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Feb. 8, 2019 – Women and Children First!
Thomas J. Madejski, MD
MSSNY President
MSSNY eNews
February 8, 2019
Volume 22 Number 6
I need your help. I need you to join me in Albany March 6th to meet with our elected officials about the health and safety of our patients Click Here to Register! New York Governor Andrew Cuomo @NYGovCuomo has proposed his budget for New York State and the NYS legislature has started budget hearings on a multitude of issues affecting the health and welfare of our patients and our profession. These issues are currently under discussion and MSSNY has provided testimony on a number of items of concern. I've indicated to you in some of my previous communications the importance of building relationships with our elected officials in the markedly changed legislative environment during the new session. Our representatives and their staff need to understand the potential effects of their proposals on our patients and families and their constituents.
Our excellent MSSNY legislative staff does a great job in getting information about our greatest concerns to our elected officials. The most critical part of advancing our goals for the betterment of public health and the proper practice of medicine is direct interaction with your personal representatives. March 6th is our best opportunity to demonstrate our care of, and care about, our patients. We have an opportunity to weigh in on reducing maternal mortality, advocating for the care of women and their infants, and to reduce the incidence of exposure to psychoactive substances to our children and young adults. Let me assure you that the situation is fluid, and your individual effort can make a difference in the health of your patients, your satisfaction in your practice, and the health of our communities.
Please sign up to join me in Albany March 6th. Your patients, and our profession, are counting on us.
P.S. I'd be honored if you would also join me in Albany for our MSSNY Council meeting March 5th. Let me know if you're coming, and any other thoughts you have.
You can follow me on twitter@tommadejski
lux, veritas, virtus– legis plenitudo charitas
Comments? firstname.lastname@example.com; @mssnytweet; @TomMadejski
Thomas J. Madejski, MD
MSSNY President
|Capital Update
MSSNY Delivers Testimony Highlighting Positives and Negatives of New York State Budget Proposal
MSSNY Senior Vice President and Chief Legislative Counsel Moe Auster delivered testimony this week to a joint Senate-Assembly Committee regarding the healthcare portion of Governor Cuomo's proposed 2019-20 budget. MSSNY's testimony applauded the several positive measures included within the budget that MSSNY believes will help physicians provide better care to New Yorkers, while also highlighting a list of issues deemed problematic to the medical community and their patients.
To view MSSNY's testimony and the several questions from legislators, Click here. To read MSSNY's written testimony, Click here.
Of note, MSSNY's testimony noted its support for NYS Executive Budget measures that would: increase the tobacco/e-cigarette purchase age to 21, provide better coverage of care for mental illness and substance abuse treatment, examine ways to prevent maternal mortality, provide stronger regulation of pharmaceutical benefit managers (PBMs) and extend the Excess Medical Malpractice Insurance program to assist physicians in affording extraordinarily expensive but needed liability insurance coverage.
MSSNY's testimony also expressed strong concerns with proposals that would legalize the non-medicinal use of marijuana, revoking from doctors the final say in coverage for prescribing medications to their Medicaid insured patients and expansion of the types of practitioners who could treat Workers Compensation patients without addressing the numerous factors that are deterring physician participation in this program. He particularly highlighted the physician community's strong concerns with a proposal that would significantly cut (an estimate $80 per patient cut) the patient deductible payments that Medicaid makes to physicians who treat patients dually eligible for Medicare and Medicaid.
Mr. Auster answered a variety of questions from the legislative panel, including the physician perspectives on the legalization of non-medicinal marijuana; the regulation of pharmaceutical benefit managers, and perspectives on single payer legislation. (DIVISION OF GOVERNMENTAL AFFAIRS)
Physicians Urged to Oppose Further Dual Eligible Payment Cuts Proposed in State Budget
All physicians are urged to contact their state legislators to urge that they reject a proposal contained in the 2019-20 Executive Budget that would significantly cut the payments that Medicaid makes to physicians to cover the Medicare Part B deductibles of their "dually eligible" patients. You can send a letter in opposition by clicking Here.
You can read MSSNY's memo of opposition to the Legislature Here.
While the exact cut for each physician would depend on the physician's patient mix and services provided, we estimate that the cut would be $80 per patient. That is because the 2019 Medicare Part B deductible is $185, and studies show that on average Medicaid only pays 56% of the Medicare fee schedule in New York.
Given that there are hundreds of thousands of patients in New York who are "dually eligible", for practices that see a large number of dual eligible patients, this will have a profound impact. For example, if a physician's patient mix includes 500 such dual eligible patients, which could certainly be the case for many types of specialty physicians, that amounts to a decrease of over $40,000 per year – funds that could go toward upgrading electronic health records, hiring additional staff to allow for more time with patients, upgrading facilities or other medical equipment. In past years, physicians have had to absorb significant cuts from Medicaid for the care that they provide to their senior and disabled patients covered by both Medicare and Medicaid, making it much harder for these physicians to deliver community-based care. Please urge your legislators know how unfair this cut is. Please urge them to oppose balancing the state
budget on the backs of dedicated community physicians seeking to deliver quality care to their patient.
Medical Liability Reform Bills Introduced in the Assembly
Assemblymembers Robin Schimminger (D-Kenmore) and Peter Abbate (D-Brooklyn) each re-introduced legislation this week aimed at reducing the exorbitant cost of medical liability insurance in New York State, and providing more fairness in the resolution of the cases.
In New York, cumulative medical liability payouts far outpace other states. A recent report by Diederich Healthcare showed that, in 2017, once again New York State had far and away the highest number of cumulative medical liability payouts. Claimants in New York were awarded nearly two times more than the state with the next highest amounts, Pennsylvania, and payments in New York far exceeded states such as California and Florida. Moreover, New York had the dubious distinction of having the highest per capita medical liability payouts in the country, about 500% greater than the State of California, which has enacted meaningful liability reforms.
Assemblyman Schimminger's Medical Liability Reform Act (A.4897) would work to ease the extraordinary liability burden on physicians in New York through the enactment of a number of policy changes, including the following:
- Requiring an affidavit of merit from a NY licensed physician to cut down on the filing of non-meritorious claims;
- Placing a reasonable limit on non-economic damages (there are currently 30 states with some form of a similar cap); and
- Requiring enhanced disclosure of identity of expert witnesses
Assemblyman Abbate's legislation (A.5018) would require a particularized affidavit of merit to function as a comprehensive vetting of medical malpractice claims prior to commencing of a legal action. Additionally, it would require full and complete discovery of expert witnesses in medical liability actions. (AVELLA, AUSTER)
New York State insurance exchange reports record enrollment numbers
NY State of Health's open enrollment period ended on January 31, and at that time enrollment in both the Essential Plan and in Qualified Health Plans had increased over last year. Essential Plan enrollment stood at 790,152, up 6.9% over last year meanwhile 271,873 people had purchased Qualified Health Plans, a 7.4% increase compared to the same point last year. In contrast, enrollment dropped by 3.8% in the 39 states that use the federal marketplace. The Essential Plan provides coverage with no deductible and is either free or costs $20 monthly. A family of four earning up to $50,200 qualify and New York and Minnesota are the only two states to offer this option. According to the Kaiser Family Foundation, the monthly premium for the cheapest individual bronze Qualified Health Plan in NY averages $402 without subsidies and the cheapest gold plan averages $638 per month. NYSOH has stated that 58% of people buying plans qualify for financial assistance. (AVELLA)
Experts Debate New York Health Act
Click here to watch a 2-hour debate of the proposed New York Health Act sponsored by the New York City Bar Association please Click here. Participants in the program included NYS Assembly Health Committee Chair Richard Gottfried, sponsor of the legislation; Eric Linzer, President of the New York Health Plan Association; Bill Hammond, Director of Health Policy for the Empire Center for Public Policy; Dr. Oliver Fein, Chair of the NY-Metro Chapter of Physicians for a National Health Plan; and Ashley Fox, an Assistant Professor at University at Albany. (AUSTER)
Workers Compensation Board Looks at Improvements to the IME Process
This week the initial meeting of the New York Workers' Compensation Board IME Advisory Committee took place. Among the members of the WCB expert panel was MSSNY Past-President Dr. Robert Goldberg. The group was created pursuant to a provision of the comprehensive Workers Compensation legislation enacted in 2017 that called on the WCB to make recommendations for improving the process by which injured workers receive independent medical examinations. In particular, the statute calls upon the Board to develop recommendations "that will ensure fairness, and highest medical quality, while improving methods of combatting fraud". For example, one of the major discussion points for the initial meeting this week was examining data that a small number of practitioners had performed an enormous number of IMEs. The group will be meeting throughout 2019 to develop recommendations for improving the IME process with a report due to the Governor & Legislature by year end. (AUSTER)
MSSNY Fights for Funding to Attract and Retain Physicians in NYS
