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The Horse Forum
- Horse Colors and Genetics
- - Dun Appaloosa? Help?
Dun Appaloosa? Help? I'll begin by saying i have NO knowledge of genetics/colours... And have never looked up/researched a horses pedigree before. So, I lease a registered Appaloosa gelding named Gus. His registered name is "Dineros Dun". I don't know his sire or dam's names. He's a dun, i think. Is this weird? Is there a way to try to find his pedigree if it's online? Any help would be greatly appreciated. I'll post a pic of him, is he dun? He does have a dorsal stripe, it is a darker version of his body colour, not black. http://i24.photobucket.com/albums/c3...redee/15-1.jpg |
I am by no means super knowledgable, but personally I am leaning more toward buckskin from that pic. However, sometimes its hard to see the dun markings in winter woolies. Does he have stripes on his legs? How distinct is the dorsal stripe? A pic of the dorsal would be great. |
I haven't noticed any stripes, but i guess i havent really looked that hard. I'm out at the barn tomorrow, i will get a pic of his dorsal stripe, he's already lost alot of the woolies since i snapped this picture. Thanks! |
I think he's dun, you can see the shading variations on the legs and the mask on the face, it *looks* like he *may* have ear tips too. Better/more pics would be helpful to tell. Dorsal stripe, side view of legs, back view of legs, wither/neck, face shot, and back of his ears are all places dun markings show up. |
Ok, i'll try to get those photos tomorrow. Thanks again. |
Soda is a dun, though I haven't gotten him tested so I guess he *could* be a buckskin with sooty/smutty/whatevertheheckitis. His dam was a palomino and his sire is a dun, so he technically could be either, but he shows basically all of the dun markings (leg barring, face mask, ear tips, zippers, shoulder/wither barring, and a dorsal stripe) so I'm going with dun.. :lol: |
Thanks xxdanioo ! i'm not sure.. hahah i'll have to find out his age and im trying to find out his parents' names. MN Tigerstripes, His mane is waht stood out to me, Gus' is the same, has the blond "top coat" |
Yup, but I've seen buckskins like that too.. So I'm not sure what that is caused by.. There are some genetic people on here who know a ton more than I do, maybe they'll pipe up? |
That would be great! |
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Decimal Degrees: Latitude: 42.8878686 Longitude: -70.8122743
Share your comments and photos of Thomas Rock, a Bar in Rockingham County, NH
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Bar: Round Rock , Thomas Rock
Bridge: Mile Bridge
Cape: Beckmans Point , Locke Point
Channel: Hampton Harbor Inlet
Church: Saint Elizabeth Church
Locale: Hampton State Pier
Pillar: Bound Rock
Populated Place: Seabrook Beach , Hampton Beach State Recreational Vehicle Park
11 Places found nearby
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Time to build: 0.0320 Secs | Cached: 26-Mar-17 05:08 PM

subset: commoncrawl


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Around Asia: Human trafficking ring busted
August 13th, 2013
A human trafficking ring that smuggled Chinese citizens into Europe and the United States has been dismantled, leading to dozens of arrests in Spain and France, authorities say. Spain's Interior Ministry said a total of 75 people accused of being involved in the China-based trafficking ring were arrested in June. Among those held were two …


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NEW YORK — Oklahoma City's Kevin Durant has capped his MVP season by being the lone unanimous choice to the All-NBA first team.
Durant was a first-teamer on all 125 ballots, and made the top squad for the fifth time. Miami's LeBron James got 124 first-team votes on the way to being selected for the eighth time, while the Los Angeles Clippers' Chris Paul earned his fourth first-team selection.
Houston's James Harden and Chicago's Joakim Noah are first-time first-team choices.
Second-team All-NBA selections were San Antonio's Tony Parker, Golden State's Stephen Curry, the Clippers' Blake Griffin, Houston's Dwight Howard and Minnesota's Kevin Love.
Portland's Damian Lillard and LaMarcus Aldridge, Phoenix's Goran Dragic, Indiana's Paul George and Charlotte's Al Jefferson were third-team selections.


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Advancing the Treatment of Depression With Personalized Medicine
Andrew A. Nierenberg, MD
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Personalized medicine holds the hope of increasing the likelihood that patients with depression will respond to treatment and achieve remission. Currently, insufficient evidence is available supporting personalizing variables. However, ongoing large individualized comparative effectiveness studies may provide detailed information in the future. Some of the features that have potential as personalizing variables that can help predict response to particular treatments, pending replication studies, include sex, hormonal status, atypical depression, childhood trauma, family history of mental illness, and certain biomarkers and genetic polymorphisms.
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Moments in Time: The mining boom in Silver Bay
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Art Fenstad is a descendent of one of Cook County's early fishing families, but Art didn't grow up fishing—at least not in the way his ancestors did. Commercial fishing on Lake Superior dropped off rapidly after the invasion of invasive species, particularly the sea lamprey. The economy along the shore changed forever. But as fishing was dying out, a new industry was emerging and a new economy was taking shape.
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Tag Archives: not for profit
Not-for-Profit Financial Literacy Survey
Grant Thornton and Probono Australia have launched their Not-for-Profit Financial Literacy Survey Results, in a document entitled: Not for Profits: Are you Ready for the Future? The survey looked at directors' and managers' perceptions of whether not-for-profit boards are financially … Continue reading
Philanthropy, Old, New and Enduring
Last week I attended a forum entitled Philanthropy, Old, New and Enduring presented by Swinburne University's Asia Pacific Centre for Social Investment and Philanthropy in conjunction with O'Keefe and Partners. Julie Johnson, Managing Director at O'Keefe Partners, presented on giving trends research … Continue reading
Posted in corporate social responsibility, donate, fundraising, higher education, philanthropy
Tagged asia pacific centre, bequest, charitable competition, Christopher Baker, corporate philanthropy, corporate sponsorship, estate, global financial crisis, Include a Charity, Inheritance, Julie Johnson, not for profit, O'Keefe and Partners, swinburne university, testamentary trust
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Giving Circles and Impact100 WA
James Boyd from artsupport Australia* was the guest of Swinburne Philanthropy Alumni at the final Maimonides Society event for the year. James has been involved in the establishment of Impact100 WA which is a giving circle based on the 14 … Continue reading
Not for Profit Summit – keynote speaker Debra Allcock-Tyler
I heard the most amazing speaker last week at the Not for Profit Summit presented by the Office of the Community Sector in the Department of Planning and Community Development at Geelong. Debra Allcock-Tyler is the CEO of the Directory … Continue reading
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Tagged Big Society UK, conference, Debra Allcock-Tyler, Directory of Social Change, George Bernard Shaw, It's Tough at the Top: No fibbing guide to leadership, Man and Superman, not for profit, Not for Profit Summit, Office of the Community Sector, Pleasure and the Pain: No fibbing guide to Working with People, social change, Social Investment, This is the true joy in life
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The Power of We
It's Blog Action Day and this year's theme is The Power of We so I thought I would just do a very brief post here to talk about the Rotary Community Service Awards which were handed out last night. I … Continue reading
PLuGIN – Mary Crooks at the Inner North Community Foundation
Writing this one with two hats, blogger and Executive Officer of the Inner North Community Foundation. A few weeks ago, the Inner North Community Foundation had its first PLuGIN (Philanthropy Leadership Group in the Inner North) – which had its … Continue reading
Public Ancillary Funds – new draft guidelines
The Federal Assistant Treasurer, Bill Shorten, has released new draft guidelines for Public Ancillary Funds (often known as PAFS and usually given the deductible gift recipient designation of DGR2). The Australian Tax Office describes Public Ancillary Funds as "public funds … Continue reading
What the Victorian budget means for not for profits
Philanthropy Australia and the Office for the Community Sector invited Melbourne's philanthropy community to hear the Treasurer, Kim Wells MP, speak about the impact of the Victorian state budget on the not for profit sector. The Treasurer was introduced by … Continue reading


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Belfast centre
2 Donegall Square West, Belfast, BT1 6JA
028 9050 9777
Apartment is sleek and modern with dark wood paneled walls and comfy leather sofas and arm chairs.
Enjoy spectacular views over Belfast City Hall and the bustling streets of Belfast below while you dine and drink in style.
We're open from 7.30am for breakfast right through to last orders.
During the week our restaurant is open 12-9pm, but we open 12-10pm on Thursdays for late night shoppers and 12-8pm on Sunday.


