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The Human Resources for Health Program in Rwanda A New Partnership
- Harold Dalton
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1 The new england journal of medicine special report The Human Resources for Health Program in Rwanda A New Partnership Agnes Binagwaho, M.D., Ph.D., Patrick Kyamanywa, M.D., M.P.H., Paul E. Farmer, M.D., Ph.D., Tej Nuthulaganti, M.P.H., Benoite Umubyeyi, R.N., M.Sc.N., Jean Pierre Nyemazi, M.D., Soline Dusabeyesu Mugeni, M.Sc., Anita Asiimwe, M.D., M.P.H., Uzziel Ndagijimana, Ph.D., Helen Lamphere McPherson, B.A., Jean de Dieu Ngirabega, M.D., Ph.D., Anne Sliney, R.N., Agnes Uwayezu, M.Sc.N., Vincent Rusanganwa, M.D., Claire M. Wagner, B.A., Cameron T. Nutt, B.A., Mark Eldon-Edington, B.A., Corrado Cancedda, M.D., Ph.D., Ira C. Magaziner, B.A., and Eric Goosby, M.D. A global shortage of 4.3 million health professionals poses a major bottleneck to poor people worldwide with regard to benefiting from the fruits of modern medicine. 1 Among existing health professionals, there are also staggering inequities in skill levels and geographic distribution. 2-4 Unsurprisingly, the deepest national gaps in human resources for health run parallel to poor population-level health outcomes. 1 Sub-Saharan Africa bears 24% of the global burden of disease 5 but is served by only 4% of the global health workforce. 1 The health graduate schools in the region face overwhelming financial, infrastructural, and personnel constraints, limiting their ability to address the shortage. 2,5,6 THE RWANDAN CONTEXT From 1989 through 1997, Rwanda had the lowest life expectancy of any country in the world 7 ; rates of preventable deaths due to infectious disease and unsafe birth skyrocketed as a result of the 1994 genocide. 8 Workforce setbacks further plagued the country; many clinicians fled or were killed. With the turn of the century, however, years of intensive reconstruction began as Rwanda emerged from a period of lingering instability. During the past decade, Rwanda has rebuilt its health system and registered some of the steepest declines in premature mortality in recent history. 9 With a population of nearly 11 million people today, 10 Rwanda had a total health expenditure of $56 per capita in 2010, of which 47% was provided by donors. 8 Deaths due to infectious disease and maternal disorders have declined dramatically since 2000, and Rwanda is now on track to achieve each of the health targets set by the United Nations for child and maternal mortality, human immunodeficiency virus (HIV) infection, tuberculosis, and malaria in the Millennium Development Goals. 9 Nearly all Rwandans have health insurance, and the poorest 25% of the population pay no fees. 9 Between 2000 and 2011, life expectancy in Rwanda rose from 48 to 63 years of age (up from just 27 years of age in the early 1990s). 7 Unprecedented global funding for HIV and AIDS since 2002 has assisted Rwanda and other countries in expanding the availability of highly active antiretroviral therapy (HAART) for the treatment of HIV infection, transforming the disease from a death sentence to a manageable chronic illness and forever altering the context of global health in the process. 11 Having achieved universal access to HAART and steeply reduced its AIDSrelated mortality, 9 Rwanda now faces the challenge of sustaining these gains while tackling a mounting burden of long-term complications of HIV infection and noncommunicable diseases including cardiovascular disease, cancer, diabetes, chronic pulmonary disease, and major mental illness. The health sector in Rwanda has pioneered task-shifting by transferring agency for many clinical decisions and activities to nurses and community health workers, 12,13 but a persistent shortage of adequately trained health professionals poses a major barrier to scaling up the availability and quality of specialized care. In 2011, Rwanda had 625 physicians, 8273 nurses, and 240 midwives providing care at 4 referral hospitals, 41 district hospitals, and 442 health centers (Table 1). 14 With a combined health-service n engl j med 369;21 nejm.org november 21, 2013
2 special report provider density of 0.84 physicians, nurses, and midwives per 1000 population, 9 Rwanda falls far below the minimum level recommended by the World Health Organization (WHO) of 2.3 providers per 1000 population. 1 Approximately 45,000 community health workers across the 14,837 villages in Rwanda offer basic empirical diagnosis and treatment services, in addition to general health promotion, and they have been instrumental in the control of infectious diseases and the reduction of costs. Until 2012, most of the physicians in Rwanda were trained as generalists, and more than 90% of the nurses have the lowest level of nursing training available (equivalent to secondary-school qualifications, or A2 level). Access to specialists is generally limited to the two university hospitals and other facilities in Kigali, the capital. Despite the increasingly high retention of health professionals trained in Rwanda, owing to publicservice contracts signed by physicians after the completion of medical school and residency as well as the performance-based financing system, it has proved difficult to narrow the gap between supply and need (especially in rural areas) when the only medical school in the country produced an average of 100 physicians each year from 2004 through HUMAN RESOURCES FOR HEALTH PROGRAM Similar to its perspective on the urgency of scaling up access to HAART in the early 2000s, the Rwandan Ministry of Health viewed a systematic effort to address long-term care for patients with HIV infection and those with noncommunicable diseases as a triple imperative: moral, epidemiologic, and economic. In line with the Health Sector Strategic Plan II 16 as well as the WHO building blocks for health systems strengthening 17 and the Treat, Train, Retain initiative, 18 the Ministry of Health identified the strengthening of a specialized health workforce in Rwanda as a priority step toward fulfilling the triple imperative while sustaining infectious-disease control. In 2011, its technical working group on Human Resources for Health developed a long-term strategy and implementation plan to increase the quantity of health professionals in the country, as well as the quality and diversity of their training. 