This week MSSNY staff joined representatives from a variety of other health care advocacy groups (including HANYS, NYACP, CHCANYS, the Center for Health Workforce Studies & the Upstate NY Physician Recruiter Network) in numerous meetings with key legislative and executive staff to support increased efforts to address the shortage of physicians in underserved regions across New York State. In addition, two physicians who are Doctors Across New York (DANY) awardees joined the group and shared their stories about how DANY positively affected their lives and ability to practice in New York. Among the notable issues was the request of legislative support of funding for DANY.
DANY is a state funded program launched in 2008 that aims to train and place physicians in areas of New York State where that specialty is most needed. The goal is to ensure adequate funding, streamline the application process and to remove barriers to application. The group is also hoping for increased funding for the Empire Clinical Research Investigator Program (ECRIP) which allows doctors to spend additional time training in research.
Other priorities for the group include funding for the Diversity in Medicine Scholarship; the expansion of the Take a Look Program, which introduces medical students and residents practicing in NYC to Upstate New York and the opportunities available in medicine; and statutory implementation of required data collection for allied health workers. (HARRING, AVELLA)
Senator Rivera Introduces Legislation to Improve Patient Access to be Treated by the Physician of Their Choice
Senator Gustavo Rivera, Chair of the New York State Senate Health Committee, introduced three bills this week that are strongly supported by MSSNY. The bills in question relate to health insurance networks and the interaction between physicians and insurance companies.
- S3461 would require that health insurers cover services provided by out-of-network (OON) providers. OON coverage is not mandated in New York and while exchange officials have "strongly encouraged" insurers to offer this coverage, many New Yorkers do not have this option available. Additionally, many patients are restricted to limited physician networks that do not provide adequate choice of physician to receive their care.
- S3462 would allow in limited instances independently practicing physicians in New York State to conduct some collective negotiations by creating a system under which the state would closely monitor those negotiations, and approve or disapprove such negotiations from going forward. Many areas of New York are dominated by a small number of insurers and this bill would help even the playing field between physicians and insurers.
- S3463 would provide physicians due process protections when health insurers seek to terminate a physician from its network by failing to renew the physician's contract. Current law prohibits a health insurance company from terminating a physician's contract without a written explanation of the reasons for the proposed contract termination and an opportunity for a hearing by a panel comprised by three persons including a clinical peer in the same or similar specialty. These provisions, however, do not apply to situations involving the non-renewal of physician contracts. This bill would correct that disparity. (AVELLA)
NYS Senate Commitee to Consider Bill Mandating Patient Education for C-Section; Physician Action Urged
Senate Bill 2888/A.318, sponsored by Senator Julia Salazar and Assemblymember Amy Paulin, would require all physicians and other health care providers to provide all maternity patients with written information as to the risks associated with Cesarean section. This measure is before the Senate Women's Issues Committee and has already passed the NY State Assembly. The Medical Society of the State of New York & ACOG are opposed to this measure as it interferes with the physician patient relationship by requiring a written communication to every single pregnant women whom the physician recommends a C-Section. MSSNY & ACOG are concerned that a individual patient may have different risk factors and health needs.
Furthermore, the terminology of the bill is not consistent with the typical medical practice. The Medical Society is also troubled by the proliferation here in New York State, and nationally, calling for legislation requiring educational information that physicians will need to cite that pertains to women's health issues. Nationally, a disproportionate number of these bills apply only to physicians when they are treating pregnant women. Furthermore, states have gagged or coerced physician communications for politicized public health issues.
This measure mandates physicians to provide "a script" that may not comply with the latest medical evidence on Cesarean section. Physicians are urged to contact members of the Senate Women's Issue Committee which are: Senator Julia Salazar, Senator Betty Little, Senator Shelley Mayer, Senator Anna Kaplan, Senator Catherine Young, Senator Jen Metzger, and Senator James Gaughon. They can be reached through the main senate switchboard at (518) 455-2800 or by sending a letter through the MSSNY Grassroots Action Center at this link please Click here. (CLANCY)
NYS Reproductive Health Act; Governor Discusses Aspects of the Law
The New York State Legislature passed the Reproductive Health Act and it was immediately signed into law by Governor Andrew Cuomo as Chapter 1, Laws of 2019. The law amended the public health law by codifying the abortion procedure within New York State's public health law and removing it from the penal law. The same provisions found in Roe v. Wade remain in same. The law creates a statement of purpose and says that an abortion may be performed by a licensed, certified or authorized practitioner acting within their defined scope of practice under Title 8 of the Education Law. Under the new law, an abortion can be performed:
- a) within 24 weeks from the commencement of pregnancy;
- b) at any time, where there is an absence of fetal viability; or
- c) at any time, when necessary to protect the patient's life or health.
This is consistent with what previous Supreme Court decisions have held.
Gov. Andrew Cuomo this past week wrote an op-ed about the law in the NY Times including responding to comments misinterpreting what the law does. His op-ed can be found Here.
MSSNY has a long standing policy that opposes the criminalization of the exercise of clinical judgement in the delivery of medical care. Moving the abortion procedure from the State Penal law to the Public Health Law is consistent with this position. The law does not expand the current scope of practices for health care providers. It does, however, specify that health care practitioners can perform an abortion if it is otherwise enabled by their current scope of practice as defined under the NYS Education Law. Nurse practitioners are allowed to perform a medicated abortion procedure already under their scope of practice. However, nurse practitioners' scope does not include "surgery" and cannot perform a surgical abortion. The American College of Obstetricians and Gynecologists (ACOG) District II and the NYS Academy of Family Physicians (NYAFP) supported this measure. MSSNY will be closely monitoring the implementation of the new law to assure health care practitioners are acting within their scope. (CLANCY)
Measles Outbreak in New York State Continues to Spread Webinars Available at MSSNY CME Website
The measles outbreak in New York State continues to spread with at least 186 confirmed cases as of last week. There have been 124 in Rockland County and 62 cases in Brooklyn with one suspected case currently being monitored. While New York State has a statewide vaccination rate of about 90% for Measles, the communities mainly affected by the current outbreak are only at about 60%. MSSNY conducted a just-in-time Medical Matters webinar entitled "The Continued Public Health Threat of Measles 2018" in December, 2018. This webinar has now been posted to the MSSNY CME website.
Additionally, be sure to watch The Importance of Herd Immunity, another Medical Matters posting that delves into how herd immunity works and why it is integral to the elimination of vaccine-preventable diseases. Please check both of these programs out and keep yourself informed about the ongoing measles outbreak throughout New York State and the country. You can also listen to MSSNY's brief podcast on the Measles, Mumps and Rubella vaccine please Click here. (HOFFMAN, CLANCY)
"What's Your Diagnosis? Psychological First Aid" Interactive CME webinar February 20, 2019 @7:30am – Registration now open
Be sure to register for the next Medical Matters interactive webinar, What's Your Diagnosis? Psychological First Aid. This program will include interactive components for participants. You will be asked to answer questions about a case and discussion will follow. Find out if you're fully prepared to include psychological first aid during an emergency on February 20th at 7:30am.
Registration is open for this program please click Here.
Faculty will be Craig Katz, MD, co-vice chair of MSSNY's Committee on Emergency Preparedness and Disaster/Terrorism Response.
Educational Objectives:
- Describe the basic tenets of psychological first aid (PFA)
- Identify resources to assist patients during and after trauma
- Describe a scenario and review questions and answers
The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Registration Now Open for New Veterans Matters CME Webinars
The Medical Society of the State of New York is proud to announce two NEW Veterans Matters webinars scheduled for February and March 2019. These webinars are: The Special Mental Health Needs of Women Veterans on Thursday, February 28th at 7:30am and Military Culture: Everything Physicians Need to Know About Veterans as Patients on March 14th at 7:30am. Register Here
for The Special Mental Health Needs of Women Veterans, and Register Here.
for Military Culture: Everything Physicians Need to Know About Veterans as Patients.
For more information relating to any of the above articles, please contact the appropriate contributing staff member at the following email addresses:
MSSNY, AMA and Medical Societies Fight to Assure Fair Resolution of Surprise Medical Bills Issue
Led by United States Senator William Cassidy, MD (R-LA), the US Senate has been examining proposals that would address surprise out of network medical bills faced by patients in hospitals, usually the result of being treated by an out of network specialist in the emergency department or other unanticipated care.
Many believe that this is one of the only health care issues in the current Congress that has bipartisan support.
To that end, MSSNY has written to the New York Congressional delegation, urging that any legislation to be considered is consistent with New York's comprehensive law on the subject enacted in 2014 (see MSSNY's letter here: http://www.mssnyenews.org/wp-content/uploads/2019/02/0349_001.pdf). New York's comprehensive law addressing this issue has been hailed as a model for the rest of the country because of the delicate balance it struck among key health care stakeholders (such as physicians, hospitals and health insurers) to protect patients from large "surprise" medical bills, while at the same time being constructed in such a way that it did not adversely affect the ability of hospital emergency departments to have adequate on-call specialty physician care.