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SVMHS Nurse was created to honor nursing at Salinas Valley Memorial by showcasing the achievements and dedication of our professional nursing staff. In this publication we highlight, nurture and promote excellence in nursing care and keep you informed about upcoming organizational, nursing and Magnet events and activities.SVMHS Nurse is designed to highlight, nurture and promote excellence in nursing care at SVMHS. This newsletter not only communicates organizational, nursing and Magnet events and activities, but it also showcases the achievements and dedication of our professional nursing staff.
Nurse Practice Council; Meet Our Nurses; Partners in Care—Infection Prevention and Control; Improving patient care through advanced technology, What's New and New Alcohol Withdrawal Protocol (AWP)
Nurses Making a Difference; Evidence Based Practice Council Update; SVMHS Nurses Attend National Magnet Conference; Meet Our Nurses; Partners in Care—Laboratory Services and Improving hand hygiene.
SVMHS nurses lead, & inspire, by example; Collaborating to improve patient outcomes; Meet Our Nurses; Partners in Care—Nutrition Services and Project Focus—Hypothermia therapy after cardiac arrest.
Benefits of Nursing Specialty Certification; MOX to Outlook conversion underway; New structure for 2010 Competency Camp; Partners in Care—Respiratory Care Services; Designated Code STEMI Receiving Center.
No One Dies Alone; Meet Our Nurses; MOX to Outlook for email; What's New; SVMHS welcomes triplets; Nurse Reflections; Link Lines.
Staff Nurse III Program, Meet Our Nurses; What's New; Working together to create the Healing Zone; Personal Fitness and Well-Being; Partners in Care.
Collaboration shines in preparation for H1N1; Enhancing the Safety of Medication Administration; Meet Our Nurses; What's New; Project Focus—Cue-based feeding protocol; Construction Update.
Nurses Making a Difference; Nurse Engagement Survey; Meet Our Nurses; What's New; Project Focus; Personal Fitness and Well-Being.
Faces of eMAR-BMV; Enhancing the Safety of Medication Administration; Nurses Making a Difference; What's New; Nurse Q & A.
Nurses Making a Difference; MSCV3 Selected for Online Physician Order Forms Pilot; Meet Our Nurses; Nurse Engagement Survey; Pressure Ulcer Initiative.
Professional Role Workshops Empower Nurses; The Power of Professionalism; The Meaning of Magnet; eMAR-BMV; Department Profile--Endoscopy
Nurses Making a Difference; Horizontal Hostility; Cancer Survivorship Survey; Bereavement Packets; Simulation Lab Coming to SVMHS.
2008 Nurse of the Year, Kathryn Maurer, RN; Clinical Policies at Your Fingertips; Department Profile - Medical/Surgical Cardiovascular 3
SVMHS Nurses--Champions for Patient Care; Increasing Comfort Improves Patient Outcomes; Nurses Saddlel up for the California Rodeo Salinas
New Clinical Ladder for Staff Nurse III; Clinical Informatics update; Update on Journey to Magnet; Unit Based Practice Councils, Personal Fitness and Well Being
The Joint Commission preparation; Fundamental of Care; Department Focus-- Pediatrics; Magnet Update; Keeping yourself well while caring for patients


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Select the desired Level or Schedule Type to find available classes for the course. |
This advanced Spanish language course will concentrate on major works of art in the Spanish-speaking world in order for students to become more proficient in the Spanish language and more knowledgeable about many aspects of Hispanic culture and civilization. The course covers works of art beginning with the pre-historic cave paintings of northern Spain and ending with the Chicano art of the American southwest. Some of the artists studied will be El Greco, Velazquez, Goya, Picasso, Dali, Posada, Orozco, Kahlo, Rivera, Botero and Lam. The questions will be: "What can I see in this work of art?" and "How can I relate what I see to the Spanish speaking world?"
0.000 TO 4.000 Credit hours 0.000 TO 4.000 Lecture hours Levels: Undergraduate Schedule Types: Lecture Language Department Course Attributes: GE-INTERNATIONAL ISSUES Restrictions: Must be enrolled in one of the following Levels: Undergraduate Prerequisites: FOR SPAN 313 General Requirements: Course or Test: SPAN 202 Minimum Grade of D May not be taken concurrently. |
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Most Viewed Stories
Late surge carries Laguna Hills to victory
LAGUNA HILLS - Laguna Hills coach Bruce Ingalls has a simple philosophy.
"We're never going to quit," Ingalls said. "We're going to play all 48 (minutes)."
The Hawks needed every last second to rally from a 10-point deficit in the fourth quarter and defeat Dana Hills, 31-27, with two touchdowns in the final 4 minutes and 12 seconds.
Laguna Hills (6-3, 3-1) clinched at least a share of the Sea View League title by halting Dana Hills' three-game winning streak. It was the first meeting between the two schools since 1997 and its was Laguna Hills first victory over Dana Hills (3-6, 2-1) since 1996.
"What we were trying to do was win the second half and try to get some doubt in their mind because its been a long time since they won a league championship. We were trying to get them down a little bit. Our kids just really did a courageous job of coming back in the second half."
Dana Hills started to unravel in the fourth quarter with a series of penalties late in the fourth quarter and Laguna Hills took advantage of the situation.
Laguna Hills trailed, 27-17, when it took over at its own 36-yard line with 5:32 remaining. A pass interference penalty and a face-mask penalty on consecutive plays moved the Hawks to Dana Hills' 37. Hawks quarterback Kevin Cunningham quickly moved his team in for the score, connecting with Adam Salcido for a 15-yard touchdown pass with 4:12 remaining. That cut Dana Hills' lead to 27-24.
Dana Hills was unable to pick up a first down and was forced to punt. Dolphins punter Logan Warren got off a beauty and had the Hawks pinned back inside their own 15, but he was forced to punt again because of an illegal procedure penalty. Warren got off another good punt and had the Hawks pinned back inside their own 20, but another illegal procedure penalty forced him to punt again.
Will King was able to return Warren's third offering and he returned it 56 yards to Dana Hills' 16.
"That punt return was huge," Ingalls said. "That got us right back in the game. It was a complete team victory. We've been winning with special teams all year long and I think you saw how resilient our team is. I mean, we're not going to give up we're going to go all 48 with you and that's what we did tonight."
Four plays after King's punt return, Cunningham called his own number and scored on a 4-yard touchdown run to give Laguna Hills a 31-27 lead with 33 seconds left.
"We came in knowing it was going to be a battle to the fourth quarter," Cunningham said. "Our motto is to play all 48 minutes and that's what we did tonight."
The Dolphins had 33 seconds to work with, but only got off two plays. Salcido picked off Dana Hills quarterback Mac Vail with 21 seconds left to seal the victory for the Hawks.
That was the final game of the regular season for Laguna Hills, but the Hawks haven't clinched a playoff berth even though they did clinch a share of the league title. Dana Hills and Capistrano Valley (7-2, 2-1) are tied for second a half game behind Laguna Hills. Dana Hills owns the tiebreaker over Capo Valley and Capo Valley owns the tiebreaker over Laguna Hills. There are only two guaranteed playoff berths in the Sea View League. If Dana Hills beats San Juan Hills and Capistrano Valley beats Aliso Niguel, it would create a three-way tie for the league title and coin flips would determine the two guaranteed playoff berths. The team that gets left out would have to receive one of the two at-large berths in the Southwest Division to get into the postseason.
"After our last game (against Capo Valley) we talked about how we didn't want to go out like that," Cunningham said. "We didn't want to not make the playoffs. We wanted to pull it together and get that league championship this week."


