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Volume 44 Number 5 2007
Pages 761 — 770
Neurocognitive enhancement therapy with work therapy in schizophrenia: 6-month follow-up of neuropsychological performance
Morris Bell, PhD;1-2 Joanna Fiszdon, PhD;1-2* Tamasine Greig, PhD;2 Bruce Wexler, MD;2 Gary Bryson, PsyD1-21Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT; 2Department of Psychiatry, Yale University School of Medicine, New Haven, CT
Abstract — Cognitive deficits are a major determinant of social and occupational dysfunction in schizophrenia, and new treatments are needed that address these impairments. The current study determined whether neurocognitive enhancement therapy (NET) in combination with work therapy (WT) would show improvement in performance on neuropsychological tests that endured 6 months after completion of training. A total of 145 participants with schizophrenia or schizoaffective disorder were randomly assigned to NET + WT or WT alone. NET included computer-based training on attention, memory, and executive function tasks. WT included paid work activity in job placements at the medical center. Neuropsychological assessment was performed at baseline, at the end of the 6-month active intervention, and 12 months after training began. Repeated measures multivariate analyses of variance revealed greater neuropsychological improvements on working memory (p < 0.05) and executive function (p < 0.05) for the NET + WT group over the 12 months. Both groups showed sustained improvements on verbal and nonverbal memory.Clinical Trial Registration: ClinicalTrials.gov, NCT00430560; <http://clinicaltrials.gov/>.
Key words: cognition, neurocognition, neuropsychology, psychosis, rehabilitation, remediation, schizoaffective disorder, schizophrenia, vocational rehabilitation, work therapy.
Abbreviations: BLERT = Bell Lysaker Emotion Recognition Test, CFA = Cognitive Function Assessment, CPT = Continuous Performance Test, DSM-IV = Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, HVLT-R = Hopkins Verbal Learning Test-Revised, MANOVA = multivariate analysis of variance, NET = neurocognitive enhancement therapy, SD = standard deviation, VA = Department of Veterans Affairs, WAIS-III = Wechsler Adult Intelligence Scale-3rd Edition, WBI = Work Behavior Inventory, WCST = Wisconsin Card Sorting Test, WMS-R = Wechsler Memory Scale-Revised, WT = work therapy.*Address all correspondence to Joanna Fiszdon, PhD; VA Connecticut Healthcare System, Psychology Service, 116B, 950 Campbell Avenue, West Haven, CT 06516; 203-932-5711, ext 2231; fax: 203-937-4883. Email: email@example.com: 10.1682/JRRD.2007.02.0032INTRODUCTION
Recent reviews of the efficacy of cognitive rehabilitation as a method to improve cognitive functioning in schizophrenia have generally been positive [1-6], although one review was equivocal [7]. The remediation of cognitive deficits is potentially clinically significant because cognitive abilities have been shown to be related to self-esteem, work success, skills acquisition, independent living, and quality of life [8-9]. A key question for judging the clinical value of cognitive remediation is whether gains made during training endure beyond the training period. If such gains do not endure past the training phase, it is unlikely that they would generalize to other areas or that they would significantly affect the impact of other psychosocial interventions that rely on adequate processing and retention of presented material. This study investigates the durability of performance effects on standard neuropsychological tests 6 months after completion of neurocognitive enhancement therapy (NET) [10], a 26-week cognitive training program.
Only a handful of reports have been published on the durability of cognitive training effects. Many of these have focused on the durability of gains achieved during training on a single task (e.g., Wisconsin Card Sorting Test [WCST] or Span of Apprehension) and, in general, indicate that improvements are sustained, although follow-up periods have been relatively brief, 6 weeks at most [11-15]. In a longer follow-up study of training effects for two computerized memory training tasks, we reported that gains made on these tasks were sustained at a 6-month follow-up [16]. In another study, Wexler et al. noted that trained-task gains were sustained at a 6-month follow-up for half the patients (three of six) who returned for follow-up testing after a 10-week remediation program of visual reading, dot localization, and manual dexterity tasks [17]. Combined, these studies support the durability of task-specific training effects. Far less is known about whether cognitive remediation gains generalize to untrained tasks and whether those improvements, in turn, are sustained. This question is important, because the overall goal of cognitive remediation programs is to improve general cognitive function, not just performance on the trained tasks.
Medalia et al. reported that a 5-week problem-solving remediation program was associated with sustained improvements on problem-solving tasks at a 4-week follow-up [18]. In another arm of the study [19] during which participants completed a 5-week memory remediation course using computer-based educational software, while trained tasks improved, these improvements did not generalize to untrained tasks, as assessed at a 4-week follow-up. In contrast, Corrigan et al. reported that a single session of memory and vigilance training with a social cue recognition test was associated with sustained improvements on an untrained cue recognition test administered 2 days later [20]. Several other studies are also encouraging, suggesting that improvements on untrained tasks may persist as long as 6 months following training. Wykes et al., for example, reported that gains on a verbal memory task made following a 40-session course of cognitive remediation training were maintained at a 6-month follow-up [21]. Similarly, our research team has reported that a 6-month cognitive remediation program was associated with improvements on an untrained working memory task and that these improvements were sustained at a 6-month follow-up [22].
In 2001, we demonstrated that an integrated work therapy (WT)/cognitive rehabilitation program (NET) resulted in significant cognitive improvements for people with schizophrenia or schizoaffective disorder [10]. In a randomized controlled study, participants were enrolled in either NET + WT or WT only. At study entry, both groups performed poorly on neuropsychological testing. Participants receiving NET + WT showed greater improvements than those receiving WT on pre- and posttestings of executive function and working memory. As many as 60 percent of those in the NET + WT group improved on some measures and were more likely to show large effect-size improvements. The number of participants with normal working memory performance rose significantly with NET + WT, from 45 to 77 percent, compared with a drop from 56 to 45 percent for those in WT. As with other cognitive rehabilitation programs, these results were based on assessments made at the end of the active phase of the intervention. Subsequently, we reported that participants in NET + WT worked more hours than those in WT, with differences emerging during the 6 months following the active intervention [23]. We also found that improvements in work functioning were greatest for those who responded to the NET training by reaching normal levels of performance on a trained working memory task. These results indicated that work outcomes could be influenced by NET + WT training even after the treatment had ended. Whether (1) neuropsychological benefits could also be sustained 6 months after training or (2) discontinuation of training had led to significant declines in cognitive performance, remained to be seen.
Based on our previous findings that improvement in cognitive performance on NET-trained tasks endured to follow-up [16] and that work outcomes differentially improved for NET + WT during follow-up [23], we expected this would be the case for NET + WT effects on neuropsychological performance. Specifically, we hypothesized that executive function and working memory gains observed at the end of treatment would still be detectable 6 months later.METHODParticipants
After being referred by their clinicians, 145 participants with schizophrenia or schizoaffective disorder, as determined by psychologists using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) procedures [24], enrolled in our study. All provided written informed consent. Participants were in treatment at the Department of Veterans Affairs (VA) Connecticut Healthcare System in West Haven or the Connecticut Mental Health Center in New Haven. The local institutional review boards at both facilities reviewed the study. Data were collected from 1998 to 2003. Participants were not considered sufficiently stable to participate if they had a change in psychiatric medications or housing in the last 30 days, an episode of drug abuse within the past 30 days, or a Global Assessment of Functioning scale score £ 30. Known neurological disease and developmental disability were also cause for exclusion. All participants were receiving antipsychotic medication before and throughout the study. Of the total, 22 percent were receiving a typical antipsychotic only, 70 percent an atypical antipsychotic only, and 8 percent were receiving both, with comparable proportions and dosages for NET + WT and WT conditions.
Retention rate was 91 percent at 6-month follow-up and 80 percent at 12-month follow-up. No significant differences existed in attrition rate by condition at either follow-up point. Of the 145 participants who completed intake assessments and were randomized, neuropsychological test data were available for 132 at 6-month follow-up, and for 116 at both the 6- and 12-month follow-ups. Comparison of the 80 percent of participants with complete follow-up data and the 20 percent without complete follow-up data on background, illness, and neuropsychological intake variables (see Table for list of variables) failed to reveal any differences, suggesting that differential attrition based on these variables did not occur.
Table.Background and treatment characteristics.* Variable NET + WT
(n = 53)
(n = 63)
Age (mean ± SD) 41.9 ± 9.9 43.6 ± 8.1 Sex, Male, n (%) 40 (75.6) 50 (79.4) Marital Status, n (%) Single 36 (67.9) 41 (65.1) Married 5 (9.4) 6 (9.5) Divorced 11 (20.8) 15 (23.8) Widowed 1 (1.9) 1 (1.6) Race/Ethnicity, n (%) White 34 (64.2) 40 (63.5) African American 17 (32.1) 20 (31.8) Hispanic 0 (0) 1 (1.6) Asian 2 (3.8) 2 (3.2) Schizophrenia Diagnosis, n (%) Paranoid 24 (45.3) 35 (55.6) Undifferentiated 1 (1.9) 2 (3.2) Disorganized 6 (11.3) 4 (6.4) Residual 6 (11.3) 2 (3.2) Schizoaffective 16 (30.2) 20 (31.8) WAIS-Global (mean ± SD) 88.4 ± 12.9 89.4 ± 13.6 Education, yr (mean ± SD) 13.4 ± 2.1 13.3 ± 2.2 Age of Onset, yr (mean ± SD) 21.8 ± 8.0 22.3 ± 7.0 Age at 1st Hospitalization (mean ± SD) 25.1 ± 7.3 25.9 ± 7.2 No. of Lifetime Hospitalizations (mean ± SD) 8.6 ± 12.9 9.2 ± 8.7 Positive and Negative Syndrome Scale (mean ± SD) Total 76.5 ± 16.3 77.8 ± 13.3 Positive Component 18.4 ± 5.6 19.4 ± 5.2 Negative Component 20.7 ± 7.1 20.4 ± 5.2 Cognitive Component 18.5 ± 6.4 17.5 ± 5.1 Hostility Component 7.6 ± 3.0 8.3 ± 3.2 Emotional Discomfort Component 11.3 ± 3.0 12.3 ± 2.6 Antipsychotic Medications, n (%) Typical 12 (22.6) 10 (15.9) Atypical 32 (60.4) 46 (73.0) Both 8 (15.1) 5 (7.9) None 1 (1.9) 2 (3.2) Medication Dose (Chlorpromazine equivalent) (mean ± SD) 782.0 ± 589.7 628 ± 388 *No statistical differences (p < 0.05) existed between conditions on any of these variables.NET = neurocognitive enhancement therapy, SD = standard deviation, WAIS = Wechsler Adult Intelligence Scale, WT = work therapy.Baseline and Follow-up Assessments
Neuropsychological testing for pre- and postcomparisons consisted of (1) Digit Span, Letter Number Sequencing, and Digit Symbol Substitution Task from the Wechsler Adult Intelligence Scale-3rd Edition (WAIS-III) [25]; (2) Visual Reproduction I and II, Figural Memory, and Logical Memory I and II from the Wechsler Memory Scale-Revised (WMS-R) [26]; (3) the Hopkins Verbal Learning Test-Revised (HVLT-R), a measure of verbal learning and temporal lobe dysfunction [27]; (4) the Continuous Performance Test (CPT), X/A version (in which the participant is asked to press the space button anytime he or she sees an "X," immediately followed by an "A" flash on the computer screen), a measure of sustained attention [28]; (5) WCST, a measure of perseveration and flexibility of abstract thought [29-30]; (6) Bell Lysaker Emotion Recognition Task (BLERT), a measure of the ability to identify affect cues in videotaped stimuli [31]; (7) Gorham's Proverb Test, a measure of thought disorder [32-33]; (8) Hinting Task, a measure of social inference [34]; and (9) Trail Making Test Part B, a measure of cognitive flexibility and psychomotor speed [35]. These measures have established reliability and validity and are sensitive to the types of deficits associated with schizophrenia.InterventionWork Therapy
