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Evidence supports the use of cognitive behavioral therapies for nightmares in trauma-exposed individuals. This randomized clinical trial replicated a study of exposure, relaxation, and rescripting therapy(ERRT) and extended prior research by including broad measures of mental health difficulties, self-reported physical health problems, and quality of life. Additionally, physiological correlates of treatment-related change assessed from a script-driven imagery paradigm were examined.
Forty-seven individuals were randomized to treatment or waitlist control.
The treatment group demonstrated improvements relative to the control group at the one-week post-treatment assessment. At the 6-month follow-up assessment, significant improvements were found for frequency and severity of nightmares, posttraumatic stress disorder symptoms, depression, sleep quality and quantity, physical health symptoms, anger, dissociation, and tension reduction behaviors. Participants also reported improved quality of life. Treatment-related decreases in heart rate to nightmare imagery were correlated with improvements in sleep quality and quantity; treatment-related decreases in skin conductance to nightmare imagery were correlated with improvements in nightmare severity, posttraumatic stress disorder symptom severity, sleep quality, and fear of sleep; and treatment-related decreases in corrugator activity to nightmare imagery were correlated with improved physical health.
Findings provide additional support for the use of ERRT in treating nightmares and related difficulties and improving sleep.
Davis JL; Rhudy JL; Pruiksma KE; Byrd P; Williams AE; McCabe KM; Bartley EJ. Physiological predictors of response to exposure, relaxation, and rescripting therapy for chronic nightmares in a randomized clinical trial. J Clin Sleep Med 2011;7(6):622-631.
Nightmares following trauma exposure are consistently associated with sleep disturbance,1 posttraumatic stress disorder (PTSD) severity,2 physiological arousal with or without PTSD,3 and functional impairment over and above PTSD.4,5 Moreover, chronic nightmares (CN) may be a significant maintaining factor of psychological distress, because successful treatment of CN with cognitive behavioral therapy results in the reduction of symptoms of PTSD, depression, and nightmare-related panic.6–8 Therefore, CN may pose a pernicious health problem independent of other psychopathology. Preliminary evidence suggests that psychological treatments which broadly target PTSD may have limited impact on sleep disturbances,9–13 and pharmacological treatments appear to have little effect14 or only a palliative effect15 for some individuals. Thus, cognitive behavioral approaches specifically addressing sleep disturbances are now being evaluated in trauma-exposed samples. The present study is a replication of a randomized controlled trial (RCT) that examined the efficacy of exposure, relaxation, and rescripting therapy(ERRT) to treat CN in trauma-exposed persons7 and expands previous work by assessing the influence of treatment on facets of health that were not included in the first RCT and examining physiological predictors of treatment response.
Current Knowledge/Study Rationale: The purpose of this randomized clinical trial was to replicate a previous study examining the impact of Exposure, Relaxation, and Rescripting Therapy on nightmares and sleep quality. This study expanded previous efforts by including a broader assessment of mental health indices, physical health symptoms, quality of life, and examined physiological correlates of treatment related change.
Study Impact: The present study supports the use of ERRT for trauma-related sleep problems and related psychopathology. Clinicians should assess for nightmares and sleep problems in trauma-exposed persons and consider utilizing interventions that directly address these problems.
The first RCT demonstrated that ERRT reduced nightmare frequency and severity, related psychopathology, and improved sleep in trauma-exposed adults.7 While the mechanisms of change in this treatment are not well understood, it is possible that nightmare-related defensive reactivity and concomitant physiological arousal may promote nightmare-related sleep and psychological problems (e.g., fear of sleep, low waking thresholds).16,17 This may also result in poor daytime functioning, decreased coping resources, and physical health problems. If this supposition is true, then reducing nightmare-related defensive reactivity and related physiological arousal should reduce fear of sleep and improve sleep quality and quantity, thus enhancing daytime functioning. Indeed, previous studies found a generalized impact of changing nightmare content and affect on PTSD symptoms, depression, and general anxiety.7,8,18 Other difficulties related to trauma exposure and sleep deprivation which may also be expected to change following alteration of nightmare content and affect, and subsequent reduction of physiological arousal, have not yet been explored (e.g., anger, irritability, physical health symptoms).
To establish an association between nightmare-related thoughts and physiological reactivity, Rhudy and colleagues3 examined script-driven imagery data collected at the baseline assessment in the current study. A personally relevant nightmare script was presented over headphones to participants who were asked to imagine the nightmare scene as vividly as possible. During imagery, heart rate (HR), skin conductance level (SCL), and facial muscle electromyogram (EMG) were recorded. Results indicated nightmare imagery evoked heightened reactivity as assessed from all physiological outcomes and that autonomic reactions were positively correlated with self-reported global sleep problems, time taken to fall asleep, the degree of panic upon awakening from a nightmare, and self-reported health symptoms. Subsequent analysis revealed that these physiological reactions to nightmare imagery were reduced following ERRT and gains were maintained at 3- and 6-month follow-ups.
Thus, ERRT is able to reduce physiological indices of nightmare-related defensive reactivity.32 What remains unknown, however, is the nature of the relationship between the reduction in these physiological reactions and other measures of treatment outcome. Specifically, it is currently unclear whether changes in physiological defensive reactivity covary with changes in nightmare frequency and severity, mental health, or physical health. Determining which outcome variables covary could provide insight into the mechanisms of nightmare and symptom maintenance. The following hypotheses were made:
As in the first RCT,7 treated participants would show greater improvements across all domains (e.g., nightmare characteristics, sleep quality, and related indices of mental health) at the one-week post assessment compared to the delayed treatment group, and treatment gains for all treated individuals would be maintained across the 6-month time period.
ERRT would reduce the additional mental health symptoms assessed, would reduce physical health problems due to the reduction in nightmare related physiological arousal,19,3 and other areas of participants' lives would demonstrate positive change.
Treatment-related changes in physiological reactivity to nightmare-related imagery would covary with treatment-related changes in psychological functioning.
See Figure 1 for the flow chart indicating attrition. Fifty-eight participants met the inclusion criteria and were invited to participate in the treatment study. Eleven individuals refused and did not enter the study. Forty-seven individuals began the study and were randomly assigned to either the treatment condition (n= 24) or the delayed treatment control condition (n = 23). Of these, 40 were randomized to study arms that included psychophysiology assessment (initially the study included a treatment arm that did not include physiological assessment, but this arm was abandoned in order to focus on physiological predictors). Twelve participants (26%) did not complete the Time 2 assessment, and these dropouts did not differ across condition, χ2 (1, N = 47) = 0.34, p = ns. The 18 people in the control group who completed the second initial assessment were invited to participate in the treatment, and 13 did so. A total of 30 individuals (treatment group and delayed treatment group) were treated, and 24 completed the 6-month follow-up.
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Of the 47 participants who entered treatment, the majority were Caucasian (81%; treatment = 91.7%, control = 69.6%), female (75%; treatment = 66.7%, control = 82.6%), married (42.6%; treatment = 29.6%, control = 56.5%) and reported at least some college education (80%; treatment = 70.9%, control = 82.6%). Most were employed (treatment = 54.2%, control = 73.9%). Average age was 47 years (SD = 38.49; Mtreatment = 38.80, Mcontrol = 38.17), and average household income was $60,115 (SD = $70,736; Mtreatment = $52079, Mcontrol = $67,453). Participants reported a mean of 5.5 traumatic events (SD = 2.75 Range = 1-11). The most frequent types of trauma reported were unwanted sexual contact (59.6%), serious accidents (57.4%), and physical assault with a weapon (57.4%). Six individuals (13%) reported combat exposure. Although having a PTSD diagnosis was not a requirement of the study, 53.2% (n= 25) of the participants met criteria, including 54.2% (n= 13) of the treatment group and 52.2% (n= 12) of the control group, χ2 (1, N= 47) = 0.02, ns.On the Clinician-Administered PTSD Scale (CAPS)20, approximately 37% reported moderate, 14% reported severe, and 25% reported extreme PTSD symptoms (M= 56.83, SD= 27.19). Participants reported experiencing nightmares an average of 18 years (SD= 12.41; range 1.5-40) and a mean of 5.92 (SD= 1.74) h sleep/night. Approximately 36% of the sample reported taking over an hour to get to sleep each night. Twenty-six percent reported that their most recurrent and distressing nightmare was exactly like their trauma; 34% reported it was similar to the trauma; 32% reported it was unrelated to their trauma; and 8% did not answer the question.
The Trauma Assessment for Adults: Self Report Version (TAA)21 assesses lifetime history of potentially traumatic events. The TAA consists of 14 items and includes follow-up questions to assess perceived threat. For the present study, the TAA was modified to include assessment of additional types of traumatic events. Age of first and most recent occurrence is determined for multiple incidents of a given type. Research indicates the TAA has acceptable test-retest reliability and convergent validity.22
The CAPS is a semi-structured clinical interview consisting of 17 items assessing frequency and severity of PTSD symptoms and 5 additional items assess associated symptoms.20 The "F1/I2" rule (frequency coded ≥ 1 and intensity coded ≥ 2 for the past month) was utilized to determine symptom presence and diagnosis. This method has adequate sensitivity and specificity rates and good reliability.20,23 All CAPS interviews were audiotaped, and 25% were randomly selected for evaluation of interrater reliability of PTSD diagnosis. The κ coefficient for the overall PTSD diagnosis was 0.87, with 97.3% interrater agreement.
The Trauma Symptom Inventory (TSI)24 is a 100-item test designed to assess symptoms of PTSD and acute stress disorder in addition to a broader range of symptoms associated with trauma. The TSI includes 3 validity scales (Response level, Atypical Response, Inconsistent Response) and 10 clinical scales. Internal consistencies for the clinical scales range from 0.74 to 0.91, with an overall internal consistency of 0.86. The TSI also demonstrates criterion-related validity.24 For the current study, we only examined those scales that did not overlap in content with the CAPS and we believed had relevance for the present study (e.g., Depression, Anger/Irritability, Dissociation, and Tension Reduction Behavior).