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Hammerwatch Review
Dear Reader,
What a pleasant surprise. Hammerwatch, a Gauntlet-style indie game, has captivated my buddy and I for about 10 hours (so far – we're not done yet) for a super-cheap price (we got it for 5 bucks each). The game is a pure dungeon crawl; the entirety of the story is "The bridge broke!" This opening line propels you and potentially your multiplayer partner (now basically essential for any game I purchase) through 4 "acts" of the dungeon, each with three floors and a unique boss.
The overhanging danger is that the game plays like an unforgiving old-school dungeon crawl. There are a finite number of lives that, if extinguished, end the game. It is actually possible to fail in this game, which has earned it the title of "hardcore," but really, it's not. It's just old-school.
I bought the game on a whim, moreso because it had a functional multiplayer than anything else, but what my buddy and I found was a real gem. We're both hard-to-please, grumpy video game veterans, but we've had virtually no lasting complaints about the design so far. It is set in an old, 8-bit graphic style, but some of the old-school graphics are still really cool looking. The different classes, too, really change the gameplay. There are two ranged and two "melee," though one of the melee becomes a mix of aoe ranged and melee after a few floors.
And secrets – oh, the secrets. They are everywhere. There are secrets within secrets, even – that's an actual message in the game: "You've found a secret within a secret!" There's breakable walls, illusory walls, switches, short memory puzzles, and all sorts of engaging, fun gameplay that helps punctuate the huge swarms of monsters that need to be put down (seriously, there's rooms with 200 monsters and monster spawn pits, just like Gauntlet). The overall experience is engaging both to killers, explorers, socializers, and achievers; it's a perfectly-balanced experience fun for all players.
My buddy and I started with a paladin, a tanky melee character, and a mage, an aoe-based medium-range character. The paladin has a shield that can block non-magical projectiles and has high armor, which reduces incoming damage. It later gains a charge, a group heal, a passive stun off melee attacks, and a whirlwind. The heal made an absolutely HUGE difference late in the game. My buddy started with the mage, who shoots a short-range fireball that has a small aoe burst at the end that ignites monsters for burning damage. It later gets an aoe meteor storm, an aoe ice spell that deals no damage but slows, an ice shield that slows attackers, and a flame breath medium-range aoe cone.
As you can see, dear reader, both classes play extremely differently. Since he had a tank and a healer, my buddy was able to largely ignore the CC aspects of his class and focus on the dps, and I was more able to focus on defense and movement skills so that I could move around and gather up mobs while staying a little ahead of them.
We played the game through in one shot, though of course we both died plenty (he more than me, for the record). In the end, though, we were able to save some money and, later in the game, use it to buy extra lives. We finished the game with more than 60 lives stored up "just in case."
As I've documented plenty, I don't often play through games more than once. However, this game got an exception; my buddy and I both immediately decided we wanted to try the other two classes. This time he played the second melee class, the warlock, and I played the ranged class, the ranger. We don't know a whole lot about the classes yet, but my buddy was, at first, very unhappy with the warlock. However, upon purchasing his first new ability, he was suddenly much happier. "This class makes sense now," he said, satisfied, and since then has been a little ball of destruction and self-healing.
So if you see Hammerwatch on sale (or even at full price, if you're not a cheapskate like I am), I'd strongly recommend you snap it up, especially if you have friends with which to play it. I imagine that the more people that play, the more fun it is, and having one of each class could really make for an interesting experience.
Stubborn (paladin/ranger)


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Calabasas Law Firm Serving the Community for More Than 25 Years
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Our firm has handled personal injury, real estate and business litigation cases for our clients since 1985. We have successfully represented individuals and businesses who are trying to collect compensation for injuries and damages and those trying to protect their property interests. We also draft, review and enforce contracts for business clients. Our firm handles real estate disputes consisting of quiet title issues, real estate broker issues, fraud, easement issues, boundary issues and landlord tenant issues.
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Contact Gary C. Eisenberg with questions or concerns about your legal case. Call 818-591-8058 or contact us online to schedule your free consultation today. If you are unable to come to our office, we are happy to come to you.
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Microsoft Trust Center
The Microsoft Trust Center offers detailed security, privacy, and compliance information for all Microsoft cloud services.
The General Data Protection Regulation (GDPR)
The European Union will start to enforce the GDPR in May 2018. Microsoft Cloud can help you stay focused on your core business while efficiently becoming compliant with the GDPR.
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Microsoft cloud products and services
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Microsoft Azure | A cloud computing platform that helps secure your data, protect data privacy, and support compliance with global standards |
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Microsoft Commercial Support | Expert consulting and technical support for enterprises that is dedicated to stringent security standards and safeguards for customer data |
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Microsoft Azure IP Advantage program is a comprehensive protection program offering Azure customers leading-edge protection against intellectual property (IP) lawsuits and risks in the cloud. In partnership with our customers, we are working hard to help create an ecosystem where developers, entrepreneurs, enterprises, and customers can innovate with confidence.
The General Data Protection Regulation (GDPR) is a European privacy law that is due to take effect in May 2018. The GDPR is a complex regulation that may require vast changes in how you gather and manage data, and require potentially significant investments by Microsoft and its customers. It's a good thing that Microsoft has a long history of helping customers comply with complex regulations. When it comes to preparing for the GDPR, we are here to support you.
Satya Nadella and Brad Smith announce A Cloud for Global Good a book they are promoting on tour in Europe that articulates Microsoft's policy vision for a trusted, responsible, and inclusive cloud.
AIG offers business interruption coverage for the Microsoft Cloud Insurance giant AIG is now offering enhanced interruption insurance to identified Microsoft Azure, Office 365 and Dynamics 365 customers when quoting a new or renewal CyberEdge policy.
Upcoming events
February 13-17, 2017 | San Francisco, US
IAPP Europe Data Protection Intensive 2017
March 13-14, 2017 | London, UK
American Bankers Assoc. Risk Management Conference
March 26-28, 2017 | Indianapolis, US


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>Importance Of The Upcoming Provincial Elections
>The December 2008 issue of the Arab Reform Bulletin had an article by Michael Knights on the importance of the upcoming Iraqi provincial elections. Knights is a Middle East specialist from England that works for the Washington Institute for Near East Policy. Knights' main argument was that… Read more
>Iraq Cuts Budget
>Iraq's High Economic Committee met on December 16 and cut Iraq's 2009 budget in the face of sinking oil prices. The committee consists of the ministers of Finance, Oil, Planning, Electricity, Industry, and Trade, along with advisors to Maliki, and experts from the ministries. The new budget is… Read more
>Sadr's Predicament
>Sadr's call for weekly protests against the Status of Forces Agreement failed in both rallying more support and in blocking the deal from passing
Recently the U.S. and Iraq signed a Status of Forces Agreement (SOFA), which sets the future relations between the two countries. The followers of… Read more
>Drought Leads To Food And Grain Imports
>As reported before, Iraq is facing one of the worst droughts in decades. Rainfall in 2007 was down 40% according to Baghdad. Central and northern Iraq have been hit the hardest in places like Diyala, Ninewa, Dohuk, and Irbil. The Ministry of Agriculture noted that this was… Read more
>Kenneth Pollack: Too Soon To Wave Victory Flag
>Kenneth Pollack is an Iraq analyst and senior fellow at the Saban Center for Middle East Policy at the Brookings Institution. At the beginning of December 2008 he was interviewed by Bernard Gwertzman from the Council on Foreign Relations. Pollack voiced his concerns over the future of Iraq, and… Read more


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Twenty-two-year-old British R&B/house singer Katy B made her much-anticipated debut last year with On A Mission. The critically acclaimed release nearly topped the charts overseas and peaked at number two. But she hasn't just caught the attention of critics and listeners.
Hit-maker Mark Ronson is now also a huge fan and a collaborator, as he recorded a 2012 Olympics jame with Katy called "Anywhere in the World." Oh, and he also sang her praises in Rolling Stone with the following statement:
"I think Katy B encapsulates young London in a way I never could. She reps London harder than anyone song-wise since Lily Allen."
Could this lead to Katy gaining more of a presence here in the States? We'll see. [NME]
The-Dream - The-Dream Sold Out S.O.B.'s As Terius Nash Last Night | Turntable.fm Goes Legit, Signs Licensing Deal With All Four Major Labels |


