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CAD Productivity
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When Word2CAD creates the document the drawing, it stores extended data on the insert. Since the date and time of creation (along with the document file name) is stored, it can easily determine when the representation needs updating. So when you reopen your drawing, Word2CAD quickly evaluates the document instances in the drawing and automatically updates only those that have changed!
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Control the application with your choice of command line entry, pulldown menu, traditional toolbars or ribbon interface (AutoCAD 2010 and higher).
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2016-2017 Connectivity Submissions
As the Regional Management Office for Indigenous and Northern Affairs Canada (INAC) Keewaytinook Okimakanak - KNet Services (KO-KNet) we invite you to submit your school's connectivity costs for the year so we can reimburse your school administration. This service is for First Nation Schools that are NOT currently on our Nationwide Broadband Network. Your school is eligible if your internet provider is a different I.S.P company other than KNet. Upon receiving your school's invoices, we will evaluate what we can reimburse. Please submit your invoice that includes the cost of your internet for the months of April 2016 through to March 2017 & a copy of your bills to: email@example.com or fax to 1 807 737 1720 attn: Angie Morris. If you have any questions, please call Angie at toll free 1-877-737-5638


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Luigi has left Mario, and gone out to prove he himself. With the help of Dimentio, Geminiman and Void; will his dreams of recognition come to fruition, or is he doomed to being second banana? Either way, we can be sure that it will be very silly. Currently on hiatus. Epilogue should be up eventually.
The Other L's Empire- Pt. 4
November 25th, 2009, 7:00 pm
Author's Comments:
Reply Gamermaster, November 24th, 2009, 10:14 pm
Shadows revealed Yes that shadowy figure from a couple of pages back was Link. He gave SubrosianDimitri the spiked cookie.
Reply Advertisement, May 25th, 2019, 12:50 pm
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Are you looking for the best Medigap insurance in Lelia Lake, TX? We can help you find affordable and quality Medicare Supplemental Insurance in Texas. You can either call 888-602-5343 or enter your Zip Code above and fill out the form. We will help you find the best Lelia Lake, TX Medigap insurance options.Buying Medigap, or Medicare Supplemental Insurance, is the key for many people over age 65 to be able to afford to use their Medicare coverage. Medigap is a separate policy that is sold by private insurance carriers that adhere to Texas laws.
For the most part, Medigap covers co-insurance, co-payments, and even includes medical coverage if faced with an emergency when traveling outside of the United States. Older Medigap plans also covered deductibles, though those were mostly phased out in 2010. Medigap covers costs seen in Medicare Part A and Part B Plans. Medicare Advantage plans are also available though not in conjunction with Medigap benefits. Likewise, be aware that it is illegal to sell a Medigap holder Medicare Savings plans.
The reason people in Lelia Lake, TX buy Medigap is to cover where an individual's money will fall short. Buying a Medigap policy will require monthly premiums in addition to Part A and Part B Plan premiums. Though, the fact is that there are still ways to save on Medigap coverage.
For one, apply for policies while in the first 6 months of your Medicare Part and Part B plan policies. During this period, guarantee issuance is extended to anyone over the age of 65 within the first six months. It means that there are no denials or increases in premiums because of pre-existing conditions, based upon past medical history, or current medical problems that spring up.
If an individual waits they may pay higher rates and fees for extending past the deadline. It is better to shop around and compare quotes and do so during the open enrollment period. The majority of Medicare Supplemental insurance plans are standard and demarcated by letters A through N. Each plan covers benefits but have added benefits. For instance, part D covers prescriptions.
That means that while cheap Medicare Supplemental Insurance plans A through G charge higher premiums, costs that are out-of-pocket are not as expensive as for Plan K through Plan N. Those carry lower premiums and like benefits but at the trade-off of costing more at the time of service.
Employer Retiree Benefits
The next way to save money beyond following the open enrollment dates is to find out if a former or present employer has a Medigap policy of its own. In general, these will be less costly than an individual policy that you buy on your own. Though, the warning and word to the wise is to carefully consider if the company is financially stable or not.
Determining Eligibility
Whenever purchasing many types of Medicare plans, you actually cancel the old policy before instating the new policy. That is not the case where Medicare A and B are concerned. The reason, recall, is that cheap Medicare Supplemental insurance plan is meant to fill the gaps of conventional original Medicare policies.
It requires still being covered under Medicare. The other benefit is to know when shopping around that the policies are the same whether you buy with Humana or Aetna or BlueCross BlueShield, for instance.
What is worth looking at is the reputation of the health insurance company, the quality of the coverage they offer, and the credit worthiness rating of the insurance company. The reason to look at the credit worthiness of the company offering up the insurance is to ensure that they are likely to have the money to pay out benefits and claims as agreed in the policy paperwork.
In addition to looking for insurance carriers that have an A or greater rating in the creditworthiness area, it is important to find out about the customer service and the customer satisfaction ratings of the companies you are comparing as well. It pays to have the company that pays claims within a timely manner, without a heroic effort on your part or the part of your doctors.
Otherwise, you will spend time having to contact the Texas insurance department or commissioner to file official complaints to get the claims paid within the acceptable two-month window. All of the Plan C Medigap coverage will be the same as that same plan from another insurer. Look at service quality and price. Look at comparing insurance company offerings to locate a cheap medicare supplement insurance plan in Lelia Lake, TX .
You will also need to look for separate prescription drug coverage, which is designated by Medicare Part D. This will add in an additional premium in addition to other costs. The key is that the majority of people who qualify for cheap medicare supplemental insurance are 65 and older, and look for their Medigap during open enrollment.
In addition , the other requirements stipulate Medicare Part B and Part A participants are eligible. Once you choose a cheap Medigap insurance it is as if it is written in stone and can not be altered.
To be eligible for cheap Medicare Supplemental insurance plans in Lelia Lake, TX apply for coverage offered by insurers within your state. All policies are available in each state, though most states will have one single policy available for Medicaid plan holders.
Everyone at age 65 and older and who is also enrolled in the Medicare Parts A and B is eligible to purchase a supplemental plan. It is advisable to decide on a plan during the 6 months of open enrollment to pay the most favorable policy premiums. When comparing costs during the open enrollment, it means pre-existing conditions are not factored into the pricing for the premiums. It is the hands-down best way to save money on a Medigap Supplemental plan in Lelia Lake, TX .
Always find out the Texas laws prior to shopping. They can vary a bit, though it is important to recall that the policies are uniform across states. Use online free quotes searches to find all of the options available to you. Narrow it down based upon credit worthiness of each of the insurers, along with their quality of care and their speed of paying out claims.
More Texas Cities We Cover:
More Tips About Lelia Lake, TX Medicare Supplemental Insurance
Every working day, health care expenses go up and up. No matter what variety of health care protection you seek or what company you decide on, it looks the price of insurance policy coverage raises every day as effectively. Even if your employer is footing component of the invoice, it seems as if your payroll deductions for well being treatment will eat up your paycheck. Here are some ideas to aid you lessen the value of health care insurance policies.
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Recently, I've undertaken the task of converting a rather large Backbone.js app to using Require.js. Since the process can get tricky at times, here's a quick recap of what I had to do to get it done.
0. Why use Require.js in the first place?
Most projects start small. A couple of script tags that include jQuery (or Zepto, or whatever else you are using), a couple of plug-ins, and your own code. As the project matures, more code is added, and to keep things sane, we divide them into gradually more modular components. We usually end up with a lot of files, each one containing a specific portion of functionality. While this seems easy enough at first, it makes reusing them really hard since they usually depend of each other in all sorts of weird ways.
Require.js helps us define exactly what our component depends on, almost like "regular" imports in other development environments. It means we can lazily load dependencies as needed, as well as reuse components easily, as dependencies are pulled automatically. In addition, with r.js we can easily combine and minify our app to reduce the amount of script tags along with the superfluous HTTP requests they incur.
