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TR-151 is a durable and water resistant GPS/GSM/GPRS tracker. Users can install TR-151 on vehicles or assets for tracking. It can send out SMS with its location (longitude and latitude) to user's cell phone by GSM network or to personal computer by internet connection of GPRS network. Then users can track the location of their vehicles or assets. TR-151 is designed to equip with high capacity of Li-ion battery for long operation time. There is one SOS button on the TR-151 for emergency help. It is very easy to install or hide TR-151 in the car to perform tracking. TR-151 is ideal application for vehicle tracking and equipment/assets monitoring.
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My GTD + Evernote system for getting stuff done
When it comes to attacking my to-do list, I like the Getting Things Done (GTD) approach. Based on the book by David Allen, this productivity philosophy is focused on getting tasks and projects out of your mind and recording them externally. Once you've recorded a task, you need to break it down into actionable items and define the next action.
You can choose any method of recording tasks that works for you - as long as they're out of your head. Although I use notebooks a lot (I have a black Moleskine one, which isn't very daring of me), my main system is in Evernote. Here's my process for making it work, which is very much inspired by The Secret Weapon.
I have four notebooks in Evernote:
- Tasks - all of my active tasks (current and planned) go here
- Cabinet - here I store articles I'd like to read, copies of documents, that kind of thing
- Clippings - my Kindle highlights and notes are automatically synced here
- Complete - I move tasks here once complete
Clippings is probably my favourite notebook of all: I love being able to find what I've highlighted in Kindle books and keep track of what's inspiring me. To export my Kindle clippings and integrate with Evernote, I use the clippings.io app.
Within Tasks, I rely a lot on tags to keep things organised. My tags are grouped into four main categories:
- .What
- .When
- .Where
- .Who
.What is probably the busiest of them all. It's broken down into:
- .Active Projects
- .Inactive Projects
- .Knowledge
- .To Read/Review
- .Buy
Each of these has a few (ok, a lot of) layers beneath them:
- .Active Projects
- Active.Business Projects
- Active.Creative Projects
- Active.Life Organisation
- Active.Personal Project
- .Inactive Projects
- Inactive.Business Projects
- Inactive.Creative Projects
- Inactive.Life Organisation
- Inactive.Personal Project
- .Knowledge
- Business Knowledge
- General Knowledge
- Science Knowledge
- Reading
- Action points from books
- Life lessons from books
- .To Read/Review
- .Buy
If something applied to General Knowledge, I wouldn't also tag .Knowledge. I only choose the tag that's lowest down in that hierarchy.
Once I've assigned the correct .What tags to a task (normally just one or two), I decide .When:
- !Daily
- 1 - Now
- 2 - Next
- 3 - Soon
- 4 - Later
- 5 - Someday
- 6 - Waiting
As every task has a time frame, this means I can then easily see what I need to get done that day or week by clicking on the relevant .When tag.
Once a week, usually on Sundays, I'll look at .Active Projects and decide on my tasks for the week, ideally with some sort of balance behind it and a focus on my current priorities.
Next up is .Where, which is simply:
- @home
- @work
The GTD + Evernote system that I based this on – The Secret Weapon – also has a .Who tag, but I never needed to use this (which might say a few things about me).
Does this system look like madness? Perhaps! But it helps keep my head a lot clearer, which in turn allows more important stuff to happen in it. Try and find a system that does that for you, no matter how simple or complex you want it.

subset: commoncrawl


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Parhelion Medical
Locum physician required for private practice. CCFP required.
Watson Lake
Situated in the rolling hills of southeast Yukon, Watson Lake offers many ways to enjoy the outdoors. Watson Lake is often called "The Gateway to the Yukon." The community is located in the southeastern corner of the Territory, just 14 km from where the Alaska Highway crosses the British Columbia border. Watson Lake is a key transportation hub. It sits at the junction of the Alaska Highway, the Robert Campbell Highway to the central Yukon and the Northwest Territories, and the Stewart-Cassiar Highway from central British Columbia. The Yukon's capital, Whitehorse, is 455 kilometres to the northwest.
The community of Watson Lake consists of the town of Watson Lake and the adjoining settlements of the Liard First Nation, including Upper Liard. Watson Lake lies within the traditional territory of the Liard First Nation, part of the Kaska Tribal Council. A community was established at Watson Lake in 1939, when the Canadian government decided to build a chain of airports across the North, including one at Watson Lake. The new community was a supply and accommodation centre for airport construction in 1941 and for the building of the Alaska Highway a year later. After these were completed, Watson Lake became a service centre for the highway and, later, for the resource-rich region of the upper Liard River and its tributaries.
Watson Lake, with a population of 800, is a town at historical mile 635 in the Alaska Highway in the southeastern Yukon close to the British Columbia border and offers many ways to enjoy the outdoors. Watson Lake is home to the Sign Post Forest, the Northern Lights Space and Science Centre and the gateway to the history and breathtaking scenery of Yukon.