WT consisted of (1) payment for work activity at the rate of $3.40 an hour for up to 15 hours a week with increasing bonus pay ($3.90 to $8.40) for 16 to 20 hours; (2) job placement at the medical center; (3) individual counseling when problems arose; (4) a group offering support, problem-solving, goal-setting, and detailed work performance feedback based on the Work Behavior Inventory (WBI) [36]; (5) a job coach for job-related difficulties and individual vocational counseling; (6) a certificate of participation in the program; and (7) referral to other vocational services on completing the 6-month active phase. The most common work sites were in dietetics, mail room, grounds, maintenance, patient transport, and medical administration, with duties similar to those of entry-level employees supervised by regular medical center personnel.Neurocognitive Enhancement Therapy
NET consisted of (1) cognitive exercises for up to 5 hours a week for 26 weeks; (2) feedback from the Cognitive Function Assessment (CFA), a rating of work-related cognition [37] in the support group; and (3) a weekly social information-processing group. In addition to up to 5 hours of cognitive exercises, participants in NET could also participate in up to 15 hours of WT (as described previously), for a maximum of 20 hours productive activity. Pay structure and maximum hours of productive activity were equivalent between the conditions (i.e., participants were paid for both WT and participation in cognitive exercises).
CFA feedback was given biweekly (at the same time as the WBI feedback) and consisted of job ratings of attention, memory, and executive function. Participants were also encouraged to develop goals based on their WBI and CFA feedback.
Cognitive exercises involved repeated practice on computer-based exercises for attention, memory, and executive function and a dichotic listening task. Participants attended up to five 1-hour sessions a week. Cognitive exercises used a modified form of CogReHab software (Psychological Software Services Inc, Indianapolis, Indiana), a multimedia cognitive rehabilitation software designed for use with individuals with compromised brain function [38]. Parameters were initially made easy enough for each participant to succeed. As soon as the participant achieved 90 percent accuracy at a given difficulty level, the task was made more difficult following a prearranged hierarchy. In that way, while the tasks were challenging enough to not become boring, they also were not unduly frustrating. Along with these computer-based tasks, participants also were trained in a dichotic listening task that involved listening to brief segments of a story (A Bell for Adano, by J. Hersey) in the left ear while a distracter of poetry reading was played in the right ear. Participants were asked questions about the content of the story segment. Progress involved correctly answering questions with increasing loudness of the distracter and longer story segments. Details of the tasks are described in Bell et al. [10] and Fiszdon et al. [39].Procedures
Following informed consent, baseline neuropsychological testing was performed over two or three sessions. Follow-up neuropsychological assessments were conducted at 6 months from intake (at the end of the active intervention) and 12 months after baseline (6 months following active intervention). Psychologists trained specifically in study methods performed all procedures. Following baseline testing, participants were stratified based on severity of cognitive impairment and randomly assigned to 6 months of either NET + WT or WT only. Severe cognitive impairment was based on six key neuropsychological indicators in four cognitive domains. Attention was represented by the number of wrong answers on the CPT; memory by HVLT-R trial 1 and WMS-R Figural Memory; executive function by WCST categories correct and Gorham's Proverbs bizarreness score; and affect recognition by BLERT score. To meet criteria for severe cognitive impairment, a participant had to have scored 1 standard deviation (SD) below the mean (established for a VA sample of schizophrenia participants) on at least two of the six indicators. Of participants in the sample, 43 percent met these criteria.Data Analysis
Neuropsychological assessment involves many tests, and many of the tests generate multiple variables. Our data reduction strategy was to enter these variables into a principal component analysis with varimax rotation. This procedure yielded four factors with eigenvalues above 1.0 that were found to be clinically coherent. We labeled these "working memory," "verbal and nonverbal memory," "thought disorder," and "executive function." Working memory included raw scores from the WAIS-III Digits Forward and Digits Backward, scaled scores for the letter number sequencing, and total score for the BLERT. Verbal and nonverbal memory included raw scores from the HVLT-R trials 1 and 3, percentile equivalents for WMS-R Visual Reproduction I and II, raw scores for WMS-R Figural Memory and CPT score. Thought disorder included Gorham's Proverbs bizarreness score, the Hinting Task total score, and the WMS-R Logical Memory I and II percentile equivalents. Executive function included number of categories correct, percent perseverative errors, percent nonperseverative errors, and percent conceptual level from the WCST and time from the Trail Making Test Part B. Rather than rely on factor scores that are not easily replicable by other investigators, we opted to group our neuropsychological variables based on their shared variance as indicated by the factor structure into clusters to be used in multivariate analysis of variance (MANOVA). We entered data from intake, 6-month, and 12-month assessments into repeated-measures MANOVA to examine condition effects, time effects and time by condition effects, and one analysis for each of the four clusters of neuropsychological variables. Significant repeated-measures MANOVAs were followed by post hoc linear trend analyses for examining effects of individual variables. All tests were two-tailed, and alpha was set at 0.05.RESULTS
No significant differences were found between NET + WT and WT participants at baseline for illness, treatment, or background characteristics (Table). Individuals in the NET + WT condition participated in a mean ± SD 47.1 ± 40.3 computerized training sessions.
Repeated-measures MANOVA for the executive functioning cluster revealed a nonsignificant condition effect (F4, 109 = 1.36, p = nonsignificant), a significant time effect (F8, 105 = 2.68, p < 0.01) and a significant condition by time interaction (F8, 105 = 2.03, p < 0.05). Linear trend analyses indicated significant time by condition linear trends for WCST categories correct (F1, 112 = 5.54, p < 0.05) and percent conceptual level (F1, 112 = 7.46, p < 0.01).
Repeated-measures MANOVA of the working memory cluster also demonstrated a nonsignificant condition effect (F6, 90 = 1.4, p = nonsignificant), a significant time effect (F12, 84 = 2.96, p < 0.01), and a significant condition by time interaction (F12, 84 = 2.21, p < 0.05). Condition by time interactions were found (linear trends) on Digits Backward (F1, 95 = 4.25, p < 0.05) and Digit Symbol (F1, 95 = 3.98, p < 0.05).
For the verbal and nonverbal memory cluster, Repeated-measures MANOVA showed a nonsignificant condition effect (F6, 103 = 1.23, p = nonsignificant), a significant time effect (F12, 97 = 4.2, p < 0.001), and a trend for the condition by time interaction (F12, 97 = 1.77, p = 0.065). Post hoc linear trend analyses indicated a significant time effect for HVLT-R Trial 1 (F1, 108 = 23.9, p < 0.001), HVLT-R Trial 3 (F1, 108 = 13.8, p < 0.001), and Visual Reproduction II (F1, 108 = 16.6, p < 0.001), indicating that participants in both conditions improved, but we saw no significant overall differences in improvement between the two conditions.
For the thought disorder variables, we found a nonsignificant condition effect (F4, 101 = 2.38, p = nonsignificant), a significant time effect (F8, 97 = 3.02, p < 0.01), and a nonsignificant condition by time interaction (F8, 97 = 1.43, p = nonsignificant). Post hoc linear trend analyses of Logical Memory I (F1, 104 = 14.9, p < 0.001) and Logical Memory II (F1, 104 = 20.8, p < 0.001) indicated significant improvements for all participants over time on these variables.
Visual inspection of performance data suggested several different patterns of change for neuropsychological variables, with change occurring only during the active phase for some variables and, for others, continuing change during the 6-month follow-up. Patterns of change also differed by condition, with some variables associated with equal improvements for both groups and other variables associated with improvement only for the NET + WT group.
Given the already high number of comparisons and the risk of Type I error, we did not further explore these patterns statistically; however, for purposes of discussion, exemplars of the different patterns observed are presented in the Figure.
This study expands on our previous work regarding the immediate effects of NET + WT on neuropsychological function in schizophrenia by examining the durability of improvements 6 months after the end of the active intervention [8]. Results indicate that participants in NET + WT showed significantly greater improvements in executive function and working memory over 12 months than participants receiving WT only. Post hoc analyses showed that specific significant changes occurred on WCST conceptual level and categories correct variables as well as on the WAIS-III subtests Digit Symbol and Digits Backward. Results also indicate that for the sample as a whole, improvements occurred over 12 months in verbal and nonverbal memory. Post hoc analyses indicated significant improvements over time on HVLT Trials 1 and 3, Visual Reproduction II, and Logical Memory I and II.
Visual inspection of the data suggested two different patterns of performance change over time. For several of the variables, the bulk of improvement occurred at the end of the active phase and was sustained at follow-up 6 months later; for other variables, the gains made during the active phase were further enhanced during the 6-month follow-up period. Although exploratory and only appropriate for hypothesis generation, this latter pattern of performance change is provocative because it suggests that the effects of the NET training may confer greater capacity to use other rehabilitation experiences that continue to enhance cognition. Although NET training stopped at 6 months, most participants continued to participate in work activity, and it may be that working, with its many cognitive demands, stimulated cognitive functioning that had already been enhanced by the NET training.
Evidence for this explanation may be found in the unexpected result that WT alone may have also led to durable cognitive improvements. This study did not include a "treatment as usual" condition to compare with the two active conditions that included WT, so we cannot conclusively judge the time effects we observed. However, the improvements in verbal and visual memory raise the possibility that WT alone may be associated with durable improvements in memory. To our knowledge, no previous literature suggests that WT alone yields neuropsychological improvements.
If WT alone can improve cognitive performance, perhaps the improvement can be explained by the cognitive demands at work. Successfully engaging in a WT program requires an individual to remember such things as time of work shifts, coworker names, location of timecards, sequences of tasks to be accomplished, etc., all of which require exercising memory function. Also, in addition to the work component, our WT program consisted of a work feedback group, and this group may have had an unexpected cognitive impact. In this group, participants were expected to engage in problem solving and goal setting related to issues identified in their systematic work feedback. The verbal nature of the group and the cognitive demands of problem solving may have combined with other features of WT to produce neuropsychological test improvements, whether or not the participant was receiving NET.
Our findings indicate that WT may improve memory but that NET training was necessary to produce additional durable improvements in executive function and working memory. Perhaps memory functioning can benefit from the general cognitive stimulation associated with work, whereas executive functioning and working memory must be targeted more directly through a cognitive remediation program. The computer-based cognitive exercises used in NET focused mostly on elemental cognitive functioning such as attention and short-term memory, and these exercises may have directly affected the working memory outcomes. Although several of the computer-based exercises included problem solving, other elements of the NET intervention may also have affected executive function. The demand of the social information processing group, dichotic listening task, and cognitive feedback from the work site, which were also part of NET and which demand executive function, likely influenced this type of outcome.