1. Adding Require.js to your project
OK so the first part is easy enough. Download the require.js distribution, or if using Bower, just issue the following command:
$ bower install requirejs
(As a side-note, Bower and require.js work really well together).
Once we have the library, we can add it to our project by adding a single <script> tag:
<script data-main="app/js/main" src="static/js/vendor/require.js"></script>
.js from the file name, since we now treat it as a module. This is a convention that require.js adheres to.
Also, this would be a good time to remove all other <script> tags you have lying around there. We won't be needing them anymore.
2. Setting up the required configuration
So we've loaded require.js, and pointed it at a currently empty file which should somehow load our app. If you haven't yet, create that main.js file. Inside our main module we'll start by describing our project's layout to require.js:
requirejs.config({ 'baseUrl': '/static', 'paths': { 'app': 'app/js', // define vendor paths 'jquery': 'js/vendor/jquery-2.0.0.min', 'underscore': 'js/vendor/underscore-min-1.5.1', 'backbone': 'js/vendor/backbone-min-1.0.0', 'handlebars': 'js/vendor/handlebars', } });
This assumes the following structure:
static/ app/ js/ base.js views.js models.js collections.js app.js main.js js/ vendor/ jquery-2.0.0.min.js underscore-min-1.5.1.js backbone-min-1.0.0.js handlebars.js
So what have we here? We told require.js that
/static is the root URL for our application. This means that all paths are from now on relative to that location.
Then, we go on to explain where our current dependencies are located.
paths object is actually a mapping between module name and a real location in our project from which to load that module.
You'll notice that we don't specify the
.js extension here as well.
3. Handling non AMD compliant modules and plug-ins
In a perfect world, our setup would be essentially over. However, require.js uses AMD style loading, which means that modules need to declare what they depend on, and more importantly, what they export.
Backbone.js and Underscore, however, are currently not AMD compliant. for that purpose, require.js introduces the concept of "shims", which let require.js load non AMD compliant libraries. Let's add them to our config object:
requirejs.config({ 'baseUrl': '/static', 'paths': { 'app': 'app/js', // define vendor paths 'jquery': 'js/vendor/jquery-2.0.0.min', 'underscore': 'js/vendor/underscore-min-1.5.1', 'backbone': 'js/vendor/backbone-min-1.0.0', 'bootstrap': 'js/vendor/bootstrap.min', 'handlebars': 'js/vendor/handlebars', }, // Shim declaration 'shim': { 'underscore': { 'exports': '_' }, 'backbone': { 'deps': ['jquery', 'underscore'], 'exports': 'Backbone' }, 'handlebars': { 'exports': 'Handlebars' } } });
Notice how jQuery does not need such a shim. This is because jQuery >=1.7 is AMD compliant, so it should just work.
So now require.js knows what our app basically looks like. Now it's time to actually load our application and convert our own code to be AMD compliant.
4. Converting our code to be AMD compliant
We'll assume for the purpose of this post that our app is laid out as such:
base.js - containing basic utilies and settings,
views.js - containing our Backbone Views,
models.js - containing Backbone Models, and
app.js - containing our main Application.
The process is pretty much the same for all files. We start by examining the file and seeing what dependencies the file uses. for example, the
views.js file will use jQuery for DOM manipulation, Handlebars for rendering templates, and Backbone for defining the View subclasses.
What we'll need to do is wrap our code with a
define() function which require.js provides. This function takes 2 arguments: an array of strings describing the dependencies and a function that should return whatever we want to export from this module. This function gets whatever we decided to import as arguments.
As always, this is better explained with an example. Our converted
views.js file should now look something like this:
define(['jquery', 'handlebars', 'backbone'], function($, Handlebars, Backbone) { var SomeView = Backbone.view.extend({ render: function() { var template = Handlebars.compile( $('#template-someview').html() ); var rendered = template(this.getContext()); ... } // more view code ... }); ... // export stuff: return { 'SomeView': SomeView }; });
Loading something such as
jquery seems a bit abstract at first. Require.js knows how to find our jQuery module using the
paths declaration we made before in
main.js. This means that the module loading configuration is centralized, and decoupled from our code. Our views module doesn't need to know where jQuery is located in our project, meaning that we can easily port this module to another project if we'd like, without changing or adjusting our imports. Awesome.
By the way - You don't have to return all View subclasses. as with any module, you should only export things that could be used by other modules. It's ok to keep some views or bits of functionality for internal "private" use by the module itself. It's up to you.
Repeat this process as necessary for other files in your project. This might also be a good time to break things down into smaller files with smaller scopes of functionality. Don't worry about having to load multiple scripts, we'll use
r.js later to concatenate and minify all our resources into a single file later.
5. Launching our application.
Time to fire up our newly converted app. For that, we'll revisit our
main.js file, and add the following beneath our
requirejs.config() declaration:
require(['app/app'], function(Application) { var app = new Application(); app.start(); // or whatever startup logic your app uses. });
This will load your main application and fire it up, the same way a "main" module would probably do in several other languages. Your app is now AMD compliant and uses require.js to manage and declare modules and dependencies. Way to go!
6. Deploying to production
A great tool that require.js comes with is r.js. It lets you automatically pull all your dependencies and modules into a single file and minify it. It also lets you do other neat stuff such as concatenating CSS files.
The easiest way to build our app for production, is to create a build.js file containing our build configuration. It should look something like this:
({ "baseUrl": "./static", "name": "app/main", "mainConfigFile": "./static/app/js/main.js", "out": "./static/js/app.js" })
I generally put this file one level above my static folder, since I don't want it to be deployed as a static asset.
The most important setting here to note is
mainConfigFile - this should be the path to our main module from before, so we keep our configuration DRY.
To actually build the project we need to first install r.js. The easiest way to do that (provided you have node.js and npm installed) is to use npm:
$ npm install -g requirejs
Once installed, we can call r.js pointing it to our build.js file:
$ r.js -o build.js
Depending on the size of your project, it could take a few seconds to resolve all dependencies and minify them. Once done, we can change our <script> tag to include the built version:
<script src="/static/js/vendor/require.js"></script> <script src="/static/js/app.js"></script>
Notice how we removed the
data-main attribute. We added the compiled version of our code instead, containing everything we need inside it.
If you want to further optimize this, you can use something like Almond.js which lets you only use a single <script> tag containing a minimal AMD loader, and your built application in a single file.
So thats basically it. I'm guessing different setups will require slight adjustments for this to work. If you have tips of your own for working with AMD and Require.js feel free to comment or to hit me up on Twitter at @ozkatz100!


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If everything has a price, how much would you charge me for the privilege of watching you inhale – deeply and fully – the detritus at the bottom of my Webber grill? Just so we're clear, it's mostly ash, with little bits of burned squash (danged slices always slip through the gaps in the grill…), and likely some mouse or rat poo, since it hasn't been used in a while. Also, it definitely smells like lighter fluid, because I always use too much. All of which is a bit of a digression, since the issue on the table is: how much?
Maybe some of you would do it for a number in the low five figures, while others would hold out for more, but it's actually not worth that much to me. Don't get me wrong: I'd probably laugh pretty hard at your lunacy if you did it, but I wouldn't pay much for the spectacle since last week we all got to watch every person in Beijing basically do this for free. Except that it wasn't nearly as funny, because they didn't do it by choice.
Think I'm exaggerating? Look at these pictures (to save you time, the stories are all basically the same). When air pollutants reach a concentration of 25 micrograms per cubic meter, the World Health Organization considers it dangerous. When pollutants reach a concentration of 300, the U.S. government tells children, the elderly, and those with respiratory problems not to go outside. When concentration levels reach 500, most measuring devices can no longer record how bad pollution is, because a concentration of 500 micrograms per cubic meter is unthinkable.