In addition, MSSNY has also joined on to a federation of medicine letter to the US Congress initiated by the American Medical Association along with over 60 other national specialty societies and over 40 other state medical societies urging that the any legislation to be considered by Congress meet a series of key principles. These principles recognize the multitude of factors that can lead to patients facing unanticipated out of network medical bills: including assuring health insurers maintain robust physician networks, assuring health insurers maintain accurate provider directories; assure patients are kept "out of the middle", and assure that any guidelines or limits on what out-of-network providers are paid should reflect actual charge data for the same service in the same geographic area from a statistically significant and wholly independent database, and not be based on Medicare or in-network rates.
MSSNY physician leaders will be in Washington DC next week along with physician leaders across the country to visit with their respective Congressional delegations on this critical issue and other key health care issues before Congress.
What's next for DSRIP?
State Department of Health officials said they plan to pursue an additional five-year federal waiver ahead of the expiration of the $7.4 billion Medicaid Delivery System Reform Incentive Payment program in April 2020. In the meantime, the governor's fiscal 2020 budget proposal includes several provisions to advance the DSRIP goal of reducing avoidable hospital use by 25% compared to the state's baseline in 2015.
So far the state's 25 Performing Provider Systems—groups of hospitals, physicians, health centers and community organizations—have reduced unnecessary hospitalizations by 17%, said Greg Allen, director of program development and management at the state Department of Health, during a webinar budget briefing.
"Many Performing Provider Systems have been engaged in conversations in what a future DSRIP program could look like," he said. "Clearly there's an interest by all stakeholders in continuing the best of what's happened here. Just about everyone agrees we should ask for renewal."
Allen noted that several other states have had their federal waivers renewed. He said health care providers' value-based contracts with insurers were "not quite mature enough" to finance the types of programs providers are pursuing. As part of the budget, the state Department of Health plans to promote best practices from providers that have been able to keep their patients out of the hospital, which it estimates will save $10 million for Medicaid next year. The department also plans to lower Medicaid payments to facilities that have high rates of avoidable hospitalizations. It would use the $5 million it expects in savings to invest in primary, maternity and ambulatory care. (Crains)
SAVE THE DATE: MSSNY's Annual "Physician Advocacy Day" (3/6)!
With nearly 40 newly elected legislators in Albany, the need for physician advocacy and grassroots involvement is greater than ever. With so much new representation, it's vital for physicians to forge new relationships, as well as strengthen existing relationships with this new Legislature to ensure the physician community's message is well-represented.
One opportunity is to participate in MSSNY's "Physician Advocacy Day" that will be held on Wednesday, March 6th in the Lewis Swyer Theatre in the Egg located at the Empire State Plaza, Albany NY. Click HERE to register!
Join your colleagues from all around New York State and come to MSSNY's Physician Advocacy Day to speak with your legislators and key policymakers to ensure they're making the right choices for New York's physicians and their patients.
Join us to urge your legislators to:
- Proceed very cautiously on paradigm shifting proposals such as legalization of recreational marijuana (proposed in the State Budget) and creating a single payor health insurance structure.
- Reject unfair cuts to physicians treating patients covered by both Medicare and Medicaid;
- Reject proposals that would add prior authorization burdens for care provided to Medicaid patients;
- Support legislation to reduce excessive health insurer prior authorization hassles that delay patient care.
- Reduce the high cost of medical liability insurance through comprehensive reforms.
- Reject burdensome mandates that interfere with patient care delivery.
- Preserve opportunities for medical students and residents to become New York's future health care leaders.
A brief luncheon to which members of each House are invited to speak with their constituents will follow the morning program. County Medical Societies will be scheduling afternoon appointments for physicians to meet with their elected representatives. (HARRING)
If you have any questions, please contact Carrie Harring: email@example.com.
NY County President Dr. Van De Walle Welcomes Legislators
The President of the New York County Medical Society Naheed Van De Walle MD at the podium at the Legislative Breakfast held on January 27.
The event featured a lineup of Manhattan legislators including Assembly Health Chair Dick Gottfried, US Representative Carolyn Maloney, Manhattan Borough President Gale Brewer, and Senate Health Chair Gustavo Rivera.
Other speakers were New York City Councilman and physician Matthieu Eugene, Senator Robert Jackson and Assemblymember Harvey Epstein. Over 70 physicians from New York County Medical Society and co-sponsoring organizations NY City Psychiatric Society and the New York Council on Child and Adolescent Psychiatry were in attendance to question legislators on everything from single payer, drug formularies, marijuana, and other important physician issues.
Presidents of all three organizations actively participated in the session. According to Dr. Van de Walle, the success of the breakfast was a product of the hard work and dedication of the organizers from all three organizations which included, Cheryl Malone, Meagan O'Tolle, Susan Tucker, Vera Fuer and other dedicated NYCMS staff such as Lisa Joseph. Although representatives from a number of organizations attended the breakfast, the initial feedback was that it was the best Legislative breakfast they had attended to date.
Anthem Tops Fourth Quarter Expectations
The Blue Cross-Blue Shield insurer Anthem topped fourth-quarter earnings expectations and unveiled a better-than-expected 2019 forecast, helped by an early start for its prescription drug coverage business. Shares of the nation's second-largest health insurer soared after Anthem said Wednesday that it will start moving customers into its new business in this year's second quarter, several months ahead of schedule.
The insurer has said that it expects to gain annual savings of more than $4 billion by running its own pharmacy benefit management operation, which it calls IngenioRx.
Anthem initially anticipated a 2020 start for its PBM business, which it will run with help from CVS Health Corp. But it said Wednesday that it was ending its deal with Express Scripts on March 1 due to that company's recently completed acquisition by another insurer, Cigna Corp. Anthem Inc. covers nearly 40 million people, including those who receive private insurance or benefits from the government-run Medicaid and Medicare programs. (AP 2/7)
Determining Whether Older Medical Professionals Can Competently Perform
The New York Times (2/1) reports that some hospitals are using "mandatory screening procedures" to assess whether medical professionals older than 70 can perform competently, with many of those professionals "unenthusiastic about the idea." The Times says mandatory screening – generally beginning at age 70 –has already begun at "the University of Virginia Health System, Temple University Hospital and UPMC in Pittsburgh." Screening generally covers physicians as well as physician assistants, nurse practitioners, and other roles.
Researchers Find Increasing Risk of Obesity-Related Cancers
The New York Times (2/4) reports on a study published in Lancet Public Health finding that "the risk of developing obesity-related cancer is increasing in successive generations, along with increasing rates of obesity." Investigators "studied the incidence of 30 of the most common cancers, including 12 that are obesity related, from 1995 to 2014 in people ages 25 to 84 — more than 14.6 million cases." The investigators "found that for six of the 12 obesity-related cancers (multiple myeloma, colorectal, uterine, gallbladder, kidney and pancreatic) the risk for disease increased in adults 25 to 49, with the magnitude of the increases steeper with younger age."
E-Cigarettes Outperform Nicotine Replacement for Smoking Cessation
Adults who smoke conventional cigarettes are more likely to quit smoking successfully when they use electronic cigarettes rather than nicotine replacement therapy (NRT) as a quit aid, according to a randomized trial in the New England Journal of Medicine. Nearly 900 U.K. adults who were looking to stop smoking were randomized to use e-cigarettes or NRT beginning on their quit date. The e-cigarette group was given a starter pack but could then use the product of their choice, while NRT participants could choose their preferred product. All participants also received at least four weekly sessions of behavioral support.
The primary outcome — the rate of abstinence at 1 year confirmed by carbon monoxide levels — favored the e-cigarette group (18% vs. 9.9% in the NRT group).
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Landlord Gas Safe Certificate
By law, under the Gas Safety (Installation and Use) Regulations 1998, it's your responsibility to get a gas safety certificate (CP12) every twelve months. You must get this from a Gas Safe Registered engineer for all pipe work, gas appliances and flues installed at your property.
GE4L specialise in providing a comprehensive service to landlords and often able to discount the service charge for landlords with multiple properties.
- CP12 gas safety certifications for all tenanted properties from £60
- Free annual reminders when safety checks expires.
- Discounted rates for landlords with multiple properties
What you'll get with a gas safety certificate (CP12):
- Your gas appliances will be checked for gas tightness.
- If test points are available, standing and working pressure will be tested.
- Our Gas Safe engineer will check burner pressure and gas rate against the manufacturer's data plate.
- Checks will be carried out for the provision of all necessary ventilation.
- Flue flow will be tested to make sure products of combustion are removed.
- All flame failure devices will be checked for satisfactory operation.
- Where appropriate checks will be made for physical stability, presence and effectiveness of stability brackets.
- Investigations for any evidence of unsafe operation will be made and reported.
Without completing all of the above checks an appliance cannot be issued a gas safety certificate (CP12) and if there are any issues in your property we try to resolve it very same day.

