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International Newsletter on Sustainable Local Development
Newsletter #58
May 1st, 2009
Message from the Editorial Team
Economic Justice from the Bottom Up
The Solidarity Economy Movement Emerges in Its First U.S. Conference
Message from the Editorial Team
A first conference on solidarity economy was held in the U.S. last March. In this issue we are reproducing an article by Carl Davidson, a Coordinating Committee member of the U.S. Solidarity Economy Network (USSEN).
In the current economic, financial and environmental crises, the development of a solidarity economy movement as public policy within a country that promotes neo-liberal globalization is a sign of fundamental change, which follows the election of Obama as president of the USA. The challenges are enormous in a context where large corporations do not wish to relinquish being major players. For example, Exxon is trying to get their hands on wind power projects!
The movement is young, but it is rooted in a variety of social movements, spread in all regions of the U.S.
Editorial Team
Judith Hitchman
Yvon Poirier
Martine Theveniaut
Economic Justice from the Bottom Up
The Solidarity Economy Movement Emerges in Its First U.S. Conference
By Carl Davidson
Nearly 400 organizers and activists gathered at the University of Massachusetts in Amherst March 19-22 for the first national gathering of the U.S. Solidarity Economy Network, exceeding the expectations of its organizers.
The deepening economic crisis made the meeting quite timely. The overall theme was 'Building Another World,' and drew participants from the East Coast, South and Midwest of the US, even Alaska and Puerto Rico. Internationally, delegations came from Quebec, Venezuela, Peru, Mexico, and Canada. People represented economic justice and green jobs projects, food coops and credit unions, worker coops and labor unions, and peace and justice organizing efforts.
"Our diversity was very dynamic and creative," said Julie Matthaei, a USSEN coordinating committee member. "It served us well in affirming our unity, discussing differences, and helping us reach a deeper understanding of the solidarity economy in our context."
The solidarity economy is a grassroots movement widely known throughout Latin America, arising from people turning to each other for survival in the face of the slashing of social safety nets imposed by globalization and neo-liberalism. It consists of peasant cooperatives, workers seizing abandoned factories and a variety of organizations of the urban poor. In Europe and Quebec, it's also known as part of the social economy, with deep ties to the trade unions, worker-owned cooperatives and the non-profit sector in social services. Together, the social and solidarity economy are quite strong there, with successes in pushing public policy.
USSEN was launched at the US Social Forum in Atlanta, 2007, which drew some 12,000 participants. SEN activists had organized over 80 panels and workshops, and the network was founded from among the participants. It has added to its numbers since then, with the Amherst meeting its first major U.S. project. It was co-convened with the Universidad de los Andes from Venezuela and RIPESS-North America, the Intercontinental Social Solidarity Economy Network.
Emily Kawano, USSEN director, welcomed everyone at the opening plenary and took note of this history. "We know the solidarity economy is new to activists here in the U.S., but we're very excited about how it is being taken up. We're very clear on its core meaning, but at the same time, we like the concept that we build the road as we travel it." Ethel Cote followed with a description of how the Canadian Community Economic Development Network (CCEDNET) she was representing was facing new challenges in coming to scale in the new period of crisis, while Benito Diaz of the Venezuelan University on the Andes described the large cooperative movement launched as part of the Bolivarian revolution in his country.
The conference was organized around some 70 workshops in eight time slots, with four major plenary sessions, as well as an opening tour of local examples of the solidarity economy in practice in Western Massachusetts. A total of 199 speakers made presentations and facilitated discussions.
A broad range of topics
The topics covered a wide-range: A common policy agenda in the context of Obama's recovery plans, cooperative housing, fair trade, credit unions, alternative currencies, cooperatives in Venezuela, worker takeovers in Argentina, feminist economics, the social economy in Quebec, the role of labor unions, worker cooperatives, green jobs alliances, solar power and many more.
The Friday morning plenary was packed. Elandria Williams from the Highlander Research and Educational Center in Knoxville, Tennessee fired people up with descriptions of organizing battles for economic justice. "We've been engaged in the solidarity economy for our survival for and long time. We just never applied that name to it." She shared the platform with Ethan Miller from the Grassroots Economic Organizing network. He delighted the session with an extensive graphic mapping of all the interconnected features of the movement cast on a giant screen.
Solidarity Economy and green jobs
The question of the solidarity economy's connection with the wider "green jobs" movement came up early in an opening round workshop on shaping a common policy in the context of the Obama stimulus. The issue was underscored by the recent appointment of Van Jones of Green For All to the White House team--Green For All and Jones are highly regarded here. While there was no consensus answer, almost all agreed that there was considerable overlap between the two, and the solidarity economy projects had an important role in the green jobs movement.
"They're not exactly the same," said one participant. "T. Boone Pickens, the Texas millionaire guy who wants all those wind turbines to make the Midwest the Saudi Arabia of wind power is clearly part of the green economy, but he's most likely indifferent at best as to what makes for a solidarity economy, worker and community ownership and the like. But that's where we come in, what we can offer to the green jobs movement."
Two main questions structured the discussions
The "Obama debate" emerged in several workshops over the weekend. There were a range of views on the new White House, with many sympathetic to Obama. Some declared themselves as Green voters, however, and a few didn't bother with the election. In fact, there are two major underlying discussions and debates in the solidarity economy movement almost everywhere.
• One is whether SE projects operate as alternatives to markets or as a dynamic option within them.
• The other concerns the state, and whether SE projects grow mainly by linking horizontally outside of government, or whether they partner with government to force structural reforms, especially on the local level. Both views were expressed, but neither saw the need to force a conclusion on the matter.
But most participants were simply upbeat about the size and diversity of the turnout, and intrigued over the array of choices of workshop subject matter they could sample.
A conference of international scope
The Friday evening plenary deepened the internationalist dimension of the conference. Nancy Neamtan from the Chantier de l'économie sociale in Quebec, the network of networks of all organizations involved in social economy, explained the deep connection with the labor movement through a number of battles and crises, and how the social economy is critical to the survival of the working class, especially working women. Graciela Monteagudo, speaking for the Argentina Autonomista Project, gave a powerful slide show on the efforts of that country's urban street poor to organize themselves in recycling cooperatives, while Jose Sojo of Venezuela described the ongoing challenges with cooperatives surviving in the marketplace.
Jobs for youth
By Saturday morning the conference workshops had the problem of being overcrowded, as more activists arrived in Amherst for the weekend. "Community Owned Green Jobs and Green Energy" was a popular choice. Organized by Massachusetts Coop Power, the presenters gave excellent detailed descriptions of creating green jobs for youth installing solar powered hot water heaters in residential homes. Even low-income families could take advantage of a number of creative plans to cover up-front expenses for the units by borrowing against their future savings on power bills from the utility companies.
"It's 'Win-Win' all round," said Lynn Benander of Coop Power. When queried about how she won over dubious inner city youth to take up the program, she replied: "I put a foam cup of hot water in the middle of the table and asked, 'How would you keep it hot?' and got them to compete for solutions. Then I said, 'OK, good, now how you keep this room and this building warmer? Here's a detector, find the heat loss, and think about how to stop it. Worked like a charm; they got into it."
Partnering to build an inclusive, equitable and green economy
A workshop that followed up on a similar theme was "Building an Inclusive and Equitable Green Economy," presented by the Massachusetts Green Jobs Coalition. "How do we actually do it?" asked Kalia Lydgate, a MAGJC organizer. A student inspired by Van Jones and his book, "Green Collar Economy," she went on to describe how they used his ideas to build cross-sectoral alliances that are inclusive of those needing green jobs the most. "If you walk in a room and it's all white guys in suits, you've got big problems. That just won't work." MAGJC turned out to be a successful statewide coalition and advocate that got bottom up job training and funding done the best way.
"This is one of the most thought provoking and enlightening experiences in my life," said Tylik Railey, a young activist with the Asbury Park Neighborhood Cooperative in New Jersey. "I'm so glad that I am a part of a movement this huge and worldwide. Not knowing too much about solidarity economy, I was a little hesitant into walking into this world of organizers, scholars, students, and small business people. But in little to no time I was sharing my experiences with these same people."
The role of unions in the social movement
The afternoon round featured a workshop on labor. Yvon Poirier of the Canadian CED Network and a retired Quebec trade unionist gave a presentation on the critical role of unions in the Quebec social movements. "With our conservative government in Ottawa," said Poirier, "a progressive agenda is not fully possible right now." Still, he went on to explain the advanced way, compared to the U.S., that since the mid-1980s, Quebec unions made use of their own pension funds to support growth in the social economy that served the basic needs of the population. Others in the workshop brought up some of the problems with "business unionism" in the U.S, but noted there were now a number of openings for work around wider issues. All agreed that SEN activists should take up the Fight for the upcoming Employee Free Choice Act that the GOP Right is trying to block.