15,19 The Ministry of Health asked the Clinton Health Access Initiative an organization that first came to Rwanda in 2002 to assist the government in the planning of its response to HIV and AIDS to extend invitations to leading universities and academic medical centers from across the United States for the establishment of an academic consortium. With a planning grant from the ELMA Foundation, the Clinton Health Access Initiative convened a U.S. academic consortium that included 16 academic medical centers, six schools of nursing, one school of public health, and two dental schools (Table 2) to forge a 7-year partnership with the government of Rwanda. The Human Resources for Health Program focuses on knowledge transfer, sustained collaboration, and the establishment Table 1. Training Targets for the Human Resources for Health Program in Rwanda, * Objective Baseline, 2011 Target, 2018 number Increase the total number of physicians 625 1,182 Increase the number of specialists in priority clinical areas Increase the total number of nurses and midwives ,384 Increase the number of nurses and midwives with A0 credentials 104 1,011 Increase the number of nurses with qualifications upgraded from A ,095 to A1 level credentials Introduce the role of health manager at the district hospital level and increase the number of health managers Increase the number of oral health professionals, including dental assistants, therapists, and surgeons * Nurses with A2 level credentials have completed a nurse-training program at a secondary school, those with A1 level credentials have completed a 3-year postsecondary program and are registered nurses, and those with A0 level credentials have completed a 4-year bachelor s degree program. n engl j med 369;21 nejm.org november 21,
3 The new england journal of medicine Table 2. Institutions Affiliated with the Human Resources for Health Program. Focus of Collaboration Rwandan Affiliates U.S. Affiliates Medical degree Nursing degree Health management degree Oral health degree General support National University of Rwanda National University of Rwanda Faculty of Medicine Byumba Nursing and Midwifery School Kabgayi Nursing and Midwifery School Kibungo Nursing and Midwifery School Kigali Health Institute National University Faculty of Nursing Sciences Nyagatare Nursing and Midwifery School Ruli School of Nursing Rwamagana Nursing and Midwifery School National University of Rwanda School of Public Health Kigali Health Institute National Dentistry Association National Council of Nurses and Midwives Rwanda Medical Association Rwanda Nursing Association Albert Einstein College of Medicine at Yeshiva University Beth Israel Deaconess Medical Center Boston Children s Hospital Brigham and Women s Hospital Columbia University Medical Center Duke University School of Medicine Geisel School of Medicine at Dartmouth Harvard Medical School Massachusetts General Hospital Rhode Island Hospital at Brown University University Emergency Medicine Foundation at Brown University University Medicine Foundation at Brown University University of Maryland School of Medicine University of Texas Medical Branch University of Virginia School of Medicine Yale School of Medicine Duke University School of Nursing Howard University School of Nursing New York University College of Nursing University of Illinois at Chicago College of Nursing University of Texas Health Science Center at Houston University of Maryland School of Nursing Harvard Medical School Department of Global Health and Social Medicine Yale University Global Health Leadership Institute Harvard School of Dental Medicine University of Maryland School of Dentistry Duke Global Health Institute of new medical residency, nursing specialty, health management, and oral health programs within the Rwandan education system. Launched in August 2012, the program deploys nearly 100 U.S. faculty members to Rwanda each year. Each school in the consortium sends full-time faculty members for 1-year periods to partner with Rwandan faculty-member counterparts in direct academic and clinical teaching. Several subspecialist physicians from the United States rotate throughout the year as well. The twinning model of the program facilitates curriculum development, clinical pedagogy, service delivery, and research capacity to develop the careers and skills of Rwandan specialist clinicians and educators who will assume all teaching and care delivery after 7 years. The model also enables scholarly collaborations between Rwandan and American training partners for clinical innovation and service delivery that will be valuable to both sides, ideally outlasting the program itself. American faculty returning to their home institutions after participating in the Human Resources for Health Program will play an integral role in strengthening global health curricula. 20 Rwandan students who benefit are those in medicine, nursing, health management, and oral health programs. More than 500 physicians will be trained in specialty and subspecialty areas by 2018 (Table 3). Approximately 5000 nurses will have their qualifications upgraded from secondary-school level to 3 years of postsecondary school (registered nurses, or A1 level) by means of an online training platform. Improved clinical education including an online health-learning platform will connect district hospitals with university classrooms in Rwanda and in the United States. 21 Nursing and midwifery faculty who teach advanced courses (e.g., critical care, pedi n engl j med 369;21 nejm.org november 21, 2013