subset: commoncrawl


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ANZ is committed to finding new and innovative ways to support customers to start, run and grow their business.
Business owners commonly express their frustrations with recruitment, compliance and general HR administration. 'Employment Hero, brought to you by ANZ', delivers a great solution to help customers run and grow their business by supporting the HR challenges faced by business owners.


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Russian 24-Hour Watch RAKETA 2623.H World Time Gold plated (Russian Version)
199.99 $
- Description
RAKETA 24h Watch World Time (Russian Version). 100% authentic! 24-hour dial. Hand-winding. Power reserve 42 hours. Mechanical movement Raketa 2623.H with 19 Ruby jewels. Central second hand. Rotating dial (bezel ring). World Time - the local time in different cities. All around the World. Cities in Russian. Shock-proof balance. Diameter 40 mm, thickness 12 mm. Comes with leather band (18 mm). Made in Russia (1991). NOS! Perfect condition. New and unused.


text: hi, here is the mac osx scrap module someone made: http://article.gmane.org/gmane.comp.lib.sdl/35258 There's another message in that thread with a main.c file too. Note, the API is different from the original scrap, and the pygame scrap... but it should be usable. Also the python version should be a good guide too. Note the scrap bmp code with pyobjc crashed osx... so be careful with that. cu, On Mon, Jan 26, 2009 at 4:13 PM, René Dudfield <renesd@xxxxxxxxx> wrote: > Awesome! > > For scrap, I've book marked a Mac OSX implementation written in objc > somewhere. Once I find it I'll post a link, so we can get the scrap > working nicely on OSX. > > cu. > > On Sun, Jan 25, 2009 at 6:35 PM, Brian Fisher <brian@xxxxxxxxxxxxxxxxxxx> wrote: >> Pygame 1.9.x no longer requires pyobjc on mac osX to build or install. >> People can get pre-release prebuilt installers for the new >> pyobjc-not-needing-pygame for 2.4 through 2.6 at the automated build page: >> http://thorbrian.com/pygame/builds.php >> >> If people could test with it (in particular using it with py2app) I'd >> appreciate it >> >> the builds don't have pyportmidi or scrap module support in them yet though. >> >> >


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Thursday, January 26th, 2012...6:43 pm
jookie Valentine Quick Takes sneak peek! | chicago childrens photographer
Here is a sneak peek of each Quick Take session at Little Threads this past Wednesday. Thank you to all the families who decided to Kiss & Tell with us and to raise money for Saving tiny Hearts Society! More Kiss & Tell Quick Takes coming up this weekend!


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It is an outrage to discriminate against any such man because of creed, or birthplace, or origin. -Theodore Roosevelt, 26th US President (27 Oct 1858-1919)
Reblogged this on O LADO ESCURO DA LUA.
I miss TR. I miss Ike. Hell, I even miss Nixon.
What a sad commentary on our life as we are "knowing" it. ~~dru~~


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Live Solo Acoustic/Eclectic Music with Miles, Mondays from 6-9pm at the 1846 Tavern, Rt. 100, W. Dover, VT. It's a great way to top off your Monday!
Back to All Events
Earlier Event: December 27Live Acoustic Music at the Inn at Sawmill Farm!
Later Event: December 29Solo Set at Harriman's


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Senior Avionics & Electrical Technicians
Senior Avionics & Electrical TechniciansSTS
STS Technical Services
STS Technical Services now offers Senior Avionics & Electrical Technician jobs in Savannah, Georgia.
Position Summary:
Provides leadership, technical expertise and guidance while performing various operational, functional tests and repairs of avionics/electronic, aircraft equipment and systems to ensure a defect free aircraft. Provides superior technical expertise in testing, troubleshooting and repairing system discrepancies to ensure minimum schedule impact. Demonstrates technical expertise and leadership by defining and implementing process changes to reduce cost and meet schedule without compromising Safety or Quality. Demonstrates the knowledge and leadership skills required to fill in for the team leader thus ensuring that the company goals of Safety and Quality are enforced all times while adhering to daily work plans to maintain schedule requirements.
Job Duties:
- Demonstrates superior technical skills and expertise in avionics and aircraft systems operational testing and troubleshooting. Provides direct training to personnel to support company cross-training goals while ensuring a safety conscience, quality oriented, skilled workforce
- Teaches the installation and functionally testing of electrical/avionics components and systems per Engineering specifications, drawings and maintenance manuals ensuring a defect free system
- Ensures quality and efficiency of all installations: troubleshoots and teaches troubleshooting processes/concepts to provide timely, quality repairs of malfunctioning systems
- Demonstrates the skills and knowledge required to effective and efficiently repair or replace defective components and wiring to ensure installations meet conformity. Demonstrates effective repair techniques using acceptable practices including splicing, soldering and pinning of wiring
- Oversees the performance and compliance with engineering changes and modifications as required
- Sets up and operates necessary test equipment. Conducts functional and operational tests to evaluate performance and reliability
- Demonstrates through diligent compliance the importance of daily logs and other paperwork. Ensures that all work performed on the aircraft is properly and completely documented
- As required, pre-inspects work of others prior to submitting to inspection for approval to reduce rework and inspection time
- Provides the knowledge and technical expertise in testing and maintaining test equipment and electronic systems and components as required
- Enforces the company FOD program, tool control program, 5-S program and all safety regulations
- Maintains required logs and records
- Adapts to sudden schedule changes
- Coordinates with other disciplines concerning projects.
- Where required, teaches the installation and functionally testing of electrical/avionics components and systems per Engineering specifications, drawings and maintenance manuals ensuring a defect free system
- Self inspection capability for all avionics testing functions in applicable areas
- In support of aircraft certification and final phase testing, may include flight tests on aircraft as required
- Performs other duties as assigned
- High School graduate/GED
- A & P license, FCC license or NCATT certification preferred
- Six (6) years experience in an avionics/electrical career field; or two (2) years of accredited schooling in aviation electronics and four (4) years related experience
STS Technical Services offers direct deposits / electric payroll, an awesome medical insurance program, cash advances, and the opportunity to refer a friend for compensation.
We know it takes great people to do great work, so if you're interested in joining the STS Aviation Group family, we encourage you to apply on this page. Have questions? Give us a call at 1-800-359-4787.
Thanks for taking the time, and we look forward to hearing from you soon.
Apply via Email
To apply for this job email your details to email@example.com