In Beijing last week, they reached a concentration of 886 micrograms of particle pollution per cubic meter.
Let's put that in some perspective. Did you look at the pictures to which I linked? If not, permit me to describe them. They're pictures of gray brown. There's no discernible sky and no discernible ground in some of them, leaving us to trust the editors that they're even right-side-up. In one there's a light that vaguely resembles the moon; this is of course the sun, which would seem to indicate that this apocalyptic cloud of brown is actually a 'clear' and sunny day. The pictures, to be blunt, show air so unremittingly filthy that my initial sensory response is actually tactile: I can't imagine what it's like to breathe that, but I'm almost certain one could feel it by swiping one's hand through the air, and my fingertips tingle as I wonder how that must feel. On the hands, that is. I can guess how it feels in one's lungs – probably a lot like it would feel to snort my Webber.
If that doesn't repulse you, do the math. We think of air as lacking mass, but in Beijing last week, the air weighed nearly a milligram per cubic meter. A man of average size breathes about 6 liters of air per minute, at which rate he'd go through a cubic meter of air in about 2 hours and 45 minutes, if each breath drew air distinct from the previous breath (dubious, but humor me). Over the course of a 24 hour day, if he breathed at a constant rate, such an average man would breathe between 7 and 8 milligrams of solid pollutants. Compare that to the 10mg dosage of the active ingredient in my 24-hour antihistamine pills (Claritin), and consider that the full dosage of Chinese air pollution is lodging in the lungs of the weak and the strong, the old and the young, the committed communist and the dissident Christian alike.
I know, Chinese social policy is not something we can directly control, and if such a powerful state wants to fumigate its citizens, that's their God-given (Mao-given?) right. If the United States didn't care enough to stop genocide perpetrated with machetes in Rwanda, there's no logical reason to think we'd stop a geopolitical rival and potential belligerent from committing mass suicide.
Even so and logic notwithstanding, I can't help but wonder if there's not some role we've already played in this murky brown drama.
I'm not interested in wading into the morass over global warming; scientists agree it's happening, but many evangelicals don't believe them. This is fact, and I'll not waste time on it. But I will argue that evangelical skepticism about climate change helped to shorten the lives of thousands – and maybe millions – of Chinese Christians last week.
The first link in this argument is the fact that some estimates say there could be 100 million house church Christians in China. I don't trust any numbers that claim to show a distribution of where they live, but 100 million would represent about 1/13th of the population of China. If we take a wild guess and imagine that this ratio holds true in Beijing – which has a population of roughly 20 million – that would make it conceivable that Beijing is home to more than 1.5 million Christians. All of whom saw their lives shortened last week.
So how can I possibly blame evangelicals for that? Because we've allowed widespread skepticism about climate change to keep us from trying to stop pollution, that's how. Look, it doesn't actually matter what you believe about climate change; anti-pollution treaties are good for creation and good for people. Unfortunately, Republicangelicals tend to see anti-pollution treaties as fighting a problem that they don't acknowledge (global warming) instead of one that's obvious (Chinese people being dosed with coal and diesel in quantities like Claritin). The result is that when the world's countries try to act on pollution (after all, you don't think that mass darkness over Beijing will magically dissipate at the edge of Chinese territorial waters, do you?), the United States is never viewed as a serious partner, which undermines the whole process.
We can't make China fix their pollution. That's not the way international relations work. But we absolutely can stop being their excuse not to do something about it. And when I write 'we,' I mean evangelicals. Democrats already want this, and if evangelicals would push for it, the Republican ability to ignore global pollution catastrophes would be mortally wounded. This is completely within the power of evangelicalism.
Many will object to my line of reasoning, and argue that I don't understand the cost to jobs/the economy/small businesses of cracking down on pollution at home in order to have more leverage abroad. My response is this: air pollution like we're seeing in China kills people. Not in the long run; in the short run. How many people do you think died last weekend from that gray-brown darkness? Most likely, nobody on earth knows (and if China ever announces figures, we all know they'll lie). But many of them were your brothers and sisters in Christ, and they died in part because we're busy arguing with scientists instead of keeping our brothers. It's an old sin, and I'm worried that it is ours.


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Bred by Joseph Orard prior to 1998 and introduced to Australia in 2009 this glorious specimen with tall single stems of the most highly fragrant dark red rose which is suitable to work with in floral art and yet easy to grow in the open garden will be a joy to all rose gardeners. The men will rush out to buy it because it has so very few thorns and tell us in the nursery that they just love the red roses … we know it's all about the lack of thorns even though we also know that men prefer their garden roses to be red!
As much as anything, Firefighter will be purchased to commemorate the wonderful work our firefighters do here in Australia and as it states on the plant label: "This rose is so named as to remember those men and women who risk their lives daily to protect ours". Quirky interesting fact: This rose was planned for release in the Winter of 2009 AFTER the Black Saturday fires and is quite separate to the CFA Firestar series of roses which commenced release in 2010!
- Highly fragrant, very dark red rose
- Very suited to floral art because few thorns on picking stems
- Commemorative rose for Firefighters across Australia
The generally sunny, dry and hot conditions of the Australian garden are particularly well suited to planting roses and roses flourish in our gardens when you take measures to provide the following:
WATER – Roses are very deep rooted plants and require one good, deep soaking at least every 10 days in hot and dry conditions.
FEED – Because roses flower throughout all but the Winter season, they should be regularly fertilized with quality (preferably organic) fertilizer which contains a balance of major nutrients (NPK) and trace elements. The fertilizer should be applied at least once a month – small amount often – with fortnightly applications of liquid seaweed over the foliage.
PRUNE – During Winter, 70% of the rose plant should be pruned and all old wood removed back to the crown and the bush pruned to shape.
During the flowering seasons, 25% of all flowering stems should be cut back after flowering to encourage strong re-growth.
MULCH – Particular attention to application of lucerne or pea straw directly around the root-zone of each rose will enhance the overall health of the rose and then the whole bed should be mulched to 75mm with any other mulch medium available.
- Buy now: dtaer
- Technical Article: dffhesdr


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It feels like the dog days of summer have been with us for a long time now and with the temperatures soaring into the mid 90's yesterday I figured a detailed entry on hydration was in order.
During the summer every weather station constantly reminds us to stay hydrated and drink plenty of water, Gatorade, Nuun or whatever floats your bladder boat – but keep in mind – no matter what the temperature is outside – it is always important to stay hydrated. However, as the temperature rises, it takes more fluids to keep a proper hydration level.
Why do we dehydrate? So let's start with the basics: dehydration happens for lots of reasons. Many of us are dehydrated every morning, just by the act of sleeping. The processes in your body are working hard while sleeping, and even just breathing results in water loss from your body. But the most common causes of dehydration are simply not drinking enough regularly and not drinking enough during or after activity to replace what's been lost.
How do we know when we are properly hydrated? We have all heard the phrase "check your pee." A light colored, almost clear urine is usually indicative of proper hydration, whereas a dark colored urine is a sign of dehydration. Note – this is a good way to keep track on a regular basis – but it is not a 100% perfect science. There can be outside factors that can cause lighter or darker urine.
When to drink fluids? Drink before you are thirsty. By the time you are thirsty you are already dehydrated and your performance will be impacted.
How does dehydration impact performance? As we lose fluids to sweating our blood volume drops. As little as a 2% drop in body weight can cause this drop. When this happens our heart works harder to move the "thicker" blood through our system. This drop in blood volume can also cause muscle cramps (I am all too aware of the painful side effect of dehydration), dizziness and fatigue. Eventually this could also cause heat exhaustion or worse yet heatstroke.