The Pittsburgh Sleep Quality Index (PSQI)25 is a self-report measure designed to assess certain qualities and problems associated with sleep. A global sleep quality score is obtained by summing the 7 component scores; higher scores reflect poorer sleep quality. The global score may range from 0-21. The PSQI has good internal homogeneity, test-retest reliability and validity.25 Buysse and colleagues determined a cut-off score of 5 as distinguishing "good" sleepers from "poor" sleepers, with a diagnostic sensitivity of 89.6% and specificity of 86.5%.25
The Trauma Related Nightmare Survey (TRNS)26 was used to assess characteristics of chronic nightmares. Likert-type, categorical, and open-ended questions assess the frequency, severity, and duration of nightmares, as well as cognitions, emotions, and behaviors related to nightmares. While one particular nightmare was targeted in the treatment, this measure assesses nightmares in general. Of interest for the present study, nightmare frequency was assessed as the number of nightmares in the past week and the number of nights with nightmares in the past week. Nightmare severity was rated from 0 "not at all disturbing" to 4 "extremely disturbing." Test-retest analyses revealed adequate reliabilities and good convergent validity.
Pennebaker Inventory of Limbic Languidness (PILL).27 The PILL is a 54-item self-report questionnaire that assesses the frequency of common physical symptoms on a 5-point Likert scale ranging from 0 (have never or almost never experienced the symptom)to 4 (experiencing the symptom more than once a week). Pennebaker reports an internal consistency of r= 0.91 and test-retest reliability of r= 0.83.27
Post Treatment Clinical Significance Survey (PTCSS).28 The PTCSS was designed to assess changes in various life areas attributed to treatment. The PTCSS consists of 19 questions assessing to what degree the participant adhered to the treatment components, the helpfulness and difficulty of various treatment components, and change in 9 areas of life (e.g., relations with others, general activity level, anxiety) rated on a 5-point scale ranging from "much worse" to "much better." The measure was utilized as an index of clinical significance at 6-month follow-up. Psychometric properties of this measure have not been established.
During the initial psychological assessment, participants were administered a structured interview that assessed for details of their nightmares. The interview asked participants to report on their most recurrent nightmare, or most recent nightmare if a single recurring nightmare was not available. Follow-up questions asked about cognitive, somatic, and sensory details. The physiological assessors used this interview data to construct a personal nightmare script for each participant. Each script was 30 sec long (approximately 100 words), written in second person, and recorded by a female experimenter in a slow-paced voice onto computer.
During physiological assessments, participants were seated alone in a recliner in a sound attenuated chamber while being monitored from an adjoining room by video camera. Before each assessment, participants were instrumented for physiological recording. After being instrumented, the experimenter left the room and participants sat quietly during a 5-min habituation period, followed by a brief (3-min) diaphragmatic breathing exercise presented by computer. Physiological reactivity was then assessed during script-driven imagery. Five imagery scripts (all 30-sec long) were presented which included the participant's personal nightmare script and 4 non-personal emotional scripts (pleasant, action, fear, neutral; script order randomized across subjects and testing periods). Immediately following the computer presentation of a script, participants were instructed to imagine the scene in the script as if it were happening to them. Each imagery period lasted 30 sec. To allow physiological reactivity to return to baseline values in between scripts, there was a 30-sec recovery period; however, HR was monitored during this period, and the recovery period was extended if necessary to allow HR to return to pre-script levels.29 Only physiological reactivity associated with the nightmare script was used for the present analyses.
A PC with dual 17-inch flat panel monitors and A/D board (National Instruments, PCI-6036E) presented scripts and acquired physiological data. Physiological signals were sampled at 250 Hz and collected/filtered using a Model 15LT Bipolar Amplifier (Grass Technologies; West Warwick, RI) with Quad AC (15A54) and Dual DC (15A12) modules. An adaptor (Grass; Model SCA1) for the 15A12 amplifier was used to measure SCL.
Miniature electrodes to measure left corrugator EMG and left lateralis frontalis EMG were placed according to the recommendations of Fridlund and Cacioppo.30 Facial EMG was amplified (×20,000) and bandpass filtered (10-300 Hz) before being stored digitally (while EMG frequencies can range from 1-1000 Hz, most of the signal power is from 10-150 Hz.31,I Electrocardiogram (ECG) was assessed from electrodes placed on each forearm and was converted to HR by calculating the distance between R to R intervals. Facial EMG and ECG electrodes were applied by degreasing the skin, slightly abrading the skin using NuPrep gel (≤ 10 KΩ), and filling the electrodes with EC60 gel (Grass Technologies). SCL was recorded from electrodes filled with isotonic paste (EC33; Grass Technologies) that were placed on the distal volar surface of the non-dominant index and middle fingers. The signals for HR, SCL, and full-wave rectified, non-integrated facial EMG were visually inspected for artifacts in 5-sec bins. Bins that did not contain artifacts were averaged to make a 30-sec pre-script baseline period and a 30-sec imagery period, as noted in the previous section. For additional details about the physiological recording procedures, see the previously published studies by Rhudy and colleagues.3,32
The study was approved by the University of Tulsa Institutional Review Board. Participants were recruited via flyers, email, and radio ads and were screened over the phone for inclusion criteria (experiencing a traumatic event and having nightmares at least one time per week for the previous month) and exclusion criteria (apparent psychosis or mental retardation, aged less than 18, active suicidality or recent parasuicidal behaviors, or current drug/alcohol dependence). Eligible individuals were invited to participate in the study and were randomly assigned using a random number generator to either the treatment or the wait-list control group. Each assessment point included psychological and physiological assessments that were conducted by trained upper level graduate students supervised by the papers' first two authors (JLD and JLR).
After the initial assessment (Time 1), the control group was not contacted during the period that the treatment group received the 3-week intervention, with the exception of a phone call to schedule a time for the re-assessment. One week following the completion of treatment, both groups were reassessed (Time 2) and the control group was offered the treatment. Follow-up assessments occurred at 3 months (Time 3) and 6 months (Time 4) post-treatment. Although attempts were made to keep assessors blinded to treatment group assignment, in some instances assessors were un-blinded at the one-week psychological post assessment for several reasons, including participant disclosure of treatment condition, potentially influencing scoring of the structured interview of PTSD symptoms at the one-week post-treatment assessment point. However, similar results were found for PTSD scores in the successfully blinded previous RCT,7 results were consistent with the one-week physiological assessments which were all blinded; and as reported above, interrater reliability PTSD diagnosis was excellent (κ = 0.87; 97.3 % agreement). At each assessment point, participants were provided compensation.
Exposure, relaxation, and rescripting therapy (ERRT) is a cognitive behavioral treatment for trauma-related nightmares and is described in detail elsewhere.7,28 ERRT is conducted for 2 h once a week for 3 consecutive weeks and may be used in either an individual or group format. Treatment consists of psychoeducation about trauma, PTSD, and nightmares, relaxation training, modification of sleep habits, written and verbal exposure to the nightmare, rescription of the nightmare based on trauma-related themes (i.e., power, trust, intimacy, esteem, safety),33 and imagery rehearsal of the rescripted dream each night prior to going to sleep.
Data were screened for any potential deviations for normality. Most variables were reasonably normal (skewness statistic divided by the standard error of skewness < 1.96). Not surprisingly, the variables that deviated the most from normal were the physiological reactivity variables. To determine whether non-normality (outliers in particular) caused problems for the models, we carefully examined scatterplots between each of the physiological variables and the psychological outcome variables. Using this approach, we did not find that any outliers had particularly strong statistical influence (i.e., outliers in X and Y space) that might be driving the relationships we observed in our analyses. This bolstered our confidence in proceeding with our statistical analyses.
Initially, ANOVA and χ2 tests were used for univariate analyses to assess differences between groups at baseline assessment (Time 1). Treatment response on psychological variables was assessed using multilevel models (SPSS MIXED procedure). Group (immediate treatment vs. delayed treatment) was entered as a nominal between-subjects variable and Time (pre-treatment vs. post-treatment) was entered as a nominal within-subjects variable. Intent-to-treat analyses were conducted on all participants who were randomized. To provide a conservative estimate of initial treatment response for the intent-to-treat analyses, initial baseline scores were carried forward for those who dropped out of the study. Completer analyses were then conducted by selecting only those participants who completed either the post-treatment assessment (treatment group) or second baseline assessment (control group). To assess the magnitude of treatment response for the intent-to-treat and completer analyses, Cohen's d effect sizes were calculated for both groups using baseline and post treatment pooled standard deviations. The overall treatment effect reported is the Cohen's dtreatment minus the Cohen's dcontrol.
Data from immediate treatment and delayed treatment groups were analyzed for pre-treatment differences. The only difference found was nightmare severity (see Results section), so this variable was controlled for in all analyses, including the follow-up analyses where the groups were combined (N = 47). These data were analyzed using multilevel models (SPSS MIXED procedure) that entered Time (pre-treatment, post-treatment, 3 months, and 6 months) as a nominal within-subjects variable. End state functioning was assessed utilizing only those individuals who completed the 6-month follow-up assessment (n= 24). Effect sizes were calculated with Cohen's d.