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Although there was more to the post I wrote more than a week ago, called "Sabotaged Again," I took it down anyway. In the post I said that I know that if I take care of my body and eat better, most of my PTSD will heal. And since I am not really sure about that anymore, I can't stand behind the statement.
I also want to apologize to anyone who read it and felt minimized by that statement.
That being said though, I still think that taking care of the body, does improve the mind. I have experienced diminishing of symptoms like hyper-vigilance after taking care to eat in a healthy way. So I do still think that self-care does play a part.
But there is a lot more to it. I know that the brain changes in the case of trauma, or develops differently, when the trauma comes from childhood, than it would have if the child had been nurtured and cared for in a loving manner.
I have a tendency to start feeling better and then I get restless. I think this is what causes me to revert back to old habits. I also think it's a combination of wanting to socialize too. I am lonely living with B. He doesn't talk much and quite frankly, I am bored with him as well as feel quite a bit of resentment toward him.
So I prefer to seek out other company. In addition that company is at a disc golf course and close to nature. So two needs of mine are met with this: Actually three: being in nature, being around people/socializing and some movement.
I love disc golf. There was a point in time when I played often, but the local course is rife with opportunity to drink and smoke. And although I have the discipline to stay away from it when I'm home, when I get out among people who 'indulge' I do the same. And of course that sets me back.
In my situation it's easy to have this happen, and in particular at my age. As much as I want to socialize with people who have healthier values, it can be difficult to meet them. It's easy to go back to the familiar. If I want to get involved with different types of people, it takes money.
I've also noticed, that no matter what type of group I'm find myself around, eventually I feel uncomfortable and don't fit in.
A couple weeks ago, B and I had a talk and agreed to make some changes. I can say that he has been following through for the most part. There is one thing I asked of him that I know he'd been following through with but I'm not sure if he still is. I'd have to ask to find out.
For me, I was following through on everything but one.
My not having an income is a problem. He wants me to earn some money. I don't blame him and I agree with that desire myself. The plan was for me to work on eBay. We have plenty here to sell and I'm quite familiar with the platform. But I have not been able to get myself to do much of anything on it.
I feel ashamed but I also feel like maybe I need to find something else to do. I just have no desire to deal with eBay. I feel so restless sitting at this computer anymore.


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Golf update: Subsidy ruled out
Any Oakmont aid to the Oakmont Golf Club (OGC) will require getting something comparable in return, and the OVA (Oakmont Village Association) is not considering any direct subsidy to the club, OVA Vice President Tom Kendrick told the board Sept. 18.
Kendrick said a subcommittee involved in discussions with the OGC is looking at transactions and partnerships and opportunities for direct voluntary support of OGC by OVA members. Others on the subcommittee include Director Carolyn Bettencourt and Treasurer Elke Strunke.
Some areas under discussion include contracting for selected maintenance services and cost sharing for projects such as for flood control and water management. Some other possibilities have been ruled out, he said. Transactions and partnerships under consideration are consistent with the principles many BOD [Board of Directors] members communicated during last springs election, that any financial contribution from the OVA to the OGC would provide in return concrete value of comparable worth to OVA members.
Since last spring, the OGC has been making a pitch for financial assistance from the OVA, saying that it is doing OK financially now, but may need help if there are other bad revenue years like 2017, when the October wildfires shut down the courses.
Kendrick had a less rosy assessment, describing the overall financial picture as not promising and a challenge.
He said the number of rounds played is stable, but the financial picture is not as positive. He cited last years fires and a rainy winter.
Kendrick stressed no direct OVA subsidy for OGC is being considered by the OVA BOD. But, he said, the issues are real, however, and must be addressed.
Kendrick also said member residents will get an opportunity to directly support the OGC individually. Details on this will be available soon. For those OVA members who are concerned about property values and Oakmonts appearance, participating in this will provide some relatively inexpensive insurance.
As discussions progress, Kendrick promised OVA will communicate specific details. We want and expect to have spirited discussions prior to any OVA BOD decisions.


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Hello everyone, I'm Anna!
I hope you are having a fantastic day or night, wherever you are. Let me introduce myself a little bit. I am a 20 year old from Indiana who will be going into my sophomore year of college in the fall. I am the oldest of three and come from a close-knit family of five. My family and friends mean the world to me and I would drop anything to be there for them. They have no doubt shaped me into the person I am today. I am passionate about a lot which makes my life so gratifying. I love being outside, reading, cooking, traveling, working out, fashion and beauty. I am your typical girly-girl but am not afraid to get down and dirty when I need to. I am highly competitive and love a friendly, or not so friendly, competition. I am compassionate and trusting, which can sometimes be my downfall. I am loyal and loving, always willing to make more lifelong connections. I am optimistic, often giving people the benefit of the doubt. I am shy until you get to know me, and assess a situation before jumping in head on. This is me.
I wanted to start a blog because I love to write and I thought it would be really fun to be able to talk about different parts of my life that I am passionate about. So follow along if you want to see what I am up to in the windy city as well as life back home in Indiana from everything to beauty and fashion, to food reviews, to college life, and more.
xoxo Anna


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It was certainly an honour for our Early Coders Academy instructors to be invited to conduct coding lessons for Singapore Management University (SMU) students. Learning code certainly starts at all ages and we wanted to give all students, regardless of background, a chance to delve into the programming world.
We structured 3 different sessions over the course of 3 days (27th to the 29th of April) with the intention of having our students build a web app at the end of the course.
During the first session, we had our students run through the basics of front-end web design, where students delved into HTML tag structuring and basic page manipulation using JavaScript and CSS. The lesson also touched on the Bootstrap framework to broaden the perspective of the students. This will be especially useful for students who want to learn how to design basic web pages or who would be taking Software Engineering in the coming semester.
The second session built upon lessons learnt in the first session. The class went one step deeper by covering the basics of JQuery, REST APIs, more advanced page manipulation techniques. JQuery's AJAX function was used to introduce students to how they are able to communicate with servers across the wire. This will be especially useful for students who want to learn how to customize server behavior, or who would be taking Software Engineering in the future.
The last session was particularly exciting for the students as we covered a new technology that is up and coming. This class covered the basics of MeteorJS, a full stack web framework built on JavaScript, HTML and CSS, which also uses a NoSQL-type database, MongoDB. The class will cover the basics of building a simple web application on MeteorJS. By the end of the lesson, students will have a basic understanding of the frontend components (Blaze) and backend components (events, helpers, routing, collections etc) of MeteorJS.
Overall, it was a humbling experience teaching these handful of bright students hungry for knowledge. We hope that in the future, these students that we have taught with will grow up to be the builders of tomorrow.


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As a gateway to the Columbia River Gorge, the Cascade Mountains, the Gifford-Pinchot National Forest, and the Mount Adams Recreation area, Klickitat County is a popular destination for outdoor recreationists from across North America. Add in the many cultural activities, such as Maryhill Museum of Art, Stonehenge and
Fishing, hunting, whitewater rafting, windsurfing, hiking, biking, horseback riding,
Visitors find Klickitat County's canyons and vistas, evergreen forests, scenic waterfalls, wildflowers, berry fields, ranchlands, sage-covered hillsides, river rapids, hiking and biking trails, deer, turkey, elk, salmon, steelhead, rodeos, festivals, and for those who seek it, seclusion, among the best in the U.S. The moderate climate makes Klickitat County a year-round outdoor recreation destination.
On its southern edge, the Columbia River provides a variety of outdoor recreation opportunities.
Visitors may even follow in the footsteps of Lewis and Clark, who, on their 1805 Corp of Discovery expedition to the Pacific Ocean, camped at the mouth of the White Salmon River.
We welcome you to the Klickitat County, Washington website and hope to see you soon at one of our many Klickitat County attractions.


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Not quite what we expected but ok overall.
We stayed in the copthorne side of the hotel which seems to be linked onto the stadium. area was nice & fulham broadway tube was around 5mins walk. the room was clean & was equipped with safe, iron, ironing board, kettle, bath & shower. it was a bit dull / dated decor wise which surprised us being linked in with the stadiium. the bathroom again was essentially clean but dull / dates. we had an english breakfast included which was buffet style & you also order pouched / fried eggs. it was nice. overall we'd stay here again when visiting london if the price was right.


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Brett Stevens
Palos Verdes Peninsula High Class of 2004
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text: We present and demonstrate a systematic method for teaching working life skills to engineering students. An intended learning outcome (ILO) based approach is used for curriculum definition and development. The teaching of working life skills is implemented coherently using special courses and integrated learning in the technology courses. The specialized courses cover engineering basics, group work and product development during the first year of studies, and further courses on project and engineering skill topics targeted towards the implementation of a large-scale multidisciplinary development project in the 4 th – 5 th study year. Integrated learning is used because there is not enough space in our educational programs for multiple special courses solely for teaching working life skills. Moreover, there is no reason to fully separate working life skills from the technical context provided in technological courses. We split the engineering profession into smaller subcomponents which can be further defined as learning outcomes for working-life skills. These subcomponents are analyzed in the context of the very turbulent and globalized working environment of the engineering profession in the future. We conclude the paper by presenting our experiences gained in implementing the teaching of working life skills.