Worker cooperatives are at the heart of the solidarity economy
One workshop discussed a number of projects in the Bronx and New York City. Workshop participant Bucket von Harmony, a member of a rural coop in Virginia, reported:
"We learned how many immigrant workers in New York City are treated poorly by their employers. So a group of folks got together and formed various collectives: a childcare co-op, a construction co-op, and a house cleaning co-op. They each have different structures. One requires that everyone put in 2 hours of marketing work a week. The construction co-op gives women the opportunity to participate in construction that they had not access to before and they all pay each other equally no matter what their skill level is. It is awesome to see how sharing and cooperation can better the lives of those who have the hardest time getting by, as so much our movement is made up of those who have had a lot of privilege in the mainstream culture."
Credit unions are also a feature of the solidarity economy.
The workshop, "Guide to a Better Banking System," organized by the Federation of Community Development Credit Unions, spotlighted how they have been hit by the overall financial crisis, when their own national center was caught with securities, supposedly safe AAA investments, that were really based on toxic mortgages. "We'll take a hit,'" said Cliff Rosenthal, "but we'll come through it better than others." He went on to explain the value of credit unions, themselves coops, in meeting the financial needs of local worker and community-base cooperatives.
Rosenthal also led off at the Saturday evening plenary with a short version of the workshop. But the role of credit unions became apparent with the other presenters with him: Van Temple of the National Community Land Trust, which works to develop affordable housing on community-held land; and Nick Regalado of West Virginia's Coal River Mountain Watch, which promotes windmill farms and opposes the "mountaintop removal" method of strip mining coal ravaging the Appalachian highlands. This session concluded with a militant call by Julio Chavez, the former mayor of Trujillo, Venezuela for greater cooperation internationally, and solidarity with the Bolivarian revolutionary process unfolding in his country.
Rejoicing together
A cabaret of solidarity culture closed out the evening with high energy. First was Raging Grannies, a colorful group doing peace and folk songs, and a number of folk singers including Red Valley Fog, Jay Mankita and Ethan Miller. "Brick by Brick", an inner city hip-hop group changed the pace with rap poetry written that day, to much enthusiasm. Finally, a spoken word group read from the writing and speech of famous labor leaders over a span of 150 years, and ended with everyone standing, singing a rousing version of "Solidarity Forever." Among the more grey-haired veterans of labor battles in the 1970s, there wasn't a dry eye to be found.
Sunday was wrap-up day, as people prepared for catching planes. A last round of workshops featured one of Egalitarian Communes led by Bucket von Harmony, and another on "Women Feminism and the Solidarity Economy" with Ethel Cote, Julie Matthaei, and Nedda Angulo of RIPESS. Angulo gave the final plenary a militant call to expand the work on all continents, and to encourage those who could to attend the upcoming RIPESS meeting in Luxembourg.
Throughout the conference, SEN had three "business meetings" on the work of building the organization and the wider network. It agreed to form a new board of directors and a smaller coordinating committee, as well as setting other priorities and refining its message and mission. Quebec's Yvon Poirier summed up the conclusion:
"Back in June 2007, in Atlanta, there were about 40 people in the final meeting, out of the 80 workshops, that decided to go forward. Now there are about 350 or 400 people in the US that know a lot more, and are certainly interested in one way or another, in promoting Solidarity Economy." With scarce resources, it won't be an easy task. But the times demand it, and if the people who gathered in Amherst are any indication, they will rise to the occasion.
US SEN website:
Original article in English
Sub-section titles added by the Editorial Team
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Special thanks to:
Évéline Poirier from Canada for the English translation
Brunilda Rafael from France for the Spanish translation
Michel Colin from Brazil for the Portuguese translation
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Thursday, May 28, 2009
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The Rigalite focuses on the People who lived in Marina...
Love Child
- by Terry147
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- Published: 23 Jun 2016
- Updated: 23 Jun 2016
- Status: In Progress
"Love Child" which tells the story of Abigail Martin. George Martin Is in love with Ellen Forrester and they want to get married but the outbreak of WW1 makes Ellen hesitate and after a night of passion she finds herself pregnant. She is forced to give up the child for adoption after George is killed. She has to look after her sick mother and her younger brother. Read what happens in this fascinating story of love, murder, and intrigue. the story will take you from 1920 -1973
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Figure. Contributions of demographic changes and mental health care components to increases in mental health care spending in Florida Medicaid from fiscal years 1996 and 1997 to fiscal years 2004 and 2005. Data are adjusted for demographic factors, mental health comorbidities, and physical comorbidities.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Fullerton CA, Busch AB, Normand ST, McGuire TG, Epstein AM. Ten-Year Trends in Quality of Care and Spending for Depression1996 Through 2005. Arch Gen Psychiatry. 2011;68(12):1218–1226. doi:10.1001/archgenpsychiatry.2011.146
© 2018
Context During the past decade, the introduction of generic versions of newer antidepressants and the release of Food and Drug Administration warnings regarding suicidality in children, adolescents, and young adults may have had an effect on cost and quality of depression treatment.
Objectives To examine longitudinal trends in health service utilization, spending, and quality of care for depression.
Design Observational trend study.
Setting Florida Medicaid enrollees, between July 1, 1996, and June 30, 2006.
Patients Annual cohorts aged 18 to 64 years diagnosed as having depression.
Main Outcome Measures Mental health care spending (adjusted for inflation and case mix), as well as its components, including inpatient, outpatient, and medication expenditures. Quality-of-care measures included medication adherence, psychotherapy, and follow-up visits.
Results Mental health care spending increased from a mean of $2802 per enrollee to $3610 during this period (29% increase). This increase occurred despite a mean decrease in inpatient spending from $641 per enrollee to $373 and was driven primarily by an increase in pharmacotherapy spending (up 110%), the bulk of which was due to spending on antipsychotics (949% increase). The percentage of enrollees with depression who were hospitalized decreased from 9.1% to 5.1%, and the percentage who received psychotherapy decreased from 56.6% to 37.5%. Antidepressant use increased from 80.6% to 86.8%, anxiety medication use was unchanged at 62.7% and 64.4%, and antipsychotic use increased from 25.9% to 41.9%. Changes in quality of care were mixed, with antidepressant use improving slightly, psychotherapy utilization fluctuating, and follow-up visits decreasing.
Conclusions During a 10-year period, spending for Medicaid enrollees with depression increased substantially, with minimal improvements in quality of care. Antipsychotic use contributed significantly to the increase in spending, while contributing little to traditional measures of quality of care.
Depression affects almost 1 in 5 adults in the United States during their lifetime1 and has significant personal and societal costs.2 Untreated depression is associated with significant clinical morbidity and worsens the morbidity of other chronic diseases.3 Depression results in increased health care use and costs,4,5 incurs significant emotional difficulties and lost work productivity,6-8 and is linked to premature death.9
During the 1980s and 1990s, the number of adults diagnosed with and treated for depression increased, and the modality of treatment shifted. The percentage of adults with depression who received antidepressants increased, and the percentage who received psychotherapy or were hospitalized for depression decreased.10 As a consequence of the shift away from psychotherapy and hospitalization, estimates of the mean cost per treated patient decreased.11 The introduction of selective serotonin reuptake inhibitors and other new antidepressants (such as bupropion hydrochloride, venlafaxine hydrochloride, etc) contributed to these treatment trends. The newer medications have a lower incidence of potentially fatal adverse effects at high therapeutic levels and interactions with commonly consumed foods than previously available antidepressants and allowed primary care physicians to have a larger role in assessing and treating depression.12 Despite the more common use of antidepressant medications for depression, several studies13-15 examining quality of depression treatment showed generally low performance throughout the 1990s.
In the past decade, multiple developments may have had an effect on spending and antidepressant use for the treatment of depression. Beginning in 1999, the selective serotonin reuptake inhibitors and other new antidepressants like bupropion began to come off patent, potentially lowering cost of care and further increasing use as generics became available.16 The Food and Drug Administration approved new antidepressants for the treatment of depression, including escitalopram oxalate in 2002 and duloxetine hydrochloride in 2004, as well as multiple new formulations of previously approved medications (eg, extended-release bupropion). After gaining approval in 1997, direct-to-consumer advertising of antidepressants may have increased the acceptance and use of these medications.17 In 2004, the Food and Drug Administration issued warnings about the increased risk of suicidal thoughts among children and young adults receiving treatment with selective serotonin reuptake inhibitors, likely decreasing the use of antidepressants in children, with some possible spillover to use in adult populations.18
In this study, we examined changes in depression health service utilization, spending, and quality of care between July 1, 1996, and June 30, 2006, in a Medicaid program from a large and diverse state (Florida). We addressed the following questions: (1) How have health service utilization trends changed over time? (2) How have the different components of mental health care spending (inpatient, outpatient, and pharmacotherapy) changed? (3) Has there been any improvement in the quality of depression care?