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Hi everyone :wavey:
How are you all feeling? lol....Anyway i am the first to post here
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Published on 08.09.08 in Vol 10, No 4 (2008): Oct-Dec
Original Paper
The ALFA (Activity Log Files Aggregation) Toolkit: A Method for Precise Observation of the Consultation
Background: There is a lack of tools to evaluate and compare Electronic patient record (EPR) systems to inform a rational choice or development agenda.
Objective: To develop a tool kit to measure the impact of different EPR system features on the consultation.
Methods: We first developed a specification to overcome the limitations of existing methods. We divided this into work packages: (1) developing a method to display multichannel video of the consultation; (2) code and measure activities, including computer use and verbal interactions; (3) automate the capture of nonverbal interactions; (4) aggregate multiple observations into a single navigable output; and (5) produce an output interpretable by software developers. We piloted this method by filming live consultations (n = 22) by 4 general practitioners (GPs) using different EPR systems. We compared the time taken and variations during coded data entry, prescribing, and blood pressure (BP) recording. We used nonparametric tests to make statistical comparisons. We contrasted methods of BP recording using Unified Modeling Language (UML) sequence diagrams.
Results: We found that 4 channels of video were optimal. We identified an existing application for manual coding of video output. We developed in-house tools for capturing use of keyboard and mouse and to time stamp speech. The transcript is then typed within this time stamp. Although we managed to capture body language using pattern recognition software, we were unable to use this data quantitatively. We loaded these observational outputs into our aggregation tool, which allows simultaneous navigation and viewing of multiple files. This also creates a single exportable file in XML format, which we used to develop UML sequence diagrams. In our pilot, the GP using the EMIS LV (Egton Medical Information Systems Limited, Leeds, UK) system took the longest time to code data (mean 11.5 s, 95% CI 8.7-14.2). Nonparametric comparison of EMIS LV with the other systems showed a significant difference, with EMIS PCS (Egton Medical Information Systems Limited, Leeds, UK) (P = .007), iSoft Synergy (iSOFT, Banbury, UK) (P = .014), and INPS Vision (INPS, London, UK) (P = .006) facilitating faster coding. In contrast, prescribing was fastest with EMIS LV (mean 23.7 s, 95% CI 20.5-26.8), but nonparametric comparison showed no statistically significant difference. UML sequence diagrams showed that the simplest BP recording interface was not the easiest to use, as users spent longer navigating or looking up previous blood pressures separately. Complex interfaces with free-text boxes left clinicians unsure of what to add.
Conclusions: The ALFA method allows the precise observation of the clinical consultation. It enables rigorous comparison of core elements of EPR systems. Pilot data suggests its capacity to demonstrate differences between systems. Its outputs could provide the evidence base for making more objective choices between systems.
J Med Internet Res 2008;10(4):e27
- Video recordings;
- process assessment;
- observation;
- attitude to computer;
- professional-patient relations;
- general practice;
- family practice;
- decision modeling;
- process assessment;
- medical informatics;
- computers;
- medical records systems, computerized;
- electronic patient record (EPR);
- electronic medical record (EMR);
- evaluation methodologies;
- usability
Electronic Patient Record (EPR) Systems Vary, and These Differences Provide Opportunities to Make Comparisons
Information and communications technology is ever more widely used in health care [
, ]; however, most EPR systems have grown organically, rather than being based on development specifications. Most countries have started with multiple small vendors developing EPR systems to meet the needs of the GP customers. Subsequently, commercial and regulatory pressures have reduced that number over time [ ]; however, even within the same health system, the interfaces and functionalities clinicians use vary [ ], as is the way they integrate the computer into the consultation [ ]. Health systems are moving toward introducing new enterprise-wide information systems, which provide the opportunity for improved efficiency and patient safety through data sharing across the health system, so-called systemic interoperability [ ]. The implementation of these new systems provides an opportunity to improve the interface and functionality, or, at the very least, have a rational reason for adopting the best design features of the existing systems.Using Video to Record the Impact of the EPR on the Clinical Consultation
For nearly a decade, we have been developing a video-based method to measure the influence of technology on the clinical consultation. We started with a single channel video, but found that, without simultaneously displaying the clinical system screen and closely questioning the clinician about their objectives behind interactions, it was impossible to interpret the video [
]. Trying to measure the precise length of interactions was also challenging.We recognized that analogue video (which did not have an accurate time stamp), and using a stopwatch to time events in the consultation, had major limitations. Our next development was to record 3 channels of video: (1) wide-angle view of the consultation, (2) view of clinician's head and upper body, and (3) screen capture. We used professional video recording tools to do this, as we needed an accurate time stamp to synchronize the videos. Although we produced useful output, the expense and the setup meant that this was not going to be a readily deployable technique [
].Therefore, we set out to develop a recording method that would enable precise and objective measurement of consultation activities. The system would have to meet the following objectives: (1) can be readily set up in real consulting rooms or clinics in less than an hour; (2) be reliable and could be readily set up by others in a range of settings; (3) provide objective time stamps of activities within the consultation, allowing the synchronization and subsequent simultaneous viewing of multiple measures; and (4) produce an output that could be used by computer software engineers to develop better systems.
Lack of Readily Available Applications to Compare EPR Applications
We initially reviewed existing applications that we could use to meet these specifications but found none. We looked at applications widely used for (1) qualitative research, (2) transcription and analysis of audio or video recordings, (3) usability testing, and (4) screen casting for demonstrations or training materials. Their shortcomings, compared with our requirements, are shown in
.There are well established applications used in qualitative research, such as ATLAS.ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) and QSR NVIVO (QSR International Pty Ltd, Melbourne, Australia) which allow detailed analysis and coding of text and multimedia data. They are not designed, however, to incorporate the precise monitoring of computer use that we require or to produce an output that can be exported into a package to develop UML diagrams. Transana (Wisconsin Center for Education Research, University of Wisconsin-Madison, Madison, WI, USA) provides facilities to perform a greater level of analysis by incorporating transcriptions; however its main analysis approach (which is based on the use of keyword, annotations, or their groupings) is not suitable to classify and measure doctor-computer interactions, which often include series of small durations or overlaps with patient interactions.
Widely used usability tools, such as Morae (TechSmith Corporation, Okemos, MI, USA), record observational data about computer use from multiple aspects. Due to the merged outputs they produce, they cannot be flexibly adopted according to research needs and are less helpful to obtain separate quantifiable measures for different combinations of interactions. Camtasia (TechSmith Corporation, Okemos, MI, USA), Adobe Captivate (Adobe Systems Incorporated, San Jose, CA, USA), and BB Flash Back (Blueberry Consultants Ltd, Birmingham, UK) are examples of screen-casting applications. While providing greater details about computer use, they are not optimized to classify interactions in a meaningful way. Focus of their outputs is too narrow to identify the effect of computer use on the overall consultation.
Rationale for This Development
In the absence of any suitable off-the-shelf application, we commenced our own development process to produce a set of applications that would enable researchers to capture the complexity of the computer-mediated consultation.
Developing a Specification
We developed a specification for our development program based on our objectives and on our experiential learning about the limitations of existing techniques. We recognized that our technique should be extendible, to combine a number of monitoring methods which, at that time, we would not be able to define. At the time, we identified: (1) an indeterminate number of video channels; (2) a transcript of the consultation, captured with a precise time stamp, possibly using voice recognition software; (3) output from pattern recognition software [
] and other change recognition technologies [ ]; (4) aggregate log files from observation techniques that we could not anticipate, as elements of our specification.Developing Separate Work Packages
We converted this work schedule into small work packages, which we developed separately on a largely opportunistic basis, as we had not received any consistent funding. The elements of this were:
1. To determine the optimal number of video channels and a low-cost way of recording. This should have time stamps to allow synchronization with other video channels and methods of data collection.
2. To find a reliable way to code the video footage, so we could navigate directly to particular activities in the consultation and measure their durations.
3. To automate the capture of body language and eye contact, using pattern recognition and gaze detection direction technologies.
4. To aggregate all these elements into a single navigable analysis output.
5. To introduce the ability to export data in a format that could readily be utilized by software engineers to improve systems.
Multichannel Video
We explored using 3, 4, and 5 channels of video, mixed onto a single screen, as well as a 4-channel version where clicking on a screen would enlarge that window to full screen (
). The additional channels experimented with since the 3-channel stage are the cameras focused on the patient's upper body and the clinician's facial view. We showed example consultations to experienced educationalists and academics accustomed to assessing video consultations, and we conducted semi-structured interviews to elicit their opinions [ ].We also needed to identify low-cost methods of filming the consultation, ideally using unobtrusive tools, which recorded sound and video with a digital time signal so that precise synchronization was possible [
].Capturing and Coding Consultation Activity
We needed to be able to code interactions in the consultation so that we could readily navigate to a particular activity (eg, prescribing) and also identify its duration. We selected a flexible software called "ObsWin" (Antam Ltd, London, UK) to do this [
] ( ). We conducted reliability tests of our manual coding method using multiple observers coding simulated blood pressure management follow-up consultations. We used intra-class correlation coefficient as an index of reliability [ ]. Subsequently, we compared the manual coding time for prescribing activities with frame-by-frame analysis of the video to further assess the reliability of our approach.Wherever possible, we set out to automate the time stamps for the start and end of activities in the consultation. We developed a User Action Recording (UAR) application to measure the precise time stamp of keyboard use (each key depression is recorded and time stamped), as well as all mouse clicks and coordinates. We also produced a Voice Activity Recorder (VAR), which detects and time stamps the start and end of speech (
).Automated Capture of Body Language
We automated the capture of body language to interpret nonverbal interactions and the direction of gaze to infer eye contact between clinician and patient. We experimented with Algol, an experimental pattern recognition software (PRS) not released as a commercial product (Main Highway Services, Winchester, UK), exploring correlation between movements detected with the software and manually detected activity [
] ( ). We explored the possibility of obtaining software that measured the direction of gaze.Aggregation and Navigation Application
We needed to aggregate the output from multiple data collection systems (
) into a single application that would be readily navigable. It needed to be able to flexibly load any number of input files and produce outputs that could be readily utilized in other applications. Unsuccessful effort to identify an appropriate proprietary application resulted in the in-house development of the Log Files Aggregation (LFA) application [ ].Output That Could Facilitate Better Clinical Computer System Development
We wanted to produce an output that would be readily interpretable by software engineers, so that our findings had a utility beyond the health care community. We specified our aggregation tool to export the combined log files in XML (extensible mark-up language) format, so they can be readily imported and interpreted by other applications. Process models of consultation tasks created using the UML, a standard modeling and specification notation widely used in software engineering, was chosen as our main mechanism for representing the use and impact of clinical system features within the consultation.
Pilot Recording of Consultations
We developed our method using simulated consultations between clinicians and actor patients within a simulated clinical environment. We initially developed the technique using standard consultations (eg, follow-up blood pressure checks [
]) and then a wider range of clinical problems.We needed to know whether our technique was practical to set up within a standard consulting room and could cope with background noise, variable lighting including window position, and room size. We next tested our technique using actor patients in GP surgery premises. We found that audio recording from 1 camera was satisfactory; modern cameras coped well with variations in lighting, and 2 people could set up the cameras and install the other data-capture methods in less than 20 minutes. We found that the cameras and other data-capture tools could capture more than an hour's data, but that it was prudent to remove screen capture and video data in a pause between consultations after 45 minutes.
We next developed a protocol that included our technical method, obtaining proper consent from patients and securing the data. We wanted to obtain pilot data from the 4 different most used brands of GP EPR systems, so we could make comparisons. These 4 brands are: (1) EMIS LV, the longest established and, at the time of the study, the most used system; (2) EMIS PCS, a more modern version from the same manufacturer; (3) INPS Vision; and (4) iSoft Synergy. EMIS LV is largely character user interface (CHUI) driven, whereas the other 3 have graphical user interfaces (GUI).
In our pilot analysis, we only included coding carried out using the picking list or other routine coding tools. We did not include data entry forms or templates that could facilitate more rapid data entry. The 4 GPs we filmed had used their current computer system for at least 3 years and had not routinely consulted with paper records for at least this period.
Statistical Methods
We planned to compare the time taken to carry out clinical coding, prescribing, and other routine tasks in the clinical consultation. We expected data from a small pilot to not have a normal distribution. This expectation is for 2 reasons: (1) we have a small sample and (2) we expected a skewed distribution because sometimes these tasks take a long time, but they always take a minimum time. We used box whisker plots to visually compare actions that were frequently recorded. We also used nonparametric tests (Mann-Whitney U test) to differentiate between EMIS LV (the then most used brand of GP EPR system) with the other systems. We next used the Krushkal-Wallis to explore any statistically significant difference in mean ranking. We used SPSS version 15 to carry out these analyses.