How much to drink? Calculate your sweat rate. As no two people are the same, the most accurate way to figure out your personal hydration needs is your personal sweat rate. It is pretty easy. Weigh yourself before and after exercise and track any fluid intake during this exercise. Say you ran for one hour in hot, humid weather. You weighed 165 before the run. You weigh 164 after the run (btw that is a 0.6% drop in body weight in 60 minutes). You drank 8oz during the run. You lost 16oz in weight, but also drank 8oz – so your sweat rate is 24oz an hour. So you would need to drink 24 ounces every 60 minutes in these types of weather conditions to keep a status quo.
Not a math major? If calculations are not your thing and you just want to be told how much to drink. Over the years I have read time and time again to drink 8 to 16 oz 1-2 hours before a run. If you are like me and run when youy first wake up and drinking 1-2 hours ahead is not an option, then 15 to 30 minutes before going out, drink 4-8 oz of fluid (note – I drink more than this – 12 oz about 40 minutes before a run). While you are running the general concensus is 3-6 oz every 15-20 minutes. Water is fine for runs under an hour, but start thinking about sports drinks when going over an hour.
What about post run? Basically you should drink enough so that you need to go to the bathroom within 90 minutes after the run. This could be very little or a lot depending on the length of your run and the conditions of the run. However, usually 8-24oz are in order.
How does weather/altitude/exertion level impact hydration needs? In a nutshell – your hydration needs rise along with the temperature, your altitude and your exertion. As a rule – higher altitudes increases your fluid loss, as does excessive heat. For example, an average person can lose 1 cup or more per hour when doing moderate exercise in a cool climate. However, that same person can lose up to four times more when it is hot and humid out. Note: don't let winter trick you. Your rate of fluid loss through respiration increases in the cold – so keeping hydrated is just as important.
Can I drink too much water? Yes. Hyponatremia is the term for low concentration of sodium in the blood, and it can occur from over-hydrating with plain water during a short period of time. This can be especially an issue during longer, hotter races. You are sweating more, losing more sodium through sweat, while drinking excessive water, thus diluting essential electrolytes in the blood, causing disorientation, illness and in rare cases death. Nancy Auer, MD, VP of Medical Affairs at Swedish Medical Center in Seattle, says, "Maybe we need to make sure there is more sodium in the beverages we're encouraging athletes to drink." It's time to rethink the conventional wisdom behind the water stations at athletic events and make sure we're properly hydrating athletes to prevent hyponatremia. (Note: because I did not know too much about it – this section on Hyponatremia and a few other tid-bits are from the Nuun website).
Which one – Water, Gatorade, Nuun or 100's of other products? Water is great for drinking daily. For your basic hydrating needs water is king. Also, for shorter runs in cooler weather water is still fine. However, as the heat or exertion rises and you begin sweating (especially if you sweat a lot) – you are losing more than just water in your sweat. That is when the electrolyte replenishment drinks come in to play.
Why do athletes need electrolytes? Electrolytes, particularly sodium, are critical for proper hydration, helping maintain electrolyte balance, and helping your body hold on to the fluid it needs. A drink like Gatorade provides the electrolytes, as well as, some carbs for energy. Whereas, a drink like Nuun provides just the electrolytes – no carbs or sugars. Note: you need to get carbs from another source if drinking Nuun (HammerGels for me).
What do I do in the real world? I try to drink plenty of water throughout the day. I am not the best at this so I tend to splurge. I find myself gulping down a large glass as part of my morning routine – every morning – not just before runs. Then I will have another large glass after a run. Then I have a water bottle at my desk that I try to drink throughout the day. then I will realize I did not drink enough and will have a large glass as part of my nighttime routine. As for during a run – in the winter I will go up to 8 miles (1 hour) and not bring anything with me, but will drink extra when I return. Whereas, these past few weeks – I have brought my fuel belt with Nuun in it for runs as little as 5 miles (40 minutes). For my long runs – In the cool weather I drink 4oz of Nuun every 2.5 miles (20 minutes) and do great. During warm humid long runs (65-75 degrees and humid) I'll almost double this intake. In hot weather I will need even more – I try not to do long runs when it is really hot – again most of my runs are in the very early mornings before it gets really hot.
What about Carly? I have trouble getting her to drink while on the run. As much as I have tried she does not seem to want to bother drinking mid run. I have brought her own water bottle and tried squirting it in her mouth and I have looped back home so she could drink from her own dish, without much success. So I use her body language and adjust her miles accordingly. If she is ahead of me or pulling me to chase a rabbit I know she is doing fine, but if she is lagging behind me or ignoring birds, rabbits, squirrels, and other dogs I know it is time to get her home. There have been two runs (out of close to 200 runs) where we have stopped running altogether and just walked home, because I thought that is what she needed. In the cold and winter months she has done up to 12 miles with me (she did drink on this run). However, just yesterday morning (74 degrees and humid) I cut her off at 3.5 miles. Keep in mind – due to my running schedule she never runs while the sun is overhead. Black dogs really should not be running in the hot sun for any extended period of time. Black absorbs the heat more than lighter color dogs. As for her hydration needs – my wife and I just make sure Carly's bowl is always filled with clean, fresh water. This is no small task, because she will drink a lot!…and Carly is not shy about asking for more. She has no problem picking up her water dish and dropping it at our feet.
…now go drink some water – yes – I am talking to you!
Free image courtesy of FreeDigitalPhotos.net


text:
1892 – Ontario Legislature, Toronto, Ontario
In the mid-1880s a fashion for American architecture brought the style of Boston architect Henry Hobson Richardson north.
In the mid-1880s a fashion for American architecture brought the style of Boston architect Henry Hobson Richardson north.
This headquarters building was commissioned by the Canadian General Electric Company, which was founded in the late 19th century to manufacture and distribute electrical equipment during the period when electrical power was first generated for commercial and residential use.
Originally constructed 1909-10, with an addition on Queen Street in 1920. Interiors altered 2001-02.
The building was commissioned by George Gooderham to house the head offices of his Gooderham &
Our Lady of Mount Carmel Church (formerly St. Patrick Church) is the 5th oldest Catholic Church in the city of Toronto.
197 Yonge Street was formerly a 4 floor Canadian Bank of Commerce building built in 1905 by architects Darling &
Former branch of the Toronto Dominion Bank, which was bought by the city for an urban revitalisation project that never happened.
The Elgin and Winter Garden Theatres are the last surviving Edwardian stacked theatres in the world.
Designed in the Beaux-Arts style, it was the largest and most opulent station erected in Canada –
The original Toronto Stock Exchange with its magnificent Art Deco interior has been preserved under the massive Toronto Dominion Bank Tower by Mies van der Rohe.


text:
- Original clinical investigation
- Open Access
Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians
© Nicholls et al.; licensee BioMed Central Ltd. 2014
- Received: 17 January 2014
- Accepted: 13 June 2014
- Published: 23 June 2014
Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions.
Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants.
Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ2 (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ2 (3) =10.7, p = 0.013).
Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin, even in the presence of falls risk.
- Atrial Fibrillation
- Warfarin
- Dabigatran
- Rivaroxaban
- Apixaban
Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting 5% of the population over the age of 65[1, 2] and around 1% in individuals >20 years of age[3]. AF is a leading cause of ischemic stroke,[4] increasing the risk of stroke six-fold[5] and is estimated to account for approximately 15% of all strokes[6, 7]. Consequently, management of AF involves preventing AF-related complications such as stroke.