The overall pattern of results suggests that certain cognitive skill areas will likely improve only as long as they are specifically practiced. Other cognitive skill areas, once they receive a "push" from cognitive remediation to change initially, may continue to improve under the general stimulation of everyday activity. Moreover, some cognitive abilities may improve from the nonspecific stimulation of WT or other rehabilitation approaches. Although one could argue that the observed pattern of continued improvement in the WT only condition simply reflects a practice effect, we believe this is unlikely, given that the pattern was not general and only found for a few tasks and given that previous research suggests a lack of significant practice effects for these tasks, even at a shorter retest interval of 10 weeks [40].
This study has several limitations. Although no differential attrition was observed based on baseline data, the loss of 20 percent of the sample over the three observations means that some undetected selection bias possibly occurred. While this does not necessarily threaten the between-group findings, time effects may be more vulnerable to the alternative hypothesis that participants excluded because of missing data were those who had been less responsive to WT. This form of differential attrition would be undetectable from baseline data and would favor a positive effect for time. Therefore, added caution is warranted in interpreting the time linear trends.
This study did not control for the amount of productive activity in which participants could engage, except to have a maximum of 20 paid hours a week. However, participants in both conditions were productive for about the same number of hours and received about the same amount of pay over the 6-month intervention. Although NET + WT participants may have had somewhat more time for nonspecific interactions with research staff around the NET procedures (which were mostly computer-based), WT participants could instead engage in up to 5 additional hours of WT and those extra 5 hours of work could, in turn, give them the nonspecific benefits of more time for interactions with coworkers and supervisors. As just mentioned, this study is also limited by not including a no-treatment control or a condition that included only computer-based exercises. Having these groups would have helped us to sort the likely contribution of WT to cognitive outcomes as well as the contribution of the training exercises alone.
Finally, the relationship of specific NET training elements to specific outcomes is speculative, and a much more complex interaction of training and cognitive outcomes is just as possible. The interaction of all elements of NET combined with WT may be what is responsible for these differential outcomes in working memory and executive function. A true synergy may exist between NET exercises that encourage mental activity and WT that allows a natural context for increased mental activity to be exercised, generalized, and reinforced. NET without WT might not have yielded the same results.CONCLUSIONS
Cognitive remediation in the context of WT may have neuropsychological benefits in executive functioning and working memory that can endure for at least 6 months after the end of training. WT alone may also improve neuropsychological functioning, particularly in verbal and nonverbal memory.
Future studies may follow two paths. The first is comparing various types of cognitive training and determining their unique contributions with neuropsychological improvement in schizophrenia. Types of training can include various computer-based cognitive remediation methods and comparison between computer-based methods and individual instructional approaches. The effects of different doses of training and methods of maximizing motivation and participation also require testing.
The second avenue of investigation can go beyond neuropsychological effects, looking at the clinical, quality of life, and vocational outcomes from cognitive training. If cognitive rehabilitation combined with WT greatly improves these outcome domains, to next explore improvements in neuropsychological pre- and posttestings as a mediating variable to these functional outcomes would be worthwhile. Also important are questions about whether adding cognitive training boosts rehabilitation outcomes from other interventions, such as occupational therapy. In so doing, we will learn the extent to which cognitive training, when combined with other forms of rehabilitation, can influence community functioning.ACKNOWLEDGMENTS
This material was based on work supported by Rehabilitation Research and Development Service, grant D2356-R.
The authors have declared that no competing interests exist.REFERENCES1. Krabbendam L, Aleman A. Cognitive rehabilitation in schizophrenia: A quantitative analysis of controlled studies. Psychopharmacology (Berl). 2003;169(3-4):376-82.
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[PMID: 12823166]23. Bell MD, Bryson GJ, Greig TC, Fiszdon JM, Wexler BE. Neurocognitive enhancement therapy with work therapy: Productivity outcomes at 6- and 12-month follow-ups. J Rehabil Res Dev. 2005;42(6):829-38. [PMID: 16680620]24. First MB. Structured clinical interview for DSM-IV axis I disorders: Patient edition. New York (NY): Biometrics Research Department, New York State Psychiatric Institute; 1998.25. Wechsler D. WAIS-III Manual: Wechsler Adult Intelligence Scale-III. New York (NY): Psychological Corporation; 1997.26. Wechsler D. Manual for the Wechsler Memory Scale-Revised. San Antonio (TX): Psychological Corporation; 1987.27. Brandt J, Benedict RH. Hopkins Verbal Learning Test-Revised: Professional manual. Lutz (FL): Psychological Assessment Resources; 2001.28. Loong J. The manual for the Continuous Performance Test. San Luis Obispo (CA): Wang Neuropsychological Laboratory; 1991.29. Bell MD, Greig TC, Kaplan E, Bryson G . Wisconsin Card Sorting Test dimensions in schizophrenia: Factorial, predictive, and divergent validity. J Clin Exp Neuropsychol. 1997;19(6):933-41. [PMID: 9524888]30. Heaton RK. A manual for the Wisconsin Card Sorting Test. Odessa (FL): Psychological Assessment Resources; 1981.31. Bell M, Bryson G , Lysaker P. Positive and negative affect recognition in schizophrenia: A comparison with substance abuse and normal control subjects. Psychiatry Res. 1997; 73(1-2):73-82. [PMID: 9463840]32. Gorham DR. The use of the proverbs test for differentiating schizophrenics from normals. J Consult Psychol. 1956; 20(6):435-40. [PMID: 13376774]33. Marengo J, Harrow M, Rogers C. A manual for scoring abstract and concrete responses to verbal tests. New York (NY): Microfilm Publications; 1980.34. Corcoran R, Mercer G , Frith CD. Schizophrenia, symptomatology and social inference: Investigating "theory of mind" in people with schizophrenia. Schizophren Res. 1995;17(1): 5-13. [PMID: 8541250]35. Reitan RM, Wolfson D. The Halstead-Reitan neuropsychological test battery: Theory and clinical interpretation. Tucson (AZ): Neuropsychology Press; 1985.36. Bryson G , Bell MD, Lysaker P, Zito W. The Work Behavior Inventory: A scale for the assessment of work behavior for people with severe mental illness. Psychiatr Rehabil J. 1997; 20(4):47-55.37. Yankowitz R, Musante S. The use of cognitive functional assessment in a psychiatric vocational rehabilitation program. Am Rehabil. 1994;20:32-37.38. Bracy O. CogReHab software. Indianapolis (IN): Psychological Software Services; 1995.39. Fiszdon JM, Whelahan H, Bryson GJ, Wexler BE, Bell MD. Cognitive training of verbal memory using a dichotic listening paradigm: Impact on symptoms and cognition. Acta Psychiatr Scand. 2005;112(3):187-93. [PMID: 16095473]40. Greig TC, Nicholls SS, Wexler BE, Bell MD. Test-retest stability of neuropsychological testing and individual differences in variability in schizophrenia outpatients. Psychiatry Res. 2004;129(3):241-47. [PMID: 15661317]Submitted for publication February 14, 2007. Accepted in revised form June 5, 2007.
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Same reason why i could never approve of getting pregnant before marriage.
Friday, March 2, 2012
Can a Woman Propose to a Man? (A Male POV)
Same reason why i could never approve of getting pregnant before marriage.
30 comments:
LOL wow...I still maintain me I no fit oh.I want my own Nollywood or Hollywood or Japanwood porposal story.I just wont get past the fact that uncle didnt desire me enough to ask..just sayingReplyDeleteReplies
I concur UGold. I want my own 'How your daddy proposed story' to tell my kids ;)Delete
First question, who is Prof?ReplyDelete
Second, do you realize he/she said yes?
Finally, you are both hilarious! LWKMD...
Nw let me go check those links.Replies
Prof keeps showing up in my blog posts :). I don't know what to make of him. After 'the chat proposal' I also offered him the position of 'Maid of honor'. He is a bit confused right now.Delete
lol. I find us funny too. We do have interesting chats.
You guys are funny. But really, at the end of the day "dropping hints" is the same thing as asking him to marry you...its just different words. If our excuse for not wanting to propose is the idea that if the man wants you, he'll ask on his own (which i wholeheartedly believe btw)...then technically you shouldn't even want to drop hints.ReplyDelete
#Gbam @ men dictating the pace of the relationship. I've been saying this for years but nobody believes me lolReplies
Lady Ngo re-echoing the #gbam!! I think women get manipulative and drop hints when they aren't sure where the relationship is going. Its not always a bad thing cause it gets the conversation going towards that topic. and it also gives both parties an idea of how the other party is enamoured with the idea of marriage.Delete
LMAO..I am asking the same questions as Myne... Who is Prof?! Ginger!!! U are keeping man secret, ba?! Issorai!ReplyDelete
As for proposal or not proposal...me i dont know o! But it doesnt sound like something I will do
And I dont necessarily agree that dropping hints is same as proposing.
I'll be totally honest. I would never ask a man to marry me. I don't see any reason why it should be one sex or the other to do the asking, personally. I just wouldn't do it because I'm a coward! That's a big brave emotional risk, and I've never envied men having the traditional role of the one supposed to do the asking!ReplyDeleteReplies
Tatty I totally agree. I do admire the women who put themselves out there. It is such a brave thing to do.Delete
I know all these are based on theory and you are not being practical. I'm not yet 25 and I've had girls ask me out. From that experience I know what to expect from older girls who want to marry.ReplyDeleteReplies
lol. A girl is allowed to be unpractical once in a while joo. You've got girls toasting you huh? way to go!Delete
Interesting conversation. Funny PoVReplyDelete
I still want to be chased and proposed to. Makes me feel worth fighting forReplies
Amen to that!Delete
This comment has been removed by the author.ReplyDeleteReplies
Adura. Come on. Women are not manipulative. we just know how to use our weak status to get the stronger men to do well by us. I call it wisdom ;)Delete
This comment has been removed by the author.ReplyDeleteReplies
And that is probably a man who doesn't care as much for her. Cause if he does, he will want to reassure her that he is there. All there.Delete
Ginger, your conversation is hilarious.ReplyDelete
Now, seriously, sometimes a woman can say "Are we getting married or what?" and it's perfectly okay. Personally, I believe a man likes to "chase" a woman. The harder he has to work to get her, the more value he places on her. Old fashioned attitude, but it's true.Replies
Mom, that attitude never became old. Its a genetic thing they are hunters. I am happy to gather!Delete
- AnonymousMarch 3, 2012 at 4:38 PM
Yes, yes, I read everything. But what I want to know is, WHO IS PROF?! DO I NEED TO BUY TICKET, EH?!ReplyDeleteReplies
Chere Nwunye. Oge eru beghi :)Delete
lmao @ I'll just clonk his head. Ginger will not kill person. The truth, like most pple have said is, guy's like to be in control and they'll rather do the chasing.ReplyDelete
So, the call kwanu? how did it go? Abi you have not called him ni?Replies
Toinlicious! I thought you knew me better :). After this public intro-manipulative-proposal, the ball is now in the man's court. he will need to bring me the tooth of a pregnant lioness, the egg of a piranha and the fang of a mamba before I will say 'Yes' in turn to him.Delete
hey there, Just nominated you for the versatile blogger award. for more info, visit http://bitemylowerips.blogspot.comReplyDelete
Thank you MsInfamous!Delete
Ginger he said yesReplyDeleteReplies
lol.I have chosen to be selectively blind/deaf/dumb to that response.Delete
Will definitely not be proposing to any man. Like Linda said men value what they work for.ReplyDelete
- AnonymousMarch 19, 2012 at 1:53 PM