Multilevel models examined whether changes in physiological reactivity to nightmare imagery were associated with treatment response on the psychological variables. These analyses included all 40 participants who completed at least one physiological assessment, although one person was excluded because of equipment problems. Because these analyses were largely exploratory, we limited the number of analyses to only those 7 variables that demonstrated significant change in both intent-to-treat and follow-up analyses (see Results section) and health symptoms (PILL) because previously published results found that health symptoms may be related to physiological reactivity to nightmare imagery.3 Therefore, 8 multilevel models were conducted; each included the 4 physiological reactions to nightmare imagery as time-varying covariates. These models controlled for medications that could potentially affect physiological responding (e.g., those that act on cholinergic or adrenergic receptors). No medication variable was a significant predictor in any model, except in the prediction of depression symptoms (not surprisingly, medications that agonize α- or β-adrenergic receptors were more likely to be taken by those more depressed). Thus, to simplify the presentation of the results, medication covariates are not reported in the table of results. Significance of individual physiological predictors in the multilevel models was tested using fixed effects tests (i.e., F tests). The significance of the overall multilevel model was tested using a χ2 difference test that compared the 7 predictor models with the no predictor "null" model. Variance explained by each multilevel model was calculated from η2.34 An autoregressive covariance structure (AR1) was used to model the error structure for repeated measurements in all multilevel models. Follow-up tests for all analyses were conducted using Bonferroni adjusted mean comparisons to control for family-wise type I error rate. Significance level was set at p < 0.05 (2-tailed).
The treatment group (M = 3.29, SD= 0.62) reported greater severity of nightmares at baseline than the control group (M = 2.91, SD= 0.65), F1,47 = 4.13, p < 0.05, so nightmare severity was entered as a covariate in subsequent analyses. The completer group (M= 14.89, SD= 2.49) reported more education than the dropout group (M= 13.17, SD= 2.69), F1,47 = 4.08, p < 0.05. No other differences were found between groups.
Intent-to-treat analyses (see Table 1) revealed a significant interaction of Group × Time for the following variables: nights per week with nightmares, nightmare severity, panic symptoms upon awakening, global sleep quality, hours slept, fear of sleep, TSI depression, and past month CAPS score. When these interactions were decomposed for the simple effect of time, results indicated that the treatment group improved on all of these variables from baseline to post-treatment, while the control group did not change. The remaining variables were unaffected by treatment, although dissociation and anger/irritability decreased over time independent of treatment.
Intent-to-treat data by condition and time
* p < 0.05.
** p < 0.01.
*** p < 0.001.
{ label (or @symbol) needed for fn } NM, nightmare; Sxs, Symptoms; CAPS, Clinician Administered PTSD Scale; TSI, Trauma Symptom Inventory; PSQI, Pittsburgh Sleep Quality Index.
{ label (or @symbol) needed for fn } According to Cohen (1988), d = 0.20 is a small effect, d = 0.50 is a medium effect, d = 0.80 is a large effect.
Completer analyses were conducted on those participants who completed therapy and the post assessment (n =17) and those participants who completed the second initial evaluation in the control group (n =18). Results mirrored those reported for the intent-to-treat analyses and, therefore, are not reported here. Data can be obtained from the authors upon request.
All 47 participants were included in the follow-up analyses. Unlike the intent-to-treat analyses, missing data were not replaced but instead were handled by the multilevel model procedures within SPSS MIXED. Time was entered as the within-subjects factor, and nightmare severity was entered as a continuous covariate (see Table 2). Analyses revealed significant improvements for each variable with the exception of panic symptoms upon awakening from a nightmare. Bonferroni-adjusted mean comparisons indicated statistically significant improvements on all variables between baseline vs. one-week post-treatment, baseline vs. 3-month follow-up, and baseline vs. 6-month follow-up (all p-values < 0.05). The only variables to show significant improvements from one-week post-treatment to 3 months were past month CAPS score and nightmares per week. No variables showed improvement from 3-month to 6-month follow-up; however, it is important to point out that all treatment gains made were maintained throughout the duration of the study (i.e., no variable worsened at any assessment point).
Follow-up analyses (N = 47)
{ label (or @symbol) needed for fn } Effect sizes calculated for baseline to 6-month differences. According to Cohen (1988), d = 0.20 is a small effect, d = 0.50 is a medium effect, d = 0.80 is a large effect.
Clinical significance was assessed for the 24 participants who completed the 6-month assessment. For nightmare frequency we determined that an absence of nightmares in the past week based on the TRNS constituted a good response to the treatment7; 71% achieved this, reflecting a 58% decrease in number of any nightmares in the past week from baseline to 6-month follow-up. It is important to note that we assessed anynightmares, not just the nightmare targeted in treatment. Approximately 63% of participants had a reduction in CAPS score > 10 points, which is generally considered to be a clinically significant change.35,36 Further, 75% (N =9) of those diagnosed with PTSD at baseline lost their diagnosis. For sleep quality, 9 (37.5%) participants achieved a score ≤ 5 on the PSQI.
We also examined changes in quality of life at the 6-month assessment via the PTCSS (Table 3).28 The majority of participants reported that each area assessed was somewhat or much better following treatment. Further, while participants reported some differences in how helpful they found the treatment techniques, the component with the highest percentage of people stating that it was very helpful was writing out the nightmare (78.3%).
Results from the posttreatment clinical significance survey
Treatment compliance was assessed in 2 ways. First, the percentage of between session homework assignments completed was determined. Individuals who completed treatment and at least one follow-up assessment averaged 78.40% (SD= 23.86) compliance with weekly homework. Second, participants were asked at the 6-month assessment how closely they followed the techniques learned; nearly 83% of the sample reported "mostly" or "completely" following the techniques learned in the study.
Results from these multilevel models are presented in Table 4. The χ2 difference tests indicated all 8 models were an improvement over the intercept only models. Decreases in HR reactivity over time were associated with improvements in sleep quality and hours of sleep. Decreases in SCL reactivity over time were associated with improvements in nightmare severity, PTSD symptoms in the past month (CAPS), sleep quality, and fear of sleep. Facial EMG was generally unrelated to psychological outcomes, except that decreases in corrugator EMG over time were associated with improvements in self-reported health. No physiological variable was significantly associated with nights with nightmares per week or depression. It is noteworthy that the variance explained by those models with significant predictors tended to be large according to η2 values, ranging from 17% variance explained (nightmare severity) to 37% (sleep quality).
Multilevel models examining the associations of relevant treatment outcomes and physiological reactions entered as time-varying covariates after controlling for medications
[i] Positive associations with PSQI sleep quality indicate that reductions in physiological responses are associated with improvements in sleep quality (higher scores on the PSQI indicate poorer sleep quality). All models with a Δχ2 > 15.51 were statistically significant (i.e., were significant improvements over an intercept only model). η2, eta squared effect size (proportion of variance explained in dependent variable). Corr, corrugator muscle. LF, lateralis frontalis muscle. HR, heart rate. SC, skin conductance. EMG, electromyogram. Est., unstandardized estimate of fixed effect (relationship between predictor and criterion). SE, standard error for the parameter estimate. Estimates in bolded text are significant at p < 0.05.
The present study provided a needed replication of the first RCT of this brief cognitive behavioral approach and extended this research by expanding the assessment domains and examining the relationship between change in physiological indicators of nightmare-related defensive reactivity and other measures of treatment response. Results support the use of ERRT for trauma-related sleep problems.
Hypothesis one was supported in that the results of the current study mirror those found in the previous RCT.7 These findings provide additional support for the efficacy of ERRT in reducing chronic nightmares and related psychopathology and improving sleep at the one-week post-treatment assessment and maintaining treatment gains through the six-month follow-up assessment. It is important to note that while only one nightmare was targeted in treatment, the assessment queries all nightmares; so the treatment appears to have a generalized effect. Further, while the effect size for improvement in sleep quality was large, the mean score on the PSQI (7.45) was higher than the cut-off of 5 which distinguishes good sleepers from poor sleepers.25 Hypothesis two was not fully supported at the one-week post-treatment follow-up. Although anger and dissociation changed, this was not related to the treatment but to the passage of time. At the six-month follow-up assessment, statistically significant changes were noted for anger, dissociation, tension reduction, and self-reported physical health. Other measures of clinical significance also show improvement. Participants reported improvements in quality of life across nine areas; further, 75% of participants with a diagnosis of PTSD at baseline who completed the follow-up assessment, had lost this diagnosis at six months post-treatment. This suggests that for some individuals, sleep disturbances may be primary difficulties in need of direct treatment rather than secondary symptoms of PTSD.18 Overall, it is clear that ERRT is successful in producing broad, sustained improvements in a wide range of functioning based on clinical interview and self-report of participants.
Support also exists for the efficacy of ERRT in reducing physiological reactivity to nightmare-related defensive reactivity. A previous study indicated that nightmare sufferers exhibited heightened physiological responses to nightmare imagery3 and that these physiological reactions were significantly reduced by ERRT relative to the control group that showed no change in physiological reactivity to nightmare imagery.32
Rhudy et al.32 argued that physiological reactivity to nightmare imagery may index activation of the fear network associated with the nightmare,37 and that engaging this fear network may be essential for processing emotional material to decrease fear and anxiety37 and improve nightmares and sleep disturbance.38 If true, then changes in physiological reactivity to nightmare imagery should covary with other indicators of treatment outcome. The present study partially supports this hypothesis. Multilevel modeling found that autonomic reactions were significantly associated with improvement in several outcome variables. Decreases in HR reactivity over time were associated with improvement in sleep quality and hours slept per night and decreases in SCL over time were associated with improvements in sleep quality, fear of sleep, nightmare severity, and PTSD symptomatology. These findings could reflect the degree to which nightmare-related thoughts result in defensive reactivity and autonomic arousal that interferes with sleep quality and quantity. The fact that SCL, but not HR, was associated with PTSD symptoms, fear of sleep, and nightmare severity may reflect a stronger association between these outcomes and sympathetic activation; given that SCL is primarily a measure of sympathetic activity. By contrast, HR is influenced by sympathetic and parasympathetic branches of the autonomic nervous system, so the relationship between HR and hours of sleep may reflect a greater involvement of the parasympathetic branch in helping maintain sleep once initiated. At this time these relationships are purely speculative, however. Future research should consider examining the influence of nightmare treatment on metrics of heart rate variability that measure the relative influence of sympathetic and parasympathetic controls over cardiac function. A final relationship observed was between reduction in health symptoms and decreases in corrugator activity. Given the well-established relationship between negative affect and poorer physical health,39 decreases in corrugator could reflect a general decrease in negative affect that was maintaining health symptomatology.
