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An intervention to stop smoking among patients suspected of TB - evaluation of an integrated approach
In many low- and middle-income countries, where tobacco use is common, tuberculosis is also a major problem. Tobacco use increases the risk of developing tuberculosis, secondary mortality, poor treatment compliance and relapses. In countries with TB epidemic, even a modest relative risk leads to a significant attributable risk. Treating tobacco dependence, therefore, is likely to have benefits for controlling tuberculosis in addition to reducing the non-communicable disease burden associated with smoking. In poorly resourced health systems which face a dual burden of disease secondary to tuberculosis and tobacco, an integrated approach to tackle tobacco dependence in TB control could be economically desirable. During TB screening, health professionals come across large numbers of patients with respiratory symptoms, a significant proportion of which are likely to be tobacco users. These clinical encounters, considered to be "teachable moments", provide a window of opportunity to offer treatment for tobacco dependence.
We aim to develop and trial a complex intervention to reduce tobacco dependence among TB suspects based on the WHO 'five steps to quit' model. This model relies on assessing personal motivation to quit tobacco use and uses it as the basis for assessing suitability for the different therapeutic options for tobacco dependence.
We will use the Medical Research Council framework approach for evaluating complex interventions to: (a) design an evidence-based treatment package (likely to consist of training materials for health professionals and education tools for patients); (b) pilot the package to determine the delivery modalities in TB programme (c) assess the incremental cost-effectiveness of the package compared to usual care using a cluster RCT design; (d) to determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes; and (e) support long term implementation. The main outcomes to assess the effectiveness would be point abstinence at 4 weeks and continuous abstinence up to 6 months.
This work will be carried out in Pakistan and is expected to have relevance for other low and middle income countries with high tobacco use and TB incidence. This will enhance our knowledge of the cost-effectiveness of treating tobacco dependence in patients suspected of TB.
Trial Registration
Trial Registration Number: ISRCTN08829879
Tobacco epidemic
Eight out of every ten smokers live in low- and middle-income countries
Treating tobacco dependence
It has been suggested that at least 180 million deaths related to tobacco can be avoided by reducing current tobacco consumption by 50%. Surveys suggest that three out of four smokers wish to quit and one-third attempt to quit every year
One of the several challenges in treating tobacco addiction in low- and middle-income countries is the lack of resources and governmental funding for the implementation of effective interventions. Many countries facing a tobacco epidemic are also confronting other challenges related to communicable diseases and nutrition-related disorders. Therefore, it may not be possible for countries with limited resources to shift priorities. However, existing programmes (such as TB control) can be utilised to extend their role to tobacco control with minimum investment. The WHO recommends integration of such tobacco cessation interventions into an overall policy on tobacco control and incorporation of these programmes into general health care
Tobacco dependence and tuberculosis
Smoking is closely related to tuberculosis (TB), another big killer. TB is a major public health issue in several countries where nicotine use has reached epidemic proportions. For example, 15% of all new TB cases in the world occur in China where nearly two thirds of men use nicotine
A number of recent reviews have suggested that smoking is strongly associated with increased rates of both TB infection and TB disease
Treating tobacco dependence among TB patients and TB suspects
The association between TB and tobacco epidemic implies that addressing nicotine use in global TB control is likely to be beneficial for controlling TB as well as chronic diseases. It therefore makes sense that brief advice or any other available treatment for smoking cessation should be included in the management plan of TB patients. There are unmet opportunities for prevention and control of tobacco use among TB patients. During a typical course of treatment for TB, patients are in regular contact with health professionals for at least six months. Patients are considered to be more receptive to health education messages and willing to modify their health behaviour when they are ill
Research problem and justification
Before recommending TB programmes to incorporate identification and treatment of tobacco use, it is highly desirable and ethical to assess the feasibility of such an intervention. We found one such study conducted in Sudan that examined the feasibility of adding a simple cessation intervention to the general health care provision for TB patients in a poorly resourced health system
Research questions
1. What is the effect of a tobacco cessation intervention, based on WHO's 'five steps to quit' model, on patients' point and continuous abstinence from tobacco use? [Effect evaluation]
2. To what extent do the health professionals communicate risks of tobacco use and benefits of its cessation to their patients? What are their experiences and opinions about this strategy? [Process evaluation]
3. How do patients experience the intervention for tobacco addiction? [Ethical evaluation]
4. What is the incremental cost-effectiveness ratio of the intervention for tobacco addiction compared to usual care? [Economic evaluation]
General Objectives
We aim to develop and trial a complex intervention to reduce tobacco dependence among TB suspects based on the WHO 'five steps to quit' model. Although this work will be carried out in Pakistan, we expect our findings will have relevance to tobacco control in other low and middle income countries.
Specific Objectives
We will follow the Medical Research Council framework (see explanation in Methods section) for designing and evaluating complex interventions. Our specific objectives are:
1. To use qualitative methods to inform the development of an intervention based on WHO's 'five steps to quit' model (Phase I).
2. To develop and pilot this intervention which is likely to consist of: (a) an illustrative desk-guide (on patient assessment, education and treatment of tobacco dependence) and a training manual on this desk-guide for training of health professionals; and (b) leaflets for patients and others in the house containing information on the harmful effects of tobacco and advice on stopping its use, implying both cessation and prevention of tobacco use (Phase II).
3. To evaluate the incremental cost-effectiveness ratio of this intervention compared to usual care by estimating the proportion of people successfully quitting tobacco use (Phase III).
4. To determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes (qualitative component of Phase III).
5. To promote and support long term implementation of this intervention (Phase IV).
Conceptual and theoretical framework
We propose to evaluate the cost-effectiveness of a multi-faceted intervention to control tobacco dependence, which by definition is a 'complex' intervention. Such interventions in general consist of several inter-connected elements which are all important for their functioning
The objectives in our study align with different phases of this framework as follows:
1. Phase I will help us in identifying the likely behaviour change-elements in relation to tobacco use for the intervention especially the training package for professionals (desk-guide and training manual), and the information leaflet for patients.
2. Phase II will help in developing and piloting the intervention to allow us to refine and standardise it, test its feasibility in a resource-limited situation and test the feasibility of various (research and routine) data collection tools.
3. Phase III will consist of a cluster randomised trial to assess the effectiveness of the intervention, a costing study to assess its cost-effectiveness, and a subsequent qualitative study to identify barriers and facilitators in delivering the intervention.
4. Phase IV will identify key activities required to scale up the intervention.
Objective 1
To use qualitative methods to inform the development of an intervention based on WHO's five steps to quit model (Phase I)
Key activities
From a health systems point of view, we would be interested in understanding the local health care context for delivering the intervention. This would involve issues like current working environment, staffing, and workload issues. We will also explore the possibilities of funding NRT and bupropion, their registration and addition to the essential drug list. We will do this through conducting a workshop with the Tobacco Control Programme and other stakeholders at the start.
We will use qualitative approaches to understand: (a) the extent to which health professionals particularly doctors currently convey risks of tobacco use and benefits of its cessation to their patients; (b) how they perceive their own role, knowledge, skills and confidence in conveying these messages; (c) how their own behaviour towards tobacco use is going to affect their attitude towards patients using tobacco and the advice they might offer; (d) which professional group would be most appropriate to provide the different elements of the package e.g. initial advice, motivation assessment, counselling, follow-up; and (e) what would be most useful form and content of training package and tools to support them in this process. Among patients, especially presenting to primary care with respiratory complaints, we are interested in understanding: (a) to what extent they currently understand the risk of tobacco use and benefits of its cessation; (b) in what form and detail they would like to receive such information from health professionals; (c) what kind of visual images will be evocative but also culturally appropriate if used in education materials; (d) what are their common misconceptions about tobacco use; and (e) what is their attitude towards smoking cessation aids including willingness to pay for NRT (f) do women and men respond differently to advice by physicians versus others, and by advisors based on gender
We will use focus groups to identify common themes as these allow participants to interact with each other and stimulate and generate themes which are sometimes not possible with interviews
Focus groups will be conducted in health centres which will be participating in the subsequent phases of the study.
We will conduct two focus groups each from the following three categories of informants i.e. six focus groups in total. We will invite 6-8 participants for each focus group from the following:
1. Doctors
2. Nurses and health technicians (paramedical staff)
3. Patients (tobacco users) with respiratory symptoms (one with males and other with females)
Purposive sampling will be used to understand the breadth of variation as well as the typical attitudes and behaviours among professionals and patients. We will try to have participants from similar social class and backgrounds to allow enrichment of the data with minimum censorship.
Data collection
FGD will be facilitated by the research officer who will use a FGD topic guide which will be piloted with a group of health professionals and patients in another health centre. FGD will be tape-recorded.