4 special report atrics, and midwifery) will be enrolled in advanced courses in those specialties. Beginning in 2014, general nurses will have the opportunity to become certified in a variety of nursing specialties. Simultaneously, some nurses with 3-year diplomas (A1 level) will have their qualifications upgraded to a bachelor s degree level (A0 level). The specific time-limited targets are expected to be met by 2018 (Table 1). As is the case in other countries in the region, Rwanda does not currently have the health care management capacity that is required to support the administrative needs of each hospital. Through the Human Resources for Health Program, the School of Public Health in Rwanda will introduce two new degree programs: a master s degree in hospital and health care administration and a master s degree in global health delivery, which will focus on administration, financial management, and policy leadership. Both programs will combine coursework with supervised fieldwork. Over the course of the Human Resources for Health Program, the School of Public Health aims to graduate 75 new managers from the master s degree in hospital and health care administration program, surpassing the minimum requirement needed to ensure that at least one trained health manager is working at each of the district, provincial, and referral hospitals by To address needs in oral health care, the Human Resources for Health Program will train more than 40 dental students, 20 dental therapists, and 15 dental assistants during the first 3 years of a newly established curriculum. The program seeks to address both the proximal and distal drivers of the human resource shortage in Rwanda by increasing the capacity and quality of medical and nursing education while also strengthening incentives to work in the public sector and in rural districts. One important consideration for the retention of health professionals that is often overlooked in discussions of brain drain is the persistent lack of basic equipment and supplies at facilities; physicians who benefit from improved training will not be retained if they cannot apply these skills to their clinical practice and to teaching future clinicians. Thus, the Human Resources for Health Program also focuses on adequately equipping health facilities to ensure proper teaching environments. Table 3. Primary Education and Training Areas in the Human Resources for Health Program. Medicine Anesthesiology Internal medicine (including cardiology, nephrology, oncology, and infectious disease) Obstetrics and gynecology Otorhinolaryngology Pathology Pediatrics Psychiatry Radiology Surgery (including orthopedics and neurosurgery) Nursing and midwifery Adult critical care General nursing Midwifery Neonatal nursing Nursing education Nursing management Oncology nursing Pediatric nursing Perioperative nursing Trauma and emergency nursing Health management Global health delivery Hospital and health care management Oral health General dentistry Oral surgery PARADIGM SHIFT IN GLOBAL HEALTH PARTNERSHIP Foreign assistance programs have traditionally contracted third-party nongovernmental organizations (NGOs) through agreements that allow little space for recipient countries to negotiate efficient cost structures by means of the issuance of competitive bids. In recent years, resourcetracking data in Rwanda has shown that a substantial proportion of foreign assistance dollars are spent on overhead instead of on direct delivery of services. 9 Rwanda has already established a strong record of success in leading donorfunded health projects similar to the Human Resources for Health Program in scope and n engl j med 369;21 nejm.org november 21,
5 The new england journal of medicine complexity; its response to AIDS has often been highlighted as an example of effective national ownership. 9,22-24 The Ministry of Health estimated that a budget of approximately $152 million would be necessary to finance the entire 7-year program. 