We used administrative data (eligibility and claims files) from Florida's Medicaid program for fiscal years 1996 through 2005 (Florida's Medicaid fiscal year runs from July 1 to June 30). We restricted our analyses to these years because Florida moved large numbers of Medicaid enrollees into prepaid mental health plans that may not reliably report encounter data beginning in fiscal year 2006. Through fiscal year 2005, Florida's Medicaid program was primarily fee-for-service, had enrollment ranging from 2.1 to 2.9 million persons, and was the fourth largest in the United States.19 Florida's Medicaid data include information on enrollees' age, sex, race/ethnicity, Medicaid eligibility category, clinical diagnoses, health service utilization (including pharmacotherapy), and spending.
We identified annual cohorts of adults with depression consisting of enrollees aged 18 to 64 years having 1 or more hospitalizations with a principal diagnosis of depression or having at least 2 outpatient claims of depression (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM ] code 296.2, 296.3, 300.4, or 311) on different days.15,20-23 A limitation of claims data is that there could be false-positives and false-negatives in establishing the cohort. Prior research has shown that using a less stringent algorithm for identifying depression in administrative data is associated with a high specificity (ie, low false-positive rates) but at the expense of sensitivity (ie, higher false-negative rates).24 The implications of the use of this algorithm are that our cohort is likely to have few false-positive results but that many enrollees who may have depression were excluded from our cohort. For these individuals, we cannot say anything about their health service utilization or quality of care. Enrollees were excluded if they were enrolled for fewer than 10 months of the fiscal year or were enrolled through family planning services. In addition, enrollees were excluded if they were dually eligible for Medicare or were enrolled in a health maintenance organization or prepaid mental health plan at any time during the fiscal year because of the possibility of incomplete encounter data. We also excluded enrollees who received a diagnosis of schizophrenia (ICD-9-CM code 295) or bipolar disorder (ICD-9-CM codes 296.0-296.1, 296.4-296.8, or 301.13) during the fiscal year because we would expect their treatment patterns to be defined by their primary mental health diagnoses. A summary of these exclusions is given in eTable 1.
Results of patient characteristics, outcome measures, and statistical analyses were obtained separately within each fiscal year for each enrollee. Findings are presented as 2-year means to minimize year-to-year fluctuation.
We used files from Florida Medicaid to identify enrollees' age, sex, race/ethnicity, and Medicaid eligibility category. For race/ethnicity, we combined Hispanic and other race/ethnicity categories, because before 1999, enrollees who were eligible for Medicaid via Supplemental Security Income only were included in race/ethnicity categories of black, white, and other.25,26 We identified the following 4 subtypes of depression (ICD-9-CM codes): major depressive disorder with psychosis (codes 296.24 and 296.34), major depressive disorder without psychosis (codes 296.20-296.23, 296.25-296.26, 296.30-296.33, and 296.35-296.36), and other depression, which includes depression disorder not otherwise specified (code 311) and dysthymia (code 300.4). We assigned 1 of 4 subtypes to each enrollee with depression via the hierarchy already given. In other words, if an enrollee had claims for both other depression and major depressive disorder without psychosis, we identified that enrollee as having major depressive disorder without psychosis. We identified individuals having comorbid anxiety or adjustment disorder (codes 300.0-300.3, 300.5-300.9, and 308.0-309.9), comorbid substance use disorders (codes 291-292 and 303-305), or other comorbid mental health condition (codes 290-319, excluding the aforelisted diagnoses) if they had at least 1 ICD-9-CM code indicating the condition within the fiscal year. In addition, because of the high levels of physical comorbidity in depression, we identified individuals having the following comorbid physical illness, defined as the presence of relevant ICD-9-CM codes for 1 or more of the following: human immunodeficiency virus or AIDS, diabetes mellitus, hypertension, back or joint pain, and chronic obstructive pulmonary disease or asthma. These conditions were chosen because they were the most common chronic medical conditions in our cohort. We identified individuals being treated by a psychiatrist if they had 1 or more claims submitted by a psychiatrist during the fiscal year.
We examined the proportions of enrollees with depression who had an inpatient hospitalization, psychotherapy visits, or pharmacotherapy with antidepressants or other mental health medication classes. We examined medication class utilization by depression type. Numerators were defined as the number of enrollees who received the health service for the given year, and denominators were defined as the total number of eligible enrollees with depression.
We tabulated the total annual health care spending and the mental health care spending for each enrollee. We categorized mental health care spending as inpatient, outpatient, or pharmacotherapy expenditures. For each category, we summed the amount paid in claims. For enrollees who were enrolled for only 10 or 11 months of the fiscal year, we annualized the claims. Using the southern region medical care component of the consumer price index, we adjusted the dollar amounts to fiscal year 2005 US dollars.
We classified a claim as being for mental health if it met any of the following criteria: (1) the procedure code was mental health specific, (2) the place of service was mental health specific, (3) a mental health diagnosis was present, or (4) the provider was a mental health specialist. Claims were then categorized as inpatient, outpatient, or pharmacotherapy expenditures. Inpatient stays included only admissions with a mental health diagnosis reported as the primary diagnosis. Any mental health claims that occurred during the period of hospitalization were included in the inpatient claims. We further categorized outpatient spending as psychotherapy, other physician or clinic visits, and other outpatient services (eg, case management, treatment planning, psychosocial rehabilitation, day treatment programs, laboratory testing, and other outpatient wraparound services). Claims that included coding for both psychotherapy and pharmacotherapy (eg, ICD-9-CM codes 90805, 90807, and 90809) were categorized as psychotherapy for the spending and health service utilization measures. Mental health pharmacotherapy claims were examined in aggregate and by mental health medication class. Medication classes examined included antidepressants, antipsychotics, antianxiety medications, and other mental health medications (the specific classification is given in Appendix).
Published guidelines recommend treatment during both acute-phase and continuation-phase episodes.27 In this study, we focus on acute-phase measures. We identified individuals from our cohort having a new acute-phase episode of depression if they entered outpatient treatment with no previous claims for mental health diagnoses for the previous 120 days and no antidepressant claims between 31 and 120 days before the initial diagnosis (given that some patients may receive medication before actually seeing the physician) or if they were discharged from an inpatient hospitalization with a principal diagnosis of depression.
We defined acute-phase episodes as lasting 112 days (16 weeks). We used this period to accommodate response to treatment and inefficiencies that can occur in usual care. The index date of the acute-phase episode was defined as the date of the first depression diagnosis or the first day after discharge from the hospital. Our quality-of-care measures are informed by prior research and published guidelines. For individuals who filled an antidepressant prescription within 30 days of the index date, we defined adequate drug treatment as receiving 75% or more days of antidepressant use from the first antidepressant fill to the end of the acute-phase episode28,29 and adequate follow-up as 3 or more follow-up visits during the acute-phase episode.30 For individuals who received psychotherapy within 30 days of the index date, we defined minimally adequate psychotherapy as 4 or more visits during the acute-phase episode, based on previous studies.13,21,31,32 Finally, for individuals being discharged from a psychiatric hospitalization for depression, we defined the following 2 measures to examine adequate follow-up visits: the receipt of an ambulatory mental health visit within 7 days or 30 days of hospital discharge (based on measures in the Healthcare Effectiveness Data and Information Set). Numerators for these quality end points were the number of eligible acute-phase episodes that met the definitions already given, and denominators were the number of eligible acute-phase episodes. Individuals who were not continuously enrolled for the acute-care episode were excluded (5.5%), as were individuals who were hospitalized during the acute-care episode (6.8%). Episodes that spanned fiscal years were included in the fiscal year of the index date.
We first described the demographic characteristics of enrollees identified as having depression for the first 2 and last 2 fiscal years of the 10-year period studied. We compared changes in demographic characteristics using theχ2 test for categorical data and the t test for continuous data.
We then examined unadjusted trends in health service utilization, spending, and quality of care during the 10-year study period. We report trends over 10 years in the mean total health care spending, mental health care spending, mental health component spending, and pharmacotherapy spending by mental health medication class. We calculated the percentage increase in spending after combining the first 2 and last 2 fiscal years of the 10-year period studied to minimize the effect of year-to-year fluctuation. As a supplement to unadjusted spending data, we adjusted each spending category for changes in underlying demographics (age, sex, race/ethnicity, and Medicaid eligibility category) and medical and psychiatric comorbidities using a linear generalized estimating equation clustered on individuals to estimate spending.33 We present the percentage of the unadjusted changes that are attributed to demographic changes over time, as well as the remaining contributions of each spending category, adjusted for changing demographics. Finally, we describe trends in quality of care and test for trends using the Cochran-Armitage trend test.