Management of AF often relies on the administration of antithrombotic therapy. Until very recently, such therapy has chiefly taken the form of antiplatelet drugs, such as aspirin, or anticoagulants including vitamin k agonists such as warfarin. The prescription of warfarin has been shown to significantly reduce the risk of ischemic stroke[8, 9]. However, the use of warfarin requires close monitoring[10] which has been and will remain an impediment to warfarin use[11, 12]. Furthermore, warfarin is itself associated with a small risk of major bleeding[13]. Studies have suggested that warfarin continues to be taken by only 30–60% of appropriate patients[5, 14]. A recent systematic review indicated no clear pattern of improved prescribing practice in 29 studies over a 10 year period[14]. While new oral anticoagulants (OACs), such as dabigatran, rivaroxaban, and apixaban have been developed,[4, 15–18] and other agents, such as edoxaban,[19] are under review, warfarin is likely to remain an important mode of prevention of strokes in patients with AF, at least in the short- to medium-term. In part this will likely be due to the cost of the new drugs, and uncertainties around their risks in certain sub-populations such as those with poor renal function or intolerance of these new anticoagulants[18]. At the same time, attempts to improve prescribing practice through the use of genotyping prior to prescription have produced mixed results, with limited clinical utility[20]. Given these current uncertainties, improving prescribing practices for warfarin will remain an important element of clinical practice.
To date, a number of barriers to warfarin prescription have been identified. In particular, attention has been drawn to the impact of the perceived risk of the patient falling, with a concomitant risk of bleeds[2, 21–23]. While some authors have suggested that the perceived risk associated with falls may be overestimated, and that it would require a substantial number of falls for the risks of falls to outweigh the benefits of warfarin prescription,[2, 21] others have noted that trials of warfarin for the prevention of stroke in patients with atrial fibrillation have been highly selective in their recruitment, often excluding patients at high risk of falls or at high risk of stroke[24]. As such, it may be that physicians are forced to extrapolate from trial data that does not match the patient in front of them or rely on personal experience when making decisions in practice. While the risk of falls has been implicated in decisions not to prescribe warfarin, there has, to date, been little research attempting to assess the impact that the perceived risk of patient falls has on the decision-making of physicians when considering the prescription of warfarin for patients with atrial fibrillation.
Other work suggests prior experience with serious adverse events may also affect prescribing practice[22, 25]. This has been argued to stem from the "availability heuristic",[26] a general psychological mechanism underlying many human judgements where the judgment of a particular outcome probability can be based on the ease with which one can recall instances of similar outcomes[27]. Because vivid events are more easily recalled than mundane ones, memory of a single catastrophic bleed event while on warfarin might lead to a generalized overestimation of the probability of bleeding for subsequent patients, and consequently reduced warfarin use. Indeed, a recent meta-analysis concluded that there is a need to consider provider characteristics such as previous adverse events in patients on warfarin, and the extent to which these effects influence prescribing decisions across physician groups[28].
The aim of this study was to explore these factors that may have a disproportionate effect on warfarin treatment decisions, and to examine whether their effects vary by physician discipline.
Survey administration
This survey formed part of a larger project that sought to identify factors that influence physicians' decisions around the use of anti-coagulant treatment for atrial fibrillation, and focused on the use of antithrombotic treatment of AF. Physician contact details were obtained from the 2005 Canadian Medical Association Directory. The survey was administered to three samples of Canadian physicians: Family Doctors, Internal Medicine Specialists, and Geriatricians. Internal Medicine Specialists were selected as a broad physician grouping that included sub-specialties of interest, such as cardiology, but which could not be selected individually with sufficient confidence, due to variation in the way physicians were categorized. Physicians were included if they were listed as having an "active" practice status, and a specialty code of family or internal medicine. In both cases, a random sample of 500 individuals was selected. In addition to these groups, all physicians whose primary specialty was listed as geriatrics were included (n = 149).
Design and administration was optimized using the Dillman Tailored Design Method, a tested and widely used approach to survey research[29, 30]. In line with this approach, physicians received an initial pre-notification letter. The survey was then mailed one week later together with a covering letter that described the purpose of the study, indicated source of funding, and reported ethical approval from the Ottawa Hospitals Research Ethics Board. Return of the survey was taken as tacit consent. Three reminders and two replacement surveys were mailed to non-responders at two-week intervals. Correspondence was addressed to the individual physicians, and signed by the principal investigator (JCB). In addition, a financial incentive ($20) was provided for completion of the survey. Surveys were completed between June and August 2007.
Survey instrument
The survey was developed and based on a narrative review of the literature in order to gather evidence regarding physicians' self-reported practice, reasoning around warfarin use in practice and attitudes towards previously identified barriers to the prescription of warfarin. Physicians were asked about their engagement with patients with AF, their prescribing practices when seeing a new patient with AF, the situations under which they would not prescribe warfarin, and other potential barriers to the prescription of warfarin. Potential barriers were drawn from a number of sources including the recommendations of physician organizations, CHADS2,[31] and the scientific literature;[7, 32–34] we looked both for factors that were known to be associated outcomes related to treatment with warfarin, or those that were unrelated to outcomes, but which may be thought to be related by some physicians.
Initial instructions indicated that unless otherwise specified, all questions in the survey dealt with patients whose primary reason for seeking medical attention is AF and where AF was defined as established paroxysmal or chronic AF, involving chronic or recurrent episodes over a period of more than 48 hours. Respondents were asked to mark a line on a graded scale ranging from 0-100% to indicate the percentage of their new patients for which they would prescribe different anti-thrombotic therapies. To indicate the items deemed relevant to warfarin use, physicians were asked two questions. The first asked respondents "When you do NOT initiate warfarin (Coumadin) treatment for patients who have chronic atrial fibrillation, what reasons account for this decision?" Six options: patient judged to be of low risk of thromboembolic event (e.g., stroke); bleeding risk (e.g., liver disease); fall risk (e.g., alcohol abuse or frail older); advanced age; expected poor patient compliance in monitoring INR; and monitoring/ management logistical issues, were provided together with an open ended 'other' option.
Details of the case vignettes
Low Stroke risk, Low risk of falls
History: The patient is a 53 year old male, a teacher who participates in regular physical activity. He has a 5-year history of chronic atrial fibrillation which is asymptomatic. For rate control, he takes metoprolol 25 mg bid. He is not taking any antithrombotic therapy. The rest of his medical history is unremarkable, including no history of diabetes, hypertension, or other cardiovascular risk factors. He is taking no other regular medications.
Physical exam: He appears fit. Blood pressure is 130/65; pulse is 78 and irregularly irregular. Cardiac exam is normal except for the irregular rhythm; and the rest of the physical exam is also normal. All laboratory work including complete blood count, electrolytes, urea, creatinine and TSH are normal. ECG confirms atrial fibrillation at 80 beats per minute, but is otherwise unremarkable. Echocardiogram (performed the next day) also shows atrial fibrillation, but is otherwise unremarkable (normal chamber sizes, normal systolic function, and no valvular abnormalities).
High Stroke Risk, Low risk of falls
History: The patient is a 74 year old woman. She lives at home with her husband; she is cognitively intact (as is her husband) and is fully independent and active for her age. Past medical history includes hypertension and an ischemic stroke 4 years ago, with no residual deficits. Current medications include hydrochlorothiazide 25 mg daily and atenolol 50 mg daily. She recalled taking aspirin in the past, but stopped on her own years ago. She prefers to walk with a cane, but has never fallen.
Physical exam: The patient looks well for her age. Blood pressure is 138/75, pulse is 83 but irregularly irregular. Cardiac exam is normal except for the irregular rhythm. Neurological exam is normal,
including cranial nerves, visual fields and visual acuity. The rest of the physical exam is also normal. All laboratory work including complete blood count, electrolytes, urea, creatinine and TSH are normal. ECG confirms atrial fibrillation at 80 beats per minute, but is otherwise unremarkable. Echocardiogram (performed the next day) also shows atrial fibrillation, but is otherwise unremarkable (normal chamber sizes, normal systolic function, and no valvular abnormalities).