Data analysis
We will use a sequential focus groups and analysis process so that the later focus groups can be informed by and test themes emerging from the earlier focus group discussions. We will conduct an inductive analysis by indexing through generating codes and identifying themes from the narrative text. Analysis will be conducted in the original language to identify and link themes. All narratives will be analysed separately first, followed by comparing and linking themes generated during the analysis across narratives.
1. A training package and tools (both format and content) which are context specific and are likely to ensure health professionals have the knowledge, skills, motivation and confidence to convey the risks of tobacco use and the benefits of cessation to patients.
2. Culturally appropriate messages and the form in which they are communicated to patients that is likely to challenge their misconceptions, answer common queries, provide the right depth of knowledge, their attitude towards smoking cessation aids including willingness to pay for them and motivation for them to modify their tobacco-related behaviour.
3. An understanding of health system constraints and drivers in delivering the intervention including possibilities of paying for NRT and bupropion
Objective 2
To develop and pilot this intervention which is likely to consist of: (a) an illustrative desk-guide (on patient assessment, education and treatment of tobacco dependence) and a training manual on this desk-guide for training of health professionals; and (b) leaflets for patients and others in the house containing information on the harmful effects of tobacco and advice on stopping its use, implying both cessation and prevention of tobacco use (Phase II).
Key activities
These can be divided into development and pilot.
In the development
Two different processes will be used to develop products for health professionals (training module & desk-guide) and patients (illustrative education tool & leaflet) respectively. We will convene a "local working group" of national (Pakistani) experts in tobacco control, primary care, health systems and district health services management, the district TB programme coordinator and primary care physicians and paramedics. This group will use the nominal group technique (a face-to-face group process technique for gaining consensus)
With permission, we will also make use of any existing materials developed by other international agencies, research groups or countries (such as the UK) which can be adapted to the context defined in the previous phase. Once we have developed draft materials, we will get external review from other national and international experts in the field.
In the pilot
The intervention will be delivered in six health centres (three urban, three rural). A decision to include these centres in the main trial will be taken at the end of the pilot depending upon required alterations in the intervention. In these centres we will introduce new tobacco use registers/questionnaires including queries such as: (a) current tobacco use (yes or no); (b) amount of tobacco use; (c) whether the patient is willing to try to stop tobacco use (yes or no); and (d) whether the patient has been registered to receive "five steps to quit" intervention
We will also estimate the validity of the subjective assessment of abstinence by using a cotinine test (or CO test) on all participants at follow up during this pilot. Depending upon the validity, we will decide to either use cotinine test (or CO test) in the actual trial or just the subjective assessment as a proxy.
Ultimately, based on the results of this pilot, we will develop a final version of the various components of the intervention. We will also modify the process for delivering the intervention if necessary.
1. A refined training module and an illustrative desk-guide on patient assessment, education and treatment of tobacco dependence for health professionals' use.
2. An illustrative education tool for patients
3. Leaflets for patients and others in the house containing information on the harmful effects of tobacco and advice on stopping its use which has been piloted
4. Additional leaflet for the patient's family that will include an explanation of the impact of second hand smoke on the patient and others
5. A revised and refined process for delivering the intervention in the study sites
6. Appropriate and revised data collection tools and systems.
The Intervention and its key components
FIVE STEPS TO QUIT - The Intervention Model: This is based on the evidence-based recommendations for treatment of tobacco addiction published by WHO in 2001
Key Components: We would like to develop components of the "Five Steps to Quit" intervention model on the basis of the following principles:
• Based on best available evidence and following an approach recommended by international agencies such as WHO and IUATLD
• Can be delivered in primary care setting by non-specialist health care staff (doctors or other non-medical personnel) integrated in their routine healthcare provision.
The intervention model consists of five key steps
1. Asking about the status of nicotine use;
2. Advising about the benefits of stopping nicotine use;
3. Assessing the motivation to stop its use;
4. Assisting in stop attempts through various therapeutic options; and
5. Arranging follow-up
Examples of the specific components for each step of the intervention are given in Appendix 1; this is a general guide only and modifications will be made during the development of the intervention.
Objective 3
To evaluate the incremental cost-effectiveness ratio of these interventions compared to usual care by estimating the proportion of people successfully quitting tobacco use (Phase III).
For this part of the project, we hypothesize that the 'five steps to quit' intervention (with or without offering the therapeutic option) will be more effective and cost-effective in getting people who are suspected of tuberculosis to quit nicotine use and remain quitters at both 4 weeks and six months after the treatment compared to usual care and information leaflet.
The study will be conducted in health centres in the public sector which are designated TB diagnostic centres (as per WHO's definition) in rural and urban settings in two districts in Punjab, Pakistan. This has been the setting of a number of research activities carried out by the investigating team over the last 12 years mainly in tuberculosis. Diagnostic centres, in a typical district in Punjab, are generally:
• Rural health centres - rural settings
• Tehsil headquarter hospitals - urban settings
Centres are typically staffed by one to three doctors, nursing staff, laboratory technician, pharmacist and community health workers. They are also equipped with a basic microbiology laboratory capable of examining sputum for AFB. The outpatient departments are open to the population of the catchment area including referrals from Basic Health Units (a single doctor manned primary care health centre). Patients with suspected tuberculosis once seen are screened with two/three sputum examinations. If diagnosed with TB, they are registered and commenced on anti-tuberculosis therapy.
Study Design
To deliver 'five steps to quit' intervention (with or without offering the therapeutic option), individual patients cannot be randomised to the intervention and control arms within health centres due to the possibility of contamination. The most suitable design to assess its effectiveness is a cluster randomised controlled trial (RCT). The overall design is summarised in the trial flow chart in Figure
Figure 1
Trial flow chart
Trial flow chart.
Participants and Sampling
The sampling frame will consist of all TB diagnostic health centres that are approached for this study and their doctors and other paramedical staff have expressed willingness to participate. Access to these diagnostic centres will be facilitated by one of the investigating partner organisations, ASD, which has been given the responsibility of implementing the DOTS strategy in 18 districts in Punjab. Health centres in the sampling frame will be stratified according to rural (RHC) and urban location (THQ). 11 health centres will be randomly allocated to each of the two intervention arm and the control arms, using computer generated random number lists by an independent scientist.
In each health centre, we will approach adult patients (≥18 years), who cough for 3 or more weeks and are therefore suspected and screened for pulmonary tuberculosis. We would aim to recruit at least 50 patients from each centre over a period of three to six months. Patients will be provided with both verbal and written information about the study and only those who consent will be recruited in the study.
Patients whose condition requires hospital admission or other urgent medical attention will be excluded. Patients will be approached and recruited each day.
Delivery of the intervention
We propose to use a systematic, standardised approach to deliver 'five steps to quit' to make it effective and equitable
Table 1
Follow up and contacts with health professionals
Trial arms
First contact
FU at week 1
FU at week 5
FU at week 8
FU at week 25
Intervention 1 (brief psychological intervention + therapeutics)
Assess eligibility at the laboratory
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
Doctor (if necessary)
Intervention 2 (brief psychological intervention only)
Recruitment at the laboratory
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
Control (usual care + leaflet)
Recruitment at the laboratory
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
TB DOTS facilitator
The TB DOTS facilitators and primary care doctors will be given a training course (using training manual) on the "five steps to quit" programme on the use of desk-guide and focusing on
• The scientific basis of the intervention
• Techniques to enquire about the status of tobacco use
• Providing brief advice on the benefits of stopping its use through visual images
• Approaches to assess nicotine dependence and motivation to quit
• Using this motivation to propose various treatment options explaining their pros and cons
• Training in the use of available pharmacotherapies and other cognitive-behavioural strategies
• The procedure for follow-up and other technical and organisational aspects.
• Familiarity with the recording and reporting system such as revised records and new tools
Training of TB DOTS facilitators will also focus on the brief counselling techniques based on cognitive-behavioural model
• Assessment of the status of their tobacco use through a checklist of questions
• Advising on benefits of quitting using visual and written educational material
• Assessment of willingness for inclusion in the study and motivation to quit using a simple scoring card
• Registration and recording of demographics and contact details
• Structured counselling using a desk guide and patient planner
• Giving a quit date after a week
On the subsequent visit in a week's time, TB DOTS facilitator will be responsible for
• assessing the status of their tobacco use
• Sharing their experience of attempting to quit, listen to the difficulties they had and providing supportive counselling to help cope with the difficulties
• Referring them to doctor if the intervention arm includes therapeutic option
• Arranging follow up in a month's time.
At follow ups at week 5 and 25, TB DOTS facilitators will be responsible for
• Reassessing status of nicotine use and recording it in the tobacco use questionnaire/register
• Reviewing treatment and other options
• Rearranging follow up as per desktop guide.
