text:
Efficacy of an internet-based tool for improving physician knowledge of chronic kidney disease: an observational study. | |
Jump to Full Text | |
MedLine Citation:
PMID: 23016990 Owner: NLM Status: Publisher |
ABSTRACT: BACKGROUND: Early recognition and management of chronic kidney disease (CKD) are associated with better outcomes. Internal medicine residency should prepare physicians to diagnose and manage CKD. METHODS: To examine whether residency training and program characteristics were associated with CKD knowledge and investigate the effectiveness of an internet-based training module in improving CKD knowledge, we analyzed data from CKD training modules administered annually to U.S. internal medicine residents from July 1, 2005 to June 30, 2009. Baseline CKD knowledge was assessed using pre-tests. The modules' effectiveness was evaluated by post-tests. Comparisons were performed using X2 tests and paired t-tests. RESULTS: Of 4,702 residents, 38%, 33%, and 29% were program year (PGY)-1, PGY-2, and PGY-3, respectively. Baseline CKD knowledge was poor, with mean pre-test scores of 45.1-57.0% across the four years. The lowest pre-test performance was on CKD recognition. Pre-test scores were better with higher training levels (P-trend < 0.001 except 2005--2006 [P-trend = 0.35]). Affiliation with a renal fellowship program or program location within a region of high end-stage kidney disease prevalence was not associated with better baseline CKD knowledge. Completion of the CKD module led to significant improvements from pre- to post-test scores (mean improvement 27.8% [SD: 21.3%] which were consistent from 2005 to 2009. CONCLUSIONS: Knowledge of diagnosis and management of CKD improves during residency training but remains poor among graduating residents. Web-based training can be effective in educating physicians on CKD-related issues. Studies are needed to determine whether knowledge gained from such an intervention translates to improved care of CKD patients. |
Michelle M Estrella; Stephen D Sisson; Jennifer Roth; Michael J Choi |
Publication Detail:
Type: JOURNAL ARTICLE Date: 2012-9-27 |
Journal Detail:
Title: BMC nephrology Volume: 13 ISSN: 1471-2369 ISO Abbreviation: BMC Nephrol Publication Date: 2012 Sep |
Date Detail:
Created Date: 2012-9-28 Completed Date: - Revised Date: - |
Medline Journal Info:
Nlm Unique ID: 100967793 Medline TA: BMC Nephrol Country: - |
Other Details:
Languages: ENG Pagination: 126 Citation Subset: - |
Export Citation:
APA/MLA Format Download EndNote Download BibTex |
MeSH Terms | |
Full Text | |
Journal Information Journal ID (nlm-ta): BMC Nephrol Journal ID (iso-abbrev): BMC Nephrol ISSN: 1471-2369 Publisher: BioMed Central |
Article Information Download PDF Copyright ©2012 Estrella et al.; licensee BioMed Central Ltd. open-access: Received Day: 7 Month: 6 Year: 2012 Accepted Day: 22 Month: 9 Year: 2012 collection publication date: Year: 2012 Electronic publication date: Day: 27 Month: 9 Year: 2012 Volume: 13First Page: 126 Last Page: 126 PubMed Id: 23016990 ID: 3536684 Publisher Id: 1471-2369-13-126 DOI: 10.1186/1471-2369-13-126 |
Efficacy of an internet-based tool for improving physician knowledge of chronic kidney disease: an observational study | |
Michelle M Estrella1 | Email: email@example.com |
Stephen D Sisson2 | Email: email@example.com |
Jennifer Roth1 | Email: email@example.com |
Michael J Choi1 | Email: firstname.lastname@example.com |
1Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD 21205, USA |
2Department of Medicine, Johns Hopkins University School of Medicine, 601 N. Caroline Street, Room 7150 G, Baltimore, MD, 21287, USA |
An estimated 15 million adults in the U.S have moderate to severe chronic kidney disease (CKD) [1]. A large proportion of these individuals have co-morbid conditions such as diabetes, hypertension, and cardiovascular disease, which often precede the onset of CKD [2]. The culmination of CKD and these accompanying disorders lead to a high rate of hospitalizations, hospitalization-related complications, cardiovascular disease events, and death among these patients. Early recognition and management of CKD can slow the progression towards end-stage kidney disease (ESKD) and may lower risk for other adverse events. To facilitate the recognition and management of CKD by medical care providers, several national and international clinical guidelines and position statements have been published. The care of CKD patients, however, remains highly variable [3]. Among areas in which the provision of renal-focused care prior to dialysis is low, the mortality rate among incident dialysis patients is higher compared to areas with higher proportions of patients who undergo pre-dialysis care.
While early referral to a nephrologist is associated with improved outcomes, the current number of active nephrologists is insufficient to meet the current and anticipated increase in patient workload [4]. Consequently, primary care providers shoulder the burden of managing CKD-related issues in addition to other coexisting chronic medical conditions. Prior studies, however, demonstrate that many primary care providers lack knowledge of existing national CKD guidelines and important aspects of CKD care [5,6]. Residency is a key stage at which CKD training occurs; however, current training leaves many physicians-in-training unfamiliar with CKD recognition and management [7]. One avenue by which this issue may be addressed is web-based medium which affords the use of interactive training tools. In this study, we evaluated the familiarity with recognition and management of CKD among U.S. internal medicine trainees and determined the effectiveness of an existing online-based training module on the diagnosis and management of CKD used by U.S. internal medicine training programs to improve CKD knowledge.
We conducted a retrospective study of data collected from the CKD training modules administered annually to internal medicine residents from July 1, 2005 to June 30, 2009 as part of their residency curriculum. This online, interactive educational module is available as part of the Johns Hopkins Internet Learning Center ( http://www.hopkinsilc.org). It is utilized by more than 140 U.S. internal medicine training programs and described elsewhere [8]. While some residency programs required the completion of the CKD training module as part of the programs' ambulatory medicine curriculum, other programs offered the training module electively. This study was approved by the Johns Hopkins Institutional Review Board.
The CKD didactic module was developed using established principles of curriculum development [9]. Based upon review of published scientific literature and the National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and commentaries, and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, key areas of knowledge to inform the focus of the module were identified and encompassed the following: 1) risk factors for CKD; 2) methods for assessment of kidney abnormalities (e.g., albuminuria and proteinuria) and kidney function; 3) recognition and staging of CKD severity; and 4) diagnosis and management of CKD-related conditions including anemia, mineral bone disease, and cardiovascular disease. The module consisted of three sections: 1) a pre-test; 2) a didactic section which can only be accessed upon completion of the pre-test; and 3) a post-test that is provided after completing the didactic section. The pre-test served to assess the user's CKD knowledge at baseline. The didactic portion of the module consisted of sections to address each of the key knowledge areas. Each didactic section was comprised of questions based on clinical scenarios followed by a written review focused on a key CKD knowledge area. Participants were not re-tested on questions they had answered incorrectly nor were they given additional questions based on incorrect answers. The written review was accompanied by summary tables and flowcharts and references which were electronically linked to PubMed, the NKF KDOQI guidelines and commentaries, and the KDIGO guidelines. Instances in which the scientific literature did not correlate with published guidelines (e.g., target hemoglobin in patients with CKD), information from both sources was conveyed. The post-test re-evaluated the user's knowledge of CKD upon completion of the didactic section. Participants were able to stop and resume the didactic portion of the module and had no time limitations to complete the pre-test and post-test questions. Participants were informed whether their answer choices were correct and incorrect and were given the correct answer upon completion of the test. These participant feedbacks were accompanied by brief explanations as to why each choice was correct or incorrect. The pre- and post-test questions consisted each of up to 14 multiple choice questions. While the pre- and post-test questions directly inquired about the contents of the CKD didactic module, the paired questions were not the same. The paired pre-test and post-test questions were generated employing established principles of question development [10]. Face and content validity was assessed by having questions reviewed by six faculty clinician-educators familiar with CKD. Questions were revised until all six faculty members agreed that the questions provided adequate information to correctly answer them. Paired pre- and post-test questions were categorized into the following categories: 1) CKD recognition; 2) CKD risk factors; 3) anemia management in CKD; 4) management of CKD-related mineral -bone disorders; and 5) management of hypertension. The didactic module and all questions were reviewed annually by the attending internist and nephrologist for the appropriateness and accuracy of its content. All components were revised annually as needed to reflect significant advances in the CKD scientific literature within the preceding year, to update changes made in the KDOQI and KDIGO guidelines, and to incorporate input from participants' evaluations of the training tool. The pre-test and post-test questions were again evaluated for face and content validity annually.
Residency programs utilizing the CKD module included primary affiliates of medical schools with substantial funding from the National Institutes of Health and community hospitals [8]. Participants included internal medicine residents and faculty. Participants who completed the pre-test, didactic module, and post-test were considered for inclusion in the study. We excluded individuals who did not complete all three components of the CKD module and who were beyond their third year of post-graduate training.
Program characteristics were obtained from data collected at the time of a program's registration. The program characteristics included whether the program was affiliated with a medical school, its geographic location, and the number of residents in each year of training. For programs which participated in the 2008–2009 CKD module, affiliation with an affiliated nephrology fellowship training program was determined through the list of nephrology programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). In addition, programs were delegated to four regions according to varying rates of ESKD available through the U.S. Renal Database System (USRDS) [2]. Data on the average length of time that users took to complete the training module were not collected.
The participants' familiarity with various CKD topics was evaluated using their pre-test performances. Participants were considered familiar with a particular topic if they had answered the majority of questions on that topic correctly. To assess relative knowledge of chronic disease management, pre-test results from the 2008–2009 CKD module were compared with concurrent pre-test results from a similarly structured didactic module on diabetes. We could not discern if the users of the CKD module were the same as those of the diabetes module. To increase the likelihood of obtaining a comparative user population of the diabetes module, however, we only abstracted pre-test results for the diabetes module from the same programs included in the CKD module for 2008–2009.
Performance data were tabulated for each year and analyzed based on year of training. Additional analyses planned a priori included comparisons of pre-test performance data by question category, by affiliation with a nephrology fellowship training program, and by whether the program was located in a region with high versus low ESKD rates. Pre-test scores across categories were compared using the X2 test, while the pre-test and post-test scores were compared by paired t-tests. Two-sided P-values were calculated. Statistical analyses were performed using Stata/MP, version 11.1 (StataCorp LP, College Station, TX).
Table 1 displays the source population and characteristics of participants included in this study. A total of 5,003 internal medicine residents and attendings completed the CKD module from 2005 to 2009. After excluding individuals who were beyond PGY-3 level of training (n = 301), our study population consisted of 4,702 internal medicine residents, of whom 38%, 33%, and 29% were PGY-1, PGY-2, and PGY-3, respectively. Over the four years examined, the number of programs utilizing the CKD module steadily increased from 23 in 2005 to 87 programs in 2009. The proportions of residents completing the CKD module were relatively similar across levels of training.
Of the programs, 9%, 11%, 30% and 50% were located within western, southeastern, midwestern, and northeastern regions of the U.S., respectively. The participating programs ranged in structure from those within community hospital settings to tertiary academic centers. Approximately half of the programs participating in the CKD module were affiliated with a renal fellowship training program, and approximately one-third of the programs were located in regions with the highest prevalence of ESKD in the U.S. Users of this CKD training tool have consistently rated it highly (4.4 out of 5).
Overall, the annual baseline performance on the CKD module was poor, with the mean pre-test scores ranging from 45.1% (standard deviation [SD]: 18.2%) to 57.0% (SD: 20.2%) from 2005 to 2009. We observed a consistent trend towards better scores with higher levels of training; this trend was significant in all years (P for trend <0.001) except 2005–2006 (P for trend =0.35) (Figure 1). With completion of the CKD module, we observed a significant improvement between pre-test and post-test scores (Figure 2). The average increase in scores between the pre-test and post-test was 27.8% (SD: 21.3%). These improvements in performance were consistent across all training levels.
A subset analysis of data from the 2008–2009 CKD module showed that baseline knowledge of CKD did not differ by whether the programs were affiliated with a nephrology fellowship program (mean pre-test score: 54.5% for both, P = 0.98). Furthermore, baseline CKD knowledge did not differ between participants whose programs were located in regions with high versus low ESKD rates (mean pre-test score: 50.4% vs. 47.2%, respectively; P = 0.29). Compared with baseline knowledge of the diagnosis and management of diabetes mellitus, baseline CKD knowledge was significantly lower (mean pre-test score: 64.6% vs. 55.2%, respectively; P < 0.001).
The lowest mean pre-test score were for questions pertaining to CKD recognition and staging (53.1%) followed by hypertension management in CKD (56.9%), then mineral bone disease (57.4%). There was, however, a significant increase in scores between the pre-test and post-test within each question subgroup (Table 2). The greatest improvement between pre-test and post-test scores occurred for questions regarding hypertension management in CKD, with a 33.5% increase from the pre-test score.
Our study demonstrated that only about half of the physicians-in-training were familiar with the diagnosis and management of CKD and its related conditions, significantly lower than residents' knowledge of diabetes. Baseline knowledge was better with higher levels of post-graduate training. Residents were least familiar with the recognition and staging of CKD severity. Upon completion of the CKD module, however, overall CKD knowledge significantly improved. The knowledge gain was consistent across the key CKD topics examined. To the best of our knowledge, this is the first study to report on a promising, highly feasible, evidence-based online method to enhance residents' understanding of CKD recognition and management.