Watson Lake is the key transportation, communication and distribution centre for mining and logging in the southern Yukon and Northern British Columbia. It is also a major service area for tourism.
The Department of Health and Social Services, Insured Health and Hearing Services is currently looking for qualified locum physicians to provide rotational services (2 week rotations or longer are available) to provide medical care to the residents of Watson Lake and Northern British Columbia.
It is anticipated that the newly constructed Watson Lake Hospital will open its doors in the Summer of 2013 which will include a relocated medical clinic from the community to the hospital.
Position Title
Rural Locum Family Practice - General Practitioner
Position OverviewTo support physician services in the rural community of Watson Lake and surrounding areas. Rural clinic practice, on-call obligations and hospital in-patients.
Essential Qualifications
Candidates must hold certification from the College of Family Physicians of Canada (CFPC) and be eligible for a license to practice family medicine in Yukon, as well as be eligible for hospital privileges.
Currency of Practice
Candidates must be able to demonstrat their currency of practice in an ER setting within the last 2 years.
Ideal candidates will be certified in the following:
- Advanced Trauma Life Support (ATLS)
- Advanced Cardiac Life Support (ACLS)
Ideal candidates should have the following certifcation in anticipation of the occassional delivery that does occur in the community:
- Advances in Labour and Risk Management (ALARM)/Advanced Life Support in Obestetrics (ALSO)
- Neonatal Resusciation Program (NRP)
- Neonatal Advanced Life Support (NALS)
For more information on this position please contact:
Lorraine Nixon,
Parhelion Medical Services Inc.
Phone: (867) 536-2565
Email: firstname.lastname@example.com
You must hold a valid license from the Yukon Medical Council (YMC) to work as a physician in Yukon.


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Member Favorites: 0
Natalia (ナターリア)Age: 14
Height: 155 cm
Weight: 43 kg
Birthday: June 29
Blood type: A
Handedness: Right
Hobbies: Belly Dancing
Born and raised in Rio de Janeiro, Natalia is fascinated by Japanese culture and entertainment. She also has an interest in traditional Arabic dance. She speaks Japanese in an awkward, non-fluent manner and views the Middle East as a haven, like in Aladdin. She is a skilled belly dancer and landed the titular role in the Voyage of the Black Rose Princess event in April 2014.
In the tie in Cinderella Girls Theater skits, Natalia is an exciting girl with a lack of common sense. She loves sushi and bananas, but her attempt at combining them both ended with predictable results. When she packs her bags for an overseas event, she puts her wedding dress costume with flowers and an entire box of sushi in her suitcase. They both rot while on the journey and stink up the airport. She believes that three people can be married and has picked up on bad habits of typical idol fans.
Natalia seems to limited knowledge about Japan, as she had to learn about the nation's New Year festivities, but does know of the shishimai and likes its dance. She normally spends New Year's in Rio, watching the fireworks. Natalia also finds it easier to play heroic roles than evil roles and is absolutely terrified when Yao Fueifuei is attacked by pigeons.
(Source: iM@S Wiki)
Voice ActorsNo voice actors have been added to this character. Help improve our database by searching for a voice actor, and adding this character to their roles here.


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A New Jersey family won't have trouble remembering three generations of birthdays.
A newborn, his mother and grandmother were all born on Nov. 19.
Grandmother Clara Gregory said she had a feeling her grandson was going to be born on Nov. 19, even though the baby wasn't due until Christmas. Theresa Dunn gave birth to Micah Lee Dunn at a Princeton hospital Sunday afternoon.
Dunn, of Lawrence, was admitted to the hospital Thursday night and doctors attempted to induce labour. Dunn said her husband kept saying the baby would be born on her and her mother's birthday.
Ghana News Headlines
For latest news in Ghana, visit Graphic Online news headlines page Ghana news page
"I finally came to the realization Saturday night that he could really be born on our birthday," she told NJ.com.
Dunn said she was previously diagnosed with pre-eclampsia, which causes high blood pressure in pregnant women. She said doctors were hoping to get closer to her expected due date before inducing labour.
REGISTER: Graphic Business Stanbic Bank Breakfast Meeting
Micah is several weeks early but is "doing amazing," Dunn said.
Dunn turned 31 on Sunday and her mother celebrated her 67th birthday.
Credit: AP/NJ Advance Media


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We're often asked the question: What's the difference between Grain-fed Beef and Grass-fed Beef? We've highlighted a few examples – and one key similarity – below:
Grain-fed Beef
Grass-fed Beef
So, Which Beef is Best?
It's a fact: Omaha Steaks has been selling grain-fed beef for nearly 100 years. Simply put, we wouldn't be successful today if it were not the best way to guarantee you the highest quality and best-tasting steaks on Earth. But when it comes to beef, more is more! So, by adding lean, nutrient-rich, grass-fed beef to our wide array of products, we're bringing opportunity to experience both varieties of high-quality beef so you can find your own favorite steak.
Grass-Fed Beef
Golden Plains 100% grass-fed beef is raised on a forage diet, creating an earthy depth of flavor and a naturally nutrient-rich food. Find all your favorite grass-fed steaks here, along with burgers and steak tips.