At this time the relationships observed between measures of physiological reactivity and nightmare-related symptoms primarily help to build a theoretical framework about what might be maintaining nightmares and sleep problems. This will help to generate hypotheses in future studies. Nevertheless, patients may benefit from knowing that physiological arousal stemming from nightmare-related thoughts might promote symptomatology. Thus, the combination of monitoring arousal (e.g., perhaps via a heart rate monitor watch available at most sports stores) and engaging in arousal-reducing interventions (e.g., progressive muscle relaxation, diaphragmatic breathing) could improve symptoms.
Overall, ERRT is found to be effective in alleviating distress specific to nightmares and sleep, underlying physiological indicators of defensive reactivity to nightmare imagery, and broader indices of distress. How this happens is still unclear, however. From an information processing perspective, in order to correct the pathological fear structures, the fear network must be engaged and corrective information needs to be presented and incorporated into the network.37 It is feasible that ERRT activated the fear network through exposure to the nightmare and provided corrective information through conducting exposure in a safe environment, achieving mastery through confronting the nightmare, and changing the storyline with rescription. Changing the fear structure should significantly reduce pre-sleep anticipatory anxiety and physiological arousal, thus enhancing the quality of sleep. An examination of the largest effect sizes (i.e., nightmare severity, past month CAPS score, and fear of sleep) and the association of treatment outcomes with heightened physiological response to nightmare imagery may support this proposition. Given the chronicity of the nightmares reported by this sample (mean of 18 years of experiencing nightmares), the small dose of exposure required is surprising. This is assuming of course that exposure is the key mechanism of change. While this possibility was also supported by the large number of people citing exposure to the nightmare as very helpful, there are several other possible mechanisms of change underlying ERRT including reduced cognitive and physiological arousal via relaxation and modifying sleep habits.7 Another possibility is that rescripting the nightmare may also have changed the cognition, affect, and meaning associated with the nightmare, which may account in part for the generalized impact of the treatment on other indices of distress including depression. More research is needed to determine what may be responsible for our findings.
One limitation of this study was the inconsistent blinding for the one-week post assessment and the potential resulting bias of the score of CAPS assessment. However, the fact that the results of this study mirror those of the previous RCT7 and the psychological indices were consistent with the blinded physiological assessments tempers these concerns. The trial included a small sample size comprised primarily of Caucasian women which may limit the generalizability of the results. The 26% dropout rate in this study matches that found in the initial RCT and is fairly typical for trauma-related therapies.40 While the rate in the current study is not exceptional, more research is needed on determining why participants drop out of treatment studies and developing additional strategies to try to increase retention. The use of a wait-list control group does not allow us to speculate about the relative efficacy of ERRT compared to other treatment approaches.41 Future studies will need to conduct direct comparisons to other viable interventions. Additionally, while the study used gold standard interview tools and physiological assessments, future studies should consider including physiological indices of sleep functioning (i.e., polysomnography or actigraphy) and an established measure of clinical significance.
Overall, current results support previous research suggesting that ERRT is an efficacious treatment for trauma-exposed individuals with chronic nightmares and advances the knowledge base in the treatment of nightmares by including an evaluation of the association of physiological and psychological changes over time.
IIt is possible that the sampling frequency of 250 Hz could have led to some EMG aliasing. However, this should not have been a significant problem given that most of the signal power is between 10-15 Hz. Moreover, our confidence in the integrity of the signal is bolstered by our findings that facial EMG reliably increases in response to the nightmare script and these increases are significantly reduced by treatment.32 Therefore, we do not believe aliasing played a significant role in signal degradation in the current study.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
This study was funded with grants from the University of Tulsa Office of Research and Sponsored Programs.
Harvey AG, Jones C, Schmidt DA, authors. Sleep and posttraumatic stress disorder: a review. Clin Psychol Rev. 2003;23:377–407. [PubMed]
Esposito K, Benitez A, Barza L, Mellman T, authors. Evaluation of dream content in combat-related PTSD. J Trauma Stress. 1999;12:681–7. [PubMed]
Rhudy JL, Davis JL, Williams AE, McCabe KM, Byrd PM, authors. Physiological-emotional reactivity to nightmare-related imagery in trauma-exposed persons with chronic nightmares. Behav Sleep Med. 2008;6:158–77. [PubMed]
Davis JL, Byrd P, Rhudy JL, Wright DC, authors. Characteristics of chronic nightmares in a trauma-exposed treatment-seeking sample. Dreaming. 2007;17:187–98
Schreuder BJN, Kleijn WC, Rooijmans HGM, authors. Nocturnal re-experiencing more than forty years after war trauma. J Trauma Stress. 2000;13:453–63. [PubMed]
Forbes D, Phelps AJ, McHugh AF, Debenham P, Hopwood M, Creamer M, authors. Imagery rehearsal in the treatment of posttraumatic nightmares in australian veterans with chronic combat-related PTSD: 12-month follow-up data. J Trauma Stress. 2003;16:509–13. [PubMed]
Davis JL, Wright DC, authors. Randomized clinical trial for treatment of chronic nightmares in trauma-exposed adults. J Trauma Stress. 2007;20:123–33. [PubMed]
Krakow B, Hollifield M, Johnston L, et al., authors. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA. 2001;286:537–45. [PubMed]
Galovski TE, Monson C, Bruce SE, Resick PA, authors. Does cognitive-behavioral therapy for PTSD improve perceived health and sleep impairment? J Trauma Stress. 2009;22:197–204. [PubMed Central][PubMed]
Lydiard RB, Hamner MH, authors. Clinical importance of sleep disturbance as a treatment target in PTSD. Focus. 2009;7:176–83
Zayfert C, DeViva JC, authors. Residual insomnia following cognitive behavioral therapy for PTSD. J Trauma Stress. 2004;17:69–73. [PubMed]
Davis JL, De Arellano M, Falsetti SA, Resnick HS, authors. Treatment of nightmares related to post-traumatic stress disorder in an adolescent rape victim. Clin Case Stud. 2003;2:283–94
Forbes D, Creamer M, Biddle D, authors. The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. Behav Res Ther. 2001;39:977–86. [PubMed]
Friedman M, author. Drug treatment for PTSD: Answers and questions. Ann New York Acad Sci. 1997;821:359–71
Raskind MA, Peskind ER, Kanter ED, et al., authors. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160:371–3. [PubMed]
Davis JL, author. Treating post-trauma nightmares: a cognitive behavioral approach. 2009. New York: Springer Publishing Company;
Krakow B, Tandberg D, Scriggins L, Barey M, authors. A controlled comparison of self-rated sleep complaints in acute and chronic nightmare sufferers. J Nerv Mental Dis. 1995;183:623–7
Spoormaker VI, Montgomery P, authors. Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature? Sleep Med Rev. 2008;12:169–84. [PubMed]
Boscarino J, Chang J, authors. Electrocardiogram abnormalities among men with stress-related psychiatric disorders: Implications for coronary heart disease and clinical research. Ann Behav Med. 1999;21:227–34. [PubMed]
Blake DK, Weathers FW, Nagy LM, et al., authors. A therapist rating scale for assessing current and lifetime PTSD: The CAPS-1. Behav Ther. 1990;13:187–8
Resnick HS, Best CL, Kilpatrick DG, Freedy JR, Falsetti SA, authors. Trauma Assessment for Adults - Self-Report Version. Unpublished Scale. 1993. Charleston, SC: National Crime Victims Research and Treatment Center, Medical University of South Carolina;
Gray MJ, Elhai JD, Owen JR, Monroe R, authors. Psychometric properties of the Trauma Assessment for Adults. Depress Anxiety. 2009;26:190–5. [PubMed]
Weathers FW, Ruscio AM, Keane TM, authors. Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychol Assess. 1999;11:124–33
Briere J, author. Trauma symptom inventory. 1995. Odessa: Psychological Assessment Resources;
Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ, authors. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213. [PubMed]
Davis JL, Wright D, Borntrager C, authors. The trauma-related nightmare survey. 2001. Tulsa: The University of Tulsa;
Pennebaker JW, author. The psychology of physical symptoms. 1982. New York: Springer-Verlag;
Davis JL, Wright DC, Byrd P, Rhudy JL, authors; Davis JL, editor. Post treatment clinical significance survey. Treating post-trauma nightmares: A cognitive behavioral approach. 2009. New York: Springer Publishing Company;
Keane TM, Kolb LC, Kaloupek DG, et al., authors. Utility of psychophysiology measurement in the diagnosis of posttraumatic stress disorder: Results from a department of Veteran's Affairs cooperative study. J Consult Clin Psychol. 1998;66:914–23. [PubMed]
Fridlund AJ, Cacioppo JT, authors. Guidelines for human electromyographic research. Psychophysiology. 1986;23:567–89. [PubMed]
Stern RM, Ray WJ, Quigley KS, authors. Muscles: Electromyography. 2001. Psychophysiological recording New York: Oxford University Press; p. 109–24
Rhudy JL, Davis JL, Williams AE, et al., authors. Cognitive-behavioral treatment for chronic nightmares in trauma-exposed persons: assessing physiological reactions to nightmare-related fear. J Clin Psychol. 2010;66:365–82. [PubMed]
Resick PA, Schnicke MK, authors. Cognitive processing therapy for sexual assault victims: A treatment manual. 1993. Newbury Park: Sage Publications;
Tabachnick BG, Fidell LS, authors. Using multivariate statistics. 2007. 5th ed. Boston: Allyn and Bacon;
Weathers FW, Keane TM, Davidson JR, authors. Clinician-administered PTSD scale: a review of the first ten years of research. Depress Anxiety. 2001;13:132–56. [PubMed]
Schnurr PP, Friedman MJ, Foy DW, et al., authors. Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: results from a Department of Veterans Affairs Cooperative Study. Arch Gen Psychiatry. 2003;60:481–9. [PubMed]
Foa EB, Kozak MJ, authors. Emotional processing of fear: Exposure to corrective information. Psychol Bull. 1986;99:20–35. [PubMed]
Levin R, Nielsen TA, authors. Disturbed dreaming, posttraumatic stress disorder, and affect distress: A review and neurocognitive model. Psychol Bull. 2007;133:482–528. [PubMed]
Cohen S, Rodriguez MS, authors. Pathways linking affective disturbance and physical disorders. Health Psychol. 1995;14:374–80. [PubMed]
Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH, authors. Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008;71:134–68. [PubMed]
Cook JM, Harb GC, Gehrman PR, et al., authors. Imagery rehearsal for posttraumatic nightmares: A randomized controlled trial. J Trauma Stress. 2010;23:553–63. [PubMed]


text:
Volvo OEM Fuel/Gas Door Red #601 3536442 fits 850 1993-1997
- Brand: Volvo OEM
- Interchange #: FTD-ND011
- Volvo Part #: 3536442
- Stock #: FTD-ND011
- Availability: Out Of Stock
- * Please look at pics, condition and verify your fitment before purchasing, If you have any questions please contact us.