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LTW tonight features Laura Potts' Poetry Nook, a Helen and Phil show about Fantasy, and a brand new regular show from Wakefield archwizard of wordery, Jimmy Andrex.
7.30pm: Poetry Nook. Laura Potts returns with her regular show. If you didn't hear her intimate and perceptive interview with James Nash last month, do Listen Again! 'From Northern Beat Poetry to electronica, Laura Potts speaks to Wakefield-based poet Jimmy Andrex on life in the open mic underworld. As its regular visitor, Andrex will discuss the typical atmosphere of an open mic night, how to calm the pre-performance nerves and exactly what the evening can offer for newfound writers. To an electronica soundtrack, he will also count down his Top 10 Yorkshire Open Mic Nights for budding performers'.
8pm: Local Seacroft resident and Chapel FM regular, Margaret, talks about her colourful childhood.
8.25pm: The Jimmy Andrex Seminal Explosion: People namecheck 'em, but have they read 'em? The most influential books, schools of thought and movements of the last 150 years. The people and works that shaped the way we think, even if you don't realise it. First up, Jimmy Andrex will be asking people to write and talk about Germaine Greer's The Female Eunuch in this first of five monthly programmes. Expand your knowledge. Impress your friends. Bluff your way through a conversation after the Jimmy Andrex Seminal Explosion.
9.10pm: Helen Burke and Phil Pattinson return. 'Tonight's programme is about fantasy in literature. What fantasy is , its memories dreams and imaginings. Letting the wooden eagle fly , we focus on The Hobbit, Lord of the Rings, The Lion, the Witch and the Wardrobe, and The Owl Service. Let us weave a web of the surreal and the fabulous around you ! With music and poems just for good measure!'
Leave us your email address and we'll remember you next time you visit.
Also if you have a gravatar it will appear next to your comment.


text:
- Breaking Mass graves found in South Sudan, says African Union report
- Developing Most passengers on 1 side when Tofino boat capsized: coroner
- Developing Parliament could be recalled by mid-December: CBC
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- Clara Hughes The great Olympian discusses her memoir & her struggle with mental illness.
- Female Desire What turns on Canadian women and why?
- Red, White & Blue Is America on the road to revolution?
Darmowy hosting CBA.PL


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Elements to Observe When Shipping Supplies
Travelling on the sea is one of the transport modes that take a long time. Whether you are cruising for fun or transporting goods, it will take you quite a long time to reach your destination. This is dependent on the amount of distance to be secured. If it is a long distance, it will take you longer than if it is a short distance. A few products are profoundly perishable and can't be transported with the ocean. Merchandise like blossoms and natural products might not have the benefit of utilizing ocean transport, since they may ruin effortlessly. They are normally transported by air transport. There are a few factors that one should consider when shipping supplies and they include the following:
One of the significant things that one needs to take a gander at is the bundling gadgets. You need to ensure that your pressing is suited for the provisions since you will do long separations. The boxes or containers used should be protected so as to reduce damages while using them. They should be fire and waterproof to avoid them destroying the supplies. The packages being used should also be renewable. Today we are trying to go green and be environmentally friendly. This assists on the global warming issues. Therefore it is important to use packages that are environmentally friendly.
Expenses are usually the foundation of our projects and businesses. We attempt as much as we can to limit costs. We lessen our overhead expenses so as to build our net revenues. It is thus necessary vital to check the price of shipping the supplies. You have to consider the shipping containers that will be cheaper for you. One can use corrugated boxes for packaging since they are renewable and cheaper. This should help in reducing the expenses. We should make sure that we look at the prices and compare with the quality that we are receiving.
In the beginning, shipment of supplies was done for military reasons. This included transporting of pharmaceutical and nourishment. This has evolved today and many shipments are done for the business. Many organizations use shipping as a means of transportation since one is able to transport a lot of goods at once. This makes it simpler and helpful in light of the fact that you can transport your transportation supplies to huge delivery holders which lessen the number of treks you have to go. With the above components above, you can settle on a solid choice on how you will transport your delivery supplies. You are additionally ready to save money on overheads while shipping your provisions.
More reading: http://cedarlaneshippingsupplies.ca


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British Adoption of Director Firing
The Royal Navy's adoption of the director occurred in a blizzard of activity immediately prior to the war and throughout its duration. Priority was placed on the ships with the largest guns and those most likely to see front-line service in the face of the enemy: dreadnoughts, battle cruisers and monitors.
The earliest use of the word "director" in the Royal Navy appears to be tied to a firing circuit only, with one trigger firing more than just its single weapon, those other weapons involved firing at a fixed elevation as the sights rolled on. There is no mention of angles being transmitted.
In the Annual Report of the Torpedo School, 1881 there is mention of electrical firing of a broadside by a "directing gun", a concept approved in late 1880 and for which suitable a firing pistol was being sought.[1]
The Annual Report of the Torpedo School, 1890 has several pages and diagrams on these systems.[2]
The Annual Report of the Torpedo School, 1891 bemourned a multiplicity of different director schemes burgeoning in the fleet, illustrating the status quo as follows:[3]
- Admiral and Trafalgar class battleships had directors "on the new plan".
- Victoria and Sans Pareil had directors for their 6-in guns only.
- turret-ram Hotspur had a director circuit of "old pattern".
- Dreadnought, Neptune, Agamemnon, Inflexible, Colossus and Edinburgh had director circuits "on an old plan".
- Thunderer, Devastation, Ajax and new battleships had no directors.
- Mersey class director for 8-in guns.
- "Belted cruisers" had 6-in gun directors.
- Imperieuse and Warspite had directors for 6-in guns and 9.2-in broadside guns only.
- Blake and Edgar class cruisers had none.
It was further proposed that:[4]
- the Mersey class have their 8-in guns removed from their circuit.
- Centurion and Barfleur not have directors installed.
- Dreadnought, Neptune, Agamemnon, Inflexible, Colossus, Edinburgh, Hotspur, Glatton, Cyclops, Hecate, Gorgon, Wivern have their systems removed upon their next refit.
- all other ships remain as fitted.
- a report on the "new plan" systems be called for on 30 December 1892.
1907 Trials in H.M.S. Africa
Directors of various forms had been tried for over twenty years, but the type used in the war traced its lineage to that proposed by Percy Scott in 1905.[5] H.M.S. Africa conducted the first tests of an elevation-only director in 1907.[6]
1910 Trials in Dreadnought and Bellerophon
Reginald Bacon oversaw the testing of a variant in Dreadnought.
Successes in the 1909 Battle Practice and thereafter fostered support for the concept, culminating in successful trials in May 1910 aboard Bellerophon. The system was not without faults, however. It was still elevation-only and the need to fire on the roll resulted in a rate of fire sufficiently low to inspire criticism. Bellerophon's commander, Hugh Evan-Thomas, reported, "In view therefore of the slowness of the system and the doubtfulness of the advantages to be gained by it, the system of Director Firing is not recommended for adoption in HM [His Majesty's] Service."[7].
Trials in H.M.S. Neptune
A final change to make the system work in elevation as well as training was tried aboard Neptune. By early 1911, confidence was sufficient that the Orion- and Lion-classes were to be completed with the extensive wiring required for the directors, but a further generation of refinement was to be tried in Thunderer to address issues of reliability and accuracy in the Neptune design.
Trials in H.M.S. Thunderer
Thunderer's refined system was subjected to a competitive shoot-out against Orion in the Channel off Portland on 4 December 1912 which finally clearly demonstrated the advantages and utility of director firing. The tests were reported in the papers as being of "the new apparatus".[8]
The acceptance of the Thunderer prototype in 1913 pushed the Royal Navy to the point it was ready to deploy the equipment in new construction and to retrofit its existing fleet.
Early Orders
At the outset of the program of equipping the fleet, a large number of suitable platforms for retrofit were on hand, and they were handled in sets as finances, dock time and equipment availability permitted. Vickers was to perform most of the work of manufacture and installation.
The "Twelve Ship Order" was to replace the prototype director in Thunderer with production gear, and to provide sets also for Monarch, Benbow, Emperor of India, Marlborough, Iron Duke, King George V, Ajax (which received the first production set), Centurion, Audacious, Queen Mary and Tiger.
The successive "Seventeen Ship Order" covered Orion, Colossus, Hercules, Neptune, St. Vincent, Collingwood, Bellerophon, Superb, Temeraire, Dreadnought, Lion, Princess Royal, Indefatigable, New Zealand, Invincible, Indomitable and Inflexible.
The combined result of these orders and the trial installations was that when the war started, 8 dreadnoughts were equipped with director firing for their main battery: Neptune possibly still with her prototype gear from 1911, Thunderer with her director from 1912 possibly updated, Ajax from 1913, and Iron Duke, Marlborough, King George V, Centurion and Monarch from earlier in 1914.[9]
In early 1913 Sir Percy Scott had informed the First Lord of the Admiralty, Winston Churchill, that, "With a big effort we could have 12 of our Dreadnoughts fitted by the Autumn."[10] This offer was clearly declined.
Once the director design was finalised, all successive dreadnoughts, battlecruisers and big-gun monitors were completed with an installation for the main battery. However, the number of unequipped vessels of these types were still considerable and beyond them, there were light cruisers and destroyers awaiting similar if less elaborate facilities, and secondary batteries of large vessels as well. Priorities were established.
Despite the overarching need to preserve wartime readiness of the fleet, the installed base of directors grew rapidly as refit opportunities permitted.
Director Installations for Main/Secondary Armament[11] Battleships Battlecruisers Cruisers Light Cruisers Monitors Leaders &
1911 1 – – – – – 1912 1 – – – – – 1913 1 – – – – – 1914 8 1 – – – – 1915 8 4 – – 14 – 1916 14 5/2 2/2 2 2 – 1917 1/15 –/1 1/1 18 – – 1918 –/3[12] – 2 25 5 118[12] Total 31/18 11/3 5/3 45 21 118
See Also
- ↑ Annual Report of the Torpedo School, 1881. pp. 19, 61. Plate X.
- ↑ Annual Report of the Torpedo School, 1890. pp. 91-93, Plates 16 and 18.
- ↑ Annual Report of the Torpedo School, 1891. pp. 123-4.
- ↑ Annual Report of the Torpedo School, 1891. p. 124.
- ↑ Brooks. Dreadnought Gunnery. p. 48.
- ↑ The Technical History and Index, Vol. 3, Part 23. p. 4.
- ↑ John Brooks. "Percy Scott and the Director". p. 159.
- ↑ "Gunnery Tests off Portland" The Times (London, England), Wednesday, Dec 04, 1912; pg. 12; Issue 40073.
- ↑ The Technical History and Index, Vol. 3, Part 23. pp. 4, 9-10.
- ↑ Scott to Churchill. Letter of 5 January, 1913. Churchill Papers. Churchill Archives Centre. CHAR 13/19/1.
- ↑ Progress in Naval Gunnery, 1914-1918. p. 37.
- ↑ 12.0 12.1 By 1st September, 1918.
- Admiralty, Technical History Section (1919). The Technical History and Index: Fire Control in H.M. Ships. Vol. 3, Part 23. C.B. 1515 (23) now O.U. 6171/14. At The National Archives. ADM 275/19.
- Brooks, John (2005). Dreadnought Gunnery and the Battle of Jutland: The Question of Fire Control. Oxon: Routledge. ISBN 0714657026. (on Amazon.com and Amazon.co.uk).
- Brooks, John (1997). "Percy Scott and the Director". Warship 1996: pp. 150–170.
- Director Firing Gear: Transfer from Dreadnought to Bellerophon, 1910 at The National Archives. ADM 1/8145