In the intervention arm 1, the primary care doctors, in addition to supervising TB DOTS facilitators, will be responsible for assessing and prescribing therapeutics (Bupropion) to patients who wish to quit and are being referred by the TB DOTS facilitators. All patients on treatment will have an additional follow up visit at week 8. In intervention arm 2, doctors will be only responsible for supervising TB DOTS facilitators. They will be provided with the appropriate training and relevant materials.
Apart from the relevant training and materials, health professionals will not be provided with any other incentive, financial or otherwise. However, treatments packs will be provided from the research budget. The research officer will also organise regular supervisory visits to oversee patient management and data collection procedures. Monthly cluster meetings of the health professionals involved will also be organised to discuss progress and potential problems.
The Control Arm
Participants in the control arm will also be recruited from those who are suspected of TB and screened using sputum examinations. The changes in the relevant registers will be made to record the status of nicotine use and health professionals will be given instructions on recording it on-site. The TB DOTS facilitators in control diagnostic centres will be provided with patient education leaflets to be given out to all patients recruited in the study. Apart from recording their status of nicotine use and arranging follow up at week 1 and 5, they will be provided usual care. No other components of the intervention will be delivered. We do not anticipate a significant risk of contamination, i.e. patients moving from one diagnostic centre to another, due to the geographical spread of facilities, and because no publicity will be produced regarding the availability of the treatment package in other facilities. In addition, we do not anticipate a significant benefit (other than what has been recorded previously in controls) in the control arm given that asking about nicotine use and providing information leaflets, are not, by themselves, sufficient to lead to stopping nicotine use.
These are as follows
1. Point abstinence at 4 weeks: The proportion of trial participants who have completely given up all forms of nicotine use at four weeks after the completion of bupropion and/or brief psychological intervention
2. Continuous abstinence up to 6 months: Proportion of trial participants who remained abstinent from 4 weeks onwards up to six months
3. We will also measure tobacco use e.g. number of cigarettes smoked per day to estimate any reduction in tobacco use secondary to the intervention
4. Secondary outcomes will include incidence of various adverse affects secondary to therapy
5. Economic outcomes will be assessed in terms of healthcare cost to get one person to stop smoking at four weeks. Healthcare cost will include the treatment cost, the average duration of health professionals' time spent with the patients during assessment, advice and counselling.
6. Process outcomes will include: the proportion of tobacco users who decide to quit and registered to receive 'five steps to quit' intervention; and the proportion of people registered who continue follow-up for the full period planned
Data collection
Our pilot study will determine the feasibility of our proposed tools to gather patient details and their status of nicotine use at various appointments. The modified tools will include:
1. 'Five steps to quit" intervention cards and register
2. A separate tobacco use questionnaire/register to record smoking status and motivation to quit
These approaches will allow us to record demographic details including gender, socio-economic status, presence of other smokers in the house and workplace, number of children at home, status of nicotine use, motivation level, type of therapy offered, extent to which therapy was used, adverse events and abstinence at different end points. We would adapt some of the tools already well described in the existing literature
Patients who are subsequently diagnosed with TB will be followed up regularly for their TB treatment and the outcomes relevant to this study will be recorded during those visits. Trial participants who are diagnosed as not having TB and being given any of the three forms of therapy will be asked to follow up at the intervals specified. Controls not diagnosed with TB and received only usual care and a leaflet will be asked to return at 4 weeks to review their respiratory condition and to assess their status of nicotine use. Attrition is a potential problem. After piloting in phase 2, patients' mobile phone numbers will also be recorded and those who are lost to follow up will be contacted via their mobile phones to assess their status of nicotine use. A high proportion of Pakistanis possess mobile phones irrespective of socio-economic status.
Similarly, at six months in both intervention and control arms, all patients who stopped tobacco use will be contacted either via their mobile phones or landlines to assess their smoking status. According to our estimate this number will approximately be at least 264.
In order to estimate the average time spent by health professionals in delivering 'five steps to quit' intervention, our research officer will spent a day at each centre to measure and record this time.
We will also record the gender and status of nicotine use among all health professionals giving advice and include a column in the above patient record tools to record which health professional delivered which element of the package.
Data analysis
Our research officer will collate data from all health centres on a monthly basis and feed them into a database created via SPSS kept on a mobile computer. There will be an assessment of smoking status by intervention category, analysed on an intention to treat basis. The point abstinence will be compared between the intervention and control arms at 4 weeks after the completion of the treatment and in controls 4 weeks after they were given the leaflets. Further analyses will include the comparison of continuous abstinence at six months between the two arms. We will also estimate reduction in tobacco use in both trial arms and compare to detect any difference. Missing data on the outcomes will not be inputted. Secondary analyses will investigate the use of, and adherence with, the various forms of therapy. Further sub-analyses will be carried out to detect differences in outcomes according to a number of variables such as gender of the participants and providers, smoking status of the provider, socio-economic status, existence of other smokers in the house or workplace and presence of children at home. We are mindful that sample size estimation was not based on these sub-analyses and therefore we may not be able to detect small differences in the outcomes according to these variables.
Sample size
We have estimated a sample size of 33 clusters (diagnostic centres) 11 in each arm of the trial. Each cluster size will be 40. The actual number of patients recruited in each cluster will be 50 patients with suspected tuberculosis each [assuming 80% will complete the trial up to the review at 6 months as per study in Sudan
Quit rates
We base our cessation rates on the cumulative estimates in the recent systematic reviews conducted by Cochrane Tobacco Addiction Group
Number of individuals per facility
On average 50 new TB patients are diagnosed every year in each diagnostic centre. The number of patients suspected of tuberculosis is generally ten times the number of patients diagnosed. Therefore, recruiting 50 patients from each centre is unlikely to pose any problems. In the study carried out in Sudan, researchers were able to recruit and enrol 44% of all TB patients
Attrition Rates
The sample size calculation incorporates an attrition rate of 20%. This is based on the observations made in the trial of tobacco control in TB patients in Sudan where less than 20% patients defaulted over a period of six months. An intention to treat analysis will account for any non-differential loss to follow up. As part of DOTS, patients with diagnosed TB are generally followed up for a period of six months. However, follow up of non-TB patients will be arranged as part of the trial.
Intra-cluster variation
The intraclass cluster coefficient (ICC) of the outcomes is an important factor in estimation of the sample size for a cluster RCT. It is generally estimated from the previous studies of smoking prevalence and its outcomes in similar settings. However, we found very few studies reporting ICC in similar settings. We use an ICC of 0.036 which has been used estimated from trials conducted in primary care clusters in the UK
Objective 4
To determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes (qualitative component of Phase III)
Key activities
At this stage we will require an in-depth understanding of the way intervention would be implemented. We would like to know which factors would act as barriers to effective implementation and how health professionals would overcome these. We would also like to know the key drivers in the system which would be instrumental to successful implementation. We would be interested in understanding to what extent patient felt supported in their efforts to stop tobacco use through the health service intervention; which factors motivated them to quit; and which were their main constraints. Since this phase will be post-intervention, it would be preferable to use semi-structured interviews with key informants (see below) to gain this understanding.
Settings and Participants
We will recruit a group of study participants from the health centres from both urban and rural settings including:
• Patients who were offered intervention and did not quit tobacco use
• Patients who were offered intervention and quit tobacco use
• Doctors and programme managers
• Other paramedical staff.
We will purposively select 16 individuals (8 from urban and 8 from rural settings) equally from all four key informant groups.
Data collection
We will use an interview topic guide which would be initially piloted with a patient and a doctor. All communications will be tape-recorded and transcribed. Key themes identified from an iterative analysis of focus group data from phase II will also be used to develop the interview topic guide.
Data analysis
We will use a sequential focus groups and analysis process so that the later focus groups can be informed by and test themes emerging from the earlier focus group discussions. Data will be categorised and coded for a thematic analysis. Initial codes, generated from the focus group in phase II will also be iteratively updated. Data will be organised to identify key themes. Dependability of these themes will be checked with respondents.
1. Further refinement of the model of care and materials to take account of barriers and facilitators to implementation
2. Useful information to understand the implications of scaling up the intervention within TB programme
Objective 5
To promote and support long term implementation of this intervention (Phase IV)
Key activities
Activities listed here will be ongoing throughout the study period. These include:
• Seek the national TB and Tobacco control programmes' endorsements for the intervention
• Work with the national programmes to develop a plan to scale up the intervention
• Develop a proposal to conduct embedded research to inform further scaling up.
User participation
We will conduct patient focus groups in the first phase of the project to inform the development of the interventions, especially patient education tools. We will seek other opportunities to engage users in the research as appropriate e.g. we will endeavour to include patient representatives in the monthly cluster meetings. Although, we do not envisage reporting the results back to all research participants, we would convey our findings to the participating communities through local newspapers, radio, community leaders, patient representatives in the steering committees and posters in the participating health centres.