subset: commoncrawl


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Kershaw, the reigning winner, wasn't as good in 2012 as he was in 2011, but his 2011 was quite dominant.
Good money says Dickey will win, but Kershaw was the best pitcher in the NL this season.
Greinke, Sanchez among Dodger rotation targets
Dylan Hernandez of the L.A. Times reported the Dodgers will try to land at least one starting pitcher, and the name Zack Greinke has come up.
I penned a post in September that the Dodgers would sign Greinke to a mega deal this winter. I still stand by that prediction. He'd be the perfect No. 2 starter to slot in behind Kershaw.
Jayson Stark of ESPN tweeted the Dodgers could also look to Anibal Sanchez to fill the rotation need. Sanchez was traded to the Tigers from the Marlins in July and pitched relatively well. He wouldn't be the big-name pitcher Greinke would be, but he'd be a solid backup option.
Garcia makes AFL debut
Dodgers' prospect Onelki Garcia made his long-awaited debut in the Arizona Fall League on Tuesday. His status was in doubt due to a potential oblique injury.
If that was the case, Garcia showed no ill effects of the injury. His line: 2 IP, 1 H, 0 R, 1 BB, 1 K, 26 pitches, 17 strikes.
Garica, 23, was the Dodgers' third-round draft pick this year.
Another 2012 draftee chimed in on Garcia's potential. From John Sgromolo, 37th-round draft pick:
"(F)aced him in a sim game, electric stuff! Great guy too!"Dominguez suspended 25 games
Prospect Jose Dominguez, a favorite of Jared Massey's (LA Dugout), was suspended 25 games for violating the Minor League Drug Prevention and Treatment Program.
No word on if it was a recreational drug or a performance-enhancer.
Dominguez, 22, threw 72 of his 79 innings for the Loons this season in Low-A before a late-season promotion to Double-A. He averaged nearly 10 strikeouts per nine innings while boasting an upper-90s fastball.
Silverio outrighted, re-signed
The Dodgers outrighted outfielder Alfredo Silverio to Triple-A and was subsequently re-signed. The move was made to clear a spot on the 40-man roster.
Silverio, coming off a breakout 2011, was in a car accident in January that resulted in him needing Tommy John surgery.
The Dodgers must have been rather confident they could re-sign him, otherwise they wouldn't have risked losing him. Then again, how many teams would be lining up to sign a 25-year-old minor-league outfielder coming off a lost season?
Photo credits
Kershaw: Dustin Nosler, Feelin' Kinda Blue
Greinke: Jninja, Wikimedia Commons