19 To fund the initial planning phase and the first year of the program without requiring additional resources, the Rwandan and U.S. governments reallocated a large portion of bilateral assistance for health from existing activities implemented by NGOs contracted through the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Agency for International Development. A large number of NGOs that had achieved their mandate by means of successful capacity transfer transitioned activities to the Ministry of Health, eliminated certain health interventions that no longer had major effects, or implemented such interventions with greater efficiency. Each of the American institutions in the academic consortium agreed to operate with minimal administrative costs of 7% and no overhead costs. After negotiations and due-process review to ensure that no essential services would be cut because of reallocation, the U.S. government channeled $27.2 million to the program through a cooperative agreement from the Centers for Disease Control and Prevention. The Global Fund to Fight AIDS, Tuberculosis, and Malaria provided $6.4 million to round out the $33.6 million budget for the initial phase of the program (August 2012 July 2013). As PEPFAR and country partners learned about the difficulties of scaling up access to HAART within debilitated health systems in countries wracked by severe shortages of health workers, essential medicines, and monitoring systems, an international consensus emerged 25,26 around the importance of an approach in which explicit intervention priorities such as HIV/ AIDS [are] used to drive desired improvements into the health system. 27 Rwanda has pioneered the deployment of this disease-specific funding to build its primary health care system, and it has maximized synergies between PEPFAR and other bilateral, multilateral, and country health initiatives. 28,29 The Human Resources for Health Program will help to fulfill the U.S. congressional mandate that PEPFAR contribute to the training of 140,000 new health workers in resource-constrained settings, as set forth in the 2008 Lantos Hyde Act, 30 as well as the action steps laid out in the PEPFAR Blueprint for Creating an AIDS-free Generation. 31 CONCLUSIONs Although the ultimate goal of aid is to facilitate development so that nations can achieve self-sufficiency and no longer require aid, few models exist that comprehensively achieve this in the health sectors of developing nations. The Human Resources for Health Program aims to change this paradigm by addressing both the proximal and distal drivers of the health workforce shortage in Rwanda. After 7 years, Rwanda plans to operate the residency and training programs within its own budget and with its own teachers and clinicians. Long-term professional connections between U.S. and Rwandan faculty are designed to be sustained past the 7-year duration of the Human Resources for Health Program. The duration and scope of this commitment is a departure from the traditional model of many shorter-term medical mission trips. With this new model for global health partnership, the program will help Rwanda meet its goal of creating a world-class health system. Global solidarity has made it possible to decrease the burden of infectious disease, and the world now looks to the next frontiers of improving service delivery. Other countries that are positioned to take on the Human Resources for Health Program model can look to Rwanda for lessons on increasing the effectiveness of foreign aid and improving health systems. New partnerships that bridge gaps in human resources will help nations achieve universal health coverage and self-sufficiency. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. We thank the Rwandan and American health professionals who were part of the launch of the program and the university presidents from Rwanda and the United States for enabling this strong partnership; the persons from each U.S. school who have assisted in establishing the Human Resources for Health Program at their home institution (Lisa V. Adams, Jane R. Barrow, Susan C. Benedict, Elizabeth H. Bradley, James Forrest Calland, Deborah A. Chyun, Matthew Dacso, Wafaa El-Sadr, Janet L. Heinzmann, Mary H. Hill, Andrea Howard, Jeffrey V. Johnson, Tina J. Kavukattu, Mi Ja Kim, Michael P. Koster, Erika L. Linnander, Adam C. Levine, Thomas A. Mackey, Irwin R. Merkatz, Marik A. Moen, Brian T. Montague, Dorothy L. Powell, Jennifer S. Puccetti, Robert Riviello, Nathan M. Thielman, and Sarah E. Trent); and Rwandan President Paul Kagame, U.S. President Barack Obama, former U.S. President Bill Clinton, and former U.S. Secretary of State Hillary Clinton, whose leadership made these efforts possible n engl j med 369;21 nejm.org november 21, 2013
6 special report From the Ministry of Health of Rwanda (A.B., A.A., U.N., J.D.N., V.R.), Kigali Health Institute (B.U.), Rwanda Biomedical Center (J.P.N.), and National Council of Nurses and Midwives (A.U.), Kigali, and the National University of Rwanda, Butare (P.K.) all in Rwanda; Harvard Medical School (A.B., P.E.F., C.C.), Brigham and Women s Hospital (P.E.F., C.C.), Partners in Health (P.E.F., C.C.), Clinton Health Access Initiative (T.N., S.D.M., H.L.M., A.S., I.C.M.), and Global Health Delivery Partnership (C.M.W.), Boston; the Geisel School of Medicine at Dartmouth (A.B.) and Dartmouth Center for Health Care Delivery Science (J.P.N., C.T.N.), Hanover, NH; the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva (M.E.-E.); and the Offices of the Global AIDS Coordinator and Global Health Diplomacy, U.S. Department of State, Washington, DC (E.G.). This article was updated on November 21, 2013, at NEJM.org 1. World health report 2006: working together for health. Geneva: World Health Organization, 2006 (http://www.who.int/whr/ 2006/en). 2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376: Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis. Lancet 2004;364: Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet 2004;364: Celletti F, Reynolds TA, Wright A, Stoertz A, Dayrit M. Educating a new generation of doctors to improve the health of populations in low- and middle-income countries. PLoS Med 2011;8(10):e Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-saharan Africa. Lancet 2011;377: DataBank: world development indicators and global development finance. Washington, DC: World Bank, 2012 (http:// databank.worldbank.org). 