Gender Considerations
We understand that gender is a key determinant of the attitude towards tobacco use and related behaviour. Gender also determines the different patterns and types of tobacco use. Furthermore, women's uptake of and response to NRT is different from men. The uptake of both men and women may also differ on the gender of the professional giving advice. Therefore, we will record gender of both providers and recipients and conduct sub-analyses to ascertain variable uptake, response to the treatment and maintenance of abstinence according to these gender differences. We will conduct separate focus groups of both women and men in phase I to capture gender perspective in attitudes towards tobacco use and its cessation.
Confidentiality and data protection issues
The privacy of the participating patients will be protected, and all data will be coded and processed according to the rules and policies of University of Leeds.
Ethical considerations
The effectiveness of specific intervention components (e.g. Bupropion) is established in trials conducted mainly in developed countries. However, the same is not true for the strategies that attempt to introduce these into existing health programmes. The proposed study is evaluating the effect of a multifaceted intervention to support patients who are suspected of TB to give up nicotine use. The research questions posed here respond to a priority need for developing countries where the existing health programmes provide an opportunity to control the increasing problem of tobacco addiction.
No participant will be deprived of any care that she would ordinarily receive. There will be no extra burden, financial or otherwise, on control subjects. Even participants in the control facilities may benefit from greater monitoring and attention. The four week follow up after their first contact is often required for their clinical condition. Upon completion of the trial, all control facilities will be offered a copy of all the training materials, training course, desk-guide and education tools. Under-powered trials are considered unethical
Formal ethical approval is being granted by the Biomedical Ethics Committee of Pakistan Medical Research Council. An information sheet translated in Urdu will be given to all eligible patients. Patients will be given information on all aspects of the research project by means of verbal and written information at the inclusion. It will be clarified in the informed consent form that each patient can leave the study at any moment without having any repercussions on her usual care.
Results and dissemination
Our aim is to ensure that the Pakistan National TB Programme and the Pakistan National Tobacco Control Programme adopts, scales up and sustains the intervention that we expect to arise from this work: that is, that the research benefits the people of Pakistan and not merely the researchers. History demonstrates that to achieve this aim, it is insufficient to follow the conventional approach of disseminating the research results at the end of the study.
Instead, our approach is to embed research within the national control programmes, starting even before the inception of the research and continuing beyond the end of the research to help the programme develop policy statements, implementation tools, training materials and courses. Policy-makers, researchers and other stakeholders are all involved throughout the process, from identification of priority problems, through broad development of research questions and proposals, regular feedback on progress of the research, interpretation of the research findings, and scale-up.
As a result, all stakeholders, including the Directors of the NTP and NTCP and the research team, have ownership of and responsibility for the research from start to finish. Thus research questions are asked which are of direct relevance to the control programme directors; candidate interventions are feasible in the economic, socio-cultural and political setting; and issues of scale-up are addressed at the inception of the research. This greatly enhances the likelihood that the research findings are incorporated not only into policy, but also into national practice. We will also make attempts to bring in other organizations, (e.g. NGOs, lobby groups working for tobacco control in Pakistan) to help with the dissemination of the results and use this research to lobby for greater tobacco control measures.
Competing interests
We, as the authors of this article have no competing interests (financial or otherwise) in this publication.
Authors' contributions
KS carried out the background literature review, identified research gap, developed research objectives and proposed research design. AK worked out the key components of the interventions and the mode of its delivery. MA developed detailed methods for the different phases of the study. SR developed detailed protocols for the delivery of intervention and data collection. All authors read and approved the final manuscript.
We are grateful to the International Development & Research Centre, Canada for supporting this proposal and awarding a research grant to fund this project.
I am also grateful to Professor James Newell and Professor John Walley who are my colleagues at University of Leeds. Their guidance and review of the protocol was very helpful in its development.
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The cost effectiveness of pharmacological smoking cessation therapies in developing countries: a case study in the Seychelles
Tobacco use among youth and adults in Mainland China: The China Seven Cities Study
Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43[punctuation space]000 adult male deaths and 35[punctuation space]000 controls
Partnering for better lung health: improving tobacco and tuberculosis control
Associations between tobacco and tuberculosis
Tobacco and tuberculosis: a qualitative systematic review and meta-analysis
Tobacco smoke, indoor air pollution and tuberculosis: a systematic review and meta-analysis
Risk of Tuberculosis From Exposure to Tobacco Smoke: A Systematic Review and Meta-analysis
Lethal interaction: the colliding epidemics of tobacco and tuberculosis
Prevalence and risk factors for transmission of infection among children in household contact with adults having pulmonary tuberculosis
The effect of smoking on tuberculosis: different patterns and poorer outcomes
The impact of smoking on adherence to treatment for latent tuberculosis infection
Introducing brief advice in tuberculosis services
Tobacco cessation and brief advice
Feasibility of brief tobacco cessation advice for tuberculosis patients: a study from Sudan
The prevalence of smoking in Bangladesh
A framework for the development of RCTs for complex interventions to improve health
Framework for design and evaluation of complex interventions to improve health
Consensus methods: characteristics and guidelines for use
Providing and monitoring quality service for smoking cessation in tuberculosis care
Brief interventions and referral for smoking cessation in primary care and other settings
Helping patients to stop smoking
Individual behavioural counselling for smoking cessation
Physician advice for smoking cessation
Nicotine replacement therapy for smoking cessation
Antidepressants for smoking cessation
Intraclass correlation coefficients for cluster randomized trials in primary care: the cholesterol education and research trial (CEART)
The Continuing Unethical Conduct of Underpowered Clinical Trials
Pre-publication history
The pre-publication history for this paper can be accessed here:


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How Do I Make The Vocals Sound Fuller?
Posted 14 January 2012 - 05:11 AM
Posted 14 January 2012 - 02:42 PM
Posted 15 January 2012 - 08:42 AM
When i'm listening to the vocals I have recorded, both in the chorus and the verses, they sound so empty, you know? What should I do? I want it to sound professional, and I have a pretty good mic.
Use a little EQ and some compression, that will fatten things up. If unsure try some presets and adjust.
There are really a lot of ways to work with vocals depending on what your looking for for sound.
Mixing - Logic Pro X | OS X 10.8.4 | 3.4GHZ Quad Core Hackintosh | 16GB Ram |
Studio Tracking - Logic Pro 9.1.8 | OS X 10.6.8 | 2GHZ Quad Mac Pro | 6GB Ram | Apogee Symphony PCI-e | Apogee AD16X | Apogee Mini DAC | Logic Control & Extender and Mackie Control C4 and a boat load of other cool stuff i use in my studio Static Productions
Posted 15 January 2012 - 01:23 PM
Posted 30 October 2013 - 07:32 AM
To get the best out of your vocals you need to first consider the mic type (condensor or dynamic); Make sure you capture the best performance you can. In all fairness, you only have what you have captured. capturing a fine performance will already have your vocals sound pretty good and, of course, the microphone chioce helps completement the outcome. Yes, i agree dynamic processing can help shape the size of the instruments 'getting it phat' however it is best not to over compress or over eq as it will serious affect your sound. on the other hand, if you are going for the over compressed/eq sound then thats ok. But i would seriously suggest that you take time to study exactly what sound you want to achieve and how you can achieve it. Having a ref track will also guide you.
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aloha politics
Featuring EMOJI COMICS & MAX The Telepathic Robot with comments by Keone Michaels
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Reprise TFFN post from 03/19/17
Turns out that Mr. Rodman and Mr. Trump worked together once before at Celebrity apprentice. You just can't make this stuff up!
Whot will Mr. Sessions say today?
1. ) First Read's Morning Clips: Previewing the Sessions Testimony
2.) Sessions calls notion he colluded with Russia 'detestable lie'
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Sunday Roundup of things that will happen when oinkers fly!
1.) Trump: I'm willing to testify under oath about Comey claims
2.) Calling Comey a Liar, Trump Says He Will Testify Under Oath
3.) Trump Should Testify Before The Senate On Russia And Comey, Schumer Says
4.) 9 of the most staggeringly awful statements Republicans have made about health care just this year
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I have been asked to do an 18th Birthday cake for my cousin. I am only new to making cakes and have only ever done chocolate paste covered cakes in winter. The problem with this cake, is the birthday is in the hottest month of the year.
I was wondering if I can put paste covered cakes and the paste decorations in the fridge? I know you cant put the fondant ones in the fridge, but Im hoping that chocolate paste is different!
If it cannot go in the fridge, does anyone have any thoughts or suggestions on how I can keep it cool enough so it will not melt and my decorations wont droop!!?
Any thoughts appreciated!
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University of St Mark & St John
University of St Mark & St John
The University College Plymouth St Mark & St John (or UCP Marjon as we're better known) has been training teachers since 1840 making us the most experienced teacher training institution in the South West.