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New Developments At Eurovacations.Com Make Planning And Booking Customized European Vacations Faster
Just when travelers are ready to make plans for their 2001 trip to Europe, the only Web site offering the capability of researching, planning and booking individual or all components of a customized European vacation, as well as off-the-shelf packages for independent travelers, EuroVacations.com
, has revamped its homepage to make the unique site easier to use.
Selected by Travelocity in late 2000 to power that site's European Destination engine, EuroVacations.com also recently announced a guarantee to match the lowest price for any similar vacation package available online.
Last week, BBBOnLine, a subsidiary of the Council of Better Business Bureaus, announced that after reviewing EuroVacations.com`s privacy policy and practices, it has granted the site the BBBOnline Privacy Seal.
"No other site gives users the value, flexibility, wealth of information, and one-click ease and speed of immediately confirming availability and price of those travel services specifically needed for a customized European vacation to the top 94 destinations," explains Bernard Frelat, President and CEO of EuroVacations.com. "The new homepage is in response to user feedback and part of our on-going effort to make the site even easier, faster and better than ever."
EuroVacations.com is also continually adding new cities, destinations, suggested itineraries, hotels and other services that can be included in a customized vacation plan. The site currently offers more than 1200 hotels, 200-plus customizable Vacation Plans (one or multi-city itineraries), all major airlines, three car rental companies, railpasses and rail tickets for travel throughout Europe and the UK, and other travel services, such as theater tickets and museum passes, all from reliable, quality suppliers. The site also regularly features Great Value Plans—packages for major cities at exceptionally good prices.
Users simply select an existing Vacation Plan to customize or they start by looking for ideas in the extensive Destination Guide and entering departure city, arrival city, next city, desired type of hotel, number of nights in each city, etc. The site begins building a customized, cohesive itinerary, which is automatically stored in the user's Cybersuitcase for future planning sessions, or with one click, availability, reservations and price for the entire package can be confirmed.
The new homepage features a user-friendly task-oriented layout, in contrast to the previous graphics-oriented design. Also, users now have immediate access to planning and booking functions and easy one-step registration. There are also links to travel community sites on the new homepage to share experiences, get special tips and chat on specific destinations and topics (currently three communities are up, We Love Paris, We Love London and We Love France, with more on the way).


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Q. I recently bought a house that has glued-down, low-quality carpeting in the Kitchen and dining areas. Can I take it up myself and save the cost of having it removed commercially? Allen Sanders St. Louis
A. There is no reason why you cannot take up the old carpet. It may take a lot of tugging but go to it What new flooring will replace the old carpeting? Do you plan to install new, Higher- quality carpeting, resilient flooring, or what?
You may need to prepare the exposed floor surface one way or another, depending on what flooring is to be laid. If you expect to install it yourself, discuss the required floor preparation with the supplier of the material you intend to use.


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ActiveWest Builders (AWB), located in beautiful Coeur d'Alene, Idaho, continues to raise the bar for building high performance, healthy, green homes and buildings while striving to achieve LEED Platinum®, ENERGY STAR®, and Indoor airPLUS® certifications. We design our homes and communities to provide a partner in your lifestyle and well-being.
Our unique communities offer locations close to a variety of amenities and conveniences, maintenance-free living, and smart, functional design. This has set AWB apart and serves a growing niche of homebuyers, from retirees and snow birds to professionals and singles.
ActiveWest Builders has received over 20 national awards and many local awards in a variety of categories, which stands as a testament to the quality of our design and construction.
We design and build our homes using the stringent guidelines of the U.S. Green Building Council's LEED® third-party verification certification program. We strive for Platinum certification with every home.
We install ENERGY STAR® appliances in our homes. Their superior energy efficiency not only reduces the homeowner's carbon footprint, but also substantially reduces energy costs.
We use materials and construction practices that minimize contaminants and air pollution. Our homes at Riviera Walk were the first in the state to achieve the EPA's Indoor airPLUS certification.
Congratulations to our awesome team for winning Best Energy Efficiency, Best Master Suite, and Best Interior Design and Layout at the 2018 NIBCA Parade of Homes! Come see our award-winning home this weekend in The Circuit @ Seltice at 3304 North Rosalia Road. Tickets for the Parade of Homes are $5.00 each and can be purchased at…
ActiveWest Builders has been chosen as a Power Builder by the U.S. Green Building Council (USGBC) as a part of the 2017 LEED Homes Awards, an annual campaign honoring projects, architects, developers, and homebuilders who are leaders and innovators in the residential green building market. LEED Homes Power Builders are an elite group of developers…


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Bicycle Times Issue #31 is here – Take a peek inside
Bicycle Times Issue #31 has mailed to subscribers and will be available on newsstands soon. As always, if you want to make sure you see it first and never miss an issue, order a subscription!
This is our family-themed issue, chock full of features, featurettes and product reviews all geared toward the active family (and those young couples planning on riding with their future offspring). There's something for everyone in Issue #31, including: a reminder to ride like you did when you were a kid, what it takes to keep adult children happy on a family tour, taking a toddler on a bike tour of Chile, and what one large family has contributed to the world of American frame manufacturing in Tennessee since 1986.
There's plenty for the family this issue, plus a tale of being kidnapped in Bangkok.
Our Provisions product review section includes a few humdingers, including an electric-assist cargo bike, plus a few recommended "For Your Consideration" products.
Does this scene look familiar? Reminds me of my bike room 15 years ago.
Finally, our Parting Shot captures the essence of all-surface riding with two old timers who could easily kick your ass if they weren't so nice, plus a short tribute to the late cyclist, actor and comedian Robin Williams.
All this and more, now available on iTunes. Print subscribers should start receiving their copies next week. You can always visit better book stores and bike shops to buy a copy too!Tweet Print


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Untitled (Self-Portrait)
acrylic based gouache on wood
20 x 16 inches
Please contact firstname.lastname@example.com for pricing and availability.
Payment plans, additional artwork images, and artist information is available upon request.
Artist Statement: I have always been drawn to a past era, imagery that reflects a simpler time. I grew up rummaging through my grandparents' garage in Houston looking for old oil cans, paint buckets, and catalogs. The artifacts I found there showed detail and style that has long been replaced by digital imitations. The flat logos on rusty cans and illustrations in men's 1950's catalogs served as perfect test subjects for learning how to draw a simple image.
In many ways, I am still creating the same simple and effective images I made when I was a kid. Traditional folk art has been the primary focus for most of my adult life. The emphasis on a single bold line or minimal color pallet continues to serve as a constant challenge. When I strip a painting down to its bare bones it helps me think more intently about the impact of each line or stroke. I find satisfaction in creating simple and concise works that convey universal messages of loss, love and redemption.
A mixture of mediums and techniques are used to achieve my vision; most recently I've been focusing on gouache and pen illustrations on paper or wood. I am most comfortable with pen illustration. In recent years, this has primarily been reflected in my warpaint series, which consists of antique cabinet photos that I've drawn and painted over. To me, this series is a revitalization of the past and a celebration of timeless beauty. The images may vary but a core elemental style remains consistent. I will generally focus on a central figure that is often floating in a blank space or with a minimal background.
I am drawn to sacred art of all kinds, especially art that emphasizes a "savior." Finding my creative voice brought freedom and redemption from everything that ails me. When I am creating work, the outside world is on pause and I can completely let go of all the trials and tribulations of the day. I feel that this is represented in the iconic images I create and is my attempt at paying homage to something greater than myself.


