOL @ Kids with bags and ****ed up fenders. You wasted your money bro, buy coils.
Willing to split the seats? I just want the fronts.
Last edited by XMB; 05-05-2012 at 03:10 PM.
I'd rather sell them as a whole lot.. Make me an offer yo
hey buddy i got a few things im looking for, wondering if you have what i need ! and you are from the milwaukee area correct ?
- oil pump
- set of rear door cards
- the plastic trim that the top of your seatbelt goes through
give me a price !


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Joyabaj Sho' la baj |
Municipality | |
Municipal Market of Joyabaj
Location in Guatemala | |
Coordinates: 14°59′42″N 90°48′27″W / 14.99500°N 90.80750°WCoordinates: 14°59′42″N 90°48′27″W / 14.99500°N 90.80750°W | |
Country | Guatemala |
Department | El Quiché |
Municipality | Joyabaj |
Government | |
• Type | Municipal |
Population (Census 2002) | |
• Municipality | 52,498 |
• Urban | 9,752 |
• Ethnicities | K'iche', Ladino |
• Religions | Roman Catholicism, Evangelicalism, Maya, The Church of Jesus Christ of Latter-day Saints |
Climate | Aw |
Joyabaj (Spanish pronunciation: [xoʝaˈβax]) is a municipality in the Guatemalan department of El Quiché. It is located about 50 kilometers from Santa Cruz del Quiché, in the Sierra de Chuacús mountains.
Joyabaj was an important part of the royal route to Mexico during the Spanish time. On February 4, 1976 the town was almost destroyed by an earthquake. Most of its beautiful colonial houses and buildings were lost and hundreds of people died. Joyabaj was also hit hard by the civil war that lasted about 30 years in Guatemala. The majority of the ladinos (people with mixed Spanish and Indian heritage) fled to Guatemala City.
The town's fiesta is celebrated from August 8–15. Many activities take place every day. One of the most important and fantastic celebrations is El Palo Volador. This is a traditional dance in which flying angels (ángeles) spin to the ground from a huge wooden pole. The Palo Volador reenacts the descend of the angels into the underworld to battle the forces of darkness. This a pre-conquest ritual that has survived many centuries.
The people from Joyabaj are called Xoyes or Joyabatecos.


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Professional Growth Program (PGP)
Only current certificants are eligible for recertification. You must be currently licensed as a Registered Nurse. A copy of your current license must be submitted with your information.
NOTE: To recertify WOC - AP credentials the requirements are different than this PGP for WOC recertification. Please click on the link below to access the portfolio information for recertification of an -AP credential:
It is not permissible to recertify through the Professional Growth Program (PGP) if you first fail the examinations for that recertification cycle.
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- You may submit a PGP portfolio up to 6 months but no later than 3 months prior to current credentials expiration
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- If revisions are required You are LIMITED to 2 resubmissions (initial plus 2 revisions)
- If a portfolio is not approved after the resubmissions, it is a failed portfolio
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We wanted to be near Firminy to visit the Le Corbusier Culture centre. This was the closest hotel. The woman who greeted us would not speak to us in French; I am fluent in French and found this very insulting - after all, we were in France!! The room seemed to be equipped for only one person; the description said "comfort room" - not sure what this category means. We had to ask for extra towels etc.
Ideal for eco tourism. Excellent hosts. Quite modern and well equipped. Smart design and functional. Great breakfast and a must for cheese lovers as they produce exquisite cheese. Bravo!