The number of enrollees with depression identified annually varied from 8970 to 13 265, with more enrollees identified toward the end of our study period. The rate of identified depression remained constant and was 5.6% in fiscal years 1996 and 1997 and 5.7% in fiscal years 2004 and 2005. Many enrollees were identified in more than 1 annual cohort. The total number of unique individuals identified with depression in our study period was 56 805. There were 107 931 observations over 10 years. Demographically, the racial/ethnic makeup of our sample changed during the study period to include a larger proportion of patients with identified depression who are of Hispanic or other race/ethnicity (Table 1). This change in demographics likely reflects the change in the Social Security Administration's definition of race/ethnicity and an increase in the Hispanic population in Florida.34,35 The percentage of our sample who had major depressive disorder with psychosis increased over this period. In addition, the percentage who had other forms of depression increased but remained a small portion. The percentage of our sample who had comorbid anxiety or adjustment disorder diagnoses decreased, and the percentage with substance use disorders increased. Except for human immunodeficiency disorder or AIDS, all other physical comorbidities increased during this time. The percentage of enrollees with depression treated by a psychiatrist decreased over this period.
During the period studied, the percentage of enrollees with depression who received psychotherapy decreased from 56.6% to 37.5%, and the percentage who were hospitalized decreased from 9.1% to 5.1% (data not shown). In contrast, the percentages of enrollees with depression who filled prescriptions within any mental health medication classes remained the same (antianxiety medications) or increased (antidepressants, antipsychotics, and other mental health medications) during this period (Table 2). Trends were similar for all subtypes of depression. Of particular note are the increases in antipsychotic use for all subtypes of depression, not just major depressive disorder with psychosis.
After adjusting for inflation, demographics, and medical and psychiatric comorbidities, spending for mental health treatment increased 29% during the study period, from $2802 to $3610 (Table 3). Spending for inpatient mental health care decreased 42%, while spending for outpatient visits increased 21%. Spending for other physician or clinic visits and other outpatient services increased more than spending for psychotherapy.
Spending on mental health pharmacotherapy increased 110% during the 10 years studied (Table 3). Spending for antidepressants increased 22% over the 10-year period and peaked in fiscal years 2000 and 2001. Spending on antianxiety medications decreased substantially during the study period despite no change in their use. By contrast, spending on antipsychotics (up 949%) and other mental health medication classes (up 328%) increased dramatically. By the end of the 10-year period, the mean spending on antipsychotics ($860) surpassed the mean spending on antidepressants ($557). Among antipsychotics, spending on quetiapine fumarate was greatest, followed by risperidone.
Compared with unadjusted data, adjusting for patients' demographic and clinical characteristics decreased the change in total mental health care spending from $1134 to $808 (Table 3 and eTable 2). Spending on inpatient, outpatient, and pharmacotherapy expenditures shows similar patterns between adjusted and unadjusted estimates. The increase in antipsychotic use seemed to contribute most to increased spending for mental health care, and the decrease in inpatient spending seemed to contribute most to decreased overall mental health care spending (Figure).
We identified 2523 outpatient acute phases in fiscal years 1996 and 1997, with 2836 in fiscal years 2000 and 2001 and 3017 in fiscal years 2004 and 2005 (Table 4). The percentage of acute-phase episodes that were treated with antidepressants increased from 65.1% to 75.2% during this 10-year period. In contrast, the percentage of acute-phase episodes that were treated with psychotherapy decreased from 42.6% to 26.9%.
Among patients who received pharmacotherapy, the proportion who received minimally adequate drug treatment increased slightly over time from 58.7% to 68.2% (P < .01), and the proportion who received minimally adequate follow-up visits decreased from 19.4% to 10.9% (P < .01) (Table 4). Among outpatients who received psychotherapy, the proportion who received at least 4 sessions within the acute phase fluctuated between 9.5% and 14.3% (P = .35).
We identified 1028 posthospitalization acute phases in fiscal years 1996 and 1997 with 1310 in fiscal years 2000 and 2001 and 1252 in fiscal years 2004 and 2005 (Table 4). The proportion of acute phases that included antidepressant use within 30 days of discharge did not change significantly during the 10 years studied. The proportion of acute phases that included psychotherapy use decreased from 32.3% to 18.6% (P < .01).
Among posthospitalization acute phases that included antidepressant use, the proportion with minimally adequate drug treatment increased from 41.5% to 48.7% (P < .01), and the proportion with minimally adequate follow-up visits decreased slightly from 35.3% to 30.1% (P = .02) (Table 4). The proportion of posthospitalization acute phases that included 4 or more sessions of psychotherapy during the acute phase fluctuated between 22.6% and 36.9% during the period studied (P = .02). Finally, the proportion of posthospitalization acute phases that included a follow-up visit within 7 days or 30 days remained low, with no significant trend. An examination of continuation-phase measures showed similar trends of an increase in antidepressant use, with no significant change in minimally adequate follow-up visits (eTable 3).
We examined treatment of patients with depression, including health care spending and quality of care, in Florida Medicaid between 1996 and 2005 and had 4 notable findings. First, there was a 29% increase in mental health care spending per enrollee with depression, after adjusting for inflation and changes in patients' demographic and clinical characteristics. Second, this increase occurred despite decreases in inpatient costs per enrollee. Third, spending on pharmacotherapy increased by 110%, with the bulk of that increase due to antipsychotic use rather than antidepressant use. Fourth, despite the increased expenditures, there were mixed changes in the quality-of-care measures that we studied: antidepressant use improved slightly over the 10-year period, psychotherapy utilization fluctuated, and follow-up visits decreased.
Because of prior trends showing reductions in the use of inpatient services and psychotherapy, as well as the introduction of generic newer-generation antidepressants, we expected to find decreasing expenditures per enrollee with depression. Nevertheless, we found the opposite, with increasing use of antipsychotics being the largest contributor to rising costs. Because our sample does not include individuals with comorbid schizophrenia or bipolar disorder, this increase in antipsychotic use is particularly notable.
During the period of this study, the use of adjunctive antipsychotics was recommended for the small portion of patients with depression who also experience psychotic symptoms36 and as one of several augmentation strategies for individuals with limited or poor response to antidepressants alone.37 Antipsychotics may also have been used off label to treat anxiety38 or insomnia,39 particularly in those for whom alternative treatments may not be appropriate (eg, benzodiazepines in patients with substance use disorders). Our data show an increase in antipsychotic use within all subtypes of depression. Furthermore, one would expect the more recent Food and Drug Administration approvals of aripiprazole (2007) and quetiapine extended-release tablets (2009) as adjunctive treatment to antidepressants for major depressive disorder to accelerate this trend.
In our adjusted analyses, we controlled for comorbid substance use disorders and anxiety or adjustment disorder; therefore, it seems unlikely that changes in clinical case mix accounts for the widespread (and growing) use of antipsychotics in patients who are being treated for depression. Our results are consistent with other research finding that the introduction of atypical antipsychotics has expanded the indications for which antipsychotics are prescribed.40 Given the risk of metabolic adverse effects associated with several of the atypical antipsychotics,41 including the most commonly used antipsychotics in this study, the large effect this use has on potential morbidity and on costs of care underscores the need for the development of targeted guidelines to address antipsychotic use for individuals with depression, as well as cost-effectiveness studies examining antipsychotic use in treatment-resistant depression.
The juxtaposition of increased mental health care spending per enrollee without a substantial improvement in depression quality of care is striking. Although public reporting of quality measures has led to greater improved performance for many aspects of care, quality performance for depression has improved more slowly and remains less than optimal. In general, Medicaid enrollees receive lower-quality care,42 as do individuals with severe mental illness.43 Factors affecting the quality of care for depression can be classified into informational and attitudinal variables, financial barriers, and lack of profitability.44 Our data suggest gains in acceptance of antidepressant and antipsychotic treatment by patients and providers, potentially reflecting the effective marketing of both types of medications by pharmaceutical companies. Despite these gains, the receipt of quality measures for depression remained low. This study does not explore the reasons for this ceiling. Results of past studies45,46 have suggested that individuals may view treatment of mental illness as less important than physical illness and may fear mental health medications as being addictive and possibly interfering with natural emotions. Collaborative care models have been identified as one of the most effective approaches to improving quality of depression care and outcomes47; however, the diffusion of this model has remained limited, partially as a result of the limited funding for costs related to these models.48 Finally, the small rise in antidepressant spending could correspond to longer periods of treatment with antidepressants, as has been shown in other research49; however, this change would not be reflected in the quality measures examining acute episodes of depression or in simple rates of utilization.