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DiscoverThinking Sideways PodcastSo long and thanks for all the f*cking fish
So long and thanks for all the f*cking fish
Update: 2018-08-304
This is the last episode of TSP and we wanted to have some fun with it. So here are the final bloopers from this years episodes. Oh, and there is a lot of swearing.
In Channel
In the early 1970s Tatunca Nara, last Chieftain of the Ugha Mongulala, revealed the existence of his tribe's greatest secret—the vast city of Akakor, hidden deep in the Amazon jungle. Several have died trying to find the lost city, but no Westerner has yet laid eyes on it. Why could that be?
Down the Rabbit Hole: The Sunken City of Akakor
In a change of pace this episode doesn't feature a mystery; instead it features the team talking about SE Asia. Steve recently returned from a trip there and Team Sideways took the chance to discuss some of the more memorable things from his travels.
Down the Rabbit Hole: Steve's Vietnam Excursion
For decades reports of a mysterious cryptid that drank the blood of goats have been circling the globe. Originating in the equatorial region of the Americas stories are now coming in from all across the globe. What is this strange creature, what does it want with our goats, and why does it insist on smoking that cigar?
El Chupacabra!
Anna was 5 years old when she disappeared on a rainy day while playing near the creek behind her house. Though it seems she could have just fallen in and been washed away, divorced parents and stories from her two older brothers seem to suggest something more sinister happened.
The disappearance of little Anna Waters
People keep finding bodies that have been burned to ash while everything around them is left untouched by the flame. Some claim these are cases of spontaneous human combustion, others say something else is going on. Who is right and what's the deal?
Is spontaneous human combustion real?
After attending mass and delivering gifts, Larry Griffin started his normal postal route at noon on Christmas Day, 1929. Despite having attended dinner at two homes and being a guest at many others, no one knows where Larry ended up that night, or any other night since.
The Missing Postman of Stradbally
In 1920 a man living in Washington state claimed to be the only survivor of the famed Battle of the Little Big Horn. Was Frank Finkel there or was he just another one of the many attention seekers who hoped to attach themselves to the story?
Did Frank Finkel survive the Battle of the Little Bighorn?
Down the Rabbit Hole, a sneak peak at the bonus content available on Stitcher Premium-Daniel Burack was on his boat, the Witchcraft, just offshore from Miami Beach, when he radioed the Coast Guard asking for a tow because of boat trouble. When the Coast Guard arrived 19 minutes later the boat and crew had vanished without a trace.
DTR-The Witchcraft
All American Ronald Tammen disappeared without a trace from his dorm room on an abnormally cold night on April, 1953 after finding a dead fish in his bed. Was the fish an unrelated, harmless frat prank? Or did something very sinister happen to Ron that night?
Disappearance of Ronald Tammen?
United States


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Giant Sea Scorpions
Eurypterids are members of an extinct order of arthropods that lived approximately 505 to 245 million years ago. Frequently referred to as giant scorpions, most eurypterids were small, although Pterygotus buffaloenis, a species from the Silurian period, was the largest arthropod ever known, reaching a length of about 10 ft (3 m). Living in brackish waters, some were predators, while others were probably scavengers. Eurypterids were similar in body plan to what modern sea creature?


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PORTLAND, Ore. –A federal court in Oregon has become the latest battleground over the care of chimpanzees and other animals at a Texas animal sanctuary now under new management.
A lawsuit filed Monday in U.S. District Court in Eugene claims that two chimpanzees, 12 gibbons and a longhorn steer transferred from Primarily Primates Inc. in San Antonio should remain in the care of other animal sanctuaries in Oregon, South Carolina and New Mexico.
The two chimpanzees, named Emma and Jackson, are currently living at Chimps Inc., a nonprofit private sanctuary in Bend, while the dozen gibbons are living at the International Primate Protection League sanctuary in South Carolina. The steer is being kept by Marguerite Gordon, a landowner who lives in New Mexico and offers refuge for animals, according to the complaint.
The case appears to have pitted various animal rights advocates against each other over the quality of care for animals discarded by researchers, owners and even zoos.
Eric Turton, an attorney for Primarily Primates in Texas, called the sanctuary near San Antonio a "retirement home for animals."
But Bruce Wagman, a San Francisco attorney who filed the lawsuit, said it was an example of "institutional hoarding," and claimed the Texas facility simply cannot effectively manage hundreds of animals its care, including more than 60 chimps.
"That facility can never come back up to speed," Wagman said Monday.
Turton said, however, that the Texas facility founded in 1978 has been unfairly attacked recently by animal rights activists who have made allegations dismissed by the courts in Texas.
In April, a Texas judge ended a legal battle over control of Primarily Primates after the Texas attorney general's office seized the roughly 75-acre sanctuary last October and appointed a receiver to manage it while allegations of misspent donations and substandard conditions were investigated.
"There was zero misuse of anything," Turton said. "Not one penny. It's never the findings of the court, it's always just 'allegations.' This is just ridiculous."