8. World health statistics Geneva: World Health Organization, 2012 (http://www.who.int/gho/publications/world_health_ statistics/2012/en). 9. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ 2013;346:f65. [Erratum, BMJ 2013;346:f534.] 10. National Institute of Statistics of Rwanda Population and housing census (provisional results) (http://www.statistics.gov.rw/publications/2012-population-and-housing-censusprovisional-results). 11. Dybul M. Lessons learned from PEPFAR. J Acquir Immune Defic Syndr 2009;52:S12-S Shumbusho F, van Griensven J, Lowrance D, et al. Task shifting for scale-up of HIV care: evaluation of nurse-centered antiretroviral treatment at rural health centers in Rwanda. PLoS Med 2009;6(10):e Rich ML, Miller AC, Niyigena P, et al. Excellent clinical outcomes and high retention in care among adults in a communitybased HIV treatment program in rural Rwanda. J Acquir Immune Defic Syndr 2012;59(3):e35-e Rwanda health statistics booklet Kigali: Ministry of Health of the Republic of Rwanda, 2012 (http://moh.gov.rw/english/ wp-content/uploads/2012/05/moh_annual_booklet-2011.pdf). 15. Human Resources for Health Program. Strategic plan Kigali: Ministry of Health of the Republic of Rwanda, 2011 (http://www.brown.edu/academics/medical/bright/sites/brown.edu.academics.medical.bright/files/uploads/moh%20rwanda% 20HRH%20Strategic%20Plan%202011%20-% pdf). 16. Health sector strategic plan. Kigali: Ministry of Health of the Republic of Rwanda, June 2009 (http://transition.usaid.gov/rw/ our_work/for_partners/images/rwandahealthsectorstrategicplanii.pdf). 17. Everybody s business: strengthening health systems to improve health outcomes. Geneva: World Health Organization, 2007 (http://www.who.int/healthsystems/strategy/en). 18. Treat, Train, Retain initiative: the AIDS and health workforce plan. Geneva: World Health Organization, 2006 (http:// 19. Rwanda Human Resources for Health Program : funding proposal. Kigali: Ministry of Health of the Republic of Rwanda, 2011 (http://medicine.yale.edu/intmed/global/sites/413_ _Rwanda%20HRH%20Proposal%20FINAL.pdf). 20. Syed SB, Dadwal V, Rutter P, et al. Developed-developing country partnerships: benefits to developed countries? Global Health 2012;8: Kim JY, Farmer P, Porter ME. Redefining global health-care delivery. Lancet 2013;382: The AIDS response and the Millennium Development Goals: Rwanda case study. Geneva: Joint United Nations Program on HIV/ AIDS, 2010 (http://www.unaids.org/en/media/unaids/contentassets/ dataimport/pub/report/2010/ _rwanda_aids_plus_mdgs_ en.pdf). 23. Goosby E, von Zinkernagel D, Holmes C, Haroz D, Walsh T. Raising the bar: PEPFAR and new paradigms for global health. J Acquir Immune Defic Syndr 2012;60:Suppl 3:S158-S Kim JY. Ending AIDS and poverty. Presented at the 19th International AIDS Conference, Washington, DC, July 22, 2012 (http:// -president-jim-yong-kim-remarks-at-the-opening-plenary -international-aids-conference-2012). 25. World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet 2009;373: Frenk J. The global health system: strengthening national health systems as the next step for global progress. PLoS Med 2010;7(1):e Committee for the Evaluation of the President s Emergency Plan for AIDS Relief. PEPFAR implementation: progress and promise. Washington, DC: National Academies Press, Price JE, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care 2009;21: Shepard DS, Zeng W, Amico P, Rwiyereka AK, Avila-Figueroa C. A controlled study of funding for human immunodeficiency virus/ acquired immunodeficiency syndrome as resource capacity building in the health system in Rwanda. Am J Trop Med Hyg 2012; 86: Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Pub. L. No ). Washington, DC: United States Congress, 2008 (http://www.govtrack.us/congress/bills/110/ hr5501). 31. PEPFAR blueprint: creating an AIDS-free generation. Washington, DC: Department of State, 2012 (http://www.pepfar.gov/ documents/organization/ pdf). DOI: /NEJMsr Copyright 2013 Massachusetts Medical Society. n engl j med 369;21 nejm.org november 21,
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text:
Released: October 5, 2016
I've never had any client come right out and say "I love to fuck" like Princess Paris did today, and ask straight-up for the chance to star in porn videos. But beyond our giggly banter, you could tell Paris was horny and ready to fuck the moment she walked into my office. While she cracked jokes and flirted with me, this redhead Euro babe was just waiting for a prompt to tear off her flowy dress and pounce on the next dick she saw. Within minutes, Paris stood ass-naked in front of me, showing me her plump natural boobs…
Size: 1462 MB | Duration: 33 min | Video: 1920×1080, 6205 kbits/s | Audio: 48000 Hz, 195 kbits/s
Spare link: (try when other links are dead)

subset: commoncrawl


text:
Virtua Fighter 2
Review by Truck_1_0_1_
"The Best Saturn Fighter, Disagree, and You Will Get a Twirl 'n Hurl!"
Virtua Fighter is one of my favourite games ever (even though It is poorly criticised for its graphics etc., but hey the music was good!), and one day when it stopped working, I was in shambles. For a year and a half I searched for a new one, but to no avail. Then, one of my friends from school had a Saturn, and they told me that they had Virtua Fighter! I was happy like no tomorrow, so the next day when he brought it, I found out it was Virtua Fighter 2. I was a bit disappointed, but when I arrived home, it was better in almost every aspect. This is a fantastic fighter, and the quintessential Saturn Fighter. Its game play time!