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Free Stuff Canada: Telus 2013 Wall Calendars
Telus customers (phone, internet or tv) can place an order for a free Telus 2013 calendar!
You can order up to 5 calendars. In the past they've been quite nice and colorful, featuring photos of animals.
Simply fill out a short survey and your mailing address and your calendar will arrive in 4-6 weeks!
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Ginseng Energy Gold
- Increases resistance to physical/emotional stress
- Promotes a healthy immune system
- Supports recovery from fatigue
- Enhances overall vitality
Natural adaptogen support for energy & adrenals
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- 1 Bottle = 2 oz (59 mL)
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What is Ginseng Energy Gold?
Ginseng Energy Gold combines several herbs renowned for their 'adaptogenic' action - herbs which improve our ability to adapt to or withstand stress, be it of a physical, mental, or emotional nature by supporting the hypothalamic-pituitary-adrenal (HPA) stress axis. This remedy is ideal for individuals who are under chronic or severe stress, run down, fatigued, low in vitality or energy, or overcoming illness.
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Eleuthero (formerly known as Siberian Ginseng) provides immune support, strengthens adrenal function, and increases endurance, stamina and physical performance. Licorice is a specific adrenal cortex-supportive herb which helps improve adrenaline, cortisol and aldosterone balance. It is considered a great 'harmonizer' herb, smoothing out the action of all herbs it is combined with.
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Best used as a long-term tonic (minimum 1 month), taken on a daily basis. When under heavy stress, you can increase frequency to 4 to 6 times per day, over the short-term.
Are there any side effects or precautions?
If you have high blood pressure, blood sugar imbalance, or any other health condition, or are taking any medications, consult your doctor before using.
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- Red (Asian) Ginseng Root (Panax ginseng)
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- Licorice Root (Glycyrrhiza glabra)
- Ginkgo Leaf (Ginkgo biloba)
- Fo-Ti Root (Polygonum multiflorum)
- Codonopsis Root (Codonopsis pilosulae)
- Fresh Ginger Root (Zingiber officinale)
Other Ingredients: Grain Alcohol, Deionized Water.
Take 15 to 60 drops, two to three times per day in water or juice.
Best used as a long-term tonic (minimum 1 month), taken on a daily basis. When under heavy stress, increase frequency to 4 to 6 times per day, over the short-term.
If you have high blood pressure, blood sugar imbalance, or any other health condition, or are taking any medications, consult your doctor before using.
If you are pregnant or nursing, consult your doctor before using.
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"A garden is a lovesome thing!"
- tomatoes--4 types
- peppers--sweet bells, jalepenos, bananas
- broccoli
- collards
- cucumbers
- zucchini
- green beans
- eggplant
- potatoes
- romaine
- onions
The strawberries are ripening and the raspberry & blackberry bushes are getting off to a good start. The allium planted in November did not disappoint and the clematis is in its glory...
I'll be back between planting and weeding to let you know how the homemade moisturizer turned out,


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Case 1799
The patient returned after 3 months with a sudden increase in pain. Plain chest radiographs revealed a small pneumothorax on the right side, in addition to the osteochondroma.
The patient agreed to undergo surgery and pathology confirmed the diagnosis.
Osteochondromas of the ribs are rare and nearly always arise at or near the anterior end of the rib. They cause expansion or deformity of the rib with calcification of the cartilaginous cap. They can be mistaken for an area of pneumonia or a solitary pulmonary mass. CT allows a more definitive evaulation, especially of the cap.
Osteochondromas are most likely caused either by a congenital defect or by trauma of the perichondrium which results in the herniation of a fragment of the epiphyseal growth plate through the periosteal bone. They can either be sessile or pedunculated (stalk-like), with a slender pedicle directed away from the joint, and appear in the juxta-epiphyseal location. They occur only in bones that develop from cartilage (endochondral ossification). They have been reported to occur as a result of radiation therapy in children. There is normally no further growth of the exostosis after epiphyseal fusion.
Clinically, they present with pain due to mechanical irritation or a painless mass. A fracture can occur through the stalk of the lesion. Occasionally they are an incidental finding.
Hereditary multiple osteochondromatosis (diaphyseal aclasis) is an autosomal dominant condition with lesions (both sessile and pedunculated) occurring on different bones or on the same bone. Nearly 50% of these patients have a rib lesion.
Plain films are normally sufficient to diagnose the condition. Sessile lesions cover a wide area and can cause metaphyseal widening. The cartilaginous cap displays irregular areas of calcification. CT is helpful in determining whether the marrow and cortices of the lesion are continuous with the bone. The thickness of the cartilage cap is best delineated on MRI. The cartilage cap ranges from 1mm to 6mm in thickness; over 2cm of cartilage or renewed growth is a sign of possible malignant transformation.
The differential diagnosis includes hereditary multiple osteochondromatosis (diaphyseal aclasis). The differential diagnosis of rib lesions includes enchondroma, osteoblastoma, osteoid osteoma, chondroblastoma and haemoangioma.
Complications may occur; osteochondromas in areas other than the knee are more likely to undergo malignant transformation. Secondary chondrosarcoma occurs in 0.5-1% of patients with a solitary osteochondroma. Chondrosarcoma transformation is more common in the hereditary form.Dynamic Gd-enhanced MR can be used to differentiate benign from low grade malignant cartilaginous tumor.Both early and exponential enhancement being predictors of malignancy.Gd-enhanced MR can further help in tumor mapping in case a biopsy is indicated. Spontaneous haemothorax or pneumothorax (as in this case) have been reported in rib lesions, as have fractures.
Pathologically, on gross examination, an osteochondroma is an irregular bony mass with a bluish grey cap of cartilage. Opaque yellow cartilage has calcification within the matrix. The base of the lesion has a rim of cortical bone and central cancellous bone. Microscopically, the lesion shows endochondral ossification on the basal surface of hyaline cartilage. The cartilage is more disorganised than normal, the thickness of the cap is usually 1-3mm, and greater thickness may imply malignant transformation.
No treatment is necessary for asymptomatic osteochondromas. If the lesion is causing pain or neurological symptoms due to compression it should be excised at the base. The prognosis of a solitary exostosis is excellent. In this case, the patient had surgery as she developed spontaneous pneumothorax and the diagnosis was confirmed at pathology.
Chest film showing a calcified lesion projecting over the right sixth rib.
Lateral view confirms the lesion arising from the rib and the calcification.
Chest film a few months later, showing the presence of a small pneumothorax on the right side (arrows).
CT of the chest shows the ossific lesion with calcification on the right side.
CT of the chest confirms the lesion is arising from the rib (arrow).
Chest PA view
CT of the chest
Any Questions? Contact us here:
EURORAD Office c/o European
Society of Radiology
Am Gestade 1,
AT-1010 Vienna, Austria


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Mathieu Roy, Ben O'Connor and Colton Fretter each scored a pair of goals as Sheffield Steelers closed to within three points of Elite League leaders Braehead Clan with a 9-2 victory over Hull Stingrays.
Jeff Legue, Mike Forney and Tyler Mosienko also found the back of the net as the Steelers completed a comfortable victory.
Nottingham Panthers' fading title hopes suffered another setback as they slipped to a 3-2 defeat to bottom club Dundee Stars.
Bari McKenzie, Shane Lust and Ryan Grimshaw were on target for the Scottish side, with Evan Mosey and Guillaume Doucet replying for the Panthers.
Also on Saturday night, Niko Suoraniemi, Jordan Fulton, Chris Auger, Kyle Haines and Matt Reber scored as Fife Flyers eased to a 5-1 home victory over Edinburgh Capitals.
Sunday 1st March 2015
Elite League
Braehead Clan v Fife Flyers – 6.00pm
Cardiff Devils v Belfast Giants – 6.00pm
Coventry Blaze v Sheffield Steelers – 5.15pm
Edinburgh Capitals v Nottingham Panthers – 6.00pm
Hull Stingrays v Dundee Stars – 6.00pm


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Quilter's Connection Magazine is the only quilting magazine published in Canada.
To thousands of quilters, we are the friend who welcomes you with a heartwarming story over a cup of tea. We show you the perfect pattern, teach you a new technique, help you find the best fabric, notions and supplies, and tell you about upcoming shows and festivals you won't want to miss.
We are a truly Canadian magazine – for quilters, by quilters.
Published quarterly, Quilter's Connection provides quilters with a connection to the rest of the quilting community across Canada. Written for quilters, by quilters, Quilter's Connection Magazine is THE source for all things related to quilting in Canada. We entertain you with news and reviews, projects, heartwarming and motivational stories about quilters and their achievements, quilting tips, and techniques – content to inspire the quilter in everyone.
Heather McArthur, Editor/Publisher
Heather McArthur lives her passion each and every day, an opportunity every quilter should be so lucky to have! After working in the not-for-profit sector as a Marketing and Communications expert, Heather found an opportunity to take her love of quilting from a casual hobby to a full-time career. The pending retirement of a couple who had developed a small quilting newsletter in BC allowed her to not only work at her hobby, but also to fulfill her dream of being a writer.
In addition to publishing Canada's only magazine for quilters, Heather belongs to two quilt guilds, has spent time as a volunteer teaching quilting for the Elizabeth Fry Society in Vancouver, and organizes donations of breast cancer pillows for the BC Cancer Agency.
Karen Christie, Administration
Loraine Corman, Advertising Sales
Loraine has an extensive sales background and a wealth of quilting experience spanning over 13 years. When not creating, sewing and quilting, she enjoys exploring new places on the boat with her husband, reading, gardening, and entertaining
Editorial Advisory Committee
Jean Boyd
Jean Boyd holds a Fibre Arts Certificate in Quilting and has taught extensively throughout Canada and the US. In June 2003, the Canadian Quilters' Association name her Teacher of the Year. Jean has appeared on the TV series Seams Canadian, and her work has appeared on the PBS show America Quilts Creatively, and in many magazines.
Jean has won numerous awards for her quilts, and since 1997 has been designing and publishing patterns. Her patterns cover a broad range of styles including memory quilts, traditional design, stitchery, Red Work, and hand piecing. these patterns are distributed throughout Canada and the US. Since 2002, Jean has also been designing pattern featuring the newest fabrics from Northcott.
Susan J. Jensen
Susan J. Jensen is the British Columbia designer of Quilted Escapes. Susan's patterns combines a variety of techniques from beading, stitchery, wool appliqué and foundation paper piecing that gives a romantic feel to her quilt designs. Her patterns can be found in quilt shops across Canada, the US, and England. Susan is also a fibre artist and teaches classes in her techniques.
She designs for Northcott Fabric, RJR, and Trend-tex and has been featured in "The Canadian Quilter", "A Needle Pulling Thread" and "Electric Quilt". She works a few days at "A Great Notion" and if she is not in her studio, she is teaching at quilt shops, quilt guilds, retreats and consumer shows.
Wayne Kollinger
Wayne Kollinger is a quilt designer from Calgary, AB. He became one because he didn't keep his mouth shut when he went with his wife to quilt shows. He knew nothing about sewing and quilting, but something about lettering, so whenever he saw badly designing pieced lettering on a quilt, he said so. Eventually his wife said, "If you think you can do better, go ahead."
Wayne is now the author of a book, Designing Quilts is Easy, which was released in 2010 by C&T Publishing. He also has two blocks in the book, Modern Blocks, by the same publisher. Wayne's work has appeared in The Canadian Quilter, Quiltmaker's100 Blocks, Quilts from Quiltmaker's100 Blocks, and Quilter's Connection Magazine. Recently, the Royal Alberta Museum acquired some of his Alberta Series patterns for their quilting ephemera collection.
Tricia Sherman
Producer/host of The Great Canadian Shop Hop, Tricia Sherman has been an avid quilter for over 20 years. She has experienced many facets of the craft, including owning a long-arm business, part-time work in a quilt shop, and teaching. Her involvement in QNNtv.com opened up the opportunity to develop The Great Canadian Shop Hop videos to promote quilting in Canada. Working on the show has provided a forum for Tricia to travel across the country filming, teaching and meeting other quilters. A quilter's dream if there ever was one!