The judge ordered management of the Texas facility turned over to Priscilla Feral, who runs the global animals rights group Friends of Animals, based in Darien, Conn.
"They vindicated the place and dropped all the charges and we arranged a settlement," Feral said Monday, adding her advocacy group has a "spotless record" for animal care for over 50 years.
Friends of Animals is merging with Primarily Primates, taking over administrative duties and restructuring its management.
The Texas attorney general's investigation grew out of a complaint about the care of some retired research chimpanzees transferred from Ohio State University last year. Animal rights activists were concerned that an older chimp named Kermit might have suffocated while sedated during transfer, but a necropsy showed he died of a heart attack associated with pre-existing heart disease.
Last year, a court dismissed a lawsuit by People for the Ethical Treatment of Animals charging conditions were substandard at the Texas sanctuary.


text: This was the only way I was willing to pose for a picture, laying flat on the ground hiding my post baby belly from view. I don't mind having one if it means I get to keep these three though. This is kind kind of my sweet spot, surrounded by my darlings.


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Note: This is the 2013–2014 edition of the eCalendar. Update the year in your browser's URL bar for the most recent version of this page, or click here to jump to the newest eCalendar.
Communication Studies : Introduction to feminist studies of the media. Impact of feminist and queer theory on media studies; current issues about gender in the media. Emphasis will be placed on critical analysis of media representations of gender in relation to other social differences, such as race, class and sexuality.
Terms: Winter 2014
Instructors: Cheryl Thompson (Winter)


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Delhi, Haryana, Himachal Pradesh, Jammu and Kashmir, Punjab, Uttaranchal, Uttar Pradesh
Kerala, Karnataka, Tamil Nadu, Andhra Pradesh, Telangana
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Is field assistance available for franchisee ? Yes
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Do you have a standard franchise agreement? Yes
How long is the franchise term for? Lifetime
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Magnetization of ferromagnetic materials in geomagnetic field by mechanical strain - Prinicple of metal magnetic memory testing and diagnostic techniqueWei-Chang Zhong
Nanjing Gas Turbine Research Institute, 47 Northern Central Road,
Nanjiing, 210037, People's Republic of China
According to Faraday's law on electromagnetic induction, this paper proves that at the mechanical strain of ferromagnetic materials in the geomagnetic field there will appear induced electromotive force, induced electric current and induced magnetic field in the materials to magnetize themselves, and only at the unsymmetrical strain the two opposite magnetizing effects can not be all offset against each other, further along with the increase of the strain cycle index a considerable scattering magnetic field strength will be accumulated out for non-destructive testing and technical diagnostics.
In October 1999 Professor A. A. Doubov from Russia came to China to participate The Chinese Society for Non-Destructive Testing 7th Conference on NDT and International Research Symposium, and he introduced a new method of NDT and technical diagnosis - metal magnetic memory technique [1], to which great interest and profound attention were given rise. Not long after in China a relevant instrument was developed and experimental investigation was carried on, and a gratifying primary result has been obtained [2].
Professor Doubov in his article [1] puts forward only in a general way that this method is based on magneto- mechanical effect, but not explains its mechanism - Why the ferromagnetic materials will be spontaneously magnetized in the geomagnetic field ? The author thinks that only this problem is answered first, then this new technique in the 21 century can be fully recognized, grasped, extended and applied.Keywords: Metal magnetic memory, Elastic-plastic strain, Ferromagnetic materials, Spontaneous magnetization.
At the end of the 70's and the beginning of the 80's of the last century the author met a series of spontaneous magnetization phenomena in production practice - some parts made from ferromagnetic materials primarily don't show magnetism, but the parts themselves and cutting tools are intensely magnetized after cutting process, and some parts and components of a machine, which originally don't have magnetism, show magnetism after a period of time of operation [3]. The author names the former "magnetization by machining" and the latter "magnetization through operation". For removing the harmful effects caused by these spontaneous magnetization, through preliminary analysis the author believes that there are 9 probable reasons causing spontaneous magnetization: the effect of geomagnetic induction, the effect of directional magnetization, the effect of thermoelectricity by cutting, the effect of magnetostriction, the transformation of stress-structure, the thermal effect of cutting, the effect of vibrational orientation and some other accidental factors [4].
Obviously the magneto- mechanical effect, which is the basis of the metal magnetic memory method should belong to the effect of geomagnetic induction in the magnetization through operation, but a further concrete analysis must be made.
Every body knows that generally at a site of the Earth the geomagnetic field strength is uniform and weak, except in the particular spots, where ferromagnetic deposit or ferromagnetic articles locate. So a common part or an assembly of a machine can be considered in a uniform magnetic field.