Game play: 9/10
The Virtua Fighter fighting system is third (in my opinion) behind Namco's fighters, and the Mortal Kombats. The controls are very easy to use, and are very noob friendly. However if you want to start using more complicated moves (such as the Twirl 'n Hurl), you have to think outside the box and use controls that are a bit more complicated. The nice improvement in game play over the first VF is that there are a lot more modes now. Aside from arcade, ranking and VS., there are now Team Battle, Expert, and Watch modes. Team Battle was a little primitive in these days, thus it isn't as good as other team battles, but what are you going to do? Game play is A-1. Story is next.
Story: 7/10
The story is a little confusing, and you have to follow it through sources not found in-game, and that is a bit of a downer. I do not know much of the story, however from what I do know, it is a very well developed story, just like Mortal Kombat and the Namco fighters. Story is good, however due to it not being followed in-game docks it 3 points. Graphics are next, and may I say a VAST improvement.
Graphics: 10/10
Wow! These are Saturn graphics? Leave it up to Saturn to prove all the Sega nay-sayers wrong. The graphics are just stunning. The Backgrounds are as good as the early Tekken games, and the Characters while still not as good as they had the potential to be, are still good looking, especially on the Saturn. Watching the intro movies of how the characters looks have changed are truly outstanding. They went from horrible to marvelous. Sound is next, nothing new here (except for 1 thing).
Sound: 10/10
The same old sounds are in game with punches kicks etcetera, only now... the characters have more than one winning dialogue! Were you annoyed with Wolf's Aoooooooo!! in the first game? Well now he says something new, as does every character. The music is still the best fighting game music I have ever heard (except for Tekken 3). The announcer's voice is still the same so that's a plus (in my book anyways). What was lacking in the first game (apart from graphics) was replay ability. Did that change?
Replay ability: 10/10
While there still aren't any unlockables, there are the three new modes that will make you play this game (alone or with some buddies) for a long time. Between the Arcade, Team Battle, VS., and Ranking modes, believe me there will be a lot for you to do.
Buy or rent?
As with every game I review, the chances of renting this game are slim to nil, and I am still offering; to anyone who has seen this game for rent anywhere, please email me and tell me. As for buying, you must buy this game. It is just too good to pass up, so load up ebay!
Virtua Fighter will always have a special place in my gaming heart because it is just too memorable, and this game will overtake it soon, because it is just a brilliant piece of software... then again, anything by Yu Suzuki is a brilliant piece of hardware.
Reviewer's Rating: 5.0 - Flawless
Originally Posted: 04/17/06, Updated 09/11/09
Game Release: Virtua Fighter 2 (US, 12/31/96)
Got Your Own Opinion?
Submit a review and let your voice be heard.


text:
Anastasia Rose – Natural Brunette Gets a Facial
Early Release: January 17, 2016
What does a naughty teen do when she's got the house all to herself? She spreads her pretty pink pussy lips and takes a fat dick is what! Anastasia Rose's hot natural body is just asking for a pounding and a pounding it will get!


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ca 1940s GIRLS; JACKET, SUSPENDER SKIRT AND BLOUSE.the blouse, finished at the neckline with a round collar and ribbon bow may have short, puffed sleeves or long Bishop sleeves, gathered to a wrist band. The circular skirt is belted at the waist, and the suspenders button on. The jacket, buttoning straight down front has flap pockets and is darted at the neckline and shoulders to fit smartly.
Links to reviews/blog posts Edit
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[insert your photos of this pattern made up]
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The display and use of drug information on this site is subject to express terms of use. By continuing to view the drug information, you agree to abide by such terms of use.
GENERIC NAME: FLUCONAZOLE - INJECTION (floo-KON-a-zole)
BRAND NAME(S): Diflucan
Medication Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes | Missed Dose | Storage
USES: Fluconazole is an azole antifungal used to prevent and treat a variety of fungal infections. It works by stopping the growth of fungus.
HOW TO USE: This medication is given by injection into a vein as directed by your doctor, usually once daily. Dosage is based on your medical condition and response to treatment. For children, the dosage is also based on weight.If you are giving this medication to yourself at home, learn all preparation and usage instructions from your health care professional. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Learn how to store and discard medical supplies safely.This medication works best when the amount of medicine in your body is kept at a constant level. Therefore, use this drug at evenly spaced intervals.Continue to take this medication until the full prescribed amount is finished, even if symptoms disappear. Stopping the medication too early may result in a return of the infection.Tell your doctor if your condition persists or worsens.
SIDE EFFECTS: Nausea, vomiting, diarrhea, stomach/abdominal pain, hair loss, or headache may occur. If any of these effects persist or worsen, tell your doctor promptly.Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: easy bruising/bleeding, new signs of infection (e.g., persistent sore throat, fever).Get medical help right away if any of these rare but very serious side effects occur: severe dizziness, fainting, fast/irregular heartbeat, seizures.This drug may rarely cause serious (possibly fatal) liver disease. If you notice any of these highly unlikely but very serious side effects, seek immediate medical attention: severe stomach/abdominal pain, persistent nausea/vomiting, yellowing eyes/skin, dark urine, unusual tiredness.A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
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text:
Which is your favorite line? What other pickup lines would you like?