Consistent with prior studies, we demonstrated that a large proportion of physicians-in-training were unfamiliar with many aspects of CKD clinical care. In an online survey of U.S. internal medicine residents, Agrawal and colleagues showed that only 54% of respondents recognized persistent proteinuria as CKD and 65% correctly defined CKD stage III [7]. Moreover, nearly one-third of residents were unaware of the KDOQI guidelines. While 82% of their respondents acknowledged mineral bone disease as a potential complication of CKD, only 57% of residents in our study were familiar with the management of CKD mineral bone disease. A survey among U.S. primary care physicians demonstrated that CKD recognition among this group varied depending on the clinical scenario presented. Primary care physicians were less likely to identify CKD among the elderly with serum creatinine values within the reported normal range [5]. In another survey in which a case scenario of a patient with progressive CKD was presented to primary care physicians and nephrologists, Charles et al. showed that only 35% of respondents were adherent to clinical testing as recommended by the KDOQI guidelines [6]. In contrast to prior studies, however, we demonstrated the efficacy of an existing training method to improve provider knowledge of CKD and its related issues.
We observed a trend for better performance on the pre-test at higher levels of training, consistent with the study by Agrawal et al. [7]. However, these improvements were slight, with an overall 56% pre-test score among PGY-3 despite completing 2 years of residency. These trends may reflect the small gains in CKD knowledge through traditional educational activities and increased clinical experience with progressive training or a cohort of residents repeating the CKD module. Nonetheless, our study underscores ongoing deficits in U.S. trainees with regards to the identification and management of CKD. For example, the residents' pre-test performance on CKD recognition and management was the poorest among the topics addressed. This is of clinical relevance as early stages of CKD in the general population have been associated with adverse cardiovascular outcomes [11]. Impaired recognition of indicators of CKD, such as albuminuria, may lead to under-recognition of individuals at greater risk of cardiovascular disease. Several factors may account for observed knowledge deficits. Residents may have limited exposure to the care of CKD patients and fewer opportunities to work with nephrologists relative to general internists or other subspecialists. While we were unable to examine these factors specifically in this study, we did not observe differences in performance by the presence or absence of an affiliated nephrology fellowship program or by regional differences in ESKD prevalence. Additional potential factors for knowledge deficits include suboptimal resident attendance at didactic conferences due to competing clinical obligations and a dearth of readily available, concise CKD educational resources. While a systematic review of the impact of the ACGME's duty-hour restrictions on resident education among other aspects of residency showed conflicting results among studies reviewed [12], a recent survey among 73 residents suggests that strict work hour restrictions may impact the setting in which clinical education occurs, with potentially more residents conducting educational activities at home rather than during work hours [13]. Additional studies, however, are needed to thoroughly evaluate the impact of these factors on resident knowledge of CKD.
Completion of the CKD module was associated with significant improvement in CKD knowledge. Given the increasing scrutiny of resident work-hours and need for flexibility in timing of educational interventions, this CKD module appeared to be feasible for residents to complete. Implementations of online educational tools in other disciplines have shown promising results. A study of 1,786 individuals who used an online educational tool with a similar structure to the CKD module to improve knowledge of cardiac diseases demonstrated a significant improvement between the pre-test and post-test [14]. Similarly, an online educational tool structured like the CKD module was also shown to improve the knowledge of primary care physicians on infectious diseases [15].
Studies assessing the durability of the knowledge gained from internet-based educational activities, however, have shown mixed results. In a study by Casebeer and colleagues, responses to a series of clinical case-based questions from physicians participating in internet-based continuing medical educations activities (CME) were compared to a group of demographically similar physicians who did not partake in these activities [16]. Compared with the latter group, physicians participating in internet-based CME activities were more likely to select evidence-based choices. The questions, however, were administered immediately following the CME activity. The effect of internet-based education on clinical practice was more robustly evaluated in a randomized controlled trial comparing internet-based CME with live interactive CME focused on management of hypercholesterolemia. This study suggested that evidence-based online medical education can lead to durable improvement in knowledge and changes in clinical practice comparable or perhaps better than those from live activities [17]. In this prior study, an audit of the participating clinicians' charts at 5 months after the intervention showed that a higher proportion of high-risk patients were appropriately treated by physicians randomized to the online intervention versus the live activities (+5% vs. -1.1%, P = 0.04). In contrast, Sangvai and colleagues demonstrated that while an internet web-based module on childhood injury prevention improved performance on post-tests given immediately and 7 months following completion of the module, the module did not impact clinical practice as assessed by videotaped clinical visits. [18] Similar findings were observed in a randomized trial comparing internet-based versus paper-based educational exercises focused on geriatric clinical issues in which neither modality improved clinical practice [19]. These recent studies highlight the difficulty in improving clinical practice and underscore the need for improved educational interventions. Unfortunately in our study, we were unable to track individual participants through their years of residency training due to data collection methods of the Internet Learning Center. As the CKD module was completed at different times across institutions, we were also unable to administer a follow-up test at a more remote period after completion of the module. As such, data were lacking on knowledge gained from the CKD module was retained and improved the clinical care of patients with CKD.
Other potential limitations of our study need consideration. Data on which participants completed the module to fulfill a residency program requirement were not collected nor were data on participants' time spent on completing the CKD module. Moreover, we did not link individual participant's rating of the instructive value with that of their performance on the pre- and post-tests. However, we have shown elsewhere using data from all modules offered through the Internet Learning Center that improvements in knowledge are associated with greater learner satisfaction [20]. In aggregate, learners were consistently satisfied with the CKD module, and the high learner satisfaction and improvement in knowledge support the effectiveness of this training modality. Since our study population represented a subset of the Internet Learning Center registrants, our findings may not be applicable to all residency programs and physicians-in-training; however, a range of program types were included in our study. As this study was retrospective, we did not have a comparative control group who received conventional CKD education.
In conclusion, this study presents the first study of an internet-based educational module for improving CKD knowledge. The CKD module appears to be a feasible approach to significantly improving residents' proficiency in CKD recognition and management. Proponents of internet-based education have highlighted its potential advantages such as ease of access and use, interaction capability, and lower cost [21,22]. Prospective trials, however, are needed to determine whether an internet-based CKD educational module such as ours leads to sustained knowledge of CKD recognition and management and improved care of patients with CKD.
Knowledge of the diagnosis and management of CKD among residents improves with training but remains suboptimal among residents completing their training. A web-based online training module is effective in educating residents on CKD-related issues whether knowledge acquired from such an intervention leads to improved care of patients with CKD needs further study.
ACGME: Accreditation council for graduate medical education; CKD: Chronic kidney disease; ESKD: End-stage kidney disease; KDIGO: Kidney disease: improving global outcomes; KDOQI: Kidney disease outcomes quality initiative; NKF: National kidney foundation; PGY: Post-graduate year; SD: Standard deviation; USRDS: U.S. renal database system.
Training programs are charged an annual subscription to gain access to the content for their residents. The annual fee was $1500/year, with lesser fees for programs with <30 residents. SDS receives an annual stipend for editorial duties associated with the Internet Learning Center. MME, JR, and MJC have no conflict of interest.
MME conceived of the study, participated in the design of the study, performed some of the statistical analyses, contributed to the interpretation of the results, and helped draft and revise the manuscript. SDS helped conceive of the study, participated in the design of the study and interpretation of results, and helped revise the manuscript. JR performed some of the statistical analyses and helped revise the manuscript. MJC helped conceive of the study, participated in the design of the study, contributed to the interpretation of results, and helped draft and revise the manuscript. All authors read and approved the final manuscript.
MJC serves as the Vice-Chair of Education of the National Kidney Foundation Kidney Disease Outcome Quality Initiative
The pre-publication history for this paper can be accessed here:
Michelle M. Estrella is supported by the NIH-NIDDK grant K23DK081317. The authors thank Amanda Bertram for her administrative support of this study.
Coresh J,Selvin E,Stevens LA,Manzi J,Kusek JW,Eggers P,et al. Prevalence of chronic kidney disease in the United StatesJAMAYear: 20072982038204710.1001/jama.298.17.203817986697 | |
U.S. Renal Data System, USRDS 2011 Annual Data Report (Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States).Year: 2010MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda | |
McClellan WM,Wasse H,McClellan AC,Kipp A,Waller LA,Rocco MV,Treatment center and geographic variability in pre-ESRD care associate with increased mortalityJ Am Soc NephrolYear: 2009201078108510.1681/ASN.200806062419321704 | |
Rosenberg ME,Adult nephrology fellowship training in the United States: trends and issuesJ Am Soc NephrolYear: 2007181027103310.1681/ASN.200610116917329571 | |
Israni RK,Shea JA,Joffe MM,Feldman HI,Physician characteristics and knowledge of CKD managementAm J Kidney DisYear: 20095423824710.1053/j.ajkd.2009.01.25819359079 | |
Charles RF,Powe NR,Jaar BG,Troll MU,Parekh RS,Boulware LE,Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physiciansAm J Kidney DisYear: 20095422723710.1053/j.ajkd.2008.12.04419371991 | |
Agrawal V,Ghosh AK,Barnes MA,McCullough PA,Awareness and knowledge of clinical practice guidelines for CKD among internal medicine residents: a national online surveyAm J Kidney DisYear: 2008521061106910.1053/j.ajkd.2008.06.02218976845 | |
Sisson SD,Hughes MT,Levine D,Brancati FL,Effect of an Internet-based curriculum on postgraduate education. A multicenter interventionJ Gen Intern MedYear: 20041950550910.1111/j.1525-1497.2004.30097.x15109313 | |
Kern DE,Thomas PA,Hughes MT,Curriculum development for medical education: a six-step approachYear: 20092Baltimore: Johns Hopkins University Press | |
Case SM,Swanson DB,Constructing written test questions for the basic and clinical sciencesYear: 20023Philadelphia: National Board of Medical Examiners | |
Matsushita K,van der Velde M,Astor BC,Woodward M,Levey AS,de Jong PE,et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysisLancetYear: 20103752073208120483451 | |
Reed DA,Fletcher KE,Arora VM,Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and educationAnn Intern MedYear: 201015382984221173417 | |
Deano RC,Dekosky A,Appannagari A,Doll J,Georgitis E,Potts S,et al. Resident time spent in clinical and educational activities at home: implications for duty hoursArch Intern MedYear: 20111711038103910.1001/archinternmed.2011.21821670375 | |
Walsh K,Rafiq I,Hall R,Online educational tools developed by Heart improve the knowledge and skills of hospital doctors in cardiologyPostgrad Med JYear: 20078350250310.1136/pgmj.2007.05950117621623 | |
Walsh K,Online educational tools to improve the knowledge of primary care professionals in infectious diseasesEduc Health (Abingdon)Year: 2008216419034832 | |
Casebeer L,Brown J,Roepke N,Grimes C,Henson B,Palmore R,et al. Evidence-based choices of physicians: a comparative analysis of physicians participating in Internet CME and non-participantsBMC Med EducYear: 2010104210.1186/1472-6920-10-4220537144 | |
Fordis M,King JE,Ballantyne CM,Jones PH,Schneider KH,Spann SJ,et al. Comparison of the instructional efficacy of Internet-based CME with live interactive CME workshops: a randomized controlled trialJAMAYear: 20052941043105110.1001/jama.294.9.104316145024 | |
Sangvai S,Mahan JD,Lewis KO,Pudlo N,Suresh S,McKenzie LB,The impact of an interactive Web-based module on residents' knowledge and clinical practice of injury preventionClin Pediatr (Phila)Year: 20125116517410.1177/000992281141902721985892 | |
Westmoreland GR,Counsell SR,Tu W,Wu J,Litzelman DK,Web-based training in geriatrics for medical residents: a randomized controlled trial using standardized patients to assess outcomesJ Am Geriatr SocYear: 2010581163116910.1111/j.1532-5415.2010.02869.x20722848 | |
Dalal D,Brancati FL,Sisson SD,Factors affecting learner satisfaction with an internet-based curriculumSouth Med JYear: 201210538739110.1097/SMJ.0b013e31825d9abb22864092 | |
Horton WK,Designing web-based training: how to teach anyone anything anwhere anytimeYear: 2000New York | |
Barnes BE,Creating the practice-learning environment: using information technology to support a new model of continuing medical educationAcad MedYear: 19987327828110.1097/00001888-199803000-000169526455 |
Characteristics of participants of the Internet Learning Center (ILC)
Characteristics | 2005-2006 | 2006-2007 | 2007-2008 | 2008-2009 |
No. of programs enrolledin ILC
No. of ILC registrants
Total no. of participantscompleting CKD module
Population included in currentstudy*
No. of programs
No. of participants (%)
161 (32)
466 (36)
503 (37)
698 (43)
176 (34)
399 (32)
483 (36)
482 (30)
172 (34)
388 (32)
365 (27)
429 (27)
Programs affiliated with renalfellowship, n (%)
11 (48)
27 (43)
33 (43)
38 (44)
Programs by regional ESKDrate, n (%)
Located in region withhighest ESKD rate
6 (26)
26 (43)
26 (34)
27 (31)
Located in region withlowest ESKD rate
1 (4)
6 (10)
4 (5)
9 (10)
Mean pre-test score,% (SD) | 45.1 (18.2) | 49.3 (19.3) | 57.0 (20.2) | 55.2 (19.8) |
*Individuals beyond PGY-3 level of training excluded.
Abbreviations: PGY, post-graduate year; ESKD, end-stage kidney disease; SD, standard deviation.
Pre-test and post-test resultsby question topic inthe 2008–2009 data
Question topic | Pre-test (%) | Post-test (%) | Change in score betweenpre- and post-test (%) | P-value |
CKD recognition and staging†
+ 27.4
Mineral bone disease
+ 23.1
Hypertension in CKD | 56.9 | 90.4 | + 33.5 | <0.01 |
Note: Anemia not evaluated due to too few questions.
Abbreviations: CKD, chronic kidney disease.
†CKD recognition and staging includes questions on risk factors for CKD and methods for assessment of kidney abnormalities and function.
Article Categories:
Keywords: Kidney disease, Education, Internet, Primary care. |
Previous Document: New trends in peptide-based anti-biofilm strategies: a review of recent achievements and bioinformat...
Next Document: Do elderly intensive care unit patients receive less intensive care treatment and have higher mortal...