Suppose the crossed sectional area of a work piece made by ferromagnetic material, perpendicular to the geomagnetic field He (A/m) is S. By the action of a directional stress through a period of time Dt, strain takes place at S, and S becomes S+DS. So the magnetic flux F through the transverse section of the work piece also from BS changes into B ( S+DS ), here B is the magnetic induction ( Tesla ), that is, the increment of the magnetic flux DF is [5]:
|DF =BDS=mrmoHeDS
|( 1 )
here,mr is the relative magnetic permeability for the material, it is a pure number.
mois the magnetic permeability for vacuum, and equal to 4p´10-7 H/m
According to Faraday's Law on electromagnetic induction, the induced electromotive force E is [5].
|E = -DF/Dt = -mrmoHeDS/ Dt
|( 2 )
Under the action of E, an induced electric current i must appear on this cross section. Thereby, the induced magnetic field H is excited out, the work piece being magnetized - the residual magnetization Mr and residual magnetic induction Br appear [5], that is, the work pieces made by ferromagnetic materials under strain in the geomagnetic field naturally produce the phenomenon of spontaneous magnetization.
It is known from the Strength of Materials [6] that the characteristics of stress s- strain e of plastic materials such as low carbon steel under extension and compression are alike in the elastic limits, but different in the plastic range ( Fig.1.a ). And the extension diagram and compression diagram for the brittle materials such as cast iron are very much different from each other ( Fig.1.b ).
Fig 1: Stress-strain diagram of materials extended and compressed.
a. Low carbon steel b. Cast iron
When the materials, whose extension diagram and compression diagram coincide with each other are acted by a pure alternative stress, because the yielded extensional strain equals to compressional strain, DS, DF, E, i and H in positive and negative two directions are all the same, that is, the magnetic field strength induced by the strain offset each other. So in this condition there not appears spontaneous magnetization. As the same principle, if an arbitrary material mentioned above is acted by an alternative stress plus a directional stress, and the yielded positive, negative strain are all in the elastic limits of extension ( or compression ), in this condition there also not appears spontaneous magnetization. Only when a pure alternative stress is acting upon a material, whose extension diagram differs from its compression diagram, and when an alternative stress and a directional stress are acting in concert upon a common material and an unsymmetrical (that is unequal) elastic-plastic strain is yielded, those materials will just produce spontaneous magnetization.
The magnetization-demagnetization character of a ferromagnetic material is demonstrated by its magnetic hysteresis loop (Fig. 2. The original magnetizing stage under a weak field strength is shown in the right bottom corner). The semi-branch of ascension in type a, b, c, d is magnetizing curve, and the semi-branch of descension in type d, e, f, a is the corresponding demagnetizing curve. And in the original magnetization it is alike (see the detail drawing in the right bottom corner of Fig.2).
|Fig 2: The magnetizing-demagnetizing process of the ferromagnetic materials - magnetic hysteresis loop.
From electromagnetics [5] we know :
|H ¥ i ¥ E
According to expression (2) there is
|H ¥DS/Dt
|Ds = S (2e+e2)»2s e
here,e is the linear strain of the material, whose value is small, and is a proportional constant.
|\ H µe
Because of the unequal elastic-plastic strain of ferromagnetic material in the geomagnetic field, the induced magnetic induction first ascends along the curve OP of the small picture in the right bottom corner of Fig.2, and descends along the curve PR as shown by the curve oa and ab in the Fig.3, and then it will ascend along curves type abcd, and descend along curves type defa in Fig.2. Due to the detour and saturation characters of magnetic hysteresis loop, after every cycle of magnetization-demagnetization, the magnitude of B will increase cycle by cycle, at last approaches to a fixed maximum Br, as shown in Fig.3.
The theoretical deduction is identical with the Russian research result (Fig.4) given in reference [1], only the abscissa of the former is |e |,the latter is Ds and the ordinate of the former is |B|, and the latter is DB : the shapes and tendency of these two groups of curves are all the same.
|Fig 3: The spontaneous magnetization process of ferromagnetic materials.
Fig 4: The diagram of magneto-elasticity phenomenon development
DB - residual induction change
Ds- cyclic load change
H e - externald magnetic field
The author gratefully acknowledges the financial support of this work by The National Natural Science Foundation of China.
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Schlegel DJ, Tanne D, Demchuk AM, Levine SR, Kasner SE, for the Multicenter rt-PA Stroke Survey Group. Prediction of Hospital Disposition After Thrombolysis for Acute Ischemic Stroke Using the National Institutes of Health Stroke Scale. Arch Neurol. 2004;61(7):1061–1064. doi:10.1001/archneur.61.7.1061
© 2019
Copyright 2004 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2004
Early determination of discharge destination after acute stroke may promote earlier rehabilitation and reduce costs by shortening the duration of hospitalization.
To determine whether the National Institutes of Health Stroke Scale (NIHSS) score predicts disposition in stroke patients treated with thrombolysis.
Cohort study.
Academic and community hospitals from 3 countries.
Five hundred forty-six patients with acute ischemic stroke treated with recombinant tissue plasminogen activator (rt-PA).
Medical records were reviewed for demographic information, vascular risk factors, location of stroke, initial NIHSS score, acute hospital disposition, and complications of symptomatic or asymptomatic intracerebral hemorrhage (ICH).