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Used Volvo OEM Fuel/Gas Door.
Condition: Good condition with some wear and no hinge
Give this Genuine Volvo
Part a Good Home!
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Warranty: 30 Day Warranty
Volvo Part Number: 3536442
Stock Number: FTD-ND011 View Donor Vehicle
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Color/Style: Red #601
Fits Volvo Models: Volvo 850 1993-1997
Notes: * Do not attempt installation in the cold. It is a good idea to heat the plastic with a heat gun/hair dryer, just a bit, before mounting the fuel door onto your Volvo *
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subset: commoncrawl


text:
Fowler makes first start in five games; Olivo in lineup
HOUSTON — Dexter Fowler has emerged from the witness relocation program, returning to the starting lineup. I kid because I care. Fowler will make his first start in five games after spending much of the past week working to shorten his swing with a tee work.
The Rockies have real issues with their lineup right now. Second baseman Clint Barmes is struggling, his average among the worst at his position all season. You could live with that if Todd Helton and Troy Tulowitzki were slugging. Both have experienced power outages. But there's no obvious replacement for Barmes because Melvin Mora is not a fit at second base. At least not from what I have seen. Mora is in at third base tonight. Ian Stewart was icing his right hand, but it was just a precaution. He's not hurt. He could use a day to gather himself after a tough series in Chicago.
As I wrote in spring training, this lineup has a chance to be potent, but incredibly streaky. There are four-to-five guys who go into long dry spells — this year that's been Barmes, Helton, Fowler, and, in cameo work, Chris Iannetta. You can't hide that many outs unless the other players are raking. But the Rockies have not had three-to-four players hot at the same time all season. The good news is that Houston's offense is worse. This is a series that the Rockies need to sweep. If the Orioles win and the Astros lose, Houston will have the worst the record.
Also. ….
–Heard today that Willy Taveras is working out in Houston. He was designated for assignment by Nationals last weekend. Good guy. Hope he gets another shot.
–Saw Cory Sullivan. Looks weird in an Astros' uniform. I will always owe Sullivan after he fixed my Treo phone last year during the trade deadline. I changed to the iPhone after returning from that trip. But he saved me.
–The Rockies are likely to make a roster move either after the game or tomorrow. Can bring up a reliever or infielder Jonathan Herrera.
A look at the Rockies' lineup:
LF Carlos Gonzalez
CF Dexter Fowler
RF Brad Hawpe
SS Troy Tulowitzki
1B Todd Helton
C Miguel Olivo
3B Melvin Mora
2B Clint Barmes
LHP Greg Smith


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Green Stations, a natural way of experiencing the train
Green Station of Sanabria © Adif
If you like nature and you love the idea of travelling by train, this is the information for you. We suggest taking a trip to any of the nine Green Stations in Spain: these are railway stations which serve as a starting point for exploring territories with natural protected spaces and Green Routes, and offer the chance to enjoy hiking and cycle touring. Which of the nine stations will you choose for your excursion?
Alcoy (Alicante, Region of Valencia) From this station you'll find yourself within easy reach of the nature reserves of Carrascal de la Font Roja (13 kilometres away) and Sierra de Mariola (15 km), home of the southernmost yew forest in Europe. Very near the station you'll find six routes (with a variety of itineraries and degrees of difficulty) and the Alcoy Green Route (an old railway line which has been restored for use by walkers and cyclists). Afterwards you can recharge your batteries by a visit to Alcoy, where typical dishes include the bajogues farades, peppers stuffed with rice. Calahorra (La Rioja) When you leave the station, head for the Riberas del Ebro (6 kilometres away), Monte de los Agudos (7 km) and the El Perdiguero reservoir (4.5 km). There are several routes leading there. One option is the Green Route of El Cidacos, and another, the routes known as the 'Senderos de la Verdura'. You'll be able to revel in the beauty of these forests of white and black poplars, alders, ash and great white willows. Don't leave without exploring Calahorra and sampling its famous dish of assorted vegetables known as menestra. Calatayud (Zaragoza, Aragon) This station is the best place from which to explore the Sierra de Armantes mountains (5 kilometres away), the gorges known as the Hoces del Jalón (9 km) and the Sierra de Vicor mountains (20 km). You'll have five routes to choose from, offering the chance to see gorges carved out of the rock by erosion, species such as the golden eagle and peaks towering over 1,400 metres... And if you're going to Calatayud, don't forget to try the conger eel.
Castuera (Badajoz, Extremadura) Come and see the landscapes of the Sierra de Castuera mountains (3 kilometres from the station) and interesting reservoirs such as those of Zújar and Orellana. Choose between routes including the Mozarabic road to Santiago. And you can't possibly leave Castuera without sampling the Iberian cured ham and the roast lamb. Fuente de Piedra (Antequera, Malaga, Andalusia) It's definitely worth a detour to visit this series of lakes which are home to large numbers of birds which are almost without equal in Spain. The lake of Fuente de Piedra is particularly worth seeing, and is just a stone's throw from the station. And for a treat for the palate, try the local gazpacho and the typical fried breadcrumbs. Ponferrada (León, Castile-León) This is the perfect starting point for exploring places such as Monte Pajariel (3.6 kilometres from the station) and the Bárcena reservoir (7.6 km). You can reach them along the path known as the Senda de los Monjes and the route up to the Pajariel mountain. For lunch, the star of the local gastronomy is the hearty cured meat dish from El Bierzo known as botillo. Puebla de Sanabria (Zamora, Castile-León) Come and walk around the Lago de Sanabria nature reserve (14 kilometres from the station) or in the Sierra de la Culebra mountains (3 km), home to the largest population of wolves on the Iberian Peninsula. There are three routes to choose from: the traditional route of Puebla de Sanabria-El Puente, Camino de las Herrerías, and Castellanos-Chaguaceda-Triufé. And what's for lunch? Habones sanabreses (a local bean stew). Ribes de Fresser (Girona, Catalonia) As soon as you come out of the station you'll see before you the Ribes valley, and 12.5 kilometres away, the Núria valley encircled by peaks almost 3000 metres high. Discover this area by taking routes such as the path of 'La Salud', or take a ride on a mountain bike. And as a souvenir to take home: honey. Ronda (Malaga, Andalusia) There are numerous hiking routes which lead to the Tajo de Ronda gorge (1.1 kilometre from the station), the Dehesilla del Mercado park (2.1 km) and the gorge of the Ventilla stream (8.5 km). Don't miss a visit to Ronda, where the olives and olive oil are highly recommended. On the web page the official website of the ADIF , you'll find a more detailed guide to the nine Green Stations (a number which is soon to be increased), and information on all the monuments, museums and most important festivities in each place. Let the train take you to these unique places.
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Investigators claim major progress in Boston bombings
Investigators are exploring a number of promising leads in the Boston Marathon bombing case, including an image of a man believed possibly involved in one of Monday's twin explosions that killed three people and injured 176.
A federal law enforcement official told USA TODAY Wednesday that the image, captured by surveillance cameras in the area of one of the bomb sites, shows a man putting down a bag near one of the bomb sites. The bag appears to be similar to the black nylon pack described earlier as possibly used to carry the explosive devices, officials who have been briefed on the inquiry told USA TODAY.
Authorities were working to identify the individual in surveillance video obtained from a nearby Lord & Taylor department store, as well as a number of other people in video and photographs near the site of the explosions. More than 70 people remain hospitalized, with 14 listed in critical condition.
The leads emerged during a chaotic day in which federal authorities dismissed a flurry of media reports, including dispatches from the Associated Press and CNN broadcasts, that a suspect had been taken into custody.
"Contrary to widespread reporting, there have been no arrests made in connection with the Boston Marathon attack,'' the FBI said in a statement.
The events in Boston included an evacuation at the federal courthouse sending streams of people into the street just two days after the explosions ripped through crowds near the finish line of Monday's iconic sporting event. Courthouse employees returned late Wednesday afternoon after authorities conducted a security sweep.
The FBI also announced the arrest of Paul Kevin Curtis of Corinth, Miss., in connection with a separate inquiry into a series of suspicious letters addressed to federal lawmakers and President Obama. Preliminarily tests had indicated the letters tested positive for the ricin; the mail was undergoing additional examination for more conclusive testing.
Federal law enforcement officials don't believe the two investigations — the tainted mail and the Boston bombings — are related.
Meanwhile, as investigators painstakingly gathered fragments of evidence from the bomb sites, a lid was recovered from a pressure cooker believed used as one of the explosive devices, a federal law enforcement official said.
An official who had been briefed on the matter but was not authorized to comment publicly told USA TODAY the lid was found on a roof near the blast scene.