To our knowledge, this study is the first to focus simultaneously on changes over time in health service utilization, spending, and quality of care for patients with depression. Although findings from prior studies11,50 have examined spending up to 2007, they have not examined changes in cost per person past 2000 or by individual drug classes. Our results are consistent with prior studies11,51,52 of overall mental health care spending showing higher expenditures for pharmacotherapy and lower expenditures for inpatient care. Past studies53,54 focusing on the use of antidepressants and other psychoactive medications through 2005 have documented increased use of antidepressants, increased use of antipsychotics for patients taking antidepressants, and decreased use of psychotherapy for patients taking antidepressants. Unlike our study, these studies did not look specifically at a population of patients with depression. Our longitudinal results of little change in quality of depression care are consistent with prior investigations in the Veterans Administration system55 and with limited changes in national Healthcare Effectiveness Data and Information Set measures over time.56,57 Our findings of increased use of medications coupled with similar or decreased use of mental health visits or psychotherapy are also consistent with literature documenting utilization trends for depression50 and for other psychiatric illnesses.58-60
There are several limitations to this study. Our claims data include information on diagnoses and health services for patients who have been identified and treated for depression. They do not reflect population prevalence of depression because many individuals in the population may go undiagnosed and not be reflected in claims data. Our quality measures were based on process measures derived from guidelines and prior research; however, we were unable to assess patient outcomes. As a result, we could not determine whether the increased use of antipsychotics in patients with depression was associated with improved outcomes. Also, our costs reflect total mental health and substance abuse costs for the year, and we did not attempt to separate out costs attributable to psychiatric comorbidities. We thought that the strength of using an observational sample was the ability to capture total spending associated with depression care, which may include spending on comorbid diagnoses. For example, if an individual was being treated for anxiety or substance use and then received a diagnosis of depression a month later, it would be difficult to parse out what elements of the previous spending were related to anxiety, substance use, or depression. Furthermore, we controlled for changes in prevalence of comorbidities in the model. There is a possibility that during the 10 years studied, coding completeness or upcoding of data occurred at different rates. To our knowledge, there were no changes in Florida Medicaid policy that would have incentivized upcoding, and we mitigated this issue to the extent possible by examining only fee-for-service enrollees and categories of spending.
Our analysis stops in June 2006 (the end of fiscal year 2005) and may not accurately reflect current practice. Since this time, more drugs similar to previous drug classes have been approved (desvenlafaxine succinate and bupropion), as well as a new medication class (vilazodone). Furthermore, the availability of generics continues to increase. Concurrent release of new antidepressant formulations with the release of more generic versions of existing antidepressants also occurred during our study period. In addition, the Food and Drug Administration has approved 2 atypical antipsychotics for adjunctive use in treatment-resistant depression since this study. We would anticipate that this development could accelerate the trends in antipsychotic use and spending that we observed in this study.
Finally, we have data from only a single state, and the Medicaid enrollees in our study may not be representative of those in other Medicaid programs or of privately insured patients given their high levels of disability, comorbidity, and low socioeconomic status. Studies have shown that Medicaid enrollees have higher rates of depression61 and antipsychotic use62 compared with commercially insured populations. At the same time, Medicaid enrollees often receive lower quality of care over a range of quality measures.42 Therefore, these results may overstate national trends in spending and medication use, while understating trends in quality metrics. Nonetheless, examining spending and quality of care within the fourth largest Medicaid population is important, as public insurance continues to cover a greater percentage of mental health and substance abuse costs over time and is anticipated to further expand under the 2009 Patient Protection and Affordable Care Act.52,63,64
In summary, during the 10-year period between 1996 and 2005, we found a substantial increase in spending for patients with depression, with minimal improvements in quality of care. Much of the increased spending was owing to pharmacotherapy, especially the use of antipsychotics. Our findings underscore the importance of continued efforts to improve quality of care for individuals with depression, as well as the need to understand the efficacy and cost-effectiveness of using antipsychotics for the treatment of individuals with depression in the general community.
Correspondence: Catherine A. Fullerton, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (firstname.lastname@example.com).
Submitted for Publication: December 23, 2010; final revision received June 2, 2011; accepted June 4, 2011.
Financial Disclosure: None reported.
Funding/Support: This work was supported by grants R01-MH081819 and K01-MH071714 (Dr Busch) from the National Institute of Mental Health.
Additional Contributions: Christina Fu, PhD, provided programming expertise, and Laura Cowieson, BA, and Kristen Bolt assisted with research.
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It is possible that the main title of the report Erythrokeratodermia with Ataxia is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.
Erythrokeratodermia with ataxia (EKDA) is a hereditary disorder of the skin and nervous system (neurocutaneous syndrome) characterized by groups of hard, red plaques that develop during infancy and childhood. When these skin lesions heal, the disorder seems to become dormant for several years, after which the neurological symptoms and signs emerge in the form of a typically awkward gait (ataxia) when the affected individual is around 40 years of age or older.
Many researchers active in the study of the family of diseases known as the ichthyoses consider EKDA to be a variant of an ichthyotic disorder, erythrokeratodermia variabilis (EKDV). However, there is no general consensus on this at this time.
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Mark Roalfe
Chairman and founder,
Rainey Kelly Campbell Roalfe/Y&R
When Campaign called me and asked if I could write Private View, they said it was a bit of a mixed bag, but there was one outstanding piece.
Now, I've had a look through all the work and it's not such a bad mix of work at all - actually, there are a couple of pieces that are rather good. So, now I'm worried. Am I going to pick a different ad from Campaign?
First, let's start where I really hope Campaign and I can agree. The new campaign for Tourism Ireland (3) is not one of my favourites of this week's picks. It is an online film that comes from quite an interesting strategy: that a holiday in Ireland is a good alternative to the hell that will be London transport this summer. And, as someone who spent two hours on the A40 this morning while they opened the Olympic lane, I get it. However, the execution lacks a bit of Irish charm.
Next is a spot for Virgin Media. It's the latest in the "keep up" campaign, this time talking about its new TiVo box. Now, I have to put my hand up and say that I have more than a passing interest here, as we used to work on Virgin Media and know how hard it is to land all the brilliant things on TiVo. This piece, with the evercharismatic Stephen Fry, does a pretty good job.
The McDonald's "just passing by" was a great piece of advertising. Its new spot for the Olympics builds on that same tone and feel. I know there has been a lot of controversy about whether or not McDonald's should be allowed to be an Olympic sponsor at all, but this ad is beautifully observed and the voiceover oozes all the wit of the original.
There is another short film for Shift.ms, the multiple sclerosis charity. It is a love story that takes us on the emotional journey of someone coming to terms with the early stages of MS. It's a really touching piece that does challenge perceptions with the lightest of touches and some fine writing. My worry here is the same as I have with a lot of these short films: do people really have enough time in their busy day to watch them?
Now we are coming to the part where I feel I may fail Campaign's test. I think the next piece from Credit Suisse was their Pick of the Week a couple of weeks ago. It's another short film, this time advertising Credit Suisse's sponsorship of a new exhibition at The National Gallery. The plot is pretty out there. A man sees Anna Friel naked in the bath and gets all horny. She then eats him at a dinner party. This is apparently inspired by Titian's famous Diana And Actaeon. It's a very cool piece of film. Whether or not anyone watches it, I have no idea. However, I'm sure those award juries with a bit of time on their hands will love it.
Finally, to my favourite of this week's picks: the Channel 4 trail for the Paralympics. When I first started watching this, I was a little cynical. It has some Paralympians doing their stuff to a great track by Public Enemy. Then the film changes direction and shows us the devastating moments they became disabled. It's a very powerful and moving piece of film, brilliantly edited and put together. And the thought of "meet the superhumans" is truly excellent. As you may have gathered, I think it is very, very good. I hope you did too, Campaign.
Dan Shute
Managing partner,
Creature London
Furious? I'm absolutely raging.
I had this all planned. I was going to start by saying that I fully understand how much work goes into the worst ads, but that doesn't make it OK that they exist. I was going to say that I understand the account exec is probably really excited about their first ad getting made, but that doesn't get in the way of it being rubbish. There was going to be a whole thing about how we, as an industry, as suits, strats, creatives and whoever else you care to mention, have to try harder, and we have to accept that "good enough" just isn't good enough. It was going to be one of those Private Views.
And then 4Creative went and made something utterly magnificent and ruined all of that. And now I don't know what sort of Private View it's going to be. We'll see.
So, the five things that aren't the Paralympics spot.
Tourism Ireland (3) has made a thing with Chris O'Dowd. I like him. I'm less fond of this, though, because it's too long, not funny enough and more laden with cliche than a leprechaun dancing a jig in a pint of Guinness. At a ceilidh.