High Stroke risk, high risk of falls
History: The patient is a 72 year old woman who lives with her husband in her own home. She is cognitively intact, as is her husband. Past history includes hypertension, and a previous ischemic stroke 3 years ago, which left her with a mild facial droop but no other neurologic deficits. She also has Parkinson's Disease which is well controlled but has resulted in her falling 3 times in the last year. She walks with a walker. Her current medications include hydrochlorothiazide 25 mg daily, atenolol 50 mg daily, Sinemet 100/25 mg tablets three times a day. She recalled taking aspirin in the past, but stopped on her own years ago.
Physical Exam: The patient has a mildly shuffling gait, but appears well for her age. Blood pressure is 139/73, pulse is 85 but irregularly irregular. Cardiac exam is normal except for the irregular rhythm. Neurological examination reveals mild left-sided lower facial weakness consistent with her past stroke and cogwheel rigidity of the extremities in keeping with her Parkinson's. The rest of the physical exam is normal. All laboratory work including complete blood count, electrolytes, urea, creatinine and TSH are normal. ECG confirms atrial fibrillation at 86 beats per minute, but is otherwise unremarkable. Echocardiogram (performed the next day) also shows atrial fibrillation, but is otherwise unremarkable (normal chamber sizes, normal systolic function, and no valvular abnormalities).
Data analysis
Data was entered into and analyzed using IBM SPSS Statistics v19 (SPSS Inc., 2010). A 10% data entry check was conducted by two researchers and indicated a 97.6% concordance, with discrepancies resolved through discussion and reassessment of the returned survey. Descriptive statistics were used to summarize the data from the total sample and the assessment of differences between physician groups. Comparisons between groups were made using χ2 and Kruskal-Wallis tests as appropriate; with column proportions compared using a z test. A level of p < 0.05 was accepted as significant.
Demographic characteristics of the sample (n = 1032)
Number (%)
Responder (n = 335)
Non-responder (n = 697)
162 (48.4)
360 (51.6)
173 (51.6)
337 (48.4)
Physician Group
Family Doctors
154 (46)
309 (44.3)
52 (15.5)
84 (12.1)
Internal Medicine
129 (38.5)
304 (43.6)
221 (65.9)
456 (65.4)
112 (33.4)
233 (33.4)
2 (0.6)
8 (1.1)
Age group
105 (31.3)
110 (32.8)
80 (23.9)
30 (9)
5 (1.5)
5 (1.5)
Certified by College of Family Physicians
174 (51.9)
118 (35.2)
43 (12.8)
Fellow of the Royal College of Physicians and Surgeons
184 (54.9)
117 (34.9)
34 (10.1)
During the last month, how many different patients with atrial fibrillation did you manage?
14 (4.2)
130 (38.8)
85 (25.4)
101 (30.1)
5 (1.5)
A total of 335 surveys were returned in which physicians reported seeing at least one patient with atrial fibrillation per year (response rate 32.5%). Of these, 154 (46%) were family doctors, 129 (38.5%) internal medicine specialists, and 52 (15.5%) were geriatricians.
Standard AF treatment practice
Estimated mean percentages of new patients treated with defined anti-thrombotic therapies
When you see new patients with atrial fibrillation, for what percentage do you administer the following anti-thrombotic therapies?
All (n = 331)
Geriatricians (n = 51)
Family doctors (n = 151)
Internal Medicine Specialists (n = 129)
no antithrombotic therapy
Plavix (Clopidogrel)
Reasons for non-prescription of warfarin
Physician reasons for not prescribing Warfarin (n = 330)
When you do NOT initiate Warfarin (Coumadin) treatment for patients who have chronic atrial fibrillation, what reasons account for this decision?
Geriatricians (n = 51)
Family doctors (n = 151)
Internal Medicine Specialists (n = 128)
Patient judged low risk
Bleeding risk
Fall risk
Advanced age
Expected poor patient compliance
Monitoring/management logistical issues
Falls risk, bleeding risk and poor patient adherence were all highly cited reasons for not treating with warfarin. A significantly higher proportion of internal medicine specialists indicated that bleeding risk would be a barrier to the prescription of warfarin. Attitudes to monitoring and management issues differed across all three physician types with 53% of geriatricians indicating monitoring or management issues as reasons for non-prescription compared with only 15% of family doctors and 30% of internal medicine specialists.
Physician experience of adverse events of serious bleed or stroke in patients
Family doctors
Internal Medicine Specialists
Ever had a patient suffer a serious bleed (% Yes) (n = 330)
Have you ever had a patient suffer a serious stroke (% Yes) (n = 322)
Prescribing responses to vignettes
Warfarin use was lowest for the first vignette, although physician groups varied significantly (G: 15.9%; FD: 37.2%; IMS: 9.2%). For a patient with a high stroke risk and low falls risk, warfarin use was universally high, and did not differ between groups (G: 97.7%; FD: 91.2%; IMS: 95%).
Physician groups differed dramatically on whether the addition of a falls risk would change their decision to prescribe warfarin. Almost all (93.2%) of geriatricians reported that they would prescribe warfarin for such a patient; this did not differ significantly from the proportion that would give warfarin to a similar patient without the falls risk (97.7%). However, only 59.2% of IMSs and 37.8% of FDs would prescribe warfarin, compared to 95% and 91.2% respectively for patients without the risk of falls; this difference between physician groups was significant (Fisher's exact test p < 0.01, Pearson χ2(6) = 45.446, p < 0.01). Stated another way, while only 4.5% of geriatricians reported a different warfarin prescription decision between vignettes 2 and 3, the number was 36.7% for Internal Medicine Specialists and 54.1% for Family Physicians.
Finally, we combined the data from the three physician groups to examine whether prior experience with a patient having had a stroke or bleed would be related to reduced likelihood of warfarin given an occasional risk of falls i.e. change in practice between vignettes two and three. Experience with having seen a serious bleed was not associated with that likelihood (χ2 (3) =3.039, p = 0.386, Fisher's exact test p = 0.319, n = 308). However, experience with having seen a stroke in a patient not prescribed warfarin was a significant influence; those who had a patient experience a stroke while not receiving warfarin were more likely to persist with, or introduce, the prescription of warfarin in the presence of risk of falls (χ2(3) = 10.7, p = 0.013, Fisher's exact test p = 0.013, n = 301).
Consistent with previous research,[11, 28, 35–40] the present study observed variation in reported prescribing practices for atrial fibrillation and the identification of variables such as perceived bleeding risk, fall risk, and expected poor patient adherence as commonly cited factors that would decrease physicians' likelihood of prescribing warfarin. While previous studies have indicated the role of factors such as perceived risk of falls as a barrier to warfarin prescription,[2, 21–23] we further this research by analyzing the impact on prescribing decisions across different physician populations.
Our results demonstrated a high reported used of warfarin, with all physician groups stating that they prescribe warfarin to 70-75% of their patients with atrial fibrillation. This suggests that there is no one group of physicians that is wildly different in their planned use of the drug, either because of a lack of knowledge about outcomes, or relevant practice differences. These rates must, however, be cautiously interpreted given the self-reported nature and are above the typical estimates of current warfarin use, which have been reported to be as low as 19%, but as high as 78%[11, 28, 32]. However, a strength of the present study is the comparisons made across different physician specialties and the reported differences in reasons for not prescribing warfarin. Specifically we identified a differential effect of risk of falls on prescribing decisions.
Several potential limitations of this study warrant consideration. Our response rate was only 32.5%, although this is similar to previous surveys with physicians regarding treatment practices[37, 38, 41]. We attribute this in part to the length of the survey, which was six pages in length and required some effort to complete. While there were no clear differences on available variables between responders and non-responders, and response rate was similar across physician groups, our limited knowledge about non-responders leaves open the possibility of a response bias. A second limitation is that the data were collected in 2007, and since then a number of new alternatives to warfarin have become available. However, a number of questions remain over the use of new therapies due to (1) the significantly increased costs over warfarin and (2) the concern regarding the treatment of side effects – such as bleeding. Until these issues have been addressed warfarin is likely to remain an important treatment for atrial fibrillation.