text:
Or call one of our customer service representatives at 1-877-624-1008.
Your local movers in Iowa
Additional Moving Resources
When you relocate to Iowa, you get to be a part of the "American Heartland". Bordered by the Mississippi River on the east, the Missouri River, and the Big Sioux River on the west, it is the only U.S. state that's eastern and western borders are formed entirely by rivers. Iowa, nicknamed the Hawkeye State, has been listed as one of the safest states to live in. Iowa's terrain consists of several lakes, tall grass, rolling hills, and some forests and wetlands. Its borders near the Mississippi River features steep hills and valleys which appear almost mountainous. The state has typical Midwestern climate with an average annual temperature of 50 °F and cold, snowy winters. Some notable people from Iowa include Elijah Wood, Buffalo Bill, William Frawley, and Ann Landers.
Iowa has several distinct regions for you to choose as your new home. Des Moines is the largest city in the state and the capital, and is located in Central Iowa. Many presidential candidates set up campaign headquarters in Des Moines, because the city is home to the first caucuses of the presidential primary cycle. The nearby Madison County has the well-known Roseman Covered Bridge that was featured in the Clint Eastwood movie The Bridges of Madison County, based on the popular novel of the same name. The movie was filmed on location there.
The Eastern Iowa region has many vibrant historic districts and landmarks, such as the Old Capital Building in Iowa City. The Cedar Rapids Museum of Art has collections of paintings by Grant Wood and Marvin Cone. The Herbert Hoover National Historic Site and Herbert Hoover Presidential Library and Museum can be visited in West Branch.
Western Iowa has remarkable scenery such as Loess Hills and the Iowa Great Lakes. Several fine resorts are situated in this area. Sioux City, located in this region of Iowa, is full of history and has a collection of museums, art centers, and theaters.
Northern Iowa is part of the Driftless Area, a region in the American Midwest noted mainly for its deeply carved river valleys. The city of Dubuque is a regional tourist destination with attractions such as the National Mississippi River Museum and Aquarium and the Port of Dubuque. In Dyersville, you will find the infamous baseball diamond from the movie Field of Dreams. Contact Allied today and we can get you started on your move to Iowa.