The discovery came Wednesday as the head of the Department of Homeland Security told a Senate panel in Washington that the Coast Guard worked with the Boston Police Department after Monday's bombings to guard against any potential water-borne attack from Boston Harbor or the Charles River.
Homeland Security Secretary Janet Napolitano said officials continue to investigate the bombing with the FBI as a solitary act of terror.
STORY:All fatalities now identified
STORY:Bombing victim loses both legs
"There is no current indication to suggest the attack was indicative of a broader plot," Napolitano told the Senate Homeland Security and Governmental Affairs Committee on Wednsesday. "But out of an abundance of caution, we continue to keep in place enhanced security measures, both seen and unseen."
Peter Burke, chief trauma surgeon at Boston Medical Center, said two of the 19 patients there still being treated remain in critical condition, including a 5-year-old boy. All are expected to survive, he said.
Burke said patients who required amputations or who lost limbs are now entering the second phase of their recovery, which is making sure that infection does not set in.
"They get injured very quickly, but it takes a long time for people to get better," he said.
Evidence investigators from ATF, FBI and other federal agencies wearing protective suits continued to scour the crime scene Wednesday. Evidence trucks and mobile labs filled Exeter Street, the side street off Boylston closest to the blast sites.
The amount of gunpowder used in the bombings is believed to be a fraction of the overall weight of the devices, estimated to weigh about 20 pounds each, a law enforcement official said Wednesday.
Much of the weight was attributed to the pressure-cooker container and a mix of shrapnel — BB pellets and nail fragments — that cut a deadly path through the crowds gathered near the race finish line, said the official who is not authorized to speak publicly.
The official said the components of the bomb — common kitchen pressure cookers, wire, batteries and gunpowder — are so widely available that barring the assistance of an informant or a telling photo from the crime scene, it will likely take investigators some time to determine where the materials were obtained and who acquired them.
"This is either quick or it's not,'' the official said, referring to the identification of possible suspects, "and right now it's looking like not.''
At the same time, the official said, bomb technicians will likely be able to reconstruct much of the entire device, from both pieces recovered from the scene and the collective knowledge of investigators who have encountered similar devices in past investigations.
"They are going to be able to figure out how this device was acquired,'' the official said. "Depending on the trade craft involved, they will be able to do it relatively easily.''
Boston FBI chief Richard DesLauriers said the recovered materials were being examined at the FBI's laboratory in Quantico, Va., where the bureau has assembled a clearinghouse of improvised explosive devices recovered from such places as the battlefields of Iraq and Afghanistan and crime scenes around the country. Some evidence will undergo an expedited analysis, FBI spokesman Special Agent Jason Pack said.
The scene of the explosions is strewn with shredded T-shirts, metal fragments and glass shards. Boston Police and National Guard soldiers guard every access point, but from the side streets, spectators have watched the investigators at work.
The ATF's evidence recovery experts have found blast debris on rooftops and embedded in nearby buildings, acting ATF Special Agent Eugenio Marquez said.
"It gives the scope of the power of the blast," Marquez said.
The latest discoveries came as investigators appealed to the public for videos and photos of the scene in hopes of getting an image of the person or persons who left the explosive devices near the finish line of the marathon.
Authorities have yet to determine the motive for the bombings and are urging anyone with tips to come forward with information.
"The person who did this was someone's friend, co-worker or neighbor," DesLauriers said. "Somebody knows who did this."
No one has claimed responsibility for the explosions and "the range of suspects and motives remain wide open."
Officials at a Northern California battery company said they believe a battery they manufacture was used in the Boston Marathon bombing.
Benjamin Mull, spokesman for Fremont-based Tenergy Corp., said that based on crime scene photos that have appeared online, the company believes one of its nickel-metal hydride batteries was used to make the bombs that detonated Monday near the marathon's finish line.
"We're all horrified and appalled that our off-the-shelf product would be used in such a horrific way," Mull said.
The company has reached out to Boston police and the FBI but hasn't heard directly from investigators, Mull said.
The company says the 1.25-volt battery seen in the photos is sold in retail outlets and is frequently used by hobbyists for various toys, including radio-controlled cars and trucks.
Tenergy has been selling the battery for several years and said it has sold "tens of thousands" of the particular battery in the past year.
Meanwhile, the blast's third fatality as Lu Lingzi, a Chinese national and graduate student Boston University. Lu, who previously studied international trade at Beijing Institute of Technology, was studying statistics at BU, according to her Facebook page and media reports.
The other two victims were Martin Richard, 8, of Dorchester, and Krystle Campbell, 29, of Medford, Mass.
The Chinese Consulate in New York said in a statement Tuesday that another Chinese citizen was wounded and was in stable condition following surgery.
Contributing: Bart Jansen; Associated Press


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Jefferson County DA reopens investigation into boy's 1988 death
Artis Echoles found dead in pond at Bark River Campground
The district attorney in Jefferson County is reopening the investigation into the death of an 8-year-old boy in 1988.
Artis Echoles of Racine was found in about 5 feet of water in a pond at the Bark River Campground near Jefferson in June of 1988. He had been camping there with his foster family.
"They told me my son drowned. The coroner said he drowned, and I tried to pick the pieces up and move on," Echoles' mother, Carmin White, said.
Echoles' death was ruled an accidental drowning.
Surrounded by her family, White told WISN 12 News reporter Nick Bohr she placed Echoles in foster care that spring because of behavioral problems and thought going to the campground with his foster parents would be good for him.
She said she was told he wandered away and drowned in the campground pond.
"A coroner drove up and told us they found him in the bottom of the pond. He was dead, and that was it and that was all, and they needed somebody to identify my son," White said.
Still haunted by his death, White recently came across the investigative police reports she had never seen and was shocked.
Three children said they had seen Echoles being thrown into the pond by a man and held under, but it wasn't investigated further.
She asked a judge to review the records and late last month Jefferson County Judge Jennifer Weston ordered the district attorney to take another look at the case.
"Whoever is out there who was on that campground June 18, 1988, please contact someone because there are other witnesses. They just didn't say anything at that time because there were too many people out there to not witness it and not see it. And I believe those children, kids know what they're talking about and they don't forget," White said.
The prosecutor has until April 30 to make a decision on whether charges are warranted.
The district attorney' office said it can't comment on an active investigation.


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ST. PAUL -- Gov. Mark Dayton this morning signed a two-year budget into law, ending a government shutdown and beginning a process of state employees returning to work and state services restarting.
In the governor's reception room, Dayton signed nine bills that fund various areas of government, much of which has been idled since he and Republican legislative leaders failed to agree on a new budget before the old one ended on June 30.
Five hours earlier, House Speaker Kurt Zellers hugged Senate Majority Leader Amy Koch and the two called it a session early today after Minnesota legislators passed a budget spending $35.7 billion in the next two years.
Once Democratic Dayton signed the budget, 22,000 state employees were recalled to work. But government will not open immediately. Dayton administration officials said some state projects, such as road construction, could take weeks to ramp back up.
"I'm not extremely happy with the budget I just signed into law," Dayton said, adding it was the best he could negotiate with Republicans who control the Legislature.
Dayton signed each bill this morning, then handed it to Secretary of State Mark Ritchie to affix his signature, which made the bills law immediately.
"It gets Minnesota back to work," Dayton said about the state's new budget.
Money does not begin to flow into state agencies until Thursday, and state workers have three days to report to work. But Dayton said many agencies already are beginning to prepare to reopen by doing things such as firing up dormant computer systems.
"Everybody is geared up and ready to do," he added.
The governor and Zellers and Koch, the top Republican budget negotiators, set aside strongly held political beliefs to work out a budget that both funded the state and ended the Minnesota government shutdown.
The Legislature convened for a special session at 3:05 p.m. Tuesday for the sole purpose of passing a budget. The House adjourned at 3:39 a.m. today, and the Senate about a minute later.
"We got the job done," Rep. Morrie Lanning, R-Moorhead, said. "It is a tremendous relief."
While the final budget spends up to $5 billion more than many Republicans wanted, Zellers and Koch said they were pleased.
"I think we did the best that we can," Zellers said moments after gaveling the special session to a close.
Zellers and Koch both looked ahead, saying they want more reforms to shrink the size of government and make it more efficient.
"We've got lots more work to do next year," Koch said.
During the 12-hour, 34-minute special session, lawmakers often went at warp speed. The longest debate on a budget bill lasted slightly more than an hour, the shortest three minutes.
The spurts of speed were interrupted by long waits for bill writing to be finished.
Republicans said little about the bills, Democrats usually criticized them.
During the debate, rushed so the shutdown could end as quickly as possible, lawmakers voted to keep health-care funding flowing to poor, disabled and elderly Minnesotans; maintain steady aid to cities (including keeping aid for Duluth, St. Paul and Minneapolis that Republicans wanted to eliminate); cut college and university funding 10.5 percent; and fund nearly $500 million in public works projects around the state.
Suspended state services range from parks to a variety of license services, from beer-buying permits to horse-racing track regulators. Those and other state services gradually will return to normal after Dayton signs the bills.
Dayton broke a lengthy budget impasse Thursday when he suggested passing a borrowing plan, with some changes, that Republicans originally suggested June 30 to increase state spending instead of the governor's idea to increase taxes. That put into motion the intense budget-writing negotiations held in the closed Capitol, out of public view.
One borrowing mechanism would use future payments from a tobacco lawsuit settlement to repay $640 million of bonds. The other plan delays $700 million in state payments to schools, freeing up the money for state programs.
The borrow-and-delay plan that the GOP suggested to allow for more spending provoked the most debate of the night.
"We are making promises we can't keep with money we don't have," Rep. Paul Marquart, DFL-Dilworth, said.
He said the tax bill that contains the borrowing plan will force local property taxes up $367 million. "This, make no mistakes about it, is going to hit communities around the state."