Our results indicate that physician groups differ in terms of the barriers reported to affect warfarin-prescribing decisions. While previous research identified geriatricians as being more likely to indicate warfarin prescription than other physicians types,[42] it only compared responses to two scenarios that varied in several aspects. Our results provide increased clarity on this issue and suggest that geriatricians seem to consider bleeding risk, risk of falls, and advanced age as less influential on prescribing decisions than the other physician groups. Similarly, family doctors were less likely than geriatricians to indicate they would be affected by logistical issues such as poor patient adherence and monitoring issues. One suggestion may be that family doctors may be more likely to refer these patients to other specialties and so may be less likely to experience adherence issues. Whether these group differences can be best explained by experience, training, or as a reflection of the capabilities of their respective patient populations requires further investigation. The subsequent development of tools such as HAS-BLED,[43] HEMORR2HAGES,[44] and ATRIA[45] for the assessment of bleeding risk – and which explicitly incorporate advanced age – may assist standardizing risk assessments for bleeding as part of the clinical assessments as to the net clinical benefit of oral anti-coagulants,[46] although there remains an ongoing need for assessment of prospective clinical utility.
Prior experience of patients suffering adverse events also appeared to affect prescribing practice. Aggregated physician data indicated a positive association between experience of a patient suffering a stroke when not prescribed warfarin and an indication that they would continue or instigate prescribing of warfarin in the presence of falls risk. We did not, however, find an association between experience of adverse bleeding and warfarin prescription in the presence of falls risk. This finding is consistent with several other survey-based studies[22, 41]. Using a cross-sectional survey of physicians within the American Medical Association, Gross et al.,[41] reported more physicians to experience regret over acts of omission (not prescribing warfarin and then stroke) than commission (prescribing warfarin then bleed) and an associated increase in stated warfarin prescription when presented with a range of case vignettes[41]. This accords with Australian data from family physicians[22] in which one fifth felt responsible for acts of commission leading to hemorrhage, whilst just under a third reported they would feel responsible for an act of omission that lead to an ischemic stroke. However, in a study of actual prescribing and past patient bleeding/stroke, an association between physician experience of serious bleeding and reduced warfarin prescription was found[25]. This may point to a disagreement between self-reported and actual behavior which indicates an important area requiring further study.
Overall, and consistent with previous results,[22] we saw a general drop in the proposed use of conventional warfarin when the risk of recurrent falls was introduced within the vignettes. However, an intriguing result was the clear differences in how the different physician groups incorporate falls risk into their decisions. Inclusion of falls risk into an otherwise comparable, high stroke risk patient resulted in avoidance of warfarin in 37% of Internal Medicine Specialists, 54% of Family Physicians, and only 5% of Geriatricians. While older patients have not been included in clinical trials, and so one might expect geriatricians to be more conservative in their use of warfarin, geriatricians may have greater clinical experience with how warfarin might affect older patients through increased exposure to atrial fibrillation. They may, therefore, be basing their decisions on this clinical experience as opposed to trial data. Whether such differences in the stated use of warfarin in the presence of falls can be attributable to reasonable differences in practice, or whether it points to a misunderstanding of the risk associated with falls in one or more physician group is an important area for further research, particularly given the lack of trial data relating to older patients, those at increased risk of falls, and at higher risk of stroke.
Our study provides a number of insights into self-reported physician prescribing practice and the barriers to prescribing warfarin. Our results replicate previous studies and identify a number of potential barriers to warfarin prescription, but have identified differing impact across physician populations. In particular, we note the variation regarding adverse events on stated prescribing practice; prior experience of a patient suffering a stroke when not prescribed warfarin was positively associated with an intention to prescribe warfarin, even in the presence of falls risk. The indication that physicians of differing specialty don't report significantly different rates of practice may indicate that general educational interventions will be ineffective. Rather, specific patient- or practice-level feedback may be appropriate. Harnessing the potential of electronic medical records and techniques such as audit and feedback,[47, 48] may provide 'personalized' feedback on clinical practice that will be both more salient and informative with respect to monitoring prescribing practice for warfarin[49]. Our results provide insight into where variation in physician decision making occurs and may point to relevant elements to be included in such feedback. Despite this suggestion, there remains a need for further research to explore how physicians weight specific indicators under different scenarios and to investigate how new agents will modify decisions given the notable impact of monitoring on physician practice.
The authors would like to thank Andrea Moore, Alison Bourgon, and all the physicians who completed the survey. The work was funded by a grant from the Canadian Institutes of Health Research (CIHR), including all survey incentives, which came from the originating institution (Ottawa Hospital Research Institute).
Funding sources
CIHR Knowledge Translation Strategies for Health Research, CIHR # KTS-73432.
Authors' Affiliations
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- De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen SD, Lip GY, Morais J, Rasmussen LH, Siegbahn A, Verheugt FW, Weitz JI: New oral anticoagulants in atrial fibrillation and acute coronary syndromes: ESC working group on thrombosis-task force on anticoagulants in heart disease position paper. J Am Coll Cardiol 2012, 59: 1413-1425. 10.1016/j.jacc.2012.02.008View ArticlePubMedGoogle Scholar
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|Saturday, May 25, 2019
|A devloper in Yorkville, Illinois.
|A three year $4,200,000 loan at 12% rising to 18% with a Prime-based floor.
|A first mortgage on a 64.8 acre tract which is part of a 300-acre Planned Unit Development in Yorkville, Illinois.
|The loan is guaranteed by the Borrower's holding company and its principal owner.
|Our loan will take out the current first and second mortgages and provide approximately $1 million towards infrastructure improvement.
|Exit strategy
|The Borrower expects to pay us out of the proceeds of sale of developed residential lots and commercial sites.
|The loan is current.
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W.K. Berger is launching his first novel this summer titled The Purples, an action-packer about Detroit in its heyday. In a recent email, Mr. Berger said that the idea for The Purples "came out of a long-ago family connection to the infamous Purple Gang, a wild group of Jewish rumrunners who ruled Detroit during Prohibition."
According to his bio Mr. Berger has written articles for The New York Times, The Los Angeles Times, and The Chicago Tribune among many other well-known publications. These days however, he is busy promoting his thriller, which must be a full time job in its own right.
In the literary world things are really ramping up on the Internet, and Berger's site for The Purples is no exception. Just when you thought getting published was the hurdle, authors must now hone their promotional and marketing skills to visually compete online. A definite nod must go out to The Purples site which (though it pains me to say) includes a very decent trailer.
Though I haven't yet read The Purples, I am thrilled at the prospect of another historically based book shedding light on Detroit and its incredibly diverse history. For past NLR reviews that touch on these subjects, try Annie's Ghosts, Grand River and Joy, and The Art Student's War.
*Support your local bookstores, libraries, and universities. It matters.
-Post by Megan Shaffer


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It is no secret that Washington, D.C., is a town that historically knows its way around a barstool. And though one could select just about any traditional hotel-lobby boîte—of which there are more than a few inside the Beltway—and have a passable time, why not opt instead for the clandestine warmth of an underground or hidden gem? At the establishments that follow, guests can expect to enjoy distinctive architecture, decor by celebrated interior designers, beautifully crafted cocktails, and understated appeal.