subset: commoncrawl


text:
Tuesday, September 11, 2007
PA 10th CD update
In an attempt to elevate the discussion I will be meeting with Chris Hackett on Thursday to discuss boring stuff like issues. I hope to talk with all the candidates before the primary. If anyone has any questions they would like me to ask Chris please leave them in the comments or send me an email. Be nice folks and please keep it clean.
21 comments:
Gort-- ask him how he feels about the prominent donors to his last campaign that want their money back because he hasn't been true to central democratic issues.
Full agreement here that the discussions were, if nothing else, entertaining, and will certainly get more interesting in the months to come.
Ask Hackett to come clean about his connection to the democratic commissioners, and what part his donations to them played in getting a county contract.
Ask him about his vision for the future, and how he will create something other than part time jobs.
Remind him that full time, permanent,well paying jobs with benefits, the type that Dan Meuser has created, are very important right here in the Wyoming Valley.
"Future former" congressman Carney is ready to be taken down, but this won't be a "slam dunk".
Republicans need to be sure they have the right man for the job, one who has worked developing relationships with leaders here, and in Washington, one who has the right kind of experience to do the job, that man, the right man, is Dan Meuser. - 8:47 AM
Am I mistaken, I did not think that Hackett had run for office before? Please enlighten us
- Bill Fitz said...
I think the first anom thought gort was interviewing Chris Carney
Kar, Is Dan Muser a better person than Hackett becuase his company creates better jobs? It is not the government's role to create jobs and i thought Dan agreed with that. maybe you do not. - 10:55 AM
I'm not talking about government created jobs, though God knows Hackett's good at that, at least on the local level.
I'm talking about an individaul who has the vision, the smarts, the passion, and the ability to ensure that conditions will exist that permit healthy job creation in the private sector.
In that area Meuser wins over Hackett hands down. - 11:19 AM
- Proud to be Right said...
Bill, you're right. It's not the government's place to create a job. It's their duty to create an atmosphere that encourages job growth and a better way of life for it's taxpayers.
We are all in this together. Trying to make ends meet. I'd rather have a guy who encourages well paying jobs and benefits than one who prefers replacing long time workers with temps at lower pay. As the main bread winner supporting a family it scares me to death that Hackett's philosophy might grow and more people will lose their jobs to be replaced by outsourced temps. It wasn't so important when I was young and single but now that I'm responsible for my kids future it's a big deal.
How would you feel about working your ass off for years and getting that modest raise every year only to get replaced when you start earning too much?
And don't even get me started on his association with the Wilkes-Barre Chamber, the biggest culprit when it comes to keeping wages down in the area. Just ask Mohegan Sun what they wanted to pay and what the chamber told them they had to pay. - 11:29 AM
- Bill Fitz said...
Yes Chris Hackett and Dan Mueser belive the same thing low taxes less regualation
I would like to see both committ to joining the Republican Study committee - 1:31 PM
You have me at a disadvantage, I'm not familair with the "Republican Study Committee", but I do know that Meuser signed a pledge to not raise taxes, pretty sure Hackett hasn't. - 2:56 PM
Gort- He was asked about the war and he said that he wanted to concentrate on winning the war instead of getting out. My question" how many dead young men and woman do we need to lose in order to realize that we should change strategy?
Meeting and interviewing candidates?!? This blog gets better all the time. Thanks for the extra effort.
- Bill Fitz said...
The Republican study committee is a group of the most fiscally conservative members of the house such as John Sheddeg, Trent Franks, Mike Pemce, ect. The group's big thing now a days is cutting wastefull spending, especially through earmarks. I think only a few of them lost in 2006 and a decent percenatge of the new GOP members joined them. the only PA member is Joe Pitts. Some good conservatives such as Peterson of Pa and minority leader bohner never joined, but a commitment to join would show someone who not only will cut taxes but cut spending. We do not want another don Sherwood who loved pork as much as Kanjo
Hi everyone this my first time posting here.
As a young proffesional I am concerned to see that our elderly population is increasing while young people are leaving. Young people are going to college getting their degrees and not returning to the area. What will be Hackett's plan to get these young people to return to the area and to invest in the place where they grew up? - 9:02 AM
- Right Winger said...
Bman78, good question. I quess one possible answer from Chris could be "I'll offer everyone jobs as temps". Ok, just kidding. I digress.
I have a question or two. #1. Have you been a consistent voter in the past?
#2. You are obviously successful but have never donated signifigant amounts of money to any republicans. Yet you donated to Skrep and your business received a nice contract with the county. How will you try to gain support from those of us who always contribute to repulicans to advance our cause and now you want our support just to advance you personally? - 11:08 AM
I'd like to know how he can reconcile his strong support of the United Way (leading Touqueville campaign) and his pro life stand. Isn't Planned Parenthood a United Way partner. (I know United Way does wonderful things- I support it strongly but I'm not a pro life candidate)
yep, Hackett will help create plenty of minimum wage and temp jobs. and those good paying full time jobs with benefits he'll make sure get replaced by more temps. if you are a young professional get the heck out of here as fast as you can.............
Can you please ask Chris Hackett if he voted for Don Sherwood and his reasons if he did or didn't?
Pretty Please???
Thanks - 2:44 PM
1. You are stating that you are pro life- are there any exceptions you would accept for a woman to get an abortion?
2. Has your company ever employed any illegal immigrants? - 5:46 PM
Did you vote for Don Sherwood or did you vote for Chris Carney because of what Sherwood did?
- Bill Fitz said...
i think the better question would be did you vote for kathy Scott in the Republican primary?
1. You have been a successful businessman but you have never donated any significant amount to the Republican Party- this blog says $1,000. You however have donated $5,000 to Democrat Greg Skrepnak after your company was awarded a 1.2 million dollar contract from him. This looks and smells like 'pay to play"? How do you defend this contribution?
2. Have you made other contributions to Democrats and if you have to whom? - 8:15 PM
This guy donates a ton to Democrats and I want to know who he voted for in this past election? My money is on Carney!!!


text:
You missed it This great deal for Studio BonTon is over. But don't despair, we've got more great deals every day.
Related Deals That You May Like
Studio BonTon
1 Crafts Class: Choose from Mosaics, Wine Bottle Luminary, or Stained Glass
88% recommended
in LivingSocial customer ratingsOffering on-going classes for all ages and artistic talents, Studio BonTon is a great place to unwind with friends as you get crafty, create a stunning piece of take-home art, and "kick some glass":
• $35 ($89 value) for one beginner mosaics class, wine bottle luminary class, or stained glass mosaics class
• All supplies included
• Bring along your own drinks or snacks to boost the fun
#ShareIt: We think this is a perfect event to enjoy with friends. Use LivingSocial's Me + 3 program to get them there with you: Have your friends buy off of your personal link and if three make a purchase, your deal is free!
Studio BonTon Website
PAID VALUE EXPIRES ON March 29, 2022
PROMOTIONAL VALUE EXPIRES ON September 25, 2017
map & location


text:
a place for zinesters - writers and readers
Back before photoshop and digital image editing was so standard, it was common for a coffeeshop to have a piece of plastic that was a halftone filter that you would literally place over an image to turn it into dots.
now the machine simulates it itself with the effect that is often just called "photo". if you turn it to the photo setting, it's actually halftoning your image.
then blow it up drastically (rotating its position on the glass 90 degrees each time) and you should get that effect.
but here's the most important thing: imitation is flattering but it's just imitation.
your use of this knowledge is best served to take it somewhere new, rather than copy (har har) what someone else has been doing for 25 years.
16 members
676 members
224 members
5 members
368 members
Ist preference given to distros and zines. Rates and details are here. Limited space. Very Low Cost!
© 2017 Created by Krissy Ponyboy Press. Powered by


text:
Advice: 'I lied when he asked if I was taking birth control'
Updated 12:42 pm, Friday, January 17, 2014
Dear Carolyn:
I always wanted kids, but managed to get to my early 40s with no husband or children -- not from lack of trying.
Three months ago I started seeing a nice guy. He has potential. But I feared he'd go the way so many had: dating for a while then moving on. This time I was determined to at least try to get something I want, so I did what I never thought I'd do. I lied about taking birth control.
My bad luck coupled with pure statistical improbability really led me to believe I had little to no chance of getting pregnant.
Well, I'm looking at a positive pregnancy test. How do I do this? How do I tell this man I barely know that I lied to him and hey, sorry, but I've torpedoed your life?
Article continues below video playerWhat I thought would be the happiest day of my life is making me want to cry and throw up.
I've made a huge mess and I don't know how to fix it. I think I just didn't realize until right now how badly I wanted the whole white-picket-fence thing, too.
-- Just Sick
Bernard Malamud's got this one. "We have two lives," he wrote in "The Natural." "The life we learn with and the life we live with after that."
Please tackle your second life with a very good therapist.
Here's why: The "right" answer is the truth. You sold your soul for a baby, so it seems obvious that fixing the mess requires truth-telling, immediately and in perpetuity. I filed a first-version of this column saying just that -- in part because this man deserves to know your frailty.
However, your mess is en route to having a life independent of you (health permitting).
Does this child deserve one parent who profoundly resents the other? In perpetuity? Does Nice Guy himself deserve to see his child through unclouded eyes?
People who cheat come to a crossroads analogous to yours, on which there are two distinct camps: those who believe a cheater's duty is to confess, and those who believe it's to bear the guilty secret -- because confessing restores the cheater's peace of mind at the cost of the victim's.
Since each camp is certain the other is very wrong, that alone says people must take their specific circumstances into painstaking account before making deep moral choices on an unwitting other's behalf.
And that's before anyone mentions possible legal implications, which someone always does.
And you need to figure out whether you care about this man as a person, or just as a squandered potential picket fencing contractor.
So, therapy. Don't mess around. You lied without regard for potential consequences, but you can think them through now, with someone objective, sharp and bound to confidentiality. Plus, you've just become rudely acquainted with what a bad person you're capable of being. Arguably everyone will, or should, have that awakening over the course of a lifetime -- but it's still tough to live with. Having a guide can help.
This is your chance to be a better, more self-aware, more compassionate person than you were pre-deceit -- to be a better mom. I realize how perverse that is for me to say, but there's no getting what we want; we all get what we get.


text:
HELP PLEASEAug 3, 2008 My husband was recently diagnosed. He's 53 yrs old. He's been on Atripla for 2 months and now his vl is undetectable. His cd4 is 119 ( used to be 8 ) his doctor was happy with the improvement but I'm scared to death about this medication messing with his liver, or kidney or heart or causing lacto acidosis. He has stomach pain since he started treatment but he says the pain is not as often as it used to be. Is this normal after 2 months?. Should I be concerned about his? THANKS |
Response from Mr. VergelAtripla does not contain Zerit and DDI, two of the main culprits of lactic acidosis in the past. Besides nightmares and sleep problems at the beginning of the therapy, Atripla has very few side effects. Gastrointestinal problems are rare. If his pain continues, I would suggest that he is sent to a GI doctor just to make sure he is ok and that he does not have an ulcer (unrelated to Atripla) or other problems. Nelson | ||||||||||
Get Email Notifications When This Forum Updates or Subscribe With RSS
- Do Black Spots Mean I Have Hiv?
- Is Painful Urination An Acute Symptom Of HIV?
- Chances Of Catching AIDS From Blowjob From A Prostitute
- Pain In Penis After Having Sex During Period What Are The Chances Of HIV
- Tingling Lips After Kissing Cut On Lip Worried I Have HIV
- Vomiting After Open Mouth Kissing Worried I Have HIV
This forum is designed for educational purposes only, and experts are not rendering medical, mental health, legal or other professional advice or services. If you have or suspect you may have a medical, mental health, legal or other problem that requires advice, consult your own caregiver, attorney or other qualified professional.
Experts appearing on this page are independent and are solely responsible for editing and fact-checking their material. Neither TheBody.com nor any advertiser is the publisher or speaker of posted visitors' questions or the experts' material.
Review our complete terms of use and copyright notice.