House Majority Leader Matt Dean, R-Dellwood, told fellow representatives that a vote against the bill was a vote to continue the shutdown.
The special session was limited to budget, public works construction and related bills. A new Vikings football stadium was not part of the session and Dayton did not promise to call one later this year.
Here are votes on budget bills (in most cases, Republicans favored the bills and Democrats opposed):
Public safety and courts, Senate, 57-7; House, 77-51.
Transportation, House, 71-56; Senate, 38-27.
Higher education, House, 71-57; Senate, 35-30.
Environment, Senate, 43-22; House, 71-57.
Jobs-economic development, Senate, 42-23; House, 76-50.
Taxes, House, 71-57; Senate, 37-27.
Health and human services, House, 71-57; Senate, 37-27.
Education, House, 71-56; Senate, 36-28.
State government, Senate, 40-24; House, 81-47.
Bonding, House, 112-17; Senate, 53-11.
Legacy (clean water, arts, outdoors programs), Senate, 63-0; House, 98-30.
Don Davis reports for Forum Communications Co.


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WALTHAM, Mass.-- After spotting Southern Maine (14-13, 5-3) a three run lead, the Beacons (16-11, 5-3) used a five-run third inning to rally past the Huskies and earn a 7-5 win at Yetten Field to earn the conference sweep. The Beacons accomplished the feat behind big days from a pair of players being placed in new roles.
Junior Nick Grassetti (Agawam, Mass.) played a key role in two of the three innings UMass Boston scored in, while making some key defensive plays in his first start of the season at second base. Grassetti started the third inning with an infield single and stolen base before scoring to spark the rally and in the eight inning Grassetti sent a ball off the fence in right field for a triple to drive in pinch-runner Luke Fischetti (Liverpool, N.Y.) and give the Beacons a key insurance run.
Sophomore relief pitcher Ryan Augustine (Burlington, Conn.) earned his first career save by pitching two innings of scoreless baseball. He allowed just one hit and two walks, while striking out two Huskies.
Junior first baseman Matt Consiglio (Southbury, Conn.), freshmen catcher Jack DeBiase (Prospect, Conn.) and Mark McCormack (Shelton, Conn.) all recorded two hits on the day and added an RBI. Sophomore Jamill Moquette (Boston, Mass.) extended his hit streak to 11 with a single in the bottom of the sixth and recorded two RBI as well.
On the mound, Michael Boughton (New Britain, Conn.) recorded his second win of the season by going seven innings, after struggling early. He allowed three runs on three hits in the first inning, before giving up just five hits and two earned runs over the next six innings. For the day, Boughton allowed five earned runs on eight hits and struck out three Southern Maine players.
Southern Maine jumped out to a quick start with a pair of extra base hits into the depths of the cavernous right field at Yetten Field. With men on second and third and no outs, Southern Maine's leading hitter Tucker White smashed a ball to right field for his eight triple of the season to give the Huskies a 2-0 lead. White would score two batters later on a groundout to first base to make it a 3-0 game, before Boughton struck out the sixth hitter of the game to end the early rally.
After two sluggish offensive innings to being the game, UMass Boston broke out in a big way in the bottom of the third. Grassetti led off and recorded the Beacons first hit of the day on a trickler down the third base line that third baseman Nick Grady couldn't handle. Grassetti proceeded to steal second base and took third base on a wild pitch with one out in the inning. He was able to walk home during the next at-bat, when McCormack crushed a ball high off the fence in right field for an RBI triple that put the Beacons on the board.
Moquette followed with a grounder to short that the Huskies failed to handle to make it a 3-2 game before Consiglio tied the game at 3 with an RBI single up the middle to extend his hit streak to nine games. Freshmen Charles LaPaglia (Marshfield, Mass.) followed with a double to right-center to put runners on first and third base with only one out. DeBiase put the Beacons ahead for good with a sharp single to left field that scored Consiglio and advanced LaPaglia to third. Senior Mike Mattei (Spencer, Mass.) finished the scoring in the inning with a suicide squeeze that scored LaPaglia.
The Beacons added another run in the bottom of the fourth when Collin Keefer (Charlotte, N.C.) and McCormack singled back-to-back to put runners on first and third. After a wild pitch allowed McCormack to advance to second with one out, Moquette extended the lead on an RBI groundout to shortstop that may have been a double-play ball if McCormack had still been on first.
Southern Maine scored a run in the sixth and seventh inning to bring the game to 6-5, but their seventh inning rally ended on a terrific defensive play by the Beacons. With Huskies on first and third base and two outs, Southern Maine attempted a delayed double steal that the Beacons broke up. White took off from first base for the Huskies but was out by several feet on a strong throw from Jack DeBiase (Prospect, Conn.) to second base. Grassetti, making his first start of the year in the infield, skied above the base to catch the ball and then converted the run down with Consiglio, while making sure the Husky runner at third wouldn't score.
Grassetti would add all the insurance UMass Boston would need in the bottom of the eight. Pinch hitter Todd Ezold (Westfield, Mass.) walked on four pitches, before giving way to Fischetti as the team's pinch runner. Grassetti then blasted his third triple of the season to give the Beacons a 7-5 lead.
Augustine finished the Huskies off in the top of the ninth by striking out David Ricker and forcing White to fly out with two runnerss on.
UMass Boston will be back in action tomorrow when they travel to Salem State University for a 3:30 p.m. matchup.


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The Persistence of Vision Raytracer (POV-Ray).
This is the legacy Bug Tracking System for the POV-Ray project. Bugs listed here are being migrated to our github issue tracker. Please refer to that for new reports or updates to existing ones on this system.
FS#282 - Unrendered region should be transparent, not black
Opened by Timwi (Timwi) - Sunday, 24 March 2013, 13:12 GMT
Last edited by William F Pokorny (wfpokorny) - Friday, 21 April 2017, 11:30 GMT
When rendering only a region of a file, using the command-line options +sc/+sr/+ec/+er, the area of the image that is excluded comes out as black in the final PNG.
Expected behaviour is for it to be transparent.
The behavior is expected. The pixels are never filled, as you explicitl requested them to not be renderd. The background in a scene only applies to pixels rendered.
This report is not referring to the background in a scene at all. The unrendered region should simply always be transparent — after all, as you correctly pointed out, it is not rendered. It should not be filled with black.
Please reopen as the closer misunderstood the bugreport.
Did you read the response to your report 283?
Report 283 is completely unrelated to this one. Report 283 is about "background { ... }". This one is not. This one is about +sc/+sr/+ec/+er.
But to answer your question, yes, I read it, and I tried +UA, and it still comes out as opaque black.
I think it is reasonable to expect unrendered portions of the image to come out transparent when alpha support is enabled for the output file. After all, the preview window also still shows the checkerboard pattern in those regions. I therefore re-opened this issue as a feature request.
I think it is reasonable to expect unrendered portions of the image to come out transparent when alpha support is enabled for the output file. After all, the preview window also still shows the checkerboard pattern in those regions. I therefore re-opened this issue as a feature request.
I agree, it would be a useful feature. Of course, we had been discussing if we want a full image generated for a partial render or not for a long time anyway. Once we add a choice for that, we can also change the current behavior.
Just an opinion to consider: outputting a partial render with transparent unrendered parts can be extremely useful. In cases when a small part of the image changes, and the rest stays the same (this is ok if there's no radiosity and reflections), rendering speed can be significantly increased if only the changing part is rendered, and then the partial image is composited over a single render of surroundings. Let's say, a render of animation that includes a rotating or morphing object in static environment (common in scientific presentations). Having a transparent background makes the compositing a trivial operation. The same technique can be used to distribute rendering across different machines (such as ad-hoc cluster over ssh): chunks can be easily merged if the unrendered parts are transparent.
- Field changed: Status (New → Tracked on GitHub)
Now tracked on github as issue #279.


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01 Oct Tree Stump Removal Yarrambat | Stump Grinding
Tree Stump Removal & Grinding Services Yarrambat
Simpson's Tree Service offers quality stump grinding and tree root removal throughout Yarrambat and surrounding suburbs. At Simpsons Trees, we have two different stump machines – one is for tight spots and the other is self-propelled. Leaving tree stumps to take care of themselves isn't a good option, as they take decades to rot away.
They can be covered with a pot plant on top, but if they are a weed species they will likely re sprout from the stump or root system. This means the best solution is to grind the tree stumps with one of our stump machines.
Stump Grinding – Depth & What Happens
Our stump grinding services grind stumps to a maximum depth of 36cm where the tree hits the ground. If you also need roots removed, that will require an additional charge as they tend to spread out across lawns, garden beds and under paths. Stump grinding is especially important for weed species, as they will regrow if left unattended. Grinding tree stumps will allow for new plantings in the space where the tree stump was.
The machine grinds up the stump into sawdust and mixes it will the surrounding dirt. These materials are all left on site to become fluffy as the soil is aerated.
We only grind where the tree hits the ground and any large roots attached to it. We can grind the roots out, but if the roots are spread over the garden as is usually the case, the stump machine will make a mess of your garden. Generally, the smaller diameter roots will rot away in a couple of years.
Our two machines allow us to access trees on banks and down stairs. The smaller machine is the width of a wheel barrow and the bigger one is just slightly wider, so both generally can fit through gates. If your property has a lot of stairs or underground services, however, that may cause a hindrance.
Front gardens contain underground services – these must be shown to the company representative Ben or Luke at the time of quotation so that you can receive the best possible service.
Another thing to consider is where your phone lines are, as they can be anywhere underground. Before we can service your property, you must let us know where they are. If you have not shown us where these phone lines are, we are not liable for any accidental damage. However, if we have been shown the phone lines and we accidentally damage them, we will take care of it right away. These terms and conditions are in our quotation sheets, which upon acceptance are binding
Tree Stump Removal Yarrambat
Our stump grinding equipment is what allows us to provide quality tree stump removal in Melbourne. Tree stump removal is required so that you can get the most out of your land, and prevent any weed species from taking over your garden.