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Size: 23-26 inches. (The largest species in South Florida.)
Color: Grayish-white with black wingtips. Juveniles are dark gray-brown and speckled, growing lighter as they mature. Legs are pinkish; bill is yellow.
Other features: Loud, squealing cry.
Range: Throughout the Northern Hemisphere.
Size: 19 inches.
Color: Resembles a small herring gull with a black ring around the end of the beak. Immature birds are gray-brown, speckled. Legs are greenish-yellow. It is South Florida`s most common gull.
Other features: Cry is higher pitched than herring gull`s.
Range: Canada and northern United States (winter) to Mexico and Caribbean (summer).
Size: 16 inches. The smallest species in South Florida.
Color: Dark legs, back, wings and bill. Its head is entirely black in summer, white with a grayish ``cap`` in winter.
Other features: Noisy ``laugh.``
Range: Entire coastline of North and South America.
Size: 18-20 inches.
Color: Whitish beneath, pale gray above, with a tuft of feathers at the back of the head. The tuft is black in the summer and gray in winter. The bill is long, thick and bright orange. Legs are dark gray.
Other features: The tail is deeply forked.
Range: Coastal areas of southeastern United States, South America, West Africa.
Size: 8-10 inches
Color: In summer, russet back, white breast with black collar. Winter and immature plumage is duller, with white breast and reddish-brown back. Legs are orange.


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Like many parents, I spend hours on youth sport fields as a spectator and coach. Like many, I also lose my cool sometimes with the results, officiating and the some of the chaos associated with these activities. Rosy and I encourage our children to participate in sports for many reasons and have had some fantastic experiences.
At high points we are at fields six nights a week and at times I wonder if I am keeping balance for my children. Travel time, expense, time away from family and neighborhood friends are hurdles we maneuver along the way. In the end, it is my hope that they discover valuable life lessons while learning to win or lose.
The spirit of competition on the field, in theory, should teach our children to compete in the classroom, playgrounds and, eventually, in their careers. This is the essence of the American Dream. Unfortunately, I have seen youth sports, all too often, reduced to screaming matches between parents. How do we reach a point where little league coaches are suspended from games for verbal and even physical acts of aggression? These incidents are isolated and the vast majority of the time our parents are great role models for our kids. That it occurs at all is inexcusable. By the way, I am not referring to some far away city these incidents occur right here in good ol' Wooster.
Last I checked, we are not filling the major leagues with world class athletes from Wooster. In fact, as a nation, we struggle to compete with nations such as the Dominican Republic and Venezuela -- (we will leave the birth certificate controversies for another time). I simply suggest we must remain focused on the priorities of competion I have already presented. My son, Max, taught me this simple lesson in seven words as we drove away from the ball field following a very frustrating night. He asked, "Dad can we get some ice cream?"
Yes. We should always stop for ice cream after a job well done whether on the ball field, classroom or board room. We need to keep the American Dream alive in our children and not shy away from daunting challenges. We need to do this by teaching our children to be assertive and fight for their beliefs while not stooping to become a bully.
Our business and political environment is full of bullies -- which is nothing new. What is new, however, is the pace at which technology, information and the world economy changes. Our children need to deal with bullies while acting in the best interests of their community. This task we all share will be more comprehensively accomplished without the screaming of volatile adults.
I invite you to join me and hundreds of fans for a real lesson in life. The PNC Bank/Elks "Field of Dreams" softball game will be played at 8 p.m., Saturday, July 14, at Wooster Foursquare Church. The game pairs Special Olympians with local business leaders for a friendly and competitive game. Bring the whole family to the tailgate party at 6:30 with music, batting cage and concessions. Then pull up a lawn chair and enjoy the true spirit of competition.


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SAN FRANCISCO - Today, Ubisoft announced the launch of Battle of Giants Dinosaurs Strike for the Wii system from Nintendo. A new installment in the successful Battle of Giants franchise, the game will be available worldwide in November 2010. Designed exclusively for Wii by Ubisoft Quebec, the development studio behind the Nintendo DS versions in the franchise, Battle of Giants: Dinosaurs Strike is the new addition to the Battle of Giants franchise, which has already sold more than one million copies worldwide.
The Battle of Giants brand offers young players the thrill of controlling a giant creature and fighting against other creatures for survival. Battle of Giants Dinosaurs Strike will immerse young players in a cataclysmic Jurassic world. Players will be able to choose a dinosaur among 18 different breeds such as T-Rex, Stegosaurus, Velociraptor, Triceratops, Ankylosaurus or Baryonyx and customize their dinosaur with 12 color options and different stripe patterns, or even upgrade horns, bone plates, fins or feathers to create the strongest possible creature. Battle of Giants Dinosaurs Strike also offers the possibility to unlock six other dinosaurs in Domination mode, where the player fights against eight other giant creatures, one by one in a ladder mode, before attacking the boss. The dinosaurs unlocked after each ladder are then available in the multiplayer versus modes.
The core of Battle of Giants Dinosaurs Strike is its fast-paced, three-round combat system, in which the player has to use each dinosaur's specific abilities and powers. Entirely based on real-time actions, players will need to act and react as quickly as possible, launching super attacks while protecting themselves from the natural casualties of the cataclysmic environment, such as earthquakes and volcanic eruptions.
Battle of Giants Dinosaurs Strike takes full advantage of Wii capabilities. The Wii Remote and Nunchuk offer immediate and natural controls, while the polished graphics of the three different breathtaking environments (tropical forest, desert and mountain) bring additional immersion to the experience. It also allows fierce multiplayer battles (with up to four players at a time) as well as three different multiplayer modes: Versus, Tournament and Tag Team.
About Ubisoft:
Ubisoft is a leading producer, publisher and distributor of interactive entertainment products worldwide and has grown considerably through a strong and diversified line-up of products and partnerships. Ubisoft is present in 28 countries and has sales in more than 55 countries around the globe. It is committed to delivering high-quality, cutting-edge video game titles to consumers. For the 2009-10 fiscal year Ubisoft generated sales of 871 million euros. To learn more, please visit www.ubisoftgroup.com.


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Caudalie Soleil Divin Anti-Ageing Face Suncare
This cream for the face provides excellent all-around protection: broad spectrum UVA/UVB, anti-ageing and cellular DNA. Its silky formula gives skin a matte, transparent and non-sticky finish. Moisturized and fortified, the skin is evenly tanned and the complexion is luminous.
Directions for use:
Before any exposure to the sun, apply generously and evenly to the face. Re-apply frequently for optimal protection.


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-A pair of woven huarache sandals
-Neon embroidery floss in two colors
-An embroidery needle
-Fabric glue
Cut about a foot and a half of each color of embroidery floss and thread the needle.
Beginning with one section of the huaraches, thread the needle up and down through the woven leather detail.
Pull the floss through, leaving a few inches loose at the end.
Thread the floss back through the leather, passing the thread over where you went under and under where you went over.
Continue weaving back and forth until the section is filled. Knot the remaining floss using the tail left from when you started the section.
Add a drop of glue to strengthen the knot.
Trim the floss a half-inch from the knot.
Use the needle to push the loose threads underneath the woven area.
Follow the same steps to add neon detail to other sections of the huaraches and around the front of the sandal. Repeat on the other shoe.