text: Backhanded Box Quotes: "Metacritic Reviews Are Often Avenues for Trolling"Owen Good4/27/12 8:30pmFiled to: Best of metacriticBackhanded box quotesFifa 12Uefa euro 2012PrototypeBotaniculaFbtweet81EditPromoteShare to KinjaToggle Conversation toolsGo to permalinkWelcome to "Backhanded Box Quotes," a collection of super pissed-off user reviews from people just like you! Whoa, whoa, don't take that personal. This week's scan of proportionate reactions to entertainment products includes condemnation for something almost universally acclaimed and a scalding appraisal of a football video game from EA Sports that is not named Madden. UEFA Euro 2012Released: April 24 Critic: Frazzi (Metacritic).Advertisement• "Lets also ignore the fact that Metacritic user reviews are often avenues for trolling."• "Be smarter than me and not waste your money on this absolutely cynical release from EA. " Score: 3.AdvertisementCritic: uk_friday (Metacritic).• "EA clearly have committed suicide with this product and heads should roll."• "Players disappear from your squad during the tournament and new players arrive ... Did they miss the plane? Did they just go home and sulk?" Score: 1.Prototype 2Released: April 24 Critic: Prototype 2 (Metacritic). • "As I learned from Mass Effect 3's review, the ending is everything, have you seen this game's ending? the ending was terrible!!!"AdvertisementSponsored• "It all builds up to a Final Epic Battle of simple quick-time events" Score: 1.BotaniculaReleased: April 20 Critic: eastrazor (Metacritic).• "**** **** **** ! Boring"• "**** for kids !"• "I fought that it will be funn or even hard but this is game for not too smart kids." Score: 0.AdvertisementBackhanded Box Quotes will be an occasional feature of Kotaku's Anger Management hour, unless it isn't.Reply81 repliesLeave a reply


text:
Washington US Senator
With 99 per cent of precincts reporting in the Associated Press tally, Cochran had 51 per cent of the vote to 49 per cent for McDaniel, a state senator. Senator Cochran, in a speech to supporters late on Tuesday night, said his victory reflected, among other things, "a consensus for more and better jobs for Mississippi workers".
Mr McDaniel blamed his defeat on cross-over voting by Democrats who were courted by Senator Cochran after he was forced into the runoff earlier this month. "There is something a bit unusual about a Republican primary that's decided by liberal Democrats," Mr McDaniel said to his backers.
Senator Cochran's victory follows the Tea Party's most notable triumph this year, the June 10 upset by David Brat of House Majority Leader
The Mississippi result could check that momentum, including, in August, contests in which Tea Party-supported candidates are challenging Senators Lamar Alexander of Tennessee and Pat Roberts of Kansas. Senator Cochran's win may also benefit business-oriented Republicans in House primaries.
Tea Party-backed candidates have captured just one US Senate nomination this year – an open seat in Nebraska – while losing challenges to House Republican incumbents other than Mr Cantor.
The Tea Party targeted Senator Cochran for exemplifying much of what it seeks to change in Washington – longevity in Congress, a willingness to compromise with Democrats, and a perceived softness on reducing the national debt and federal deficit. The fiscal issues are at the movement's core.
Senator Cochran, a former Appropriations Committee chairman, was ranked in 2010 as the top requester of now-banned home-state spending projects known as earmarks by the nonpartisan Citizens Against Government Waste. The group recorded his total that year as $US490 million ($524 million).
In his final efforts in the runoff campaign, Senator Cochran sought to turn the Tea Party criticism of his record into a positive. He stressed his Washington clout and history of bringing federally funded projects to his home state. He also sought to expand the electorate, urging Democrats – especially African Americans – to vote in the runoff, saying he could secure benefits for the state that Mr McDaniel would eschew.
Mr McDaniel was endorsed by Tea Party favourite
The Australian Financial Review


text:
The Corinth Rural Fire Board and Volunteer Fire Department have received a $100,000 FEMA grant for the purchase of a new 2,000 gallon water transport truck. The new equipment should be in the fleet within the next 45 days.
In addition, the above groups are working with Grant County Fiscal Court in preparation of a $200,000 grant to construct a new six bay firehouse. The building will have one bay devoted to house an ambulance to serve local area residents.
If you currently subscribe or have subscribed in the past to the Owenton News, then simply find your account number on your mailing label and enter it below.
Click the question mark below to see where your account ID appears on your mailing label.
If you are new to the award winning Owenton News and wish to get a subscription or simply gain access to our online content then please enter your ZIP code below and continue to setup your account.
ZIP Code: | |


text:
Pas de Deux
Report abuseMore by this contributor
About this contributor
Join the Discussion
This art/photo has 24 comments. Post your own now!This is so good! Could be a poster for a ballet company or a show~
beautiful! I love the subject matter~ its not something you see ever day. well done. you did a wonderful job on the lighting~ it looks very realistic
Really love this drawing, very great detail and amazing in every way, keep drawing :D
This is WONDERFUL! I love the detail! You did an amazing job!
This is so wonderfully, amazingly, beautifully, detailed!!! there aren't enough adj. to described how talented you are!!!!!
there really are no words to describe how beautiful this is!! Its breath taking
I really hope that you understand just how gifted you are...this is absolutely fantastic.
This is aboslutely amazing! I've tried drawing pointe shoes before, and it's super hard, much less drawing feet!
i absolutely love this so so so much! since i'm a dancer this catches my eye so well and you have everything to a great point!
this is amazing and beautifully sketched!
wow this is really good, i have some artwork too but i cant figure out how to put it on the computer. lol.
Wow its beautiful you did a great job :) keep it up, don't let your talent go to waste :)


text:
ENGLISH | Español
Boxscores | Photo Gallery
LAS VEGAS (2007 FIBA Americas Championship) - If the United States was trying to send a message that it is the team to beat in this tournament, most would agree that Venezuela got that message loud and clear on Wednesday night. The USA scored early and often, opening the game on a 9-0 run and rolling to a 112-69 victory to cap the action on day one at Thomas & Mack Center on the campus of UNLV. The USA employed a balanced attack, with seven players scoring in double digits. Carmelo Anthony and Michael Redd led the United States with 17 apiece. The USA also dominated inside, outscoring the Venezuelans 58-14 in the paint. Defensively, Dwight Howard led the USA with three blocks while Kobe Bryant and LeBron James teamed for 6 steals. Collectively, the USA forced Venezuela into 20 turnovers, capitalizing on those miscues with 41 fast break points. Greivis Vasquez led Venezuela with 12 points. by: Tim Kuck USA Basketball


text:
Roland SH-09
It's not great, but it ain't bad! A very stripped down monosynth from Roland's classic SH-series. Its single oscillator only has PWM, ramp, square and noise waveforms. It has a similar architecture to the SH-101, the VCA can switch between gate or envelope, the VCF is pretty standard, and there is a sample-hold function which is great for voltage controlled filtering into acid and back! Another cool feature is its external input which will allow you to filter external audio through its VCF. Because they are pretty old now they will most likely have some functional problems like sticky keys, and noisy knobs and signal. It is used by Orbital, Vince Clarke, BT, Conemelt, Josh Wink, Banco De Gaia, Mr. Oizo, Ladytron, Jimmy Edgar, Dave Holmes, Freddy Fresh, OMD, and 808 State.
Lookup Roland SH-09 Prices
The link above will take you to an eBay search for this synth to see active listings with more images, specs and information. If you don't find it there, try looking in our forum marketplace. Our marketplace gets thousands of visits every week so make sure to check back often if you want to buy or sell a synth.
Related Forum Topics
User Comments & Reviews
Are you looking to buy or sell a Roland SH-09? Post an ad in Gear For Sale or a request in Gear Wanted. For spare parts and repair services check out Gear Services & Other Goods. Our forums also has a Buyer's Guide section where you can ask for advice on buying synthesizers.
- Demos & Media
Roland SH-09 Analog SynthesizerAudio Clip 1 - Demo basslines for techno/house styles, from the Future Music CD, issue 53.
Manual - Roland has made manuals for most of their products available as free PDF downloads.
- Specifications
- Polyphony - Monophonic
- Oscillators - 1 VCO with selectable ramp, PWM, noise or square waveforms
- LFO - switchable sine, square or random waveforms
- Filter - cutoff/res/env
- Arpeg/Seq - NO
- Keyboard - 32 keys
- Control - CV / Gate
- Date Produced - 1980
- Websites of Interest
Errors or Corrections? Send them here.