For the best tree stump removal, look no further than the experienced team at Simpsons Trees.
Call us on 9438 2238 or us the contact us page to send us a query.


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- Font:
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ATLANTA — U.S. women are dying from childbirth at the highest rate in decades, new government figures show. Though the risk of death is very small, experts believe increasing maternal obesity and a jump in Caesarean sections are partly to blame.
Some numbers crunchers note that a change in how such deaths are reported also may be a factor.
"Those of us who look at this a lot say it's probably a little bit of both," said Dr. Jeffrey King, an obstetrician who led a recent New York state review of maternal deaths.
The U.S. maternal mortality rate rose to 13 deaths per 100,000 live births in 2004, according to statistics released this week by the National Center for Health Statistics.
The rate was 12 per 100,000 live births in 2003 — the first time the maternal death rate rose above 10 since 1977.
Still rare
To be sure, death from childbirth remains fairly rare in the United States. The death of infants is much more common — the nation's infant mortality rate was 679 per 100,000 live births in 2004.
Maternal deaths were a much more common tragedy long ago. Nearly one in every 100 live births resulted in a mother's death as recently as 90 years ago.
But the fact that maternal deaths are rising at all these days is shocking, said Tim Davis, a Virginia man whose wife Elizabeth died after childbirth in 2000.
"The hardest thing to understand is how in this day and age, in a modern hospital with doctors and nurses, that somebody can just die like that," he said.
Some health statisticians note the total number of maternal deaths — still fewer than 600 each year — is small. It's so small that 50 to 100 extra deaths could raise the rate, said Donna Hoyert, a health scientist with the National Center for Health Statistics. The rate is the number of deaths per 100,000 live births.
In 2003, there was a change in death certificate questions in the nation's most populous state, California, as well as Montana and Idaho. That may have resulted in more deaths being linked to childbirth — enough push up the 2003 rate, Hoyert said.
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Some researchers point to the rising C-section rate, now 29 percent of all births — far higher than what public health experts say is appropriate. Like other surgeries, Caesareans come with risks related to anesthesia, infections and blood clots.
'Inherent risk'
"There's an inherent risk to C-sections," said Dr. Elliott Main, who co-chairs a panel reviewing obstetrics care in California. "As you do thousands and thousands of them, there's going to be a price."
Excessive bleeding is one of the leading causes of pregnancy-related death, and women with several previous C-sections are at especially high risk, according to a review of maternal deaths in New York. Blood vessel blockages and infections are among the other leading causes.
Experts also say obesity may be a factor. Heavier women are more prone to diabetes and other complications, and they may have excess tissue and larger babies that make a vaginal delivery more problematic. That can lead to more C-sections. "It becomes this sort of snowball effect," said King, who is now medical director of maternal-fetal medicine at Riverside Methodist Hospital in Columbus, Ohio.
The age of mothers could be a factor, too. More women are giving birth in their late 30s and 40s, when complications risks are greater.
Other characteristics of the maternal mortality rate include:
- Race: Studies have found that the maternal death rate in black women is at least three times greater than is it is for whites. Black women are more susceptible to complications like high blood pressure and are more likely to get inadequate prenatal care.
- Quality of care: Three different studies indicate at least 40 percent of maternal deaths could have been prevented.
No explanation
Sometimes, there is no clear explanation for a woman's death.
Valerie Scythes, a 35-year-old elementary schoolteacher, died in March at a hospital in New Jersey — the state with the highest Caesarean section rate. She had had a C-section, as did another teacher at the same school who died after giving birth at the same hospital two weeks later.
However, Scythes died of a blocked blood vessel and the other woman died from bleeding, said John Baldante, a Philadelphia attorney investigating the death for Scythes' family.
"I'm not sure there was any connection between the two deaths," Baldante said.
Also mysterious was the death of Tim Davis' 37-year-old wife, Elizabeth, who died a day after a vaginal delivery at a Danville, Va., hospital in September 2000.
She had a heart attack after a massive blood loss, Davis said. It's not clearly known what caused the heavy bleeding. There was no autopsy, he said, a decision he now regrets.
Two previous births had gone well.
"Nothing led us to believe anything was wrong with this pregnancy. She was like a picture of health," he continued, noting she had been a YMCA fitness instructor.
A lawsuit against the hospital ended in a settlement. Davis also sued the obstetrician, but a jury ruled in the doctor's favor.
The child born that day, Ethan, starts second grade next week. "He's a happy kid," Davis said. "He's just never had a mom."
© 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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City of Lincoln
Mayor's Office
2004 Media Releases
Decision on the November 4, 2004 Recommendation
of the Procurement Appeals Board on the Pumper Fire Truck Bid
November 15, 2004
Today, I have directed the Finance Department to begin a new bidding process for purchasing replacement pumper fire trucks.
The pumper fire truck bid specifications are to be reviewed to eliminate multiple city contacts which caused the confusion and facilitated the lack of communication. Also, the specs should be further reviewed to make them as generic as possible by eliminating references to brands and other descriptions which may appear to be proprietary or restrictive. Since the basic specifications will remain the same, the bid period should be shorter. This also will prevent the City from further delay in the critical need to replace the aging fire trucks.
The pumper fire trucks have been needed for more than a year. The six or seven pumper fire trucks being replaced are 10 to 20 years old and are living on borrowed time. There is a risk if a pumper fire truck has a catastrophic breakdown happen during an emergency.
A different purchasing agent will be assigned to conduct the rebid. This will allow for a fresh perspective on the rebid. There is to be no contact between the future bidders or their attorneys and/or representatives with any one except the Finance Director and/or the purchasing agent to be assigned to conduct the rebid.
At the same time, I have directed the Law Department and Finance Department to design a new and better appeal process. The current appeal process was created in 1993. The City Law Department has identified a number of deficiencies in the current appeal process that need to be clarified and improved. These improvements to the appeals process include clarifying when an appeal can be filed, how many appeals a vendor can submit, whether an appeal decision can be appealed and when the appeal period ends.
The improvements to the procurement process appeals need to be to me by December 31, 2004 and ready for introduction to City Council in January 2005.
I am particularly troubled by how some have tried to change the pumper fire truck appeal process from a purchasing decision to a referendum on efficiency of the Fire Department. This is about a purchasing decision. All those involved acted within their appropriate authorities. But it is apparent that the bid process and the specifications created ambiguity in this case. Purchasing specifications and the appeals procurement process need to be clear.
My other observation is that while I am constantly barraged about how everyone should "buy" Lincoln, in this case, a hometown business has had no support from the local business community. I hear weekly about the importance of using local business to acquire services and products ranging from printing to concrete, but in this case no one has mentioned the importance of buying locally. Instead, some have attempted to use this fire truck appeal to cast doubt on the efficiency of the firefighters and Department as though the city was once again determining emergency ambulance service. The emergency ambulance selection is over, was over and life needs to move on. While the City will follow the City Charter requirements, I will always believe that local business needs our support.


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Oscar Thinnification: Victoria Beckham
Posh! We get it! We'll never ever question whether or not some yo yo crack whore dieter like Lindsay Lohan is thinner than you…never again.
You keep it consistent. You maintain the Skinny. You relentlessly pursue the brink point of emaciation vs survival. You are the Boniest Queen of Them All.
So please, we are sorry.
Will you stop trying to prove it to us?
This is Victoria Beckham at the annual Elton John Oscar party last night in the most slimming black dress, at every f-cking angle. As you can see, Posh is proud of her lean lines. She cocked her pose extra hard last night to show them off.
And it totally paid off.
Eva Longoria, Kate Beckinsale, and Dita von Teese all looked like monstrous gluttonous carbohydrates addicts next to her. Yay!
Who's waking up happy this morning!
Photos from Wenn.com and Gettyimages.com


text:
EventsHome » Things To Do » Events Calendar
Book By Phone
Call now for reservations at
Now taking reservations for the 2019 season! Be sure to let us know if your celebrating a special event while staying with us!
Reservation Request
Stay 2 nights, and receive the 3rd night FREE!
Use discount code WEB2019 when making your reservation.
No double discounts.
Excludes Columbus Day weekend.
Expires Oct. 31, 2019.
CAMPING in the FALL
25% Off Your Stay!
Offer Valid: September 6 - October 31, 2019
Excludes Columbus Day weekend. To receive this discount, you must ask for it at the time of your reservation. 2 Night Minimum. No double discounts. One discount per family.
October 11-14, 2019
Columbus Day Weekend
Invite your family and friends to come along for a enjoyable weekend relaxing in the great outdoors and the kids enjoy all the Halloween activities!
"Gas Saver Value Program"
Spring & Fall
Pay for 2 consecutive weekends
Receive 3rd consecutive weekend FREE
$5/night on site fee NO utilities during the week
Valid 4/1/19 - 5/20/19 and 9/6/19-10/31/19
Limited campsite availablity. Not vaild on rentals. One discount per family.
Excludes Holiday Weekends.
$530 savings value based on 2 Adults.
Kymer's is our favorite getaway! The campgrounds are very well kept, the staff is polite and friendly, and there are a lot of games and activities to keep the children busy. The individual sites are very well maintained as are the shower and bathroom facilities.
- Penny Schneider Clark
1st time camping @ Kymers had an awesome time very clean grounds,personable & attentive staff bathrooms were clean & maintained regularly. They also had activities & presentations for the kids. On our arrival another camper hooked a cable line on their way to their site staff had it repaired that day. Can't say enough about our experience we will definitely be back.
- Shane Mckinney
May 2017
My family and friends always have a wonderful time. The kids enjoyed their weekend to the fullest!
- Roxana Elizabeth
thank you Kymers and all the staff for the excellent customer service, we enjoyed our memorial day weekend!
- Melinier Rodriguez


text:
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