The up-and-coming Union Market District may be the last place you would expect to find a cocktail crafted with black walnut–infused glycerin smoke and a Michelin-starred restaurant, but that's not the only unlikely pairing at Masseria. The high-design haven balances industrial elements (like a massive rust-color door) with more refined flourishes like one-of-a-kind celeste-blue Mediterranean tile and Carrara marble. Worth admiring: the hostess stand, which is fashioned from an 18th-century dentist's worktable. Worth Instagramming: that glycerin smoke, which comes with the Fumo di Uva, a beautifully balanced libation featuring brandy and black walnut liqueur. 1340 4th Street NE; masseria-dc.com
Off the Record
Look for the discreet side door, and then order up a Trumpy Sour or Obama's Last Fall. At O.T.R., the artwork nearly steals the show, with portraits and political caricatures on display by famous and Pulitzer Prize–winning cartoonists—part of a collection recently acquired by the Library of Congress. Come closing time, bid farewell to the cozy haunt's old-world charm and take home one of the collectible coasters, featuring political figureheads. The Hay-Adams, 800 16th Street NW; hayadams.com/washington-dc-bars
Denson Liquor Bar
It's easy to get lost trying to find this subterranean speakeasy—take the stairs on 6th—but the reward is being teleported to a cocktail lounge F. Scott Fitzgerald might have frequented. With every detail carefully labored over, some standouts include the elegant black-and-white-tile flooring, handsomely appointed leather booths, and Art Deco influence throughout. Order the Gran Oaxacan (mezcal, Gran Classico bitters, and Lillet Blanc, all barrel-aged for 14 days) before you decide to top it off with some sustenance—like the exceptional $144 caviar flight. 600 F Street NW; densondc.com
Root Cellar Whiskey Bar
Wander below buzzy Mediterranean restaurant Pinea and you'll stumble upon this hidden prize, which will impress any whiskey enthusiast with its stellar collection of rare bourbons and local ryes. Sleek interiors by Los Angeles–based designer Dianna Wong serve as the backdrop to the intimate six-seat bar, an almost theatrical stage for soigné mixologists to shake up your drink. As the fire flickers, recall the sage counsel of the menu's Mark Twain quote: "Too much of anything is bad, but too much good whiskey is barely enough." 515 15th Street NW; pinead.com/rootcellar
The Gibson
Designed by acclaimed firm Streetsense, this liquor den hides behind an unmarked door. Within, dangling lightbulbs set a cozy mood around the U-shaped bar, along with playful red booths and a giant chalkboard. Debonair cocktails like the Dragon Breathing Fire (jenever, Bonal Gentiane-Quina, crème de cassis, lemon, chili-infused bitters) are served up elegantly. Or take a mixology class with the nimble barkeep and learn to make one for yourself. 2009 14th Street NW; thegibsondc.com
Harold Black
Tucked above Acqua al 2—look for the unmarked door and proceed up the dimly lit steps to a large sliding wood wall—you'll feel instantly removed from any stress of the day thanks to the thoughtfully designed interior (okay, and a cell phone ban). With nostalgic books and antiques dotting the sitting room, sidle up to a cozy round leather booth and sip slowly on the Aviation, a blue-hued gin sour with subdued floral notes, whose roots date from early-19th-century New York City. 212 7th Street SE; haroldblackdc.com


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This wonderful Grade II listed coach house conversion enjoys a sunny southerly outlook.
The accommodation is arranged over three floors and comprises on the lower ground floor of: front entrance lobby, large dining kitchen, utility room with quarry tiled flooring and fitted wall and base units, cloakroom/WC, impressive galleried dining room with feature arch window, open archway to the music room/family den.
The rustic style farmhouse kitchen has a gas powered Aga, a central island with tiled worktops and a marble chopping block. There is exposed brickwork with stone features, ceiling beams, a double pot sink and a built in feature wine rack.
To the upper ground floor: entrance hall, study, bright and sunny sitting room with feature period fireplace with open grate, inner hallway with useful storage cupboard, two double bedrooms and a bathroom.
There are also two attic bedrooms and an additional bathroom. The property benefits from partial double glazing and a gas central heating system.
The south facing terraced gardens extend to the side of the house with a walled rear boundary onto Midgley Road. The gardens include a paved patio area and level lawn with garden pond, outside lighting and mature trees and shrubs.
In front of the coach house is an extensive cobbled area which in turn leads to a tarmac driveway. There is a turning circle off the cobbles. The driveway provides ample off-road parking and leads to the detached tandem garage.
Located off Midgley Road, a country lane between the village of Mytholmroyd and Midgley, this is a delightful, semi-rural setting, yet still convenient for local amenities, stations and schools.
Price: £400,000
Agent: www.clairesheehan-estateagents.co.uk


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Jun 16, 2013
In the latest episode of The Infinite and the Beyond, we speak with Australian author and teacher, Lee Morgan about her new book A Deed Without A Name: Unearthing the Legacy of Traditional Witchcraft. Lee identifies as a pagan animist – witch and runs a blog titled My Craft and Sullen Art where she identifies herself as a Traditional Witch, non traditional dichotomy-smasher, line-blurrer, bone-singer, folk-healer, head-bender, and sometimes poet.
We hear some awesome music by Swallows from their latest album, "Witching and Divining." Swallows is an Americana/rock band from Minneapolis, Minnesota who has recently released their second full-length album, the roots-oriented Witching & Divining. Since its release, Witching & Divining has received strong media support in the Twin Cities and was in rotation on over 160 college and public radio stations throughout the U.S. and Canada, including several weeks of charting in the CMJ and Earshot! top 30 on 15 stations.
In A Corner in the Occult, we learn about Scottish witch Isobel Gowdie who was tried for witchcraft back in the 17th century. One of most of the witchcraft confessions obtained in trials from the past centuries, Isobel Gowdie's, a flaming red haired woman from Auldearn, Scotland, is said to be the most elaborate and compelling and offers a unique look at what Scottish Witchcraft may have been like.
And in The Essence of Magick Series, we consider the values and issues surrounding authenticity. The desire for truth and the concern for authenticity in one's spiritual and religious practice, has a tendency to even filter into one's personal magickal practice. Which begs the question, what does it mean for one's magick to be considered as authentic? Does this issue refer to history and the accuracy of a practice or does it refer to the level of sincerity behind the act? All this an more in this episode of The Infinite and the Beyond. Enjoy!


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The Saudi Neglect
Having visited Saudi Arabia this year with her parents. She describes in detail the harsh policing, the aggressive crowds and the chaotic organisation that could have led to the death of her mother. Grateful to be alive, she is now demanding radical change to save pilgrims from inhuman treatment in Saudi Arabia A key observation she made which [...]Mudassar


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The power to have the traits and abilities of Chinese Deities. Variation of the Transcendent Physiology.
Also Called
- Buddhist Deity Physiology
- Confucist Deity Physiology
- Taoist Deity Physiology
- Shenist Deity Physiology
The user can have the traits and abilities of the Deities of Chinese Mythology, which is directly connected to Confucianism, Taoism, and Buddhism.
The Three Pure Ones
All: Cosmic Awareness, Ethereal Physiology, Omnilock
- Daode Tianzun/Grand Pure One
Chinese Deities
- Dragon King
- Asian Dragon Physiology
- Human Disguise
- Lake/River Manipulation
- Ocean Manipulation
- Replication (Dragon Kings of the Four Seas)
- Weather Manipulation
- Guanyin/Kwan Yin
- Jade Emperor/Yu Huang
- Nüwa
- Xi Wangmu
Minor Deities
- Sun Wukong
Known Users
- The Eight Immortals (Marvel)
- Niang-Niang (Toaru Majutsu no Index)
- Zao Shen (Supernatural)
- Yu-huang Shang Ti (Stargate SG-1)
- Nezha (Valkyrie Crusade)
- Nuwa (Valkyrie Crusade)
- Yama (Valkyrie Crusade)
- Monkey (Valkyrie Crusade)
- Chinese gods (Smite)