Virgin Media (2) has made an ad with Stephen Fry in it because, God knows, we all needed one of those. It has been ages. (NB. It has not been ages, and we did not need another ad with Stephen Fry in it.)
McDonald's (5) has made an ad. It's all about its in-no-way-inappropriate sponsorship of the Olympics. I like McDonald's and I like its advertising; I'm also very excited about the Olympics, so this one is cheating a little bit. Anyway. Olympics + cheeseburger = Happy Dan = this Private View lark is EASY.
Credit Suisse (4). I'll be honest, I shuddered before I clicked on the link for this one (I'm only human). But I needn't have worried, because it's not an ad for an investment bank, it's an ad for an investment bank's sponsorship of The National Gallery, and it has got Anna Friel in it, and it's creepy and beautiful and really rather wonderful, so you can all just chill out, yeah?
And Shift.ms (6). It's ten minutes long. Am I allowed to be rude about advertising for such a good cause? Probably not. Oh, well. It's a classy piece of film, but I'm not entirely sure I'd have watched all of it if I didn't have to - and that's a pity.
And, so, the main event - Channel 4 (1). The caveats first: they've got the luxury of making it as long as it needs to be, not as long as the media agency can afford it to be, and I can't fight the feeling that it would have been better (screw you, I'm demanding) if they'd given the backstory moments a little bit more time, but, let's be honest, I'm being churlish.
This is advertising as it should be. It's brave, it's gut-wrenching, it's long, but there's not a wasted shot in there. The writing is brilliant, the cinematography is brilliant, the performances are brilliant and the music is REALLY brilliant. And, as the slew of anodyne, saccharine, BORING Olympics-related work that we're currently being subjected to demonstrates, there isn't even a "well, it's an easy brief, innit" excuse. They've just nailed it.
So, I'm still furious. But largely because somebody has made an ad that I wish I'd made. And that's probably a pretty good thing.


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Grand Theft Auto IV Walkthrough
|Trespass (cont.)
The next few floors of this disheveled factory are easy enough to climb. There are two floors that you have to climb up (via debris, just like before), and there are plenty of enemies standing in between you and your ultimate destination. The enemies here are armed with a variety of weapons, from pistols to automatic rifles, so take cover as best you can (there's plenty of it around) and make sure to collect their guns when dropped. You're absolutely going to need their assault rifles for a little later (you'll see why), so make those a priority to grab.
After climbing the second debris pile, you'll see your target with a red arrow over his head (he's also represented as a red dot on the HUD). He'll bust out a nearby window, leaving his henchmen to deal with you. There's no rush here, so take it easy and methodically take out all of the enemies you encounter, remembering to grab their gear as you proceed. Then, you'll be able to emerge from the window, where you will be fighting on the roof. Don't bother pointing your gun at the main target, as you won't be able to hurt him or stop him from getting to his location. Instead, work your way towards his location each time you see him, killing enemies in between you and him. There are a few ladders to climb as well, so if you're at a loss as to how to proceed, simply seek out a ladder to climb to higher and higher areas.
If you follow the basic aforementioned techniques, you'll have no trouble eventually catching up with your mark, who will make an attempted overly-grand getaway on a helicopter. You'll have to take down the helicopter, which seems like a daunting task if you don't have an RPG in your inventory (and chances are, you don't), but this is exactly why we told you to be mindful of grabbing assault rifles dropped by dead enemies. With this powerful weapon, you can pummel the enemy helicopter, which takes off extremely slowly (you can shoot the gunner in the helicopter, but not your mark). Concentrate your fire on the rear rotor of the chopper. A clip or two of concentrated fire on it will set it ablaze, and the helicopter will crash back into the factory, taking your mark with it. This will end the mission in success, but don't be too hasty about leaving this area. You're high up, so climb down slowly!
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I think you do it a diservice calling it tree-trunk style - I would say more like a rouched drape / Austrian Blind. My guess late 40s / early 50s going by the style. What I call Hollywood style.
I would guess Italian from the graceful gold surface finish.
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text:
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ExactSpy-Cell Phone Conversation Recorder App
If your target device is an iPhone or Android and you want to be able to listen to their device surroundings from the safety of your ExactSpy online account then you need to record the surroundings using ExactSpy-Cell Phone Conversation Recorder App ambient recording feature.
– Record the device surroundings without needing the TARGET device physically
– Save the recording to your computer for easy reference
– Remain hidden at all times
– Specify the duration of the recording to suit you and your schedule
– Record from 5 minutes up to 1 hour at a time
Listen and record the device's surroundings from your computer at any time. Just Click on the button Start on your control panel (my.exactspy.com) and you will be able to listen what is happening around your device immediately. All the audio will be stored in a MP3 file to allow you download them lately.
Why You Need To ExactSpy-Cell Phone Conversation Recorder App
You want to record the surroundings but you want to stay hidden. You also have a busy schedule on top of monitoring someone so what can you do to make sure you stay hidden but do not miss out on a thing?
It never used to be this easy but ExactSpy understands that people are busy and do not have time to monitor someone all the time but, most importantly, they want to remain hidden and that is what led to us creating ExactSpy-Cell Phone Conversation Recorder App ambient recording feature.


text:
(Updated 7:55 am) -- LODGE GRASS, Mont. (AP) - The FBI says it's still trying to piece together what led to the fatal shooting of three people on Montana's Crow Reservation after the arrest of the suspected gunman Wednesday night in Washington state.
Sheldon Bernard Chase was arrested without incident in Spokane, Washington. The FBI says he's suspected of using a rifle Tuesday afternoon to kill his grandmother, 80-year-old Gloria Sarah Goes Ahead Cummins; his cousin, 21-year-old Levon Driftwood; and Driftwood's boyfriend, 20-year-old Rueben Jefferson.
Schools on reservations in southeastern Montana and western North Dakota were closed and residents stayed indoors for safety during the search for Chase.
The FBI's supervisor in Billings, Eric Barnhart, says Chase has a history of mental illness.
The shootings happened at Cummins' home about 10 miles outside Lodge Grass, a town of 500 people near the Wyoming border.


text: This graphic demonstrates how the plug-in handles failover. When the Microsoft Internet Information Server Plug-In attempts to connect to WebLogic Server, the plug-in uses several configuration parameters to determine how long to wait for connections to the WebLogic Server host, and, after a connection is established, how long the plug-in waits for a response. If the plug-in cannot connect or does not receive a response, the plug-in attempts to connect and sends the request to other WebLogic Servers in the cluster. If the connection fails or there is no response from any WebLogic Server instance in the cluster, an error message is sent.


text:
Computer Sciences Corp.'s new president and CEO, Mike Lawrie, is putting his imprint on the senior management team with several new appointments announced today.
The moves are a key step to executing the company's turnaround strategy, according to the June 5 CSC announcement.
The leadership appointments include:
David Zolet takes over as president of the North America Public Sector, succeeding James Sheaffer, who will be retiring later this month.
Zolet has served as president of CSC business development for the sector and has held leadership positions at IBM Corp. and Northrop Grumman Corp.
He will be responsible for overseeing NPS operations focused on strengthening cost and profit management disciplines. Zolet will report to Lawrie.
Gary Budzinski is now president of global infrastructure services.
He joins CSC from Hewlett-Packard Co., where he was senior vice president and general manager of HP's $12 billion technology services business unit.
He also will report directly to Lawrie.
Sunita Holzer has been named chief human resources officer responsible for overseeing all aspects of CSC's global human resources.
She will join CSC on June 18, reporting directly to Lawrie.
Holzer comes from the Chubb Group for Insurance Companies, where she was chief human resources officer. She has held executive HR positions at GE Capital Corporate, American Express and AIG.
"These individuals were chosen not only for their knowledge and skill, but for their track records in managing key functions during enterprise transformations," Lawrie said in the announcement. "I am committed to appointing leaders who are decisive, accountable and results-oriented and, above all else — those who uphold a deep sense of values. I look forward to working with these leaders as we move forward with our turnaround strategy to drive the performance our stakeholders expect of CSC."
CSC, of Falls Church, Va., ranks No. 11 on Washington Technology's 2011 Top 100 list of the largest federal government contractors.
About the Author
David Hubler is the former print managing editor for GCN and senior editor for Washington Technology. He is freelance writer living in Annandale, Va.
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CSC does need a lean organization, but that can be accomplished in part with increased agility by empowering staff while holding them accountable. An example of James Scheaffer's approach to cutting costs was requiring his approval on all overhead travel in excess of $500. For the president of a 16,000 person organization to approve such expenses is crazy. Empowering and holding accountable subordinates will hopefully be the new order. However, a reorganization in the Federal Consulting Practice saw a major reorganization without any discussion with those having knowledge of some of the areas being reorganized. It remains to be seen if the lack of collaboration, and resulting myopic view of the technology world, will impede the new CEO's efforts.