text:
Jessica Dahldorf wasn't trying to beat the clock, but she was trying to use it to her advantage.
The Poly Prep junior had her eye on the scoreboard as the whistle blew and she headed for goal from 20 yards outs along the right sideline with a tie score and 5.3 seconds left in double overtime.
"I was trying to time it just right," the Northwestern-bound midfielder said. "I was trying to hit it at two seconds, just so that draw would be with one second."
Dahldorf did one better.
With her right ankle reinjured earlier and still throbbing, she ran past the Riverdale defense and veered right of the cage. As her shot beat Falcons goalie Brittany Brown to the left corner, the buzzer sounded and cheers engulfed the field. Dahldorf's goal, her fourth of the game, gave Poly an emotional, 15-14 win over previously unbeaten Riverdale in both teams' Ivy League girls lacrosse finale on May 16 in Bay Ridge.
It also marks the first time many of the players have beaten Riverdale, which won the first meeting 18-8. Kayla Metelenis scored five times and added two assists and Sam Domurat had three goals for Poly Prep.
"I just saw an open corner," said Dahldorf, who also won numerous key faceoffs. "I just said, 'Hey, if I miss we go into overtime and its sudden death.' If I make it, it's a hell of a win."
The victory is the seventh straight for the Blue Devils (9-3), who placed third in the division. They beat both Riverdale (11-1) and second-place Hackley during the string of victories. The young and inexperienced team when the year started is peaking at the right time.
"The whole time we were thinking this is our day, this is our day," Domurat said. "We are going to beat Riverdale. We have this. We are not going to let them go undefeated. We just can't."
Both teams played with steely will in the final minutes of regulation and into overtime. Riverdale, which trailed by a goal at the half, grabbed a 9-6 lead when a shot by Lindsay Picard (four goals) deflected off Poly keeper AnaLisa Westfield (22 saves) and rolled into the cage with 12:51 left in regulation. Poly responded by tallying five of the next six goals to grab an 11-10 advantage with 42.4 seconds remaining.
"We are used to this," said Blue Devils coach Anni Zukauskas, who leaped into the arms of assistant Terry Densen after the win. "This is Poly lacrosse. ... Riverdale hasn't seen a fight yet this season. Our girls are ready to go."
Domurat scored the next two. After one of Zoe Loveman's three tallies for Riverdale, Dahldorf bounced one in. Domurat scored and Metelenis ran past a defender to give Poly the lead after Riverdale led 10-8 with 5:38 remaining. Madeline Hopper scored off the rebound of a Katherine Coles shot to tie the score at 11 with 23.6 seconds left, sending the game to overtime.
"From Day One, [Coach] is like there is no such thing as too little time," Domurat said. "There is no such thing as too big a lead."
The Falcons opened the first three-minute overtime with a goal from Zoe Michas, but Poly scored the next three, including a Kailin Twomey goal with 1.2 seconds on the clock to go ahead 14-12. Riverdale tied things at 14 with 21.7 remaining in the second extra session on goals from Loveman and Coles.
The game appeared headed to sudden death when a cross-field pass to Mary Kate Nolan began rolling near the sideline, but Ali Hyman was called for playing the ball from out of bounds and the ball — and a chance to win — was given to Poly and Dahldorf.
"That's why she is going to Northwestern and that's the truth," Zukauskas said. "She should want that ball. She should have the confidence to take that shot."
It provided a win and moment that will be burned into the memories of everyone associated with the Poly Prep team.
"Oh forever, man," Dahldorf said. "Forever."
©2011 Community News Group
By submitting this comment, you agree to the following terms: You agree that you, and not BrooklynDaily.com or its affiliates, are fully responsible for the content that you post. You agree not to post any abusive, obscene, vulgar, slanderous, hateful, threatening or sexually-oriented material or any material that may violate applicable law; doing so may lead to the removal of your post and to your being permanently banned from posting to the site. You grant to BrooklynDaily.com the royalty-free, irrevocable, perpetual and fully sublicensable license to use, reproduce, modify, adapt, publish, translate, create derivative works from, distribute, perform and display such content in whole or in part world-wide and to incorporate it in other works in any form, media or technology now known or later developed. |


text:
The Pilgrimage
We climbed out of the ocean, squirmed up the frowning cliffs and jumped into the bushes while big-breasted housewives tried to menace us with red lip-stick botox scowls.
With heavy hearts we laughed in packs of threes and fours trying to light the desert on fire before our boredom could stifle us.
We crept at the feet of Titans and squeezed our way through dusted mountains and cried under granite boulders while the cold sun crept across a pastel sky.
With eyes full of fear we strove across sallow plains and leapt over white rivers that were too hot to swim in.
We came in cars and motorbikes and buses and coughed on each other the whole way there.
Amid hazy foothills we shuddered in green and blue trailer parks and tried not breathe too deeply.
We descended on the White City and scratched runes into the sides of monuments until the street lights came on…
We huddled around the Obelisk and exposed our flea-bitten torsos to the North!
With souls unhinged we roved up the cold coast like wild lap dogs and nipped at each other's heels.
We reached the altars of Industry and crumbled through the alleyways before a cold sun could ricochet through the mirrored mazes of violent skyscrapers to catch us in our most desperate hour.
We baptized ourselves in the salty mechanisms of brilliantine souls and when we reached the steps we couldn't stop our bones from clicking like marbles down an empty hallway…
Exhausted we fell down at your feet and tugged at your skirt.
You closed your eyes, and your mouth opened wide, but all we heard were coyotes yipping on the high plains of Nebraska…
( Headphones are a must)


text:
Cut-out Rose Design Plastic Case for Samsung Galaxy Note 3 N9000 N9005 (Pink)
This cut-out rose design plastic case is designed to protect your Samsung Galaxy Note 3 N9000 N9005 from scratches, bumps and dust. The open-face design makes it convenient to operate. It is also a great decoration for your phone.
For more info and to Buy, visit - https://goo.gl/jW6qQW
Best electronic products at our electronics online shopping store at the best price with free shipping.
For more electronic products and accessories, visit - http://shrsl.com/?e4xf
Ad ID: 291922


text:
A 17-year-old boy who escaped from the Lucas County Juvenile Justice Center was back in the juvenile lockup early Friday after Toledo police arrested him the night before in central Toledo.
Willis Johnson was arrested about 9:15 p.m. at 816 Vance St., charged with delinquency in connection with escape, and booked into the Lucas County Juvenile Justice Center, police said.
Young Johnson escaped about 8:30 p.m. Oct. 3 from the juvenile lockup, 1801 Spielbusch Ave., in downtown Toledo along with Dontae Moore, 16, who was arrested two days later.
The pair escaped after a 16-year-old Michigan boy broke a window on the second floor.
Young Johnson was being held on seven felony delinquency charges - two felonious assault, two aggravated robbery, and three burglary - and a probation violation from a domestic violence conviction from June, 2007, authorities said.


text:
Chasing A Shakeout
Kelley HollandGuess who's chasing after insurance companies these days? The unlikely answer: banks. Especially noteworthy is a new venture called Insurance Partners, a joint venture involving Chase Manhattan Corp.; Keystone Inc., formerly the Robert M. Bass Group; and Centre Reinsurance Holdings Ltd., a unit of Zurich Insurance Co., the Zurich-based concern. Insurance Partners, which will have at least $400 million in assets and is slated to close within a month, will invest in insurers with problems or those that it believes are undervalued, say sources close to the deal. J.P. Morgan & Co. is also in the game. Along with two partners, Morgan is raising a $500 million fund to invest in insurance startups.
Among the goals of Insurance Partners will be to capitalize on the accelerating insurance-industry consolidation by fixing up companies, then selling out at a profit. Since its investments, unlike the Morgan fund, will be leveraged, Insurance Partners will be able to buy or invest in companies with assets of more than $1 billion. The three founding partners are investing a total of $200 million in Insurance Partners. About 80% of the rest will come from institutional investors including other Bass investment vehicles and individual investors, a market source says. Chase declined comment on the fund, as did Keystone and Centre Re.
BREAKFAST MEETING. Banks and insurance companies have long been separated by regulations. Most U.S. banks are forbidden to get involved in managing an insurance company or to acquire more than 24.9% of an insurer. Chase will leave the day-to-day management of the fund to the other founding partners and its investments will be less than the maximum allowed, but the bank could provide senior debt financing to supplement Insurance Partners' equity investments.
Chase had been mulling a fund to invest in insurance companies for more than a year before Insurance Partners came together, and Centre Re and Keystone had also been considering such a venture, according to a market source. But it wasn't until a Chase-sponsored conference on insurance held last March that the three got together. Over breakfast, officials from the three companies discussed their ideas and decided to try and launch a fund together. They inked a deal a month later and began soliciting investors last fall.
The partners made their first bid last summer. They tried to buy Prudential Reinsurance Co., a subsidiary of Prudential Insurance Co. of America, when it came up for sale. But Prudential took the unit off the block because bids did not meet its asking price of $1.2 billion.
Insurance Partners is entering a crowded field. Conning & Co., a Hartford investment firm, is raising $100 million to take positions in mid-size insurers. Conseco Inc., an insurance holding company, is raising $615 million for life-insurance deals. These ventures may not become bonanzas, but as the banks see things, it beats making loans.


text:
Start with a Blank Canvas
Instead of spending tons of money on multiple "conservative" dresses for work, just buy two or 3 simple, a-line dresses in solid colors. They don't stand out on their own, so your co-workers won't notice if you repeat them. From here buy (or raid your mom's or friend's closet) for decorative belts, brooches, chunky necklaces and patterned neck scarves (yes, these do look cute even if you're under the age of 60). These are a much cheaper way to make ten outfits out of just one canvas dress.
Show Them Who Wears the Pants
For days when you don't want to feel so girly, it's time to accept pants that rise above your belly button. Buy a pair of simple, creased and wide legged trousers in beige, navy blue, grey or black. These look elegant but are surprisingly comfortable, and they kind of sway in this really satisfying "I'm a professional" way when you walk
Business in the Front, Party Under Your Jacket
I know, you probably wont wear the trousers out of the work place, so just buy one or two pairs. You can, however, pair them with tops that you would also wear out to a bar or dinner party. Think ruffled tops, blouses in bright colors, satin camisoles under a blazer, even clean and simple v-neck or crew-neck fitted t shirts. The key is to toss a fitted, solid colored blazer over these to keep it professional.
Throw on some of the accessories mentioned earlier if you're feeling too drab.
So, the whole work-clothes shopping list consists of:
Canvas dress
Wide-legged trousers
….The other stuff, you probably already have.


text:
Interesting result.
These are exactly the types of tests we do with our clients every day.
With any price test, it's important to test several prices and their corresponding conversion rates. Then you can calculate the ROI of each result and determine your optimized price for each product.
The same principle applies to testing product images, benefit headlines and copy points.
More info on creating valid tests here.


text:
18 weeks
Designed for the INTERMEDIATE level, competitive age group triathlete, this challenging Half Ironman training program by 6x Ironman World Champion Dave Scott draws on his 40+ years of experience as an athlete and coach. This plan starts out with moderate volume and intensity at 10 hours per week and builds to 13 hours per week over the course of the plan prior to tapering to prepare you optimally for race day. The 3 sessions each week per discipline (swim, bike, run) include progressive workloads with unique marker sets, which will determine your optimal race pace. Long Brick workouts are included on the weekends starting at week 7 to enhance your race preparation by allowing you to monitor your nutritional needs. Wednesday is the designated day off. Successfully racing the half Ironman distance requires an element of speed so this plan includes some anaerobic, higher intensity session that you will give you a higher metabolic return than only doing moderate intensities. This program may be set to start or end at any time for a goal race that takes place on a Sunday. If your race is on Saturday, please chose the Saturday version of Dave's plan. This program can be adjusted to fit your shortened training schedule if you miss the first few weeks. If you can complete 70%+ of the workouts, you will see results through race-simulated sets and bricks that replicate the physical and psychological tests of your race.Included: This plan comes with Dave's comprehensive Triathlon Training Plan Guide explaining Dave's training methodology and all the workout terminology plus video training tips by Dave covering optimal fueling, proper pacing, mental training tactics, race day strategy and more! Questions? Please visit Dave on the web at davescottinc.com or email: email@example.com.