Main Outcome Measure
Discharge destination to home, acute rehabilitation, or nursing facility.
In multinomial regression analysis, increasing NIHSS score was a robust and independent predictor of discharge to rehabilitation or nursing facilities, roughly doubling for each 5-point increment. Patients who developed symptomatic ICH were never discharged to home, but asymptomatic ICH had no significant independent effect on disposition.
Stroke severity as determined by the admission NIHSS score is the major independent predictor of disposition after hospitalization and treatment with rt-PA for acute stroke in a broad-based population. However, symptomatic ICH after rt-PA is a catastrophic event that may preclude discharge to home.
After acute stroke, decisions must be made regarding the next level of care, such as transfer to rehabilitation or a nursing facility. Hospitalization may be prolonged because of the need for comprehensive assessments by physical, occupational, and speech therapists, as well as approvals by patients or families, insurers, and rehabilitation sites before discharge. However, extended hospitalization increases the risk of nosocomial infections, prolongs immobilization, postpones recovery, and increases costs. Reducing the length of stay could improve patient outcome by accelerating access to aggressive rehabilitation, benefit hospitals by having a bed available sooner, and enable third-party payers to pay for fewer days of hospital care. Streamlining care by early identification of stroke patients in need of rehabilitation or long-term nursing facility care may thus promote more efficient use of resources and improve outcomes.
The National Institutes of Health Stroke Scale (NIHSS) is a quantitative measure of stroke-related neurological deficit that has proven intrarater and interrater reliability and has predictive validity for long-term stroke outcome.1-3 It includes items to assess level of consciousness, gaze, visual fields, facial palsy, motor strength, ataxia, sensation, language, dysarthria, and extinction or inattention. It is widely used, easy to learn, and can be performed rapidly on admission. Prior studies have found that the NIHSS score could be used to predict disposition. The Northern Manhattan Stroke Study4 described a predominantly Hispanic population in a specific geographic area, and Schlegel et al5 described a single hospital–based cohort. However, these studies have limited generalizability, and neither sought to determine if the NIHSS was reliable in patients treated with recombinant tissue plasminogen activator (rt-PA). Furthermore, neither examined the effect of intracerebral hemorrhage (ICH) after thrombolytic therapy on disposition. The present study draws on information about patients treated in community and academic hospitals and across several different countries. We hypothesized that in this diverse population the NIHSS score could predict immediate hospital disposition for patients treated with rt-PA and that the complication of ICH would increase the likelihood of discharge to rehabilitation or a nursing facility.
Individual patient data were collected, in part prospectively and in part retrospectively, from 1205 patients with ischemic stroke.6 All were treated with intravenous rt-PA within 3 hours of stroke onset according to the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial protocol.7 Fifty-six stroke centers were invited to participate; 2 declined. The participating centers and groups included the Standard Treatment With Alteplase to Reverse Stroke study; the Stroke Treatment in the Community study; Cologne, Germany; 2 centers in Canada; and 49 centers in the United States. From this cohort, patients were excluded if data about disposition or initial NIHSS score were missing. Patients were also excluded if they died during hospitalization or left against medical advice, because these outcomes make discharge planning irrelevant.
At each center, investigators reviewed the medical records of each patient treated with rt-PA after publication of the results of the NINDS rt-PA Stroke Trial (December 14, 1995)7 until December 31, 1998. A standard data collection instrument with written instructions was used to collect information about age, sex, race, history of hypertension, diabetes mellitus, atrial fibrillation, prior stroke, smoking, alcohol abuse, location of stroke (anterior or posterior circulation territory), and ICH (symptomatic or asymptomatic). Data on the site of disposition after hospitalization were also obtained. Admission NIHSS scores were extracted from the medical record8 unless specifically documented. Data on socioeconomic status, prior living situation, and insurance were not available. Computed tomographic scans of the head were reviewed by a qualified investigator for the presence of ischemic stroke and ICH. Clinically, ICH was categorized as symptomatic vs asymptomatic, in accord with the NINDS rt-PA Stroke Trial.7
Univariate analyses were performed to test for associations between disposition site and each of the individual patient characteristics. Continuous variables were tested using analysis of variance, and categorical variables were evaluated using χ2 or Fisher exact test. All tests were 2-sided. Variables associated with disposition in univariate analysis at P<.05 were considered for multivariate analysis. Multinomial (polytomous) logistic regression analysis was performed to identify the variables associated with disposition to rehabilitation or nursing facilities, using discharge to home as the reference. The NIHSS was analyzed as an indicator categorical variable in 5-point intervals. In addition, for comparison with prior studies,4,5 we analyzed the NIHSS scores categorized as 5 or less, 6 to 15, and greater than 15. Regression analysis was performed to assess the importance of each potential variable as it affects the other assessments in the model. In the final model, associations were considered significant at P<.05. Primary results are expressed in terms of relative risk (RR). All analyses were performed using Stata version 7.0 (Stata Corp, College Station, Tex).