If you enjoyed this, then please use the buttons below to tell your friends about this post! Follow us! Email | RSS | Twitter | Facebook
Being a Star Trek fan, I'm going with Spock all the way on this one! His DNA pickup line was funny and it took me an extra second to "get it" but was so worth it. The one about him dying that appeals to the conscience is a goodie to. Now you have me feeling kinda disloyal for not siding with my favorite characters: Data and Captain Kirk. Although I did like that "Next Generation" line and the "Beam me up" one...it's Spock who gets the panties at the end of the day. Ha! :)
The last one wins for me!
All the Picards FTW!
Come on who hasn't used... the pon far at a convention?
Any with Jean Luc Picard would work on me.
The last one is the best . . . but the rest are hilarious too. :)
These are too funny. I'm sure they'll pick up many Trekkie babes with these lines.
Spock is always popular with the ladies
It's gold


text:
Martin T. Williams (1924 – 1992) edited The Third Book of Oz (1986), and wrote the Foreward to the 1969 Bobbs-Merrill edition of "A Kidnapped Santa Claus."
Williams was best known as a music critic, especially in reference to jazz. He co-founded The Jazz Review and wrote a series of books on the subject. He directed the Jazz and American Culture programs at the Smithsonian Institution for a decade (1971–81).
Williams also wrote on subjects on popular culture. He co-edited, with Bill Blackbeard, The Smithsonian Collection of Newspaper Comics, Volume 1 (1977), and, with Michael Barrier, A Smithsonian Book of Comic-Book Comics (1981).


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You may not know the name Alan Howarth, but you'll surely have heard his music before. He's been involved with the sound design of movies like Raiders of the ...
They Live Soundtrack // John Carpenter & Allen Howarth -- Death Waltz [Full Vinyl Rip] MP3
(via Discogs) Tracklist A1 Prologue Broadcast A2 Coming To L.A. A3 A Message A4 The Siege Of Justiceville A5 Return To Church A6 All Out Of Bubble Gum ...
John Carpenter - Christine soundtrack - Extended MP3
Special thanks to Dark Knight! His channel: https://www.youtube.com/channel/UC9-ZRZNBnj1L27FWFo12RwQ/featured.


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Did the 2011 draft hurt us more than anything else?
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One of These Days
Join Date: Apr 2007
Posts: 9,198
vCash: 500
Originally Posted by
Joey Hoser
Yes, hindsight shows we arguably could have made better choices in the 20-40 range 2 drafts ago. How could you even expect it to be any different?
If you're going to complain, at least find something reasonable to complain about. There's lots to pick from.
Originally Posted by
dean youngblood82
I hate this Biggs pick. Not a fan at all.
Toronto didn't need a bruising 3rd line winger, they needed a skilled player capable of playing in the top 6.
I makes me even more angry that Burke gave up a solid 2nd round pick (39th) to move up to get Biggs.
He should've sat tight and took the best player available or traded up to get a player like
(big skilled center)
He passed over players like Puempel, Rattie, Phillips, Namestnikov and even Grimaldi who have good offensive futures for another 3rd liner who's compared to Colby Armstrong.
In the process he dealt the 2nd round pick where we could have selected Percy (not worth 25th), Ritchie, Saad, Rask, Mayfield, Catenacci, Jenner or any other player who fell to him.
Terrible, terrible, terrible first round for the Maple Leafs.
Now we have to wait until the 3rd round (86th) to pick.
Stupid Burke is destroying this franchise with his stubborness to draft tough players over skilled. If he wanted to go this truculent route then I have no clue why he traded for Kessel.
Taken from a Biggs thread immediately after he was drafted.
Seems like some Leafs fans were very vocal about how bad of a first round it was.
The guy who wrote this post nailed it though.
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Cloud computing technology and its applications are being used in almost all the sectors, according to the purpose of their usage. It enables to transform the entire business processes rather than only improving its operational efficiencies. There have been various challenges while moving towards cloud mobility and it is being expected as a game changing innovation in the industry. The evolution of cloud based application will convert organization into an organism in which the basic parts even assist in the services. According to the researches there have been various methods that will lead the industry and business to a new level.
There are massive numbers of challenges coming on our way as we enter into the new era of connected devices. There will be a large requirement of IP addresses with billions of devices connecting online and thus cloud providers need to support internet protocol that will enable billions of new addresses. Cloud computing is a reliable, elastic and agile platform which is required to support apps that are created via interconnection of several devices. Automated provisioning, multi-tenancy and usage accounting are few technologies supported by cloud computing. SaaS, Paas and IaaS are its three basically deployed services. Several Tech Giants are providing a software development platform in order to build an innovative machine to machine and the Internet of Things applications.