Ethical Considerations
We obtained ethical approval for the pilot recording of live consultations via the National Health Services Central Office for Research Ethics Committees (COREC). The protocol included making proper provision for the secure transport and storage of media and limiting access.
We used a 3-step process to obtain consent from patients to be video recorded. First, the video sessions were marked as such in participating practices, so that patients who booked into these sessions knew they were going to have their consultation video taped by 3 cameras as part of a research project. Second, they signed consent at the start of the consultation and were told that, if they did not want the video used after the consultation, they were free to say so. Finally, they and the clinician signed consent after the consultation stating that they remained willing for the consultation data to be used in research.
Technical and Pilot Investigation Results
The results initially report a summary of our final technical method and then the results of our pilot study. The full description of the technical process is contained in Appendix 1.
Number of Video Channels Optimal for Analysis
We found 4 video channels to be optimal for observing the consultation. Our 3-channel video method, which provides an overview of the consultation, the clinician's upper body, and screen capture, overcame most of the problems associated with single-channel observation [
]; however, a qualitative investigation suggested a fourth channel filming the head and upper torso of the patient was essential to capture the patient's body language [ ] (see Multimedia Appendix 3). In 2006, we found we could source the necessary hardware for 3-channel video around 1100 Euros [ ] (or 1500 Euros for 4 channels).Coding Consultation Activity
We used our in-house–developed UAR to capture mouse and key movement and VAR to time stamp the start and end of speech. We have piloted the use of UAR to compare the time taken to code a new problem and to issue a single acute prescription on 2 different GP computer systems [
].The use of VAR overcame the limitations of manual coding of the start and end of speech. Prior to using VAR, we found that training manual raters could reliably code simulated consultations [
], but when presented with a heterogeneous mixture of real consultations, some activities were less reliably coded. The VAR also enables us to identify who initiates and terminates silence. We have observed how the clinician sometimes makes purposeless use of the IT to initiate silence to control the consultation [ ].Automated Capture of Body Language
We have extensively tested pattern recognition software to see if we can automate the capture of body language and movements such as affirmative head nodding; however, limitations in this technology, and our ability to process it, have left us unable to correlate this with the output from our manual observations.
The Log File Aggregation (LFA) Tool for Synchronizing and Simultaneous Viewing of Log Files
The LFA tool combines any number of time-stamped log files of different formats. The data imported into LFA can be viewed as histograms or occurrence graphs (
). The power of this tool in analysis is that clicking on a rectangle representing a specific variable takes the user directly to the appropriate spot in the multichannel video (see Multimedia Appendix 4). This enables users to navigate into any spot in the consultation they wish to study and simultaneously view all the log files relating to that point in time. Reader programs could successfully interpret XML output from the ALFA tool.Output That Can Be Used by Software Developers
UML sequence diagrams demonstrated the clinicians' use of EPR system components within the consultation. They contrasted the variations of computer use and how this might be related to interface features. Software developers could examine these process models to evaluate the use and performance of design characteristics within a consultation. We have used the UML outputs to contrast the definition of the presenting problem, prescribing [
], past encounter reviewing, and BP data entry stages ( ) [ ]. Examples for design features that we could identify as having an impact on the consultation are: (1) navigation method (use of icons, function, or arrow keys), (2) structure of the main interface (single, sub, or tab-separated windows, (3) display of alerts or prompts, (4) mechanism for searching coded data, (5) retrieving of historical data, etc. The output from LFA automatically creates the framework of a UML sequence diagram. It takes approximately an hour to manually annotate the remaining sequences in a 10-minute consultation.Pilot Data
There is considerable heterogeneity of computer use between consultations. We collected initial data from 22 consultations from 4 practices. Each computer system was only used by 1 GP. The GPs generally coded between 1 and 3 items per consultation, though 12 items were coded in one iSoft consultation, and the GP using EMIS LV appeared to code more. The summary of the coding carried out in each consultation is shown in
. Only 2 of the 22 patients seen in this pilot asked to have the cameras switched off. No patients or clinicians withdrew consent for video material to be used post consultation.We observed differences in time taken to code data, prescribe, and repeat prescribe into the computer systems, though we only had sufficient episodes of coding data and acute (new) prescribing to make any sort of statistical comparison. The descriptive findings are shown in
, and the coding and repeat prescribing data are illustrated using box-whisker plots ( and .) The clinician using EMIS LV (the CHUI interface) appears to take longer to code items than users of other systems. Their mean ranking (Kruskal-Wallis test) was in the following order: EMIS LV, slowest (highest median); then iSoft Synergy was second slowest to code data; the fastest two were INPS Vision and EMIS PCS, having similar medians. The difference in medians was statistically significant (P = .007). Nonparametric (Mann-Whitney U) tests showed that they were all statistically significantly faster than EMIS LV; for EMIS PCS and INPS P < .01 and for iSoft Synergy P < .05 ( ).Acute prescribing appears to be faster with EMIS LV; however, although the EMIS LV prescriber was consistently at the faster end of prescribing time, there is overlap with the other systems shown in the box-whisker plots. Not surprisingly, the difference in medians was not statistically significantly different from the other two systems for which we have acute prescribing data (P = .71 and P = .64).
Principal Findings
The ALFA toolkit allows greater precision of observation of the clinical consultation than other techniques. The current toolkit allows multiple video channels including screen capture, the consultation transcript, computer use, and speech to be precisely synchronized, timed, and navigated through. There is enough scope to add other input as required. Its output can be used to create models that software engineers could use to develop better EPR systems.
The multichannel filming appears to be acceptable to patients; however, the 4 practices involved were teaching and training practices where both medical students and trainee doctors regularly video tape themselves.
Our pilot data shows how the method allows small, but statistically significant, differences between clinical systems and users to be measured. Although these differences in time per coded item and prescription are relatively short, when multiplied up through a clinician's day, better interfaces might result in a considerable time saving.
The UML models of BP recording show how having the previous reading readily available positively influences the clinical process and provide insights into how the new computer interfaces might be developed in the future. This principal could be carried forward into the recording of other common clinical information, for example, recording a smoking habit or adverse reactions to medication.
We developed this tool to meet our aspirations to evaluate the impact of technology on the consultation. Its precise time stamps could be used to compare clinical computer systems or to contrast the time taken with paper systems versus computerization. Comparative analysis of computer use and clinician-patient interactions could determine the common tasks and be used to develop theoretical models for computer-mediated consultation. We hope that our UML sequence diagrams will enable the clinical system designers to evaluate existing systems and also develop and evaluate new features.
The ALFA toolkit can also be used to measure the performance of the clinician or the reaction of the patient. Colleagues who have seen this technique have suggested that remedial doctors assessed in simulated surgeries could be given multichannel videos of their performance as a tool for reflection; if we could automate measures of body language, then this might be used as a formative assessment of communication skills.
The full set of tools created by the team and their source codes are freely available under a GNU General Public License (GNU GPL). Instructions for download, set up, sample files, and links to other related resources are made available as Web resources [
].Limitations of the Method
Some of the parts of our development failed. We were unable to use the log file from the motion recognition software effectively. As yet, we have not been able to achieve a transcript from a voice-recognition system; these technologies still require training and are unable to recognize differing patients' voices. We have not been able to access suitable methods to measure direction of gaze; commonly available tool kits are intrusive.
We have run this development as a series of small-scale components, rather than as a comprehensive program.
Our pilot data only used one clinician per system. More data are needed to discover if these differences were clinician-related or system-related.
Comparison With the Literature
We are unaware of any similar technique that provides such precision of observation (see Multimedia Appendix 2).
compares the features of ALFA against popular existing techniques. Although the study of human computer interaction (HCI) is a well developed discipline, it focuses on the interaction between 1 or more individuals and 1 or more computer systems [ ]. In HCI, the user-computer interaction has primacy; we wanted instead to develop a toolkit to capture the complex social interaction of the consultation, within which the clinician-patient activity is pre-eminent.Evaluation methods in software engineering combine multiple techniques for observation [
, ]. The analyzable products of these are often a data file stream combining visual or audio representations of sequence of activities in sensory channels [ ]. We are not aware, however, of any application that enables such a range of log files to be aggregated, synchronized, and, where needed, exported into other applications. Some keyboard listening or spyware applications could identify the sequence of keyboard activities. Voice spectrum analyzer applications that can present visual data about sound levels also exist. Unlike UAR and VAR applications, these are not capable of timing the computer use or verbal interactions in an analyzable format.This method examines the impact of the computer on the consultation from a broad sociotechnical perspective, as advocated by Coiera [
], rather than from a purely technical perspective. Rigorous and broadly acceptable evaluation frameworks of IT in health care should be capable of identifying problems, suitable tools for evaluation, and methods for applying them sensibly [ ]. It potentially helps fill some of the gaps in the methods for evaluation of health care systems [ ].Call for Further Research
More research is needed on how to automate data collection regarding the impact of technology on the consultation. Improved voice-recognition techniques would save the time spent in transcribing. As well as filling in the gaps about how to use pattern-recognition software and visual gaze estimation software to capture body language, we need to consider how we might embed logs into active clinical systems so that, for example, the change in length in consultation associated with a new release of software can be automatically measured and potentially investigated.
We also need to explore with a larger sample what are true differences between EPR systems and what is clinician variation. Recording several clinicians using 1 system should enable us to do this.
We set out to develop tools that would provide objective time stamps of activities within the consultation, allowing their simultaneous viewing and analyzing interactions in detail. The ALFA toolkit allows multiple observations of the consultation to be aggregated, simultaneously navigated, and output into other applications. The output from the ALFA tool should provide the evidence, based on which improved technology and models for the consultation can be developed.
The authors wish to thank the Foundation Doctors and students on placements who have worked on these developments over the last 5 years. Elske Ammenwerth is Bernhard Pflug's academic supervisor. The authors also thank MainHighway for use of the Algol software and technical support.
Conflicts of Interest
None declared.
Authors' Contributions
Simon de Lusignan and Pushpa Kumarapeli contributed equally to this work. Simon de Lusignan has set out a strategy for the development of better tools to study the impact of IT on the consultation with Tom Chan. Simon de Lusignan wrote this paper with comments from the other authors. Pushpa Kumarapeli has developed the UAR and VAR applications and specification for UML modeling; he has also been involved in developing the specification and design of the ALFA application. Bernhard Pflug developed the ALFA application. Simon de Lusignan, Beryl Jones, and Tom Chan are Pushpa Kumarapeli's academic supervisory team for his PhD. Jeremy van Vlymen provided technical support and input throughout the project, supporting many critical technical developments. George K. Freeman is the chair of the SGUL Clinical Consultation Research Group and has contributed to these developments.
Multimedia Appendix 1
Technical design of ALFA toolkit
PDF file (Adobe Portable Document Format File), 881 KB
Multimedia Appendix 2
Comparison of ALFA toolkit features with existing tools
PDF file (Adobe Portable Document Format File), 614 KB
Multimedia Appendix 3
Sample multichannel video file
WMV file (Microsoft Windows Media Video File), 3.2 MB
Multimedia Appendix 4
Demonstration video of navigable occurrence graph created by LFA stage
WMV file (Microsoft Windows Media Video File), 6.8 MB
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ALFA: activity log file aggregation |
BP: blood pressure |
CHUI: character user interface |
COREC: Central Office for Research Ethics Committees |
EPR: electronic patient record |
GP: general practitioner |
GUI: graphical user interface |
GPL: general public license |
HCI: human computer interaction |
LFA: log files aggregation |
ODC: observational data capture |
PRS: pattern recognition software |
UAR: user action recording |
UML: unified modeling language |
VAR: voice activity recording |
XML: extensible markup language |
Edited by G Eysenbach; submitted 04.04.08; peer-reviewed by A Black, A Holt, E Borycki; comments to author 24.04.08; revised version received 09.06.08; accepted 23.07.08; published 08.09.08
© Simon de Lusignan, Pushpa Kumarapeli, Tom Chan, Bernhard Pflug, Jeremy van Vlymen, Beryl Jones, George K Freeman. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.09.2008. Except where otherwise noted, articles published in the Journal of Medical Internet Research are distributed under the terms of the Creative Commons Attribution License (http://www.creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided 1) the original work is properly cited, including full bibliographic details and the original article URL on www.jmir.org, and 2) this statement is included.