The complete cohort comprised 1205 patients. Of these, 546 had complete data on baseline NIHSS score and disposition and therefore served as the primary cohort for this study. The population that was excluded because of missing information on disposition did not differ from the primary population by age or sex, but had more white participants (85.0% vs 72.0%, P<.001). The population that was excluded because of missing information on NIHSS score did not differ from the primary population by sex, but was slightly older (mean ± SD age, 69.2 ± 13.2 vs 66.2 ± 13.4 years; P = .006) and more often white (93.8% vs 75.4%, P<.001).
The mean ± SD age of the cohort used in the analysis was 65.6 ± 13.9 years (range, 24-92 years), and 56.3% were men. Most patients (72.0%) were white, 22.0% were black, and 6.0% had another racial identity. The baseline NIHSS score was 5 or less in 9.9% of patients, 6 to 10 in 28.4%, 11 to 15 in 24.0%, 16 to 20 in 24.2%, and greater than 20 in 13.6%. Similar numbers were discharged to home (44.0%) or rehabilitation (41.8%), and far fewer went to a nursing facility (14.3%). Table 1 summarizes the discharge destination for each degree of stroke severity.
Multinomial regression analysis was performed, retaining age, sex, and race in the model. Age, sex, and race did not significantly affect the likelihood of discharge to rehabilitation. However, increasing age was an independent predictor of nursing home placement (RR, 1.09; 95% confidence interval [CI], 1.06-1.12 per year; P<.001). Men were about half as likely as women to be discharged to a nursing facility (RR, 0.57; 95% CI, 0.32-1.02; P = .06), although this was of marginal significance. Whites were less likely than nonwhites to be discharged to nursing homes (RR, 0.50; 95% CI, 0.26-0.94; P = .03).
Baseline NIHSS score was a robust independent predictor of discharge to rehabilitation or nursing home, roughly doubling for each 5-point increment, as shown in Table 2. In addition, for comparison with prior studies,4,5 we analyzed the NIHSS scores categorized as 5 or less, 6 to 15, and greater than 15. Compared with those with the least severe strokes, patients with NIHSS scores of 6 to 15 were significantly more likely to go to rehabilitation (RR, 2.13; 95% CI, 1.06-4.31; P = .03) but not nursing homes (RR, 3.39; 95% CI, 0.74-15.57; P = .12). Patients with NIHSS scores greater than 15 were significantly more likely to go to rehabilitation (RR, 6.15; 95% CI, 2.94-12.83; P<.001) and particularly likely to require a nursing home (RR, 19.36; 95% CI, 4.23-88.61; P<.001). All other baseline variables were not independently associated with disposition.
For the 22 patients who survived a symptomatic ICH, none were discharged to home. In contrast, asymptomatic ICH was not associated with discharge destination in multinomial regression analysis adjusted for age, sex, race, and baseline NIHSS score.
This study demonstrates that stroke severity, as measured by the NIHSS, is the predominant predictor of discharge destination after initial hospitalization for patients with acute ischemic stroke treated with intravenous rt-PA. As expected, increasing severity is associated with greater likelihood of discharge to rehabilitation or nursing facilities. This result is logical and consistent with reports from 2 prior studies: the community-based Northern Manhattan Stroke Study cohort4 (which comprised a mostly Hispanic population in a specific geographic area) and a single hospital–based cohort study.5 These 2 prior studies and the present investigation concur that severe stroke symptoms (NIHSS score, >13 to 15) at the time of hospital admission is strongly predictive of nursing facility disposition. The disposition of patients who have had moderate strokes (NIHSS score, 6-15) is less well-defined in these studies, possibly reflecting a graded effect within this range or uncertainty with regard to prognosis in this category. We found that NIHSS scores of 6 to 10 were associated with discharge to home, while NIHSS scores of 11 to 15 were significantly associated with discharge to rehabilitation or nursing home placement. Posthospitalization disposition for moderate strokes may depend on several factors, including responsiveness to rt-PA, socioeconomic status, and support at home after acute hospitalization.
The distribution of stroke severity differed among the prior and present studies. In both prior studies,4,5 more than half of the patients had mild strokes (NIHSS score, ≤5). The present study's small proportion (9.9%) of these milder strokes probably reflects a treatment-related bias. Because of the risk of complications inherent in the use of rt-PA, clinicians likely reserve this therapy for patients with more potentially disabling strokes. Therefore, the specific inclusion of patients treated with intravenous rt-PA in the present study increases the relative proportion of those having moderate or severe strokes and the number who ultimately require rehabilitation or nursing facility placement after acute hospitalization.
The relationship between baseline NIHSS score and disposition to rehabilitation or nursing facility was less robust than in prior studies,4,5 particularly among patients with moderate strokes (NIHSS score, 6-15). In the present study, the likelihood of discharge to home was higher, and the variability of the dispositions relative to baseline NIHSS score was greater. Both effects are most likely related to the administration of intravenous rt-PA to all patients, and this is the first report, to our knowledge, on the use of the NIHSS score as a predictor of hospital disposition in a population composed of such patients. Many patients may have improved from their initial NIHSS score because of this treatment and were more likely to go home or less likely to go to a nursing facility, as previously reported in an economic analysis of the pivotal NINDS rt-PA Stroke Study.9 Even among patients with the most severe strokes (NIHSS score, >20), 18.9% were able to go home directly from the hospital. The greater variability may also reflect the complication of symptomatic ICH after rt-PA in some patients, which greatly reduced the chances of discharge to home.