Interesting appointments, but all of the new people are deeply dipped in government or bureaucratic kinds of fat organizations. CSC needs lean orgs and lean people. They will continue to lose share and have problems with some of their programs, in my opinion.
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During the past year, certain events have occurred in the fitness industry that give me hope that we will see more growth next year. The dark cloud that has hung over the industry for the past two or three years seems to be lifting.
Not that turbulence has completely left the industry and not that some negative events did not occur this year, but why focus on that and bring ourselves down when we finally have a few things to be happy about?
So what did I find to be the most hopeful trend in 2011? Two contenders: the improved revenues of some of the largest public companies (health clubs and manufacturers) and the acquisition flurry we saw at the end of the year. Even though most of the club companies and manufacturers are not back to their pre-recession revenue levels, a movement upwards is cause for celebration. And the acquisitions in the last half of the year—LA Fitness bought 171 Bally Total Fitness clubs, Life Time Fitness bought four (and possibly more) Lifestyle Family Fitness clubs and Equinox bought the four Sports Club/LA clubs from the Sports Club Co.—show that some major money is available to some of the top club companies, and they are making use of it. (Although LA Fitness got a truly sweet deal at under $1 million per Bally club.)
Both of these trends offer hope for a turnaround as we enter 2012.
But another hopeful event occurred this year that did not get a lot of press because it was a quiet event for a specific audience. In October, we held our first annual CEO Summit at the Club Industry conference. Forty CEOs from some of the most profitable and best-known commercial, corporate and hospital-based fitness facilities around the country came to learn and share. Where else would you find CEOs such as Carl Liebert of 24 Hour Fitness, Mike Sheehan of Bally Total Fitness, Jim Snow of Gold's Gym, Steven Schwartz of TCA Holdings, Peter Taunton of Snap Fitness and Matthew Stevens of Western Athletic Clubs along with other big names all in the same room sharing openly on a variety of subjects? Although initially hesitant, once the conversation started, the CEOs were surprisingly open. I even saw many of them taking notes. We received several gushing reviews afterwards about how much these CEOs, most of whom oversee multi-million-dollar companies, learned from the event and from the networking.
It showed me that no matter how much revenue your facility brings in, how much you brainstorm with your own people and how much you study business operations, nothing compares to looking beyond your little world and listening to your peers. No matter how far people come in their businesses, the smart ones know that they still have much to learn. They know that they cannot stand alone; they must reach out to peers—and, yes, even the CEOs of the largest companies have peers in the industry. These leaders can share with staff, but only other owners and CEOs understand the pressures faced at this level.
So as we enter 2012, that is what I will take with me from 2011. Never insulate yourself with the impression that you are only the teacher, never again to be the student. It can make for a lonely and faltering existence, even if the dark clouds are lifting.


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Item 31 (shaded area) is for central office use only. It shows the Effective Date (Item 2) that benefits were authorized (Type Actions 10,11, or 12).
Cash - Item 31 shows the first month that cash benefits were authorized.
Medical - Item 31 shows the first month that medical benefits were authorized.
Do not make an entry in this item.


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This post is the 55th in a series on Booby Traps, made possible by the generous support of Motherlove Herbal Company.
Have you heard any of these statements at your four or five month well child visit?
"She looks great! Ready to start solids?"
"Won't sleep through the night? Try some cereal in a bottle."
"If he's still feeding really often, maybe it's time to start solids."
"Her growth seems to be slowing (looking at CDC or older growth chart). Why don't you add some formula or start solids?"
If you heard any of these statements at your baby's four or five month visit, you aren't alone. And it's actually not that surprising, given what the research says about how pediatricians view exclusive breastfeeding, which I'll describe in a minute.
But first, why do we care that babies are breastfed exclusively to 6 months, as recommended by the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the Academy of Breastfeeding Medicine, the World Health Organization, and the United Nations Children's Fund?
In their breastfeeding policy, the AAP explains:
Support for this recommendation of exclusive breastfeeding is found in the differences in health outcomes of infants breastfed exclusively for 4 vs 6 months, for gastrointestinal disease, otitis media, respiratory illnesses, and atopic disease, as well as differences in maternal outcomes of delayed menses and postpartum weight loss.
Compared with infants who never breastfed, infants who were exclusively breastfed for 4 months had significantly greater incidence of lower respiratory tract illnesses, otitis media, and diarrheal disease than infants exclusively breastfed for 6 months or
longer. When compared with infants who exclusively breastfed for longer than 6 months, those exclusively breastfed for 4 to 6 months had a fourfold increase in the risk of pneumonia.
In spite of this, a survey of pediatricians conducted in 2004 found that nearly 30% of pediatricians routinely recommended the introduction of solid foods or formula for exclusively breastfed infants before 5 months of age. This figure was unchanged since the prior survey in 1995. And while 74% of pediatricians reported recommending exclusive breastfeeding in the first month, one in four either recommended exclusive formula feeding (3%), breastfeeding and formula (8%), or had no opinion at all (16%).
This is reflected in mothers' own reports of what they think their providers recommend. Data from the CDC's Infant Feeding Practices II study show that only 34% of mothers believe that their doctor favors exclusive breastfeeding, and nearly an equal number (32%) said that they believed that their doctor had no preference for breastfeeding or formula feeding at all.
The problem, of course, is compounded by the slow adoption of the World Health Organization's growth charts. Use of outdated growth charts, based on formula fed and mixed fed growth patterns, can make a normally growing exclusively breastfed baby appear to be slowing down, resulting in recommendations to supplement or start solids before six months.
As Dr. Lori Feldman-Winter pointed out in my interview with her, pediatrician training is part of the problem: "Clearly, the lack of training [on breastfeeding] makes for pediatricians who are not supportive – particularly if mothers have problems, have poor attitudes, don't think exclusive breastfeeding can work out for many women."
But as the 2004 survey of pediatricians shows, those doctors who have had personal experience breastfeeding (a number on the rise) are more likely to make evidence-based recommendations and more likely to believe that breastfeeding is "worth it" and possible for almost all women. This, coupled with better training in residency, shows that there is in fact hope.
Did your pediatrician support exclusive breastfeeding to six months?


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Origami Sourdough and Yeast Water Panettone
After the last panettone fiasco where they were under baked and plopped themselves onto the carpet when overturned on the skewers to cool, we decided to do some origami panettone molds out of one inside layer of parchment paper and one outside layer of regular printer paper.
There is no problem with the outside paper burning at 350 F. I had seed on Susan's Wild Yeast blog on chocolate panettone that she had made some origami panetonne molds in the shape of Easter baskets but thought that there must be some other shape that you could make to get the more traditional vertical look of panettone rather than a loaf shape.
Sure enough Sue was right. I found an origami tall trash can liner on the internet and used that to make the panettone molds. They came out very nice but didn't work all that well in the end. My apprentice was as apprehensive as last time but heck, she is afraid of her own shadow and not a reliable disaster predictor – except apparently for panettone plopping on the floor. .
2 of the 3 panettone fell out of the molds when overturned to cool again, even though they were baked to 205 F (the right temperature if you ask me) on the inside instead of the recommended 185 F. At least this time we were ready with a cutting board underneath so it didn't plop on the kitchen tile.
The problem was that the parchment on the inside of the mold was so slippery and the bread so heavy, it just fell out even when baled correctly. You really need paper to stick to the bread so it doesn't slip for this to work if you want to hang them upside down to cool. Instead of the paper on the outside, it should have been on the inside to stick to the bread.
Live and learn. At least we were able to save on of them this time and there was no blow out on at the base. We used Sue's recipe with a few changes found here:
The changes were instead of using commercial yeast with the SD we subbed 83 gof Yeast Water based levain for the yeast. For the fruits we used raisins, cranberries, red and green cherries, pineapple, citron, lemon and orange peel and some home made orange peel and Minneola zest in place of the orange zest. We also used the glaze on top too but no other toppings.
This is some pretty darn tasty, if totally; fattening, sweet, buttery and unhealthy as bread can get.
But, if you only make it for special and rare occasions and walk 4 miles extra every day for every slice you eat – then why not! The one that we cooled on its side, rotating every so often until cool, was not the worse for wear so no more panettone hanging for me or my apprentice.
Toasted and buttered with Minneola marmalade. Normally I would put whipped cream on top with some chocolate sauce but i'm trying to eat better these days!


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Amerihood C311AHCATFHW - Amerihood Chrysler 300 Type-HC Style Functional Ram Air Hood; 2011-2019.