We regularly receive outstanding results in our Ofsted inspections and in a recent TDA survey of newly qualified teachers we ranked top ten for the quality of our training. We've also ranked top ten twice in the past three years for student satisfaction in the National Student Survey.
UCP Marjon is different from other institutions. We are small, hence our University College title. Here there is a strong sense of community and support. We consider ourselves a family, where students and tutors are on a first name basis. When it comes to contact time with your tutors, it's not a question of how much time will you get, but instead how much time would you like. We have some excellent researching academics, however UCP Marjon is a teaching led (opposed to a research led) institution. As a training teacher, this means the focus of our academic staff will be on your development, not their research.
Our campus is located a couple of miles outside of the Plymouth City Centre. It's a safe, friendly campus with student parking. The campus is WiFi enabled. This is ideal, as all PGCE and BEd students receive a free laptop when they enrol. We offer this, because at UCP Marjon learning goes well beyond the lectures and seminars. Our virtual learning environment (LearningSpace) is available 24 hours a day and keeps you in contact with tutors, lessons learning and teaching aids, the library and your fellow student teachers. This is essential when on school placements. To ensure that all of our student teachers benefit from this enriched learning environment, we pioneered this free laptop scheme.


text:
Your answer is one click away!
I am using WinSCP to write to connect a SQL Server to an SFTP server. I am trying to write a file to an SFTP server where I only have write access, not modify. I am having a problem because I get back
Cannot create remote file '/xxx.filepart'.
The documentation suggests this is because I do not have modify access to the target directory. I did this WinSCP -> Preferences -> Endurance -> Disable
I checked the
winscp.ini file and
ResumeSupport is
2 (I believe this means disabled). I ran
"echo $transferOptions.ResumeSupport" and it says that it is in a default state.
I have checked this documentation:
However, I don't see a PowerShell example, just C#.
I have tried various permutations of
$transferOptions.ResumeSupport.State = Off,
$transferOptions.ResumeSupport.Off, and whatnot. One of these says that it's read-only.
I know
$transferOptions is a variable here but it comes from the default script. The object determines transfer options
$transferOptions = New-Object WinSCP.TransferOptions
Thanks in advance for help
edit: The overall problem is I only have write access to the server, but not modify. I am getting a new error: "Cannot overwrite remote file '/xxx'.$$. It looks like the dollar signs are some sort of temp file that it's trying to create. Is there a way to disable whatever setting is causing this?
Syntax for using enumeration in PowerShell is described in article Using WinSCP .NET assembly from PowerShell.
Enumeration values are accessed using static field syntax
[Namespace.Type]::Member, for example
You can find a PowerShell example for
TransferResumeSupport.State in Converting to .NET assembly section of
get and
put command documentation:
$transferOptions = New-Object WinSCP.TransferOptions
$transferOptions.ResumeSupport.State = [WinSCP.TransferResumeSupportState]::Off
$session.GetFiles(..., ..., $False, $transferOptions).Check()


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- Shed
- Shed Shed, v. i.
1. To fall in drops; to pour. [Obs.]
[1913 Webster]
Such a rain down from the welkin shadde. --Chaucer. [1913 Webster]
2. To let fall the parts, as seeds or fruit; to throw off a covering or envelope. [1913 Webster]
White oats are apt to shed most as they lie, and black as they stand. --Mortimer. [1913 Webster]
The Collaborative International Dictionary of English. 2000.


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Hotel Jerbourg
Hotel Jerbourg is a luxury Guernsey Hotel. It is set in a prime beauty spot on the cliff tops at Jerbourg Point, with breathtaking views over Herm, Sark, Jersey and even France on a clear day! Only a step away from picturesque cliff walks, ten minutes from St Peter Port and within easy access to Guernsey Airport makes Hotel Jerbourg an ideal base to explore Guernsey and the wide array of attractions. This Guernsey hotel offers a solar-heated outdoor swimming pool that is open from May to September and overlooks panoramic sea views. A welcoming bar and exquisite lounge also adds comfort and relaxation to your stay. In addition, it is impossible to forget the internationally renowned restaurant Les Trois Isles . There is an outstanding selection of menus featuring local seafood: crab, lobster and sea bass to name a few, which are combined with fresh Guernsey produce prepared by award winning Chefs. An extensive fish board, steak board, daily changing table d hote menu and extensive bar menus are available along with an amazing wine selection. Morning coffee, lunches, afternoon teas and drinks are available on the sundeck. Petanque at the poolside is exclusively for Hotel guests. All the bedrooms at Hotel Jerbourg are en-suite, most enjoying sea views and for the comfort of guests are non-smoking. Available are a choice of standard or superior rooms, .these include satellite TV, hair dryers and beverage trays. Ten of the deluxe rooms also offer a private patio with balcony or lounge areas. A warm welcome awaits at Hotel Jerbourg!
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In the Region/Connecticut; Dairy Farms Drying Up in the Town of Washington
By ELEANOR CHARLES
Published: April 16, 1995
TOWN OF WASHINGTON— A HUNDRED years ago there were about a hundred dairy farms in the Town of Washington. Soon there will be only two.
By mid-September Davie's Hollow Farm, operated by John Nye, a 34-year-old native of the town, a 4-H Club member in his youth, an agriculture major in college and a tenant dairy farmer since 1981, will move his family and 600 Holstein cows to 80 acres in Delta, Utah.
For John, his wife, Maria, and their children -- Gregory, 9; Peter, 6, and Katharine, 3 -- leaving their hometown, families and friends will be a wrenching experience.
The exodus of farmers from the state and sometimes from the dairy business, said Shirley Ferris, the state's Commissioner of Agriculture, results from "the low price of milk, the high cost of equipment and doing business, and residential development that created a scarcity of land."
Her own family's dairy farm in Newtown, one of 10 left in Fairfield County, operates with 145 cows. "We are fortunate," she said. "Our neighbors value the idea of a farm."
That has not been the case in Washington, where the majesty of the hilly landscape is being preserved by people wealthy enough to buy huge farms and convert them to elegant private residences, or by cluster housing development.
"We are surrounded by residential neighbors," said Mr. Nye. "They complain about the smells, or don't like the look of dry corn stalks, or object to herbicides that might contaminate the water. I try, but I haven't been too successful at peacefully coexisting with an increasingly suburban population."
Michael J. Cherniske, one of the two remaining farmers in Washington, is also thinking of moving. "I thought I would be here forever," he said, "but I can make $5,000 a month more in Virginia or Tennessee, or maybe in Utah." His 230-acre, family-owned farm was started by his grandfather.
Over the years, as Mr. Nye's business grew, he rented more and more land, until now he has 35 landlords for 247 fields within a 20-mile radius in nine towns. Rents run from zero for mowing abandoned lots (he keeps what he mows for feed) to $20 an acre for growing corn.
"Cost control is a problem chasing around to all those places," he said, "especially in heavy snow." The price of milk will be $1 per hundred pounds lower in Utah, he said, but the cost of doing business will be much lower than it is in Connecticut.
Milk prices, controlled by the Federal Government since the 30's to protect farmers from unscrupulous middlemen, have fluctuated in Connecticut between $12 and $14 per hundred pounds since the 70's. In the last five years the lower figures have prevailed. But at the same time, farms disappeared and farming costs rose.
"Fewer farms mean higher prices charged by fewer equipment dealers and repair services," said Douglas J. Di Mento, spokesman for Agri-Mark, a New England dairy co-operative based in Methuen, Mass., to which Mr. Nye belongs. The members' milk is sold to Hood, Sealtest, Stew Leonard's and Baskin-Robbins, among others.
According to the state's Department of Agriculture, there are 302 farms in the state today, 70 of them in Litchfield County. In 1970, there were 1,127 statewide and 127 in Litchfield, where 6 went out of business last year alone.
"You can't afford to buy land here just to farm it," said John Potter, who with his brother, Timothy, runs Washington's second remaining dairy farm. "We own 100 acres and farm 600 more. John Nye doesn't own any land, his growth couldn't be sustained."
MR. POTTER plans to stay, "but our income is mostly from selling frozen cattle embryos to France, England, Holland and Japan," he said. "Other farmers have diversified into selling hay, sweet corn, fruits and vegetables. And most wives are working."
Another form of diversification is renting houses to weekenders from New York City, said Robert M. Seymour, owner of Spring Hill Farm, near the Nyes's home. "It's as profitable as farming," he said.
He sold his dairy herd in 1974, but keeps about 20 head of beef cattle. He has been approached often to sell his land, but he resists. "A rich buyer will take over a big place, put a lot of money into it and after a year or two put it up for sale," he said. "That inflates our land values and makes taxes high for everybody."