text:
Canada to make it easier to shut down problem railroads
By David Ljunggren
OTTAWA (Reuters) - Canada will bring in new rules making it easier to quickly shut down unsafe railroads, the government said on Friday, eight months after 47 people died in the Lac-Megantic, Quebec, crude-by-rail disaster.
Once the regulations come into force later this year, all rail companies operating on federally regulated railroads will require a valid Railway Operating Certificate, the transport ministry said in a statement.
In case of serious problems, Transport Canada "could suspend or cancel the company's operating certificate. This could put an immediate stop to the company's railway operations in Canada," it said.
Under current regulations, the ministry's only option to deal with companies that flout safety rules is prosecution. The ministry is responsible for overseeing 31 rail networks and said it estimated that 66 companies operating trains on those networks would need the new certificates.
While railways under federal jurisdiction must show they have enough insurance to operate, "there are no requirements to ensure that baseline safety standards are in place prior to companies beginning operation", the ministry said.
An official watchdog said last November that Canada was not doing enough to ensure rail safety. It cited inadequate audits, ill-trained staff and too little focus on high-risk railroads.
Last July, a train carrying crude oil, with no operator on board, moved off by itself from where it had been parked overnight. It later derailed and exploded in the Quebec town of Lac-Megantic, killing 47 people.
The disaster generated questions about how closely Transport Canada had been watching the railway involved - the Montreal, Maine and Atlantic - before the disaster. A subsequent investigation found that some of the track operated by the company was in poor condition and did not meet safety standards. Continued...


text:
Brent Saunders is Chairman of the Board of Directors, Chief Executive Officer and President of Allergan plc.
He previously served as Chief Executive Officer and President of Forest Laboratories and had served as a Director of Forest since 2011. Mr. Saunders has significant healthcare industry expertise and a proven track-record leading business transformations and integrations. Prior to Forest, he was chief executive officer of Bausch + Lomb, a leading global eye health company, serving in this capacity from March 2010 until August 2013. Mr. Saunders also held a number of leadership positions at Schering-Plough, including the position of president of Global Consumer Health Care and was named head of integration for the company's merger with Merck & Co. and for Schering-Plough's acquisition of Organon BioSciences. Before joining Schering-Plough, Mr. Saunders was a partner and head of Compliance Business Advisory at PricewaterhouseCoopers LLP. Prior to that, he was chief risk officer at Coventry Health Care and senior vice president, Compliance, Legal and Regulatory at Home Care Corporation of America. Mr. Saunders began his career as chief compliance officer for the Thomas Jefferson University Health System. Mr. Saunders serves on the Board of Directors at RWJBarnabas Health, and is a member of the Business Council and PhRMA. He is also the former Chairman of the New York chapter of the American Heart Association. Mr. Saunders, 46, earned his MBA from Temple University School of Business, his J.D. from Temple University School of Law and his bachelor's degree from the University of Pittsburgh.
Bob Stewart was appointed Chief Operating Officer effective May 9, 2016.
Previously, Mr. Stewart served as President, Generics and Global Operations since March 2015; Chief Operating Officer of Actavis from July 2014 – March 2015; and President, Global Operations and Executive Vice President, Global Operations, from August 2010 – July 2014. He joined Actavis (then Watson) in November 2009 as Senior Vice President, Global Operations. Prior to joining Watson, Mr. Stewart held various positions with Abbott Laboratories, Inc. from 2002 until 2009 where he most recently served as Vice President, Global Supply Chain. From 2005 until 2008, he served as Divisional Vice President, Quality Assurance and prior to this position served as Divisional Vice President for U.S./Puerto Rico and Latin America Plant Operations as well as Director of Operations for Abbott's Whippany plant. Prior to joining Abbott Laboratories, Inc., he worked for Knoll Pharmaceutical Company from 1995 to 2001 and Hoffman La-Roche Inc. Mr. Stewart received B.S. degrees in Business Management/Finance in 1994 from Fairleigh Dickinson University.
Bill Meury was appointed Chief Commercial Officer effective May 9, 2016.
Previously, Mr. Meury served as President, Branded Pharma since March 2015. He joined Actavis in July 2014 as Executive Vice President, Commercial, North American Brands. Prior to joining Actavis, he served as Executive Vice President, Sales and Marketing, Forest Laboratories, Inc. He joined Forest in 1993 and held positions in Marketing, New Products, Business Development, and Sales. Most recently, as Executive Vice President, Sales and Marketing, Mr. Meury oversaw the activities of several departments including Product Management, Market Research, and Commercial Assessments, as well as Forest's Global Marketing and Early Commercialization groups. Mr. Meury directed 10 product launches during his tenure at Forest. Before joining Forest, Mr. Meury worked in public accounting for Reznick Fedder & Silverman and in financial reporting for MCI Communications. He has a B.S. in Economics from the University of Maryland.
David Nicholson was appointed head of Brand R&D effective March 17, 2015.
Dr. Nicholson joined Actavis as Senior Vice President, Global Brands R&D in August 2014. Previously, he served as Chief Technology Officer and EVP, R&D for Bayer CropScience from March 2012 to August 2014; Vice President of Licensing and Knowledge Management at Merck from 2009 to December 2011; and Senior Vice President, responsible for Global Project Management and Drug Safety at Schering-Plough from 2007 to 2009. From 1988 to 2007, Dr. Nicholson held various leadership positions at Organon, where he most recently served as Executive Vice President, Research & Development and was a member of the company's Executive Management Committee. He received a B.Sc. from the University of Manchester and his Ph.D. from the University of Wales.
Maria Teresa (Tessa) Hilado was appointed Chief Financial Officer effective December 8, 2014.
Prior to joining the company, Ms. Hilado served as Senior Vice President, Finance and Treasurer for PepsiCo, Inc. since 2009. Before joining PepsiCo, she previously served as Vice President and Treasurer for Schering-Plough Corporation from 2008 to 2009. Before joining Schering-Plough, Ms. Hilado spent more than 17 years with General Motors Corporation in leadership roles of increasing responsibility, most notably Assistant Treasurer from 2006 to 2008 and CFO, GMAC Commercial Finance LLC from 2001 to 2005. She began her career with Far East Bank and Trust Company, Manila, Philippines. Ms. Hilado received a B.S. in Management Engineering from Ateneo de Manila University in the Philippines, and an MBA from the University of Virginia's Darden School of Business Administration.
Bob Bailey was appointed Chief Legal Officer and Corporate Secretary effective July 1, 2014.
Previously, Mr. Bailey served as Senior Vice President, Chief Legal Officer, General Counsel and Corporate Secretary of Forest Laboratories, Inc. He previously served from 2007 to 2013 as Executive Vice President, Law, Policy and Communications at Bausch + Lomb. Before joining Bausch + Lomb in 1994, Mr. Bailey was an attorney at Nixon Peabody (formerly Nixon Hargrave Devans & Doyle). Mr. Bailey received his law degree from the University of Minnesota and his undergraduate degree from St. Olaf College in Northfield, MN.
Karen Ling was appointed Chief Human Resources Officer effective July 1, 2014.
Prior to joining Actavis, Ms. Ling served as Senior Vice President and Chief Human Resources Officer for Forest Laboratories, Inc. Ms. Ling joined Forest in January 2014 from Merck & Co., Inc., where she served as Senior Vice President, Human Resources, for the company's Global Human Health and Consumer Care businesses worldwide. Prior to that role at Merck, she was Vice President, Compensation and Benefits. Before Merck, Ms. Ling was Group Vice President, Global Compensation & Benefits at Schering-Plough. She also spent 14 years at Wyeth in various positions of responsibility in human resources as well as in Wyeth Pharmaceutical's Labor and Employment Department. Prior to joining Wyeth, Ms. Ling practiced corporate law with Goldstein and Manello, P.C. in Boston. Ms. Ling holds a B.A. from Yale University and a J.D. from Boston University School of Law.
Alex Kelly was appointed Chief Communications Officer on April 20, 2015.
Previously, Mr. Kelly served as Senior Vice President, Chief Integration Officer since July 1, 2014. In this role, he led the integration of Forest Laboratories following its acquisition by Actavis. He also co-led the integration of Allergan. Prior to joining Actavis, Mr. Kelly was Senior Vice President, Chief Communications Officer, Public Affairs and Investor Relations at Forest Laboratories. In that role, he led Forest's corporate communications and investor relations programs, including internal and external communications, media relations, corporate branding, product communications, and public affairs. While at Forest, Mr. Kelly led the integration of Aptalis Pharma following its acquisition in January 2014. Prior to Forest, Mr. Kelly served as Vice President, Investor Relations at Bausch + Lomb. Mr. Kelly was Senior Vice President, Investor Relations at Merck & Co., Inc. following the combination with Schering-Plough where he led the Global Communications and Investor Relations team. He previously worked for Novartis as Executive Director, Investor Relations, after spending 14 years at Pharmacia, including ten years in pharmaceutical sales and sales management and four years in investor relations. Mr. Kelly holds a Bachelor of Science in Pharmacy from Purdue University, where he graduated Cum Laude.