Amerihood Functional ram air hoods are perfect replacement for the ordinary factory hood. Direct cold intake air to work with performance air intake system by major manufacturers such as AirRaid and K&N. AmeriHood utilized factory hinges and striker for easier installation, smooth gel coat finish on top and underside for easy prep and shorten work time for that perfect finish.
**** These Amerihoods are made of High Quality Fiberglass ****
IMPORTANT DELIVERY INSTRUCTIONS: PLEASE INSPECT ALL TRUCK FREIGHT SHIPPED ITEMS OUT OF THE BOX BEFORE SIGNING FOR THE DELIVERY. If parts arrive damaged or missing, please do not SIGN for delivery and REFUSE the package. If the driver will not let you refuse it without signing for it then sign "DAMAGED" or "PARTS MISSING". If the parts are refused and not damaged or missing, the customer will be responsible for shipping. If the driver refuses to let you inspect the delivery please accept the package and sign "DRIVER DID NOT LET ME INSPECT PARTS".
Legal: Some or all of these parts may not comply with Federal, State, Province, and/or Local laws, ordinances, and regulations. Buyer takes all responsibility to ensure that any modifications or upgrades that have done conform to all applicable laws and regulations for road use, especially pertaining to safety and emissions. LMPerformance is not responsible for buyer not complying with Federal, State, Province, and/or Local laws, ordinances, and regulations. This policy shall be in force for all past, current, and future purchases from LMPerformance, Inc.
* FREE SHIPPING: Please note FREE Shipping refers to shipping within the contiguous contential US only. All other locations extra.
Search Terms: C311AHCATFHW Amerihood Chrysler 300 Type-HC Style Functional Ram Air Hood TypeHC 300 300C All Exterior Styling Hoods Amerihood Chrysler 300 Type-HC Style Functional Ram Air Hood 2011 2012 2013 2014 2015 2016 2017 2018 2019
These are parts that other customers have purchased while purchasing the product on this page.
History and information about Amerihood and their products.
When a company is recognized as the foremost designers and distributors of Fibre-reinforced plastic composite body kits and other products like fenders, ram air hoods, spoilers and Carbon Fiber hoods you can be sure you are getting a quality product. AMERIHOOD, a division of AIT, is just such a company. Having proven their value in the aftermarket performance industry since their inception in June 2002 they deserve the recognition they have achieved because of their dedication to precise fitment and excellence in quality of product. The AMERIHOOD racing line is celebrated for its sui generis quality and specificity of fit and as a consequence is used in D1, Formula Drift, NOPI Drift, Red Line Time Attack, Super Lap Battle, SCCA, and NASA races as well as in minor track events. The company is able to accomplish all of this in their 25,000 sq. ft. warehouse located in Chino, California assuring you of a commitment to quality by one of the largest aftermarket performance body parts distributors. Attention to detail and quality of product are paramount and have led to the success of Amerihood aftermarket car hoods in the industry both for racing and every day use.
Reviews for Amerihood's Other products are show below.
Current Mods:
Amerihood for 2005 Chevy Duramax LLY
Below are other popular parts other customers have purchased for their Chrysler 300 300C.


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A crowd of around 400 people helped one Chillicothe school raise more than $55,000 this weekend.
A crowd of around 400 people helped one Chillicothe school raise more than $55,000 this weekend.
Bishop Hogan Memorial School held its 10th annual dinner auction Saturday night. Administrative Assistant Linda Drummond considers the event a success, and says it wouldn't have been possible without the support of the community.
"It just amazes me the people that come together from start to finish to help us out with the donations, the decorating, the meal, the serving and working the rooms," Drummond said. "They just all pull together to transform the school into an event. It felt like you were walking out of a small town into a big town event."
Principal Pam Brobst echoed Drummond's sentiments, and thanked all the people who made Saturday night special.
"I want to thank everyone who donated or purchased items during the auction," Brobst said. "I especially want to thank Mike Miller Auction Service, Dave May and their entire team; Brian Wills, Jeff Frampton and the Hy-Vee team for an elegant meal; and Tom Tingerthal for the sound and music."
In addition to raising funds help serve the school's 70 students, Brobst said it was equally important to host an event that brought the school and the community together.
"Seeing the good time everyone had made it all worth it," Brobst said. "It's really important to us that everyone comes together and enjoys the evening. We're really blessed to live in this community."


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Thank you for visiting our past auction result archives. If you have an item identical (or similar) to this auction lot, please call, write or contact us to discuss. We will be able to help you.
Lot # 187 (of 1727) < Previous Lot | Next Lot >
1911 M110 Sporting Life Cabinet Frank Chance
Starting Bid - $2,500, Sold For - $11,163
Graded EX 60 by SGC. Highest-graded example! Incredible high-grade card of Hall of Famer Frank Chance from the exceptionally rare M110 Sporting Life cabinet-card set issued in 1911. This card features a striking image of Chance in a throwing pose. This auction includes the complete M110 set, assembled and presented by the same consignor, with each card offered individually. M110s are similar in design to, but far rarer than, the contemporary T3 Turkey Red cabinets. These cards have always been revered for their extreme rarity as well as their impressive design and distinctive style. This is an extremely high-grade card with just the slightest hint of corner wear; it is otherwise in virtually flawless condition. Bright, fresh, and impeccably clean, both front and back, with bold blue text on the reverse. Very conservatively graded EX by SGC, this card has a strong Excellent to Mint appearance. This card would make a significant addition to any world-class collection of sample cards, high-grade rarities, Hall of Famers, or prewar cards. Dimensions: 5-5/8 x 7-1/2 inches. Reserve $2,500. Estimate $5,000+.
(Click the smaller thumbnails to the left and right (if any) to cycle through each photo in the gallery of images for this lot.)


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Jaime Hernandez: The 2003-P First Flight Commemorative Silver Dollar was issued to celebrate the Wright Brothers first successful flight on a controllable airplane on December 17, 1903.
Obverse: The obverse features Oriville and Wilbur Wright next to each other. The obverse has the inscriptions, "Liberty, In God We Trust, 1903, 2003, Oriville & Wilbur Wright."
Reverse: The reverse of the coin shows an airplane in flight. The reverse has the inscriptions, "One Dollar, E Pluribus Unum, United States of America."
Issue Date: July 01, 2003
Pre-Issue Price: $31.00
Regular Issue Price: $33.00
© 1999-2018 Collectors Universe NASDAQ: CLCT


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Projects were judged on five criteria, with a score from 0-100 awarded for each. RT's website received the perfect 100 for content and 99 for site functionality.
According to the IMC, "the Best in Class award is the highest honor bestowed by the Interactive Media Awards. It represents the very best in planning, execution and overall professionalism. In order to win this award level, your site had to successfully pass through our comprehensive judging process, achieving very high marks in each of our judging criteria - an achievement only a fraction of sites in the IMA competition earn each year."
RT.com is RT's multimedia online platform. From live updates on breaking news stories to in-depth analysis of current events to full episodes of RT's most popular shows, RT.com delivers all of RT's best content in a way that encourages audience engagement and dynamic conversation. Following the 2013 website redesign and streamlining of the editorial approach to further emphasize news content, RT.com has nearly doubled its audience to 50 million page views (and more than 130 million page views for English, Russian, Arabic, Spanish versions of the site combined) in March 2014.
Other winners for News have included entries from CBS, NBC, Examiner, The Atlantic, CBC (Canadian Broadcasting Corporation) and RTVE (largest Spanish-language broadcaster in Spain).
The Interactive Media Awards(TM) recognize the highest standards of excellence in website design and development and honor individuals and organizations for their outstanding achievement. Created by the Interactive Media Council, Inc. (IMC), a nonprofit organization of leading web designers, developers, programmers, advertisers and other web-related professionals, the competition is designed to elevate the standards of excellence on the Internet and offer winners a boost in marketing and exposure. IMC serves as the primary sponsor and governing body of the Interactive Media Awards, establishes the judging system and provides the judges for the competition.
RT is a global international news network that broadcasts 24/7 in English, Arabic and Spanish from its studios in Moscow and Washington, DC, and is available to 644 million viewers worldwide. RT is the first TV news channel in history to cross the billion views mark on YouTube. RT is the winner of the Monte Carlo TV Festival Awards for best 24-hr broadcast, and the only Russian TV channel to garner two nominations for the prestigious International Emmy Award in the News category.


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California White OakQuercus lobata
The California white oak is considered the king of all western oaks, and rightly so. Trees of this species are among the largest oaks in North America. Although it doesn't thrive in many Hardiness Zones, the tree makes up for that limitation with graceful, drooping branches, a fast growth rate and nice shade.
It's a choice tree for restoration or specimen planting.