Intracerebral hemorrhage is a known complication of treatment with rt-PA7 and was expected to have an effect on disposition. Our findings were consistent with clinical expectations. Symptomatic ICH was a catastrophic event, resulting in discharge to rehabilitation or a nursing facility, never directly to home. In contrast, asymptomatic ICH did not significantly affect disposition, after adjustment for other baseline factors. Because asymptomatic ICH is by definition clinically silent, it seems logical that this event had no discernible effect on disposition after acute care.
In addition to stroke severity, we found that increasing age was a predictor of nursing home use, but not rehabilitation placement. The Northern Manhattan Stroke Study4 reported a similar relationship, with age older than 65 years increasing the probability of discharge to a nursing facility 2.5-fold. The effect of age is not surprising, and it is likely that psychosocial and clinical factors, not apparent in our data, are responsible for the increased requirement for nursing facilities with increasing age. Furthermore, older patients may be less able to care for themselves and may more commonly require long-term placement. This is supported by the fact that 90% of nursing facility residents are older than 65 years.10 Sex was a marginally significant independent predictor of nursing home use. Women comprise 72% of the nursing facility population in the United States and in other nations.10,11 Finally, nonwhite patients appeared more likely than whites to go to nursing homes. The cause of this possible racial disparity is unknown and may relate to differential socioeconomic status, but because race did not significantly affect discharge to rehabilitation, this finding may be more indicative of insufficient resources for care and recovery efforts at home in this population. Overall, these issues related to sex and race must be considered with great caution, as the population studied was drawn from multiple health systems, countries, and cultures, which could have contributed to these findings.
Our study is limited by the exclusion of 659 of the potential cohort of 1205 patients. The excluded population was mostly white, probably because data on disposition and NIHSS score were missing mainly from sites in Europe and Canada. Excluded patients also tended to be slightly older than the study population. The effect of these excluded patients is unclear, but may limit the generalizability of our findings. However, the present study population is diverse, drawing on patients from several different geographic locations in the Western hemisphere, and may be more generalizable than the 2 prior studies.4,5 Our study also lacks a detailed assessment of other factors that may affect posthospitalization discharge destination, such as socioeconomic status, prior living situation, and availability of support at home, but it is unlikely that these factors would have been associated with baseline stroke severity and therefore are unlikely to have been major confounders of our primary analysis. In contrast, cognitive and visual impairments could have been associated with severity and disposition, but these details were not systematically collected in this study.
This study found that increasing stroke severity, particularly with NIHSS scores greater than 10, increased the likelihood of discharge to rehabilitation or nursing homes instead of to home. This multinational community and academic center–based study reinforces the usefulness of the NIHSS score as a predictor of disposition after stroke. The NIHSS score can predict discharge disposition when thrombolysis is used, although possibly with less precision than in patients not given this treatment. Furthermore, symptomatic ICH is a devastating complication that significantly minimizes the possibility of discharge to home, while asymptomatic ICH has no effect on disposition.
Future studies should search for other variables, rapidly available at admission like the NIHSS score, that could improve prediction of disposition after acute care. In addition, simulations or decision analyses could be performed to assess whether cost savings may be realized by using the NIHSS score to initiate early planning for disposition immediately on admission.
Correspondence: Scott E. Kasner, MD, Comprehensive Stroke Center, Department of Neurology, University of Pennsylvania Medical Center, 3400 Spruce St, 3W Gates Building, Philadelphia, PA 19104 (email@example.com).
Accepted for publication February 3, 2004.
Author contributions: Study concept and design (Drs Schlegel, Tanne, and Kasner); acquisition of data (Drs Tanne, Demchuk, Levine, and Kasner); analysis and interpretation of data (Drs Tanne, Levine, and Kasner); drafting of the manuscript (Drs Schlegel, Tanne, and Kasner); critical revision of the manuscript for important intellectual content (Drs Schlegel, Tanne, Demchuk, Levine, and Kasner); statistical expertise (Dr Kasner); obtained funding (Drs Schlegel, Demchuk, Levine, and Kasner); administrative, technical, and material support (Drs Schlegel, Tanne, Levine, and Kasner); study supervision (Drs Levine and Kasner).
This study was supported by grants R25 MH58818 (Dr Schlegel), NS30896, NS23393, and K24 NS043992 (Dr Levine), and K23 NS02147 (Dr Kasner) from the National Institutes of Health, Bethesda, Md; and the Canadian Institutes of Health Research, Ottawa, Ontario, and the Alberta Heritage Foundation for Medical Research, Edmonton (Dr Demchuk).
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