According to the researches, it was estimated that with the increase in productivity, the machines will continue to evolve. As devices will become connected and intelligent, Internet will continue to revolutionize industrial function. This is going to take place as far as we will demonstrate a leading increment in productivity. In order to augment escalation and profitability, Organizations are investing high revenues in creating sensors that will abstract data from distinct device. As speculation runs high, it is being estimated that by 2020 there will be around 50 billion connected devices in the world. With this the focus has been shifted on the massive amount of data that will be used to develop distinct functionality by adhering upon smart building, factories and smart grids. This all will result in increased opportunity, disruption and larger revenues.
Formalized framework for cloud adoption has been highly beneficial for the application development community. It has been excluded with respect to graphics intensive projects, as games or video streaming, business logic development and editing that caters cloud to support the load. So business executives must prefer for public, private or a hybrid cloud while deploying an application as it can be visited frequently multiple times as per needed.
There are several methods by which these cloud computing services can be deployed. Consumers can pay for it accordingly or it can be made via capital purchase as they can, even opt for pay-for-use and rent the peak average.
There have been several threats in the cloud computing environment among which data loss is very common. The key aspect to preserve against the data loss is to safeguard recommendations from being stolen. Strong authentication techniques are required and businesses must look to inhibit the sharing of credentials between users and services rather than sharing among all. Biometrics as fingerprints is also the major aspect that can be used as a method of developing authentication. Superior authentication techniques will serve in augmented cloud adoption strategy.
Original: http://www.mobileappsprogramming.com/2014/07/16/how-cloud-adoption-would-help-support-billions-of-connected-devices/
By: Ridhima Gupta
Posted: July 16, 2014, 1:09 pm
For more than a decade, Mobile Programming LLC, a Certified Mobile Application Development Company, has been providing high-end custom mobility solutions to its clients. We strive hard to provide...


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If you're a fan of the Buffalo Bills or just a fantasy owner who was lucky enough to have the explosive CJ Spiller on your team last year, chances are you were incredibly frustrated by how the third-year back was utilized by Chan Gailey throughout the season.
Spiller averaged an unbelievable 6.0 yards per carry in 2012, which was good enough to lead the league. Aside from the numbers, good things just seemed to happen on offense when the ball was in his hands. Even so, Spiller was relegated to the bench for more than half of the Bills' run plays, making way for Fred Jackson and, for some mind-blowing reason, Tashard Choice.
Thankfully, it seems that Buffalo's new coaching staff has at least a bit more common sense than was evident on the sideline last year. According to Spiller himself, the Bills plan to use him in a bigger role on offense this season. This comes just days after Bills new head coach Doug Marrone denounced the perception of Spiller as a situational back saying: "My philosophy's always been if someone starts off and they're running well, keep feeding them the ball," Marrone said on Wednesday.
In a Friday interview with Lindsay Rhodes on 'NFL Total Access', Spiller confirmed this philosophy and elaborated on how he might be worked into the team's game plan during the upcoming season.
"We're gonna try to use me as much as possible and not let teams get one beam on me and say I can just run the ball. Hopefully I'll be utilized in space, in the slot, whatever the case may be to try to help us find those mismatches to take advantage of."
I think I speak for Bills fans everywhere when I say it's about time.
Matt Ploss is a Buffalo Bills writer for RantSports.com. Follow him on Twitter @MatthewPloss, "Like" him on Facebook or add him to your network on Google


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Creating opportunities for people with disabilities.
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What is the Threshold?
The Threshold Incorporated is a 501c(3) non-profit organization that strives to help individuals with disabilities of all ages reach their potential, and become an integral part of their community. Our focus is mainly in Washington County, WI and surrounding areas.
For over 50 years, we have been committed to providing meaningful service options that meet individual needs and promote independence, employability and inclusion within the community.
We are more than just a place; we are an important community service! So get to know us better. Explore our website to see all that we do to help individuals succeed!
We are pleased to inform you that The Threshold is enrolled through Thrivent Financial's Thrivent Choice® program.
If you are an eligible member, please consider us when directing Choice Dollars.
To learn more about Thrivent Choice, visit Thrivent.com/thriventchoice. Or call Thrivent at 800-847-4836, and say "Thrivent Choice" when prompted.
The Threshold will be a provider of the Project SEARCH Mission starting in the 2017/2018 School Year. Project Search provides necessary life skills and employment training to young adults with disabilities. For a printable brochure, click here.
Click here to check out the h.e.l.p. Corner – (health equipment lending program)
Click here to request a tour.
We are a member of the West Bend Area Chamber.
4th Annual WBBA Men's Baseball Benefit Game
2017 Sweepstakes Winners
$5,000.00 – Gayle Steiner
$500.00 – Alfred & Rita Schmitt
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Award Winners
Samantha Manley – Client Achievement Outstanding Community Employee
Shannon Krell – Client Achievement Organizational Employee – TTI
Kyle Haws – Client Achievement Organizational Employee – Rolfs
Client from Adult Day Services – Doris Fisher Personal Achievement
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Geidel's Piggly Wiggly, Kewaskum – Employer of the Year
Sky Ranch Flyers – Friend of the Threshold
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