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contributed by
Dr James Sheldon
on August 30, 2015
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Amyand hernia is an uncommon form of inguinal hernia in which the vermiform appendix is located within the hernial sac. It is seen in less than 1%..."
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The Barcelona coach is the best dressed manager in any sport that I have ever seen. Everyone praised the sartorial elan of Jose when he wore that fantastic Armani coat a few years back, but the suits were never as fashionable as what I've been seeing Pep Guardiola dressing in on the touchlines. Slimly cut almost always with a crisp white shirt and a narrow tie, he is a walking advert of how the suit doesn't need to be stuffy and also doesn't need to make you look like you shop too much in the Topman skinny-cut section.
I've tried to find out whether they are off-the-peg. It was a long-shot and invariably it turns out they are bespoke, but if you look for the general cut, then you can find some good ready-to-wear out there. The thing so beautiful about these suits is that, unlike the Dior Homme and high street versions of the slim suit, the jacket is not cropped so retains the same masculinity and elegance of the traditional suit jacket just with a 21st century silhouette.
It's the little touches that elevate him to a genuinely stylish man. Known to wear a pocket square matching the colour of his shirt and often matching the colour of his tie to his suit, it's simple but effective and his use of v-necks and cardigans to is impeccable. He even has a beautiful mac for if it gets a bit chilly.


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...Greg took his truck back so now we are left with non-mountain worthy vehicles so this might be the last desert trip for awhile.
So there I was early on Saturday morning, calmly getting ready to clean the house. OK, technically I wasn't calm.... I was whining and stomping my foot and slamming doors....sigh.... and Steve came and said "gee...we have Greg's truck...we should use it and go over 4 Peaks! Let's get outta here in the next 30 minutes!"
Reluctantly I said yes. Of course the thrill of bathroom cleanser and dust rags was compelling but I am nothing if not accomodating so I sulkily said YES!
In 22 minutes I had a cooler packed with water, found an extra roll of TP, put my dusty tennis shoes (hey, it's too hot to wear regular shoes here in the summer). You know that saying "The only real mistake is the one from which we learn nothing?" Well I learned something last trip and that was "take water you idiot! and don't wear sandals on a desert trip! and cactus spines do not made good toilet paper!) so this time I was much more prepared.
We swung by my parents to pick up my Dad, who is always game for any adventure. And we were off.
Now you might think on initial viewing that these are the same pictures from our trip to Crown King (remember my comment that there is a same-ness to the desert) but they aren't! You can see different mountains, different cactus and different dirt.
So... c'mon!
Our whole purpose of this trip is to go over these mountains and come out the other side. Yes, I know that made you think of the "why did the chicken cross the road joke"!
Look at these amazing prickly pear blossoms! If we get the truck again I am going to find out when to harvest them and attempt making jelly. These beauties were as big as plums.
...and since the plum remark made me hungry I'm gonna grab some breakfast and start the rest of my day.
Stay cool, keep your shoes and water handy cuz this trip will continue soon!
Wednesday, July 22, 2009
Think of the positive side....
Posted by Jenny at 7:08 AM
3 comments:
- Amy said...
Beautiful! The photos and you!
- July 22, 2009 at 7:26 AM
- Terri and Bob said...
Beautiful photos and looking forward to more!
- July 22, 2009 at 10:26 AM
- Lisa said...
Jenny, the landscape of Arizona is beautiful! Never been there but your photos are great. Thanks for visiting my blog today and entering my GIVEAWAY. I love your ideas!
- July 22, 2009 at 11:18 AM
Subscribe to: Post Comments (Atom)


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Free: Contests & Raffles
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Hello and thank you for your time, My 10-year-old collie was just diagnosed with
lymphoma. Her vet has (predictably) prescribed chemo, but I would prefer to treat
her with diet and supplements -- I have been researching online, but can't seem
to find a conclusive response to the success of any kind of treatment. Can you share
any information or suggestions? My entire family is devastated by this news, and
I am anxious to fight this disease in any way we can. Thank you again for your response,
and for providing this much needed forum.
Thank you for visiting Only Natural Pet Store. I am sorry you are facing such
a tough diagnosis with your dog. We can give you some general recommendations from
Dr. Siegler for immune boosting supplements, but for a thorough cancer fighting
protocol we do recommend you
contact a holistic veterinarian.
Here are some basic suggestions:
Here is a link to the American
Holistic Veterinary Medicine Association's website to locate a holistic veterinarian
in your area. If you cannot find a holistic veterinarian within reasonable
driving distance of your home, many of them do phone consultations.
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We always offer you the lowest of the sale price, the price with a coupon code discount, or the Auto Delivery price. You can tell which one applies because it will say "Sale Savings:" if the item is on sale and that is the lowest price, "Coupon Savings:" if you have applied a coupon code discount and that is the lowest price, or "Auto Delivery Savings:" if you selected Auto Delivery and that is the lowest price.


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This article appears today out of Honolulu. It further supports the theory that she was a castaway. It is a second opinion to whether a crash site was fond or not.
Enduring mysteries can be fun to wonder about. On the other hand, it would offer closure as to what happened to end the life of such a pioneer.
#AmeliaEarhart #TIGHAR #Mystery #Nikumaroro


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8 - 1155 North Service Rd. West.
Oakville, Ontario, Canada
Tel: (905) 849-4346
Fax: (905) 849-4347
Send us an email
In 1857, Hermann Sichel founded H. Sichel Söhne, his wine business in Mainz, Germany. He launched the Blue Nun wine brand in 1923 with the 1921 vintage. By the 1950s it had become Germany's largest international wine brand. For most of its existence, Blue Nun was a single German wine, which until late 1990s was classified as a Liebfraumilch, but the name is now used for a whole range of wines of various origins. When it was created, the label was designed as a consumer-friendly alternative to the innumerable German wine labels with Gothic script and long, complicated names. With the creation of its UK office in 1927, Sichel targeted the export market, and beginning in the 1950s, Blue Nun was advertised as a wine that could be drunk throughout an entire meal, thereby eliminating the often intimidating problem of wine and food pairing. Blue Nun can be said to have been the first wine to have been produced and effectively marketed with an international mass market in mind. After World War II, the brand became spectacularly popular in the United Kingdom and the United States, selling for the same price as a second growth red Bordeaux wine. At its peak of popularity in 1984-1985, annual sales in the United States were 1.25 million cases, with another 750,000 cases sold elsewhere.
In 1996 Sichel merged with the Mosel-based German family firm Langguth, and Blue Nun was repositioned and reclassified as a a regular Qualitätswein bestimmter Anbaugebiete (QbA) from a Liebfraumilch. The grapes were changed from Müller-Thurgau to 30% Riesling, and making it less sweet. It remains relatively low in alcohol at 9.5%. From 2001 on, Langguth also embarked on a brand extension, and has introduced several other wines under the Blue Nun name, including a German Riesling ice wine, a Languedoc Merlot and a Spanish rosé. The Langguth head office is in Traben-Trarbach, Rheinland-Pfalz.
Visit the web site


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Crazy As Me
"When I listen to this album, the songs are so terrific that I feel like I'm listening to a greatest hits record from somebody, like I bought a greatest hits record from one of the pillars of country music – but it's a brand new album coming out in 2000. It just blows me away." -Alison Krauss A rose wrapped around a barbwire fence – where the plush red petal meets the rusted spike. That's Robert Lee Castleman. His music is a lush type of folk, subtle and warm. His songs and his voice, though, are rugged. Weary. True. For too long he has been an industry secret, his songs having been recorded by Chet Atkins and Alison Krauss. Now this singer, guitarist, and songwriter is stepping out with his own album: a gem of sublime, intricate composition – songs that are at once soothing and unpredictable.


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Aims and objectives
To develop further the keyboard skills taught in Parts IA and IB of the Music Tripos; to acquire a knowledge of the application of such skills in practical contexts.
Description of the course
The paper will be taught in a combination of seminars, run by the Faculty, and supervisions, organised by the Colleges.
Description of the examination
The exam consists of six components. Four are examined after a total of forty minutes' preparation by the candidate:
- Harmonization of a melody in a late nineteenth-century or early twentieth-century style.
- Score-reading 1: playing a passage from a sixteenth-century piece using any combination of C1, C3, C4 and F4 clefs.
- Score-reading 2: playing a passage from an orchestral score dating from after 1830.
- Transposition of a piece of keyboard music, limited to two semitones up or down.
The other two components will be given out at least three days before the examination:
- Realisation of a figured bass on either harpsichord or organ (manuals only) of a texture involving either melody instrument and basso continuo or voice and basso continuo.
- Accompaniment of a song or short set of songs.
The Faculty will provide the additional musicians required for these two components.
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Electric Fluid - Drops Free
- Publisher: Electric Fluid Entertainment
- Genre: Entertainment
- Released: 3 Mar, 2010
- Size: 9.0 MB
- Price: FREE!
- App Store Info
DescriptionInteractive water drop simulation that has the ability to choose the reflective environment as well as the background. The water reacts in many ways to the orientation of your device. The orientation effects how the drops fall as well as how they bend and reflect light.
Touch to add drops.
Water falls according to the orientation of the device.
Water refracts the background and the device's orientation effects the refraction angle.
Water reflects the chosen environment image and the reflection direction is effected by the orientation of the device.
You can change the background by choosing from one of the included images or by using your photo library or camera.
You can change the reflection environment by choosing one of the included images.