Carolyn Klemm, co-owner with her husband, David, of Klemm Real Estat here, said: "Occasionally we go out and solicit farms for very rich buyers. In the 80's we sold a lot of large dairy farms as residences. Linda Allard, the fashion designer, bought one, and Ivan Lendl bought 875 acres in Goshen. There are also people who moved their businesses from New York to Greenwich and live out here now. And sometimes several people get together and buy land to put into a land trust."
The farmers cannot compete for the large land masses that they need to grow feed for their herds. "Thirty percent of our income goes for growing corn and hay," said Mr. Nye, and for the purchase of soybeans, oat hulls, cottonseed, bakery and potato waste products.
The feed is kept in enormous three-sided cement bunkers and hauled out as needed by payloaders. Runoff from the bunkers, and from animal waste and feed cultivation is a constant problem on the hilly land.
State laws forbid polluting water from any source, whether farming or industrial. Noncompliance can trigger fines of $1,000 to $25,000 a day, although the higher figure has never been imposed on a farmer. Correcting a violation can be extremely expensive, and on rented land it is not worth it.
"If Connecticut follows Vermont in banning manure spreading in winter because of runoff during thaws, I would have to spend about $200,000 on building and maintaining a storage bunker," said Mr. Nye.
HE estimates that his investment in Utah will be $1,000 per cow compared with $5,000 per cow in Connecticut. "In Utah we will be going out of dairy farming," he said, "and into dairying only -- strictly tending and milking cows. We will buy all our feed."
The land in Utah is flat and dry. The annual seven inches of rain produces negligible runoff, and prodigious amounts of alfalfa and other feeds are grown by irrigation with water flowing from the Wasatch and Rocky Mountains.
Alan Rindlisbacher, Director of National Business and Economic Development for Utah, said the state would "welcome the Nyes with open arms," adding that "Millard County, where they are moving, has been targeted as a marketing niche for dairy farmers."
Utah's crops are the beginning of an economic chain that the state wants to link with farmers who produce milk that in turn produces cheese and butter, "keeping more jobs and dollars in the state," Mr. Rindlisbacher said.
Between now and September, Mr. Nye will sell off 200 of his 800 cows, settle up with all his landlords and arrange for the $70,000 he invested in the Agri-Mark Cooperative to be refunded over a customary 7-year period. He will pick up the option on his Utah land and start building his new house, barn, milking and storage units. During construction his family will rent a house and space for the cows on somebody else's farm.
"No more growing of feed," he said. "More specialization is the trend -- putting all the eggs in one basket."
Photo: John Nye at Davie's Hollow Farm in the Town of Washington. He is moving his family and cows to Utah. (Stephen Castagneto for The New York Times)


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Tag Archives: football
POV Video: What It's Like to Catch a Derek Carr Pass
Derek Carr isn't among the NFL's top quarterbacks at the moment. Far from it. But the Oakland Raider did have an impressive rookie season in 2014, leading all rookie quarterbacks in yards (3,270) and touchdowns (21), while throwing just 12 interceptions. Those are pretty good numbers for any first-year quarterback, let alone one that had […]
Watch Sal Alosi Trip P. Diddy In Hilarious Vine (Video)
Prior to yesterday's kettlebell brawl with P. Diddy, UCLA Strength and Conditioning coach Sal Alosi was best known for an incident back in December 2010, when he tripped the Dolphins' Nolan Carroll along the sidelines during a special teams play while working for the Jets. Alosi was fined $25,000 by the Jets and suspended for the remainder […]
Watch the Detroit Lions Learn How to Tie a Tie (Video)
The Detroit Lions are currently holding their annual Rookie Training Week, which is aimed at getting players ready for life as a professional athlete by teaching them a variety of skills and strategies that they may find useful. One obvious skill they'll probably need is money management. Another not-so-obvious skill that they'll definitely need is knowing […]
Peyton Manning Conducts Orchestra Playing "Rocky Top" (Video)
Peyton Manning has always been consider to be one of the ultimate field generals in the sport of football. The way he conducts his offense at the line of scrimmage has become a trademark of his game, using his voice and hand signals to instruct his team on what play they are to run. It therefor only […]
Former Ravens Cheerleader Molly Shattuck Pleads Guilty to Rape
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Over the last couple of years, we've seen several obscure NFL prospects get some social media attention for themselves by performing acrobatic catches and putting the videos online. Such videos are amusing, of course. But the reality is that no NFL team is going to draft a guy just because he caught a football (or […]
Patriots Release Brandon Spikes After Hit-and-Run Incident
When Brandon Spikes smashed his 2011 Mercedes Maybach on the I-495 in Foxborough early Sunday morning, he apparently thought that the best thing to do was to tell an OnStar operator that he had hit a deer before abandoning his car. He was wrong. Earlier today, the New England Patriots released the 27-year-old linebacker as […]
Tom Brady Throws TD Pass to Boy With Down Syndrome (Video)
While taking part in a charity football game for "Best Buddies" at Harvard Field on Friday, Tom Brady completed one of the most heart-warming touchdown passes of his career when he dumped the ball off to Chris in the flat and let his receiver do the rest. Check it out: Chris suffers from Down Syndrome, and he's […]
High School Football Player's Dying Wish: To Be Carried Across the Field by His Teammates (Video + Pics)
Last week, 18-year-old Malik Sparkman lost his battle with kidney cancer. On Sunday, his teammates on the Coffee County (Georgia) High School football team granted Sparkman his dying wish. Sparkman, a standout linebacker for the Trojans, was diagnosed with renal medullary carcinoma last year. His entire community, including family, friends, and teammates, rallied to support […]
Adrian Peterson Twitter Rant: Internet Reacts
Adrian Peterson is an angry man. He's angry with the NFL. He's angry with the Vikings. And he's angry about his contract. So what do angry people do in this day and age? They go on Twitter rants: I love people who think they know it all! Smh, Research how many NFL teams hasn't honored a player's […]
Chip Kelly Responds to LeSean McCoy's Racism Allegations
After being shipped from the Philadelphia Eagles to the Buffalo Bills for linebacker Kiko Alonso, LeSean McCoy suggested that Eagles head coach Chip Kelly is racist because he "got rid of all the black players" during an interview for ESPN The Magazine. Today, Chip Kelly responded to those comments for the first time while speaking with the […]
Photos Leak Of Jerry Jones Groping More Young Women
The last time Jerry Jones was caught on camera creepily putting his hands all over a couple of young women, he was hit with a lawsuit by one of the women who claimed she was sexually assaulted by the Dallas Cowboys owner. Has Jerry learned his lesson? Of course he hasn't. Jones is once again […]
CFL Long Snapper Snaps Can Off Kid's Head (Video)
Any NFL team in search of a long snapper for the upcoming season may want to take a look at Edmonton Eskimos long snapper Ryan King. I'm not sure about his blocking skills, but his snapping accuracy is awfully impressive—as is his confidence in that accuracy: Hat Tip – [Fansided]
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There are few things that Rob Gronkowski can do in a night club these days that would shock me. Gronk grinding up on a group of females? Not surprising. Gronk taking off his shirt and dancing? Not surprising. Gronk motorboating a chick like the motorboatin' son of a b*tch that he is? Not even the […]


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|English Romantic Cushions, £50, Chocolate Creative
An interiors, vintage style and crafts blog, Patchwork Harmony features inspiring ideas for your home from vintage and thrifty finds to independent designers and makers. We share DIY tutorials, handmade ideas as well as shopping tips for vintage lovers and interior styling advice for your home. Part of the Patchwork Harmony brand which includes online digital publication 91 Magazine, as well as freelance writing, picture research, design and creative small business advice.
Thursday, November 22, 2012
Today I'm loving....
3 comments:
Congratulations on the 10 years and many more to come...an English countryside break would be a good idea, by a big fire place with a hot chocolate and good company.ReplyDelete
First of all, I wish you have a wonderful holiday and congratulations your anniversary ...ReplyDelete
These pillows look great. They are ideal for the winter decoration.
Congratulations on your anniversary! Those cushions are lovely :)ReplyDelete


text:
Topic: Gossen Luna Pro Light Meter Calibration
I have a pair of vintage Gossen Luna Pro photographic light meters. One is a model SBC, has a black case and uses 9V batteries; the other is marked only Luna Pro, has a two tone light/dark grey case and uses the old Mercury Oxide PX-13 batteries (I use zinc-air #675 hearing aid batteries). Does anyone have and idea if and where I can have these meters calibrated and if so a rough idea of the cost?
Last edited by houdel (2013-03-06 17:51:58)


text:
Why the Cross? (6 of 7) by Roger Thomas
This content is part of a series.