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The NMSU Carlsbad Nursing Department held its annual Nursing Pinning Ceremony for the 2018 NMSU Carlsbad Nursing Student Graduates on Friday, May 11th at the Leo Sweet Community Center during National Nurses Week. The Graduates were presented with Nursing pins and were pinned by their family or friends and afterwards received their Nurse's Cap and graduation candle. The Nursing Pinning Ceremony is a internationally recognized tradition to honor Nursing School graduates.
NMSU Carlsbad Nursing Pinning Ceremony 2018
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How To Add BotDetect CAPTCHA Protection to ASP.NET MVC Core 1/2 Applications
BotDetect ASP.NET Core Captcha protection can be added to your ASP.NET MVC 6 applications using the
MvcCaptcha class, a BotDetect
TagHelper and a custom
ActionFilterAttribute implemented in the
BotDetect.Web.Mvc.dll assembly.
First Time Here?
Check the BotDetect ASP.NET MVC Captcha Quickstart for key integration steps.
You can also see how BotDetect Captcha protection has been added to the starting ASP.NET MVC application by running the BotDetect Captcha ASP.NET MVC integration code examples coming with the BotDetect installation.
You can reuse the example projects source code that fits your application requirements.
CAPTCHA Integration StepsWhen adding BotDetect CAPTCHA to an ASP.NET MVC Core application:
- Display a Captcha challenge on the Asp.Net MVC View
- Check is the visitor a human in the Controller action
- Further Captcha customization and options
I. Display a CAPTCHA Challenge on the ASP.NET MVC View
Before protecting a Controller action in your ASP.NET MVC application with BotDetect Captcha, you should decide how to call the Captcha instance and the related textbox you will use. In this guide, we will use
ExampleCaptcha and
CaptchaCode. If you plan to protect multiple Controller actions within the same ASP.NET MVC application, you should take care to give each Captcha instance a different name (e.g.
CommentCaptcha etc.).
Add BotDetect Captcha NuGet Package
ASP.NET MVC Core applications should reference both the base
BotDetect.dll assembly and the ASP.NET MVC-specific
BotDetect.Web.Mvc.dll assembly by adding package
CAPTCHA (ASP.NET Core applications running on .NET Core Frameworks) or
CAPTCHA.asp.net.core.on.legacy.net.frameworks (ASP.NET Core applications running on the legacy .NET (non-Core) Frameworks) via nuget.org package source. If you don't want to access Microsoft package manager, you need to set up your own offline local NuGet repository. To hosting your own NuGet feeds, please click here for more details.
Configure Your ASP.NET Application Startup
In order to make BotDetect works properly, you need to modify the Startup class which configures the request pipeline that handles all BotDetect Captcha requests made to the application.
Additionally, BotDetect Captcha ASP.NET Core validation requires ASP.NET Session midlleware – generated random Captcha codes have to be stored on the server and compared to the user input.
- Add the highlighted lines into your app's
Startupclass (
public class Startup { public void Configure(IApplicationBuilder app, IHostingEnvironment env, ILoggerFactory loggerFactory) { ... // configures Session middleware app.UseSession(); // configure your application pipeline to use Captcha middleware app.UseCaptcha(Configuration); ... } // This method gets called by the runtime. Use this method to add services to the container. public void ConfigureServices(IServiceCollection services) { // Uncomment the next line if the .NET Core 1.x compatibility is required // services.AddSingleton<IHttpContextAccessor, HttpContextAccessor>(); services.AddMemoryCache(); // Adds a default in-memory // implementation of // IDistributedCache // Add framework services. services.AddMvc(); // Add Session services. services.AddSession(options => { options.IdleTimeout = TimeSpan.FromMinutes(20); }); } }
- Add
@addTagHelperdirective makes Tag Helpers available to the view. To expose
BotDetect Captcha Tag Helperin your project, you would use the following in
@using AspNetMvc6BasicCaptchaExample @addTagHelper *, Microsoft.AspNetCore.Mvc.TagHelpers @addTagHelper "BotDetect.Web.Mvc.CaptchaTagHelper, BotDetect.Web.Mvc"
Use <captcha> tag helper to display Captcha in the view
BotDetect ASP.NET Core Captcha provides
<captcha> tag helper to add Captcha in your forms. The forms also need a
<input ⁄> tag in which the user is to type the Captcha code:
Retype the code from the picture:
<captcha id="ExampleCaptcha" user-input-id="CaptchaCode" />