text:
Click here to go to Day 1 of the 2012 Japan Election Diary.
I'm flying to Zurich from London Heathrow, my telephone told me this morning.
This was news to me, having no connection to Zurich or any interest in cuckoo clocks at all. But there it was in black and white, an email confirmation of two tickets bought and paid for in my name on a Swiss Air flight.
This had to be a scam or something, I thought. But the email wasn't seeking money. And then a second email arrived with the e-tickets attached, already bought and paid for. In my name. Looks like I was going to Zurich for a long weekend in March.
Odd, I couldn't remember buying the tickets. Was it possible that in a haze of diary writing in the middle of the night (given the the thrills of this election) I'd inadvertently bought myself the tickets? Certainly, I'd knocked back a fair bit of Chile wine to get through the Day 16 entry, and it could well have happened. But Zurich? Why in God's name Zurich?
Everything was in my name, spelt just like it is in my passport. I looked again at the email details. It was sent to my gmail address, but had a dot between my first and last names.
That wasn't my email address.
So, I was receiving someone else's private emails. Someone else who happened to have the same name as me. How on earth did it slip through the ether to my address box? Then I had another thought. If I was receiving this chap's emails, maybe he was receiving mine, the poor man, no matter how well-named. So I did the only sane thing under the circumstances, I wrote an email to myself.
Dear Me,
You don't know me, but I am you. I have received emails addressed to me, but they are for you. I am writing this to you because I have no intention of going to Zurich in March. I wonder if you have any odd emails for me?
All the best,
PS it is entirely possible that you are not me, but are somebody else. However, our passports have the same name, and the evidence is stacking up to the contrary.
I sent the email and drank my coffee. Then my telephone told me I had an email from myself.
So, that proved it. It was me. All I had to do was wait for my hotel booking to come. Hmmm. Who was the second ticket for? Zurich. Shame it wasn't Rio, I could have contemplated throwing caution to the wind and trying out for a second life. But I wouldn't want to jettison my current life only to end up in a convention of insurance salesmen.
I was out of ideas, so I asked twitter for advice. Apparently it's quite common to have digital dopplegangers. A friend gets regular unsolicited email updates on her digital doppelganger's infant embryo. I didn't have to work till the afternoon, so I decided to take a quick nap and see if couldn't start the day again with fewer outakes from Jose Saramago's The Double.
My snooze was interrupted though by loudspeakers on trucks. First there was an indeterminable woman's voice, I couldn't catch the name of the candidate. Then as I drifted off, a man's voice shouted a slogan, which I didn't catch. I closed my eyes and thought of Swatch watches and Toblerones. Then a truck pulled up outside my bedroom playing children's music loud enough to rattle the windows. It was a paraffin delivery truck.
I gave up trying to start the day again.
It's 10:30pm and the cover life is done. The brush with the campaign sound trucks was just a memory and now I'm ready to tackle the day's election news. That means I just did what anyone with a vague interest in the 2012 Japan Election would do, and that is type in "2012 Japan Election" into Google and check the most recent story. That happened to be a Daily Yomiuri story from 18 hours previously, which I normally would steer clear of on matters of principle, taste and bad memories of being bamboozled by their graphics. You have not been bamboozled until you have tried to follow one of their flowcharts. The Yomiuri is the only newspaper group I'm aware of that uses explanatory graphics to explain their explanatory graphics. But this Yomiuri story featured a sexy headline:
'Assassins' add edge to election
If only they were assassins. Actually, they are rival candidates who have a reasonable chance of defeating a prominent incumbent. Not exactly an assassin. But beneath the paper's surprisingly legible, if dull graphic, was a reasonable race to watch.
The Prime Minister, Yoshihiko Noda (remember?), who has a bit on his plate nationally, has to fight against not only a former LDP winner of his constituency, Mikio Fujita, but also his own former party member Yukiko Miyake who jumped ship and joined the Lady of the Lake's Japan Future Party. Squeezed doubly from the right and left, there's every chance Noda will lose, or as the Yomiuri would have it, be assassinated.
This blog series
is now a great
book. Honest.
Cleaned up and
all presentable,
Guts Pose: Diary of a
Japanese election
gone bad
features a previously
unpublished afterword
by me and foreword
by Michael Cucek.
You can buy it here.
Go to DAY 21


text:
All Because Two People Fell in Love
March 05, 2013
New Background
Oh boy! I've failed. Epically. My poor blog has been neglected x3. We've been so busy with work, kids, life, I haven't had a chance to do anything...I even neglect my Facebook!
I might just let this one go and start a new one about the boys for family. I don't know yet. Life is busy.
These boys keep us busy.
September 09, 2012
My 2nd post for 2012 happens in September!! Really don't know how I let it get this far! So this is what happened while I was absent from my poor blog, that is still decked out in christmas!
I went back to school starting in January, which kept me preoccupied, and got straight A's!
Played with these two beautiful boys!
Celebrated Logan's 3rd Birthday
Studied for MONTHS for the the nursing school entrance exam, which I'm happy to report, I passed!
Played all the time with these boys!
Painted our kitchen! Wythe Blue by Benjamin Moore, if y'all are interested.
Celebrated Chris' birthday!
Married my best friend on June 9, 2012! It was beautiful and fun! Wish I could do it again!
Went canoeing in Arkansas with my new hubs!
Cut my hair! Love it!
Watched one of my besties get married!!
Went to the Outer Banks. Our cousins gifted this trip to us and it was by far the best wedding present ever! And yes, we took our boys!
My grandparents met their great grandkids for the first time.
My nephew, Ephraim, was born.
Logan learned how to pinky promise and was making me pinky promise to everything!
I made some whoopie pies!
Went to New Orleans to see my grandfather who needed to have a cardioaversion.
Started my 2nd semester.
Got Mason into a big boy car seat!
Found out that living in Memphis has given me asthma! Thanks TN.
Celebrated one of my besties sons' birthday!
And celebrated my baby boy's first birthday! So bittersweet!
There was a whole lot more that went on and a whole lot more to come!
Hopefully I can keep up! I miss blogging.
January 03, 2012
It's Official!
We've set a date
to ring some wedding bells!
♥ June 9th, 2012! ♥
We've got some ideas and I'll probably be blogging
them so that I know what I'm doing. Ha!
December 24, 2011
Merry Christmas!
It's the night before Christmas!
We've been waiting for this night all month
and year (if you're like me).
We've done some crazy shopping, eating, and drinking.
We've gone to parties and hosted parties.
We've stressed ourselves out and probably spent a lot of money.
In reality we wouldn't do anything differently.
We do this for our families and our children.
The twinkle in their eyes and their smiles make all the craziness worthwhile.
We should remember that this is the season for giving.
We should also remember why we celebrate Christmas, if you celebrate Christmas,
we should remember our Savior.
Thank you Jesus for this holiday, for my family, our memories, my children, my friends,
and everything in between, big and small! You are the reason we celebrate!
Don't forget tomorrow to just
Merry Christmas!
From my house to yours!
December 21, 2011
Chocolate Banana Muffin-time!
Last year HarperCollins Publishers did 65% off of their books for employees employed by News Corporation, for the holiday (thank you!) I'm sure they do it every holiday but last year was the first year I knew about it. Anyways, this year I took full advantage of the 65% discount and lookie at what came in the mail for moi!
What would've cost close to $200 was only about $75! How amazing! And I bought my first cookbook (how sad, haha)! I want to start working on a collection of sorts for the new kitchen that is light years away from being conceived! Anywho, I went through the cookbook this morning and was looking for a banana bread recipe, because we have some very ripe bananas on the counter, and I found one for chocolate muffins! Can't wait to see how good Nigella's recipe works! Up next, chocolate banana muffins! xo
December 19, 2011
A Christmas House Tour!
I saw Kelly's Korner doing this post last week and I truly wanted to do it as well but like always there was no time to do it then, so I'm going to do it now! I have never been so behind on Christmas, EVER! This year I was so excited and then it got here and I felt rushed and disorganized and sad but it did get done.
Here's our Christmas decorations for our first home!
Outside lights!
Logan's own little Christmas tree! Next year Mason will get one too!
Christmas Tree 2011! This one really did come all the way from NJ!
The little niche that house developers LOVE down here in the South!
Logan took this picture! It's the tree at the vantage point of a toddler!
Some of the spots that we have found Frank the Elf! He told us we need more shelving!
And our Christmas card this year!
Merry Christmas
Happy New Year
♥ ox ♥
December 14, 2011
Jingle Jam 2011!
Chris and I went to Jingle Jam in Tunica for my birthday! It was our first time going to a concert, together, which is sad because we've been together almost 4 years! Anywho, the local radio station put it together and the concert consisted of The Cab, Nick Carter, Simple Plan, James Durbin (American Idol contestant), and Hinder! I think they should've mixed it up genre wise but I guess local stations take what they can get! All in all it was a good show, played good songs (and a lot of my favorites) and Nick Carter even sang an old Backstreet Boys song!
But before we went to Jingle Jam, we checked into our hotel! We stayed at the Veranda, in the Paula Deen suite!! It was the biggest hotel room I've stayed in yet and it was so much fun! Of course I had to take some pics!
Haha I was fascinated by the fact that a telephone was next to the toliet!
Our bathroom! I had a standing shower and a jacuzzi jet bath tub!
These king size beds I keep staying in make me want to upgrade my own bed!
Our living room area!
There was also a half bathroom!
I had to take a pic of the doors because I've never stayed at a place with double doors! I will admit I felt a little bit like Julia Roberts in Pretty Woman! Ha!
Our view! You can see my reflection because I have no idea how to keep that from happening.
Ok, now on to the show's pics! Bear with me =)
The Cab!
Nick Carter!
Simple Plan!
James Durbin!
My and the my love!
I'm gonna get a little mushy!
I love you honey! Thank you for making this night and every day, night, month, year possible! You're my greatest support, my best friend, my shoulder to lean on, and everything else! You make me so happy and I can't wait until we complete each other by getting married! I'm a very lucky girl to have you! ♥
Older Posts
Subscribe to:
Posts (Atom)


text:
Terra Natura
Contact details
Foia del Verdader 1
Benidorm, Alicante - Alacant
- Autonomous region: Valencia
- Province/Island: Alicante - Alacant
- Types of park:
- Zoo
Terra Natura, in Benidorm, offers a journey across three continents with one unifying thread: animals.
Terra Natura is a theme park for the whole family and for all ages, and is conceived to provide much more than just a simple leisure and nature activity. It offers the chance to travel to exotic places in Europe, Asia and America, to discover the folklore, culture, customs, gastronomy, crafts, and the flora and fauna of these three continents in just one day, and without setting foot outside Benidorm. As soon as you enter Terra Natura, you'll feel like a traveller about to experience all kinds of adventures, thanks to the themed areas in each zone: South America, with its magical atmosphere; Asia, a land of spirituality; and Europe, a life beside the sea. The other main protagonists in the park are the animals: there are 1,500 animals belonging to 200 different species, 54 of which are endangered. The site has full disabled access and also has a water park and a children's play area for younger visitors.
Schedules and prices
Check the website for information on opening times.
- Adults: €29
- Children: €23.50
- Retired persons: €23.50
Suplemento acceso a Aqua Natura 12 €.