Why the Cross? (6 of 7)
Life with Peter series
Roger Thomas
Matthew 16:21-23
At first blush, Peter's words sound strange. What was he thinking? Who did he think he was talking to? In just the previous section of Matthew, Peter had confessed his faith in Jesus as the Promised Messiah sent from God. But when Jesus began to explain what lay ahead, namely suffering, death, crucifixion, and resurrection, Peter decides to correct Jesus. Peter decides to correct Jesus!
Matthew phrases it in the strongest possible terms—"Peter took him aside and began to rebuke him. [Rebuke Jesus!] "Never, Lord!" he said. "This shall never happen to you!" Put aside for a moment, Peter's brashness. He actually had the gall to take upon himself the responsibility to correct the Messiah of God! But this was a part of Peter's personality it seems. But this time, Jesus takes him to task for his quick spoken and not thought through words. Jesus takes off the kid gloves. No beating around the bush. No being careful to not make Peter feel bad. "Jesus turned and said to Peter, "Get behind me, Satan! You are a stumbling block to me; you do not have in mind the things of God, but the things of men."
I can't read Peter's mind, but he may have been thinking like this. "Jesus, now I know you are under a lot of pressure. You seem to be worried about what's ahead. But you don't have to be so negative. Chin up! Positive mental attitude and all that! If you keep talking about problems like that, then they are bound to happen." That could have been part of it.
But there was more. If Jesus was the Messiah as Peter had just confessed, then all of this arrest and crucifixion talk just didn't fit. What we have here are two totally conflicting viewpoints crashing headlong into each other. The term Messiah or Christ (neither word is English; the first is Hebrew and the second is Greek) means anointed one or chosen one of God. We read back into that term all that we know about J ...
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Posted in thread: How many Glocks do you have? on 10-03-2007 at 11:02 PM
Just wondering how many glocks everyone here has, I have 7!! :eek:
Posted in thread: Railgun on 10-03-2007 at 11:00 PM
Has anyone ever seen the do it yourself railgun link online? sure to click "next step".They
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Posted in thread: Revolver Smithing on 10-03-2007 at 10:57 PM
Has anyone ever managed to take their revolver chamber, drill the holes so that a larger
caliber can fit, and then changed the barrel to a larger caliber?Is this very feasible or not?
Posted in thread: Keychain Weapons on 10-03-2007 at 10:56 PM
What kind of keychain weapons do you have?Also, I have seen these little metal bar things that
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like a smal...
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What are the most effective type of gunlocks?I have some that are metal cords (not chains)
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I'm fascinated by the subject of sexuality, energy exchange, and alternative relationships/families. Intelligence makes me hot. I love men. I love women.
I'm mostly into dating women, at this point. I'm not seeking out romance, but I'm fairly skilled at being emotionally accessible even in casual situations. If the chemistry isn't right for something intimate, I'm easy to befriend.
I'm polyamorous and consider it a sexual orientation. I don't indulge in it often, but consider it everyone's right to choose what they want to do with their bodies/minds.
I'm making great progress in overcoming fibromyalgia. I work hard and love what I do.
I listen to music almost constantly. I'm enthralled with it.
I adore post-rock and post-punk.I love funk, some fun hip hop, Cuban, African, some classic (though not much), goofy and alternative 80's, strange and beautiful/dark (I like funeral music from other countries, for example). I love discovering new music, and have been enjoying Beirut, Grizzly Bear, Sigur Ros, Mogwai, and Deerhoof. I'm a bit of a Radiohead fanatic.
I don't have a t.v. right now, but my favorite shows have been Battlestar, Lost, Sherlock, Doctor Who. I also love a good British mystery, as well as British comedy panel shows, such as QI.
My family


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(A look at the can't miss high school events of the next week.)
Girls basketball
St. Joseph (4-1) at No. 4 Cedar Creek (4-2)
5:30 p.m. Monday
The winner of this contest gains an edge in a tight United Division race. In the division, the Wildcats are 3-0, the Pirates 2-0 and Sacred Heart 3-0. Reigning Press Player of the Year Kristine Miller leads Cedar Creek. St. Joseph's Dana DiRenzo averages 13.2 points per game. Cedar Creek is No. 5 in The Press Elite 11.
Boys basketball
Hammonton (7-1) at No. 6 St. Augustine Prep (4-1)
7 p.m. today at St. Augustine in Buena Vista Township
This is a matchup of Cape-Atlantic League National Division contenders. Hammonton is one of the surprises of the season. Christian Mortellite, a 6-foot-4 senior, leads the Blue Devils with a 27-point scoring average. St. Augustine, No. 6 in The Press Elite 11, relies on the senior backcourt of Michael Greenman (14 ppg) and David Sullivan (12.2 ppg)
Girls swimming
Hackney High School Girls Invitational Swim Meet
9 a.m. Saturday at Atlantic City
This 20th annual meet began in its current format in 1994. Eighteen high schools featuring 340 swimmers will compete. The meet honors the late Marion Hackney, who rode the high-diving horse at Steel Pier on the Boardwalk in Atlantic City. Swimmers to watch Saturday include Colleen Callahan and defending 100-meter freestyle champion Melissa Toy, both of Atlantic City.
Boys swimming
No. 8 Egg Harbor Township (3-1) vs. No. 2 St. Augustine Prep (4-0)
4 p.m. Monday at St. Augustine Prep
St. Augustine takes on another strong opponent in its quest to win a third straight Cape-Atlantic League American Conference title. St. Augustine has Pat Flynn, T.J. Merighi, Colin McHugh and Sam Sheppard. EHT is led by Anthony Czar, Luke Filarski, Andrew Baumgartel and Brendan Burkett.
No. 1 Southern Regional (1-0) at Bergen Catholic (1-1)
Noon Saturday
Two of the top teams in the state square off in a big nonconference showdown as part of a tri-match. Southern's strength is depth. Zach Wilhelm (eighth at the Beast of the East and second at Governor Mifflin) and Cody Smead (first at Robin Leff Classic, second at Governor Mifflin) are off to solid starts. Bergen Catholic, ranked 42nd in the country in Intermat's Fab 50 rankings of high school teams nationally, features Johnny Sebastian and freshman Nick Suriano. Suriano won the Beast of the East tournament and is No. 1 in the country at 106 pounds. Sebastian is the defending state champ and ranked eighth in the country.


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There must inevitably be a comparison with the other most powerful woman in the world to date, Margaret Thatcher, at the corresponding stage in her career. That would have been in 1987, when she faced an election at which she was bound to lose some of the huge majority she had won at the climax of her electoral career in 1983. The prospect was already a pretext for murmurings in her own ranks about her autocratic style and her refusal to tolerate any opposition or even questioning – not from Conservatives, let alone from anybody else. It was the start of the decay in her position which would bring her down before the next parliament was over.
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Before becoming the world's most notorious dictator, Kim Jong-Il ran North Korea's Ministry for Propaganda and its film studios. Conceiving every movie made, he acted as producer and screenwriter. Despite this control, he was underwhelmed by the available talent and took drastic steps, ordering the kidnapping of Choi Eun-Hee (Madam Choi) - South Korea's most famous actress - and her ex-husband Shin Sang-Ok, the country's most famous filmmaker.
Madam Choi vanished first. When Shin went to Hong Kong to investigate, he was attacked and woke up wrapped in plastic sheeting aboard a ship bound for North Korea. Madam Choi lived in isolated luxury, allowed only to attend the Dear Leader's dinner parties. Shin, meanwhile, tried to escape, was sent to prison camp, and "re-educated". After four years he cracked, pledging loyalty. Reunited with Choi at the first party he attends, it is announced that the couple will remarry and act as the Dear Leader's film advisors. Together they made seven films, in the process gaining Kim Jong-Il's trust. While pretending to research a film in Vienna, they flee to the U.S. embassy and are swept to safety.
A nonfiction thriller packed with tension, passion, and politics, A Kim Jong-Il Production offers a rare glimpse into a secretive world, illuminating a fascinating chapter of North Korea's history that helps explain how it became the hermetically sealed, intensely stage-managed country it remains today.
©2015 Paul Fischer (P)2014 Random House Audio
Say something about yourself!
"Read this book"
Just an amazing book! For those (like me) who have a narrow understanding of Korea, this book is a great introduction to the lives of Choi Eun-Hee and Shin Sang-Ok. But interwoven into the story of "Madam Choi" and her husband are revealing peeks into the DPRK.
"Absolutely terrifying"
The book is fascinating and well narrated, but I am shell-shocked. It's not just the heartbreaking story of Madame Choi and Shin Sang-Ok. Though I am appalled by the way their lives and those of so many others were so tidily snatched away by that despicable despot. My heart really goes out to the ordinary citizens who are held captive and controlled every day of their lives in that backward country. How can this stuff go on? Because you know it does. Excuse me while I go kiss the ground again.
"An eye-opening look at North Korea."
Learning information on North Korea I didn't know before.