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Topic Contents
Quitting Smokeless Tobacco
Skip to the navigationTopic Overview
What is smokeless tobacco?
Smokeless tobacco comes in many forms, such as snuff, chewing tobacco, and snus .
- Snuff is finely ground tobacco sold in cans or pouches. Most of the time, snuff is used by putting a "pinch" or "dip" between the lower lip or cheek and the gum.
- Chewing tobacco is sold as loose leaves, plugs, or twists. It is chewed or placed between the cheek and the gum or teeth.
- Snus is tobacco in a small pouch that you put between your upper or lower gums and teeth. It appears to be safer than other forms of smokeless tobacco, but more study is needed to see if it is risk-free.
The nicotine in smokeless tobacco is absorbed through tissues in the mouth.
Why should you quit?
There are plenty of reasons to quit. Smokeless tobacco products are harmful. They are not risk-free alternatives to smoking. They're addictive. Although they are safer than cigarettes, they can cause serious health problems.
Using smokeless tobacco can lead to:
- White patches or red sores in your mouth, called leukoplakia. These can turn into mouth cancer (oral cancer) involving the lip, tongue, or cheek. In fact, you have a 50% greater risk of getting mouth cancer if you use smokeless tobacco, compared to people who don't use it.
- An increased risk for pancreatic cancer.
- Tooth loss and other dental problems.
- Gum disease. Your gums may pull away from your teeth and not grow back.
Quitting smokeless tobacco has benefits you can see. Your mouth sores will slowly start to go away. Your gums will begin to look healthier. Seeing these changes may motivate you to stay tobacco-free.
You probably have your own reasons to quit. Maybe you want to set a good example for your family. Or maybe you want to avoid other health problems. You might want to quit because you feel ashamed of your habit. Whatever the reason, make sure it is meaningful to you.
Why is it so hard to quit?
It's just as hard to quit smokeless tobacco as it is to quit smoking. Quitting tobacco is hard because your body craves the nicotine. Giving it up is more than just kicking a bad habit. Your body has to stop the cravings. That's why you may feel grouchy or restless or have a hard time concentrating for the first 2 to 3 weeks after you quit. For some people, these feelings can last several weeks. Nicotine gum, lozenges, patches, and other medicines can help reduce the cravings.
But it's not just the nicotine that makes it hard to quit. It's the habit of using smokeless tobacco. It's part of your daily routine. You enjoy it. You may use it to deal with stress. And when you quit, you have to give all that up (or at least find something to replace it).
Quitting chew or snuff isn't easy, but you can do it. Just thinking about quitting is the first step.
How can you quit smokeless tobacco?
Quitting smokeless tobacco is a lot like quitting smoking. Both cigarettes and smokeless tobacco products have nicotine and are addictive. And they are all tough to quit. The good news is that you don't have to do it alone.
Whether you're ready to quit today or just thinking about quitting, take a look at the topic Quitting Smoking. You can read stories from people who have quit smoking and identify your triggers and line up the support you need to quit for good.
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ByHealthwise Staff
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David Lebovitz's Chocolate Sorbet
Author Notes: Recipe from The Perfect Scoop by David Lebovitz (Ten Speed Press, 2007). —Kenzi Wilbur
Makes about 1 quart (1 liter)
- 2 1/4 cups (555 ml) water
- 1 cup (200 g) sugar
- 3/4 cup (75 g) unsweetened Dutch-process cocoa powder
- Pinch of salt
- 6 ounces (170 g) bittersweet or semisweet chocolate, finely chopped
- 1/2 teaspoon vanilla extract
- In a large saucepan, whisk together 1 1/2 cups (375 ml) of the water with the sugar, cocoa powder, and salt. Bring to a boil whisking frequently. Let it boil, continuing to whisk for 45 seconds.
- Remove from the heat and stir in the chocolate until it's melted, then stir in the vanilla extract and the remaining 3/4 cup (180 ml) water. Transfer the mixture to a blender and blend for 15 seconds. Chill the mixture thoroughly, then freeze it in your ice cream maker according to the manufacturer's instructions. If the mixture has become too thick to pour into your machine, whisk it vigorously to thin it out.
More Great Recipes:
Chocolate|Ice Cream & Frozen Desserts


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FORT BRANCH—Tell City had a shortage of hits in a Diamond League baseball doubleheader loss to Gibson Southern last Thursday. Gibson Southern won the first game 3-2 despite an RBI double by Tell City's Trent Rainey down the left-field line in the first inning. Rhett Baumeister pitched the first 3 2/3 innings for Tell City to take the loss. Gibson Southern took advantage of Tell City pitchers' control problems to win the second game 7-6.
TELL CITY—Bryce Lain and Jimmy Phillips combined for 11 RBIs as Coca-Cola beat Logos 20-5 Monday to raise its record to 8-0 in the Babe Ruth League. Coke clinched at least a tie for the regular-season title with the win. Lain went 4 for 5 with six RBIs in the four-inning game. Phillips went 2 for 2 with five RBIs. Reed Goffinet went 3 for 4 with two RBIs. Mike Landers also had three hits and Andy Froehlich added two. Goffinet also made a strong pitching effort for the win.
VIENNA, Austria—Tell City graduate Lauren Goffinet was one of the leading scorers for the USA team that competed in the Vienna Cup Pentecost women's basketball tourney June 11-13. The 5-foot-11 Goffinet started every game as the U.S. team went 3-2 in the 16-team tourney. The team then played an exhibition game in the Czech Republic against that country's university team June 14. The USA won that game by 23 points as Goffinet scored 20.
TELL CITY—Kevin Davis and Mike Wilson shot a 13-under-par 127 to win the Glen Ress Memorial Open golf scramble June 11-12.
By LARRY GOFFINET Sports Editor
TELL CITY—Tell City football coach Travis Atwell submitted his resignation Monday to take a teaching job with Apollo High School in Owensboro, Ky.
DERBY – Cedar Valley's annual bluegrass festival will feature six bands and a tribute to the legendary Bill Monroe. Scheduled July 7-9 at Cedar Valley, 12478 Indiana 70, near Derby, the festival will highlight the Karl Shiflett & Big Country show Friday evening. Tommy Brown and the County Line Grass is scheduled for Friday and Saturday. The festival will start Thursday evening with an open stage at 5 p.m. where participants are asked to bring their own instruments. A bean dinner will be served. Diners are asked to bring a covered dish.
INDIANAPOLIS – Julia A. Wickard, state executive director for USDA's Farm Service Agency in Indiana, announced that the 2011 reporting deadline for all prevented planted crops has been extended to coincide with the final crop reporting date. For all crops, the FSA County Committee may accept a CCC-576 for prevented planting as timely if filed by the final crop reporting date for the applicable crop. By filing a prevented planting claim by the final crop reporting date of July 15, producers will not incur late-filed fees.
TC Boosters schedule meeting TELL CITY – The Tell City Band Boosters will hold their organizational meeting at 7 p.m. June 27 at the William Tell Elementary School cafe. "Please note that this is a change of location from our previous notification," urged booster Kelli Braunecker. "This is a mandatory meeting for all Tell City Junior-Senior High School band members and their parents. Please bring completed health forms if you have not already turned them in."
By STUART CASSIDY, Spencer County Journal-Democrat
ROCKPORT – Repairs to the historic covered bridge at Huffman Mill may be conducted with or without grant funding. After discussions Tuesday with Spencer County commissioners and councilmen about how to proceed with the project facing cost overages, Spencer County Engineer Tara Lloyd is prepared to ask Perry County officials if they will be willing to contribute toward repairs if Spencer County declines a $240,000 grant.
By VINCE LUECKE, Editor
TELL CITY – A man who escaped from the Branchville Correctional Facility in 2009 was sentenced Monday to 17 years in prison. However, 33-year-old Bobby G. Cockerell won't serve the first day of the sentence until he finishes a federal pris-on sentence.