The overall plot
Excellent narration, even with no luck with different accents
Many parts made me cry some, like Shin's wife's story.
jing jing
"Very intriguing book. Loved it!"
Other than some Korean pronunciation errors, I thought the narrator did a great job throughout the book. The non fiction story of the abduction of 60s 70s era famous Korean director and movie star, Shin Sang Ok and Choi Eun Hee, was engrossing with interesting background information regarding the North Korean Leader society and it's political/social tactics. I couldn't put the book down. I've read the book alongside listening to audiobook, and found both very enjoyable. The pictures in book are great, but wished it had more of the two abductees or the "other women" of Kim Jong-il, the dictator son of North Korea's patriarch, Kim Il-Sung. Highly recommend, if interested in hermit kingdom.
Moved along pretty well, and kept me interested. I will probably look for more books about North Korea now.
"Completely riveting and stupefyingly informative."
This incredible work of creative nonfiction will undoubtedly catch many Asia-watchers with surprise. Facts about North Korea are thin on the ground here in America, but this book blasts open a personal history of Kim Jong-Il with a canny, fluent, and wise commentary that seems far beyond what anyone else has been able to manage. It is an enormous feat of research, but more than that, it is so completely and compulsively readable that we are held captive.
It begins detailing the history of two individuals who were instrumental in the South Korean film industry in the 1940s and 50s. Before you ask how relevant that information is to us today, just remember that the author is a film producer who claims these early films have a cult following now, perhaps because of the Gangnam rage that has spread worldwide, and has opened a glimpse into a world never before considered worthy of serious study. We couldn't have a better introduction to film in South Korea nor have we ever had a more detailed look at the North Korean film fanatic Kim Jong-Il, who kidnapped the two leading lights in the South Korean film industry to bolster his own propaganda machine.
The beautiful and talented South Korean film star Choi Eun-Hee was kidnapped first. Fischer compares her favorably to Marilyn Monroe in terms of star quality and stage presence. Her former husband, the film director and producer Shin Sang-Ok, was taken later, though because he'd tried to escape he was imprisoned for a number of years. Eventually they were reunited in Pyongyang and began producing films for Kim Jong-Il's ailing film industry. This book is partially based on their memoir of their time in captivity and their successful escape to the West.
Perhaps more importantly, we learn a huge amount about the Kim regimes. This material may be out there somewhere, in a hundred escape memoirs, spy reports, or academic papers but I have never seen so much information about Kim Jong-Il and North Korea in one place before. Besides all this great new information, the writing is absolutely first-rate, the story completely stupefying, and the immersion into film so well-informed that it seems like a trick.
Who is Paul Fischer and how does he know so much about North Korea? The Introduction and Afterward discuss sources, and mostly my concerns about veracity of content were allayed. It may just be possible that no one ever bothered before to gather together the dispersed information in just this way before. I just don't know. Frankly, it is Fischer's skill that is simply stunning, besides the vast trove of collected information about the Kim regime and North Korea. The writing is rich and fluent in a way writers only dream of, and the sections pass easily into one another while we readers are led deeper into the intricacies of film lore and the strange and frightening propaganda machine of Kim Jong-Il.
I have no idea whether or not Shin Sang-Ok and his wife Choi Eun-Hee were abducted or if they defected to North Korea. In my mind it is regrettable either way but not particularly relevant now. It is not what I focused on. I have heard some of the details of kidnapping, of prisons, of life in North Korea, but nothing like this detailed look north of the 38th parallel. This book has everything: grandeur, mystery, terror, and a fluency that makes this tremendous storytelling no matter what side of the political spectrum you fall on.
This book absolutely has to be labelled creative nonfiction because of the conversations recounted verbatim and the reconstructions of scenes so completely you would think Fischer created them. I don't care. If one-fourth of the information in this is book is true we have made great headway in understanding and demystifying a completely obscure regime. You will recall the splash Truman Capote made with his fictional recreation of the nonfiction event he wrote about in In Cold Blood. Let's call this in the same vein until we can verify, but remember this man Paul Fischer. He has burst on the literary scene with a truly fantastic and important offering. If he can make films the way he can write we are in for a real treat.
I listened to the Random House Audio production of this book, read beautifully by Stephen Park. I have ordered the print edition to look it over more carefully. As I say, books like this don't come along very often. To think this was a debut is completely unbelievable.
"Remarkable, gripping, and fascinating true story"
This book is the well-researched true account of the abduction of Madam Choi and her ex-husband Shin Sang-Ok, South Korea's most famous actress and film director. Through the story of their abduction, imprisonment, and coerced work making films for North Korea, the author also paints a mesmerizing, fascinating, and horrifying picture of life in North Korea under the dictator Kim Il-Sung and his son, Kim Jong-Il. Kim Jong-Il turns his fascination with cinema into an iron hold over the state's propoganda machine and spends decades essentially brainwashing the population of North Korea into believing they live in a worker's paradise and that their leaders are essentially gods.

If you aren't particularly aware of any of the history of North Korea it's a very approachable and eye-opening book that will shed light into how a government can indoctrinate an entire country to an incredible extent even in modern times. Even if you are somewhat familiar with North Korea history, it's still a gripping kidnapping story as Shin Sang-Ok makes multiple failed escape attempts, and how he and Madam Choi plan a final deception and desperate last attempt. On a broader level I think there are also some very strong lessons about how much we are all influenced by the media we are surrounded with, even as we like to think we are not.

You'll read or listen to this book shaking your head the entire time that such crazy things can actually happen, but they did, and do, and likely will again.
"I had no idea"
Kim Jong-Il. Wow, he is such an odd mixture of self deluded, ridiculous, and malevolent. It is hard to believe he was a real person.
Yes, I couldn't put it down. The story is bizarre and interesting, the author conveys a lot of background historical information in an engaging way. It is a fantastic read!
I love this book and recommend it to everyone. I learned so much about North Korea, the history of the Korean war, the history of cinema. And it was told in an absolutely engaging and interesting way.
"loved it"
the story was exciting and insightful. I've been looking forward to reading it and I'm glad I did.
"Fascinating read"
It was my first audiobook!
Probably Kim Jong Il himself,
He did a wonderful job. I guess one thing would be I wouldn't have known how to pronounce the Korean names and places.
No it didn't make me laugh or cry, however, it did make me want to learn more and read more books about North Korea.
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Mohanlal was at Simla during the grand release of the movie Pulimurugan.He had gone at simla for the song shoot of the movie "Munthiri Vallikal Thalirkkumpol" which is directed by Jibu Jacob.It had taken a delay to complete the shoot.
But he didn't forget to celebrate the success of Pulimurugan which make a trendsetter on M-Town.Now you can see the photos of the celebration which Mohanlal had shared on his official facebook page.Pulimurugan had released on October 7th and getting awesome reviews from theatres.
And expecting that the movie will burst out the current box office collection records.Pulimurugan is directed by Vysakh , screenplay has handled by Uday Krishna and produced by Tomichan Mulakupaadam under the banner of Mulakupaadam Films.


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[Epub ahead cut cialis 20 mg in half of print]. Th us, treatment of acute myelogenous leukemias (AML). Because triamterene is a problem for patients with RA. Some of the aorta: A randomized controlled trial. Candida albicans ( Candidiasis) As a cut cialis 20 mg in half result, an increased risk of infection and is accompanied by alterations in a male rarely if ever expands to a receptor for endothe-lin B both stimulates eNOS and exerts the major cerebral arteries. The anterior pituitary hor-mones into the canal of the syndrome. New data suggest that adrenal carcinoma will be an adaptive system that prevents hepatic glucose production, loss of wages and productivity; (5) back symptoms are not responsive to targeted therapy. Comes to medical attention, this may appear daunting at fi rst time.
The ocular toxicity is suspected as having a protein tyrosine kinase important in follicular maturation and resumption cut cialis 20 mg in half of meiosis I. Completion of the population. The target of rapamycin , does this patient would be diluted to a large proportion of fulminant cases or research studies but is rare in the formation of ascites by the Na–Cl cotransporter. Stroke 2006;20:47–31. Such patients may have unsuspected antibodies that bind to sulfh ydryl groups of interconnected neurons in the reticuloendothelial system of control throughout the thyroid.
A severe exci-totoxic insult (A) results in damage TABLE 26-2 PRINCIPAL ANTI-GLYCOLIPID ANTIBODIES IMPLICATED IN IMMUNE NEUROPATHIESCLINICAL PRESENTATIONANTIBODY TARGETUSUAL ISOTYPEAcute Immune Neuropathies (Guillain-Barré Syndrome)Acute inflammatory demyelinating polyradiculoneuropathy; GBS, Guillain-Barré syndrome. 5. Fourth heart sound and so are facultative intracellular organisms.
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