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Rohto Cool
Redness Relief
(6 Reviews)Clears and brightens
Size: 0.4 fl. oz. (13 mL)
- Relieves Redness
- Soothes for up to 8 hours
- Refreshes and Moisturizes Eyes
- Fast Acting
Active ingredients:
Naphazoline hydrochloride 0.012% … Redness reliever Polysorbate 80 0.2% … Lubricant
- relieves redness of the eye due to minor eye irritations
- temporarily relieves burning and irritation due to dryness of the eye
For external use only Ask a doctor before use if you have narrow angle glaucoma When using this product
- do not touch tip of container to any surface to avoid contamination
- replace cap after each use
- do not use if solution changes color or becomes cloudy
- overuse may cause more eye redness
- pupils may become enlarged temporarily
- remove contact lenses before using
Stop use and ask a doctor if
- you feel eye pain
- changes in vision occur
- redness or irritation of the eyes lasts
- condition worsens or lasts more than 72 hours
Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away.
- put 1 or 2 drops in the affected eye(s) up to 4 times daily
- tightly snap on cap to seal
Other information
- do not store above 25°C (77°F)
Inactive ingredients
alcohol (0.1%), benzalkonium chloride, boric acid, chlorobutanol, edetate disodium, menthol, purified water, sodium borate


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Santa Pictures Are Ready!
Santa Claus pictures are ready to be downloaded from our Flickr account. If you came to our Holiday Open House, and had a picture taken with Santa, then you should be able to find your photo here. We had tons of fun at our Holiday Open House, and Santa told Maggie that he was really impressed with how many good boys and girls he saw at Baldwin Boettcher during his visit. Remember to leave some treats for Santa and his reindeer on Christmas Eve! (I think this was probably the real Santa, FYI.) A special thanks to all the customers who made this Holiday Open House a pleasant one with their company and good cheer.


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Warnings that lack of parking space was a factor in the demise of Hamilton's CBD were being aired 14 years ago.
Under a heading "City parking tolls 'death' for CBD" the-then mayoral candidate Gordon Chesterman vowed to make more parking a major priority, if elected.
The Hamilton News article was dated August 6, 1998 and included a prediction that, if nothing was done, "at some point a developer will appear and build a supermall several kilometres from this city's heart".
It went on, " ... such a development, with ample car parking, would ensure huge flows of potential customers for its retailers at all times".
"There are now 3000 free car parks for shoppers at Tainui's The Base shopping centre. I don't know how we can compete with that," says Mr Chesterman.
Now deputy mayor, he says "nothing has changed".
With a decade of city council experience under his belt, Mr Chesterman still believes central city car parking should be free to assist a struggling business centre.
He recognises that car parking is a revenue driver and providing free parks would have a financial and staff loss implication.
"But we need more than free parking to bring our CBD back to life," he says.
Mr Chesterman says several factors are required for a vibrant city centre.
"Hamilton needs unique shops offering unique products - not just a selection of national and international brand stores anyone can find in any mall throughout New Zealand and Australia.
"Another ingredient would be more central city residents. To attract those we need suitable accommodation, well-appointed with garages."
But opinions differ on saving the city heart.
Recently Waikato University Professor of Environmental Planning Bob Evans said there are three things Hamilton should do to ensure survival of its city centre.
Speaking at the third of the University of Waikato's Winter Lectures he said all new development outside Hamilton's built-up area should be stopped, all new and planned road construction should be halted, and car use and parking should be constrained in favour of bus lanes, bike and walk-ways; "discriminating" in favour of inner city developments.
"If we lose the city centre, Hamilton is finished."


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Southwest Preparatory School District 1258 Austin Hwy San Antonio, TX 78209 Phone: 210-829-8017 Fax: 210-829-8514
Southwest Winners Foundation, Inc. Board
Chairman - Mr. Carl Engleman Secretary - Mrs. Sherri Jermier Trustee/Treasurer - Mr. Jim Alley Executive Director - Gary Short, Ph. D. President - Mr. Jim Neal Vice Chairman - Kathryn Kunkel
Southwest Preparatory School Board
Southwest Preparatory School Seeks Parent and Community Engagement in Turnaround Planning Process
Southwest Preparatory School has limited spaces at all campuses for grades K-12. Making the switch is easy. Call 210-829-8017 to register today!!
Southwest Preparatory is an an open enrollment, tuition free, SACS accredited, public charter school offering college preparatory and career readiness to students living in Bexar County. Come by for a tour and see what SW Prep has to offer you and your child. We can accept your child any time of the year. It's never too late to make the switch. For more information or to set up a time to tour please contact the school at 210-829-8017
Our Campuses:
The school district has five campuses supporting the North, West, and East regions of San Antonio. *Elementary, Middle, and High schools grade levels from Pre-K4 through 12th Grade are offered.
Some pictures from our Seguin Campus 1st Week of School!!!!
Our Newest Campus!!! Seguin Elementary
· School dedicated to academic success and the enrichment of the Arts.
· Students learning through Project Based learning models to be presented during the year to parents and community.
· Strong Commitment to Community – Each grade level will select a community project that will positively impact their community.
· Students will be encouraged to creatively problem solve through their projects, their commitment to learning and their use of the arts.
· Leadership attributes will be strongly encouraged and taught and encouraged as part of their overall development.
· Morning Assemblies will encourage Character Development, Music, Performance, Leadership, and Patriotism.
· High standards for behavior and academics will be stressed throughout the curriculum.
Southwest Preparatory School Campus Earns Accreditation from Southern Association of Colleges and Schools Council on Accreditation and School Improvement (SACS CASI)/AdvancED™...CLICK TO READ MORE


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Obituary: Ernest Gansereit, 83
Ernest Gansereit
CLIFTON – Ernest J. Gansereit, 83, of this city, died on Sunday, June 29, 2014.
Born in Passaic, Mr. Gansereit was a lifelong resident of Clifton. He was a U.S. Army veteran, serving for 23 years before retiring as a lieutenant colonel. Later, he was a self-employed public accountant in Totowa before retiring in 2011. He was a parishioner of St. John Kanty R.C. Church, Clifton, and a member of the Knights of Columbus 3969 Regina Mundi Council. He served on the Financial Advisory Board of the Salvation Army in Paterson and volunteered at Clifton City Hall. And, he was a member of the American Bridge Association and the American Contract Bridge League.
Mr. Gansereit is survived by his sister, Rosemary Thaler, of Clifton; his brother, Raymond, of Georgia; and many nieces, nephews, great-nieces, and great-nephews.


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United Arab Emirates St. Regis Hotel Map
The St. Regis Abu Dhabi
PhotosThe St. Regis Abu Dhabi
Nation Tower, CornicheP.O. Box 60476Abu Dhabi, United Arab Emirates (971)(2) 694 4444SPG Category 5
- Road
- Aerial
- Bird's Eye
The information detailed on these pages is subject to change. No representation is made and no warranty given as to the validity of the content, including road conditions, route usability and expeditiousness. The user assumes all risk of use. Microsoft, Starwood Hotels and Resorts, Inc., and their suppliers assume no responsibility for any loss or delay resulting from such use.