<input asp-for="CaptchaCode" />
<input type="submit" value="Validate" />

@if ((Context.Request.Method.ToUpper() == "POST") && ViewData.ModelState.IsValid)
Correct!
Include the BotDetect CAPTCHA Layout StyleSheet
Since the Html markup generated by BotDetect includes a number of different elements (the Captcha image, the icons for Captcha reloading and Captcha sound playing, the Captcha help link etc.), there are some CSS declarations which need to be included for those elements to display correctly.
The best place to include CSS style declarations is in the page
, and since you are controlling the View markup, you know best where exactly to add them. The BotDetect layout stylesheet can be included with the following declaration:
@section header { <environment names="Development,Staging,Production"> <link href="@BotDetect.Web.CaptchaUrls.Absolute.LayoutStyleSheetUrl" rel="stylesheet" type="text/css" /> <⁄environment> }
If your View generates its own
 section, you can add these declaration directly in View code. If you're using a Razor Layout and individual Views only generate main content, you can add them to the Razor Layout.
Even better, your layout can include a
@RenderSection() – and then individual Views can add their required declarations there without affecting other Views.
Once all of these steps have been performed, the Captcha should be displayed when you open your form in a browser:
If the Captcha image isn't being rendered properly, please check the BotDetect integration FAQ.
II. Check is the Visitor a Human in the Controller Action
Once the Captcha challenge is displayed on your View, the Controller code processing submissions can check if the Captcha was solved successfully and deny access to bots.
Captcha validation is encapsulated within an
ActionFilterAttribute that can be added to actions accepting
HtppVerbs.Post requests; the
CaptchaValidation attribute just needs to be passed the names of the Captcha instance and Captcha code textbox used. ASP.NET Session state must also be enabled before Captcha validation can work.
Mark the Protected Controller Action with the
CaptchaValidation Attribute
CaptchaValidation attribute takes three parameters:
- Captcha code textbox name
MvcCaptchainstance name
- the error message that will be displayed when Captcha validation fails
// // POST: /ExampleController/ExampleAction [HttpPost] [AllowAnonymous] [CaptchaValidation("CaptchaCode", "ExampleCaptcha", "Incorrect CAPTCHA code!")] public ActionResult ExampleAction(ExampleModel model) { if (ModelState.IsValid) { […] // You should call ResetCaptcha as demonstrated in the following example. MvcCaptcha.ResetCaptcha("ExampleCaptcha"); […]
If everything has been configured correctly, the above
ActionFilterAttribute will automatically add the appropriate
ModelState error when Captcha validation fails, and checking
ModelState validity will include the Captcha validation result.
III. Further CAPTCHA Customization and Options
BotDetect ASP.NET Captcha allows detailed customization of many Captcha properties, and you can read more about them in the BotDetect Captcha configuration How To.
Current BotDetect Versions
BotDetect ASP.NET CAPTCHA
BotDetect Java CAPTCHA
BotDetect PHP CAPTCHA
BotDetect ASP Classic CAPTCHA
(Classic ASP port is discontinued)


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Why do Muslim mobs in Islamic countries go on violent rampages in response to perceived insults to their religion? This question has surfaced once again in the wake of the riots across the Islamic world apparently triggered by the film, misleadingly titled, "Innocence of Muslims." A range of reasons is being debated, including the nature of Islam, cultural inferiority of pre-modern societies, lack of democratic traditions, anti-Americanism inspired by decades of American support to Arab dictatorships and its unqualified support to the Jewish state.
While there may be some truth in all these, for a fuller understanding one should examine the other question that crops up in this context: Why don't Christians in Western countries resort to violence even in the face of extreme provocation, including terrorist attacks by Islamic radicals? Is it because Christianity is a peaceful religion?
That can't be true, because despite what the New Testament preaches, the history of political Christianity – from Constantine the Great to Christopher Columbus and beyond — is marked by relentless violence. No other religion, not even Islam, comes close to the scale of violence, physical and structural, that has been inflicted in the name of Christianity.
That said, one must note that for the most part — barring revolutions, ethnic and racial pogroms – societal violence for redressing grievances has been notably absent in modern nation-states of the Christian West. It has something to do with the philosophical and inherently secular construct of the European State in which the subjects, as if they were under a social contract, surrender their right to violence to the sovereign.
According to German sociologist Max Weber, the very existence the State is contingent on having "monopoly on the legitimate use of violence." As the key appropriator of social passions and competing interests, the State enabled the formation of a civil society and a set of deliberative institutions like parliaments and the media. It also helped develop the modern notion of "citizenship" that inspired what political scientist J.W. Garner terms as a "habitual obedience to law" – by which, for instance, most people pay taxes or respect traffic rules or refrain from encroaching on other peoples' liberty even when outside the scrutiny or reach of legal authority.
The European State, notwithstanding its Christian orientation, evolved into a secular construct, largely because the intellectual foundation of Western civilization lay, not in the Christian doctrine, but in Greek political philosophy from where the State originated. If anything, the attributes of religion were projected on to the State, thus rendering it the very the embodiment of morality and justice. German philosopher G.W.F. Hegel even compared it to "the march of God on Earth."
Alongside, the "Protestant ethic" contributed to the rise of the capitalism which also diminished the influence of religion in public affairs. Of course, the same idea of State, in its extreme and perverse form, gave rise to fascism and totalitarianism. (It did not lead to utopian communism that Marx believed would eventually make the State redundant, causing it to wither away.)
Outside the West, only a few countries have been able evolve as modern nation-states where citizens displayed "habitual obedience to law." Notable are Japan after the Meiji Restoration, and Turkey, where Mustafa Kemal Ataturk decided that it was futile to resist what he termed "the impetuous torrent of modernization." In India, notwithstanding the success of its democratic institutions, the State continues to compete for loyalty with parochial factors like the caste, religion, language and ethnicity. As a consequence, the country remains hostage to violent subnational movements and sporadic rampages by murderous mobs.
In most of the Afro-Arab countries where the idea of State did not take root, competing interests of disparate tribes and sects thrown together by arbitrarily drawn political boundaries were held in check by authoritarian regimes that had the monopoly of violence. But with the fall of dictators in the wake of the so-called Arab Spring, and with nascent forces of modernization struggling to assert themselves the power vacuum is being filled by traditional power structures.
Against this background, if the State monopoly of violence accounts for the Western countries taking a legalistic view of violence – only violence sanctioned by the State is deemed legitimate – in Islamic countries, with weak allegiance to the authority of State and relative indifference to law, violence has come to be accepted an expression of popular will in the defense of the tribe, tradition, custom, religion or, a combination of all conveniently swept under the rubric of honor.


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As is Guild Wars, SWG, and from what I hear, Lineage IIMydin,May 5 2007, 02:24 PM wrote: I miss read that rating for a secon, thought it was a 10 .
I aggree though. Runescape is an insult to society
I'd almost assume play one of those Final Fantasy games.


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If you have a complaint about SureSave or one of our partners, feel free to contact our Customer Relations Team by post, email or telephone.
Customer Relations Team – nib Travel Services (Australia)
PO Box A975,
Sydney South, NSW, 1235
1300 625 229
nib Travel Services will acknowledge your complaint within 5 business days and provide you with the contact details of the person handling your complaint. We will respond to your complaint within 15 business days. If more time is needed to collect necessary information or complete any further investigation required, nib Travel Services will agree with you a reasonable alternative timeframe.
Dispute Resolution Process
If you are not satisfied with the response to your complaint, you should contact the Lloyd's General Representative in Australia for consideration under their dispute resolution process.
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Lloyd's Underwriters' General Representative in Australia
Level 9, 1 O'Connell St
Sydney NSW 2000
+61 2 8298 0700
Your dispute will be acknowledged within 5 working days of receipt, and Lloyd's will send a final response on behalf of the Underwriters within 15 business days.
Independent Review
If we are unable to resolve your complaint within 8 weeks of receiving your original complaint, or if you are still not satisfied with the outcome, you can choose to have your complaint independently reviewed by the Australian Financial Complaints Authority, or AFCA. AFCA provides fair and independent financial services complaint resolution that is free to consumers.
ACFA can be contacted at:
Australian Financial Complaints Authority
GPO Box 3, Melbourne VIC 3001
1800 931 678 (free call)


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OVO Fest in Toronto is usually all about surprises. But there was nothing shocking about the fact that Rihanna stole the show once Drake brought the bad gal out to perform their collaborative tracks 'Work' and 'Too Good' on Sunday night. She also performed her own hits 'Needed Me' and 'Bitch Better Have My Money.' See clips below.
Drake just brought out Rihanna. #OVOFest2016 pic.twitter.com/VVGWcklend— Nigel Int'l D. (@Nigel_D) August 1, 2016
Rihanna cantando "Work" na #OVOFest. pic.twitter.com/jIDb6uxddL— Rihanna Angel Brasil (@RihannaAngelBR) August 1, 2016


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So, I am about to play in a D&D 3.5 version game. It will be my 2nd time playing the system, even though it almost the exact same as pathfinder (Which I run).
This is the character I made.
He is a Cleric of Fharlanghn. He is 36 years old (Making him middle aged in this game) and has been traveling the world as a cleric for 13 years.
There is quite a story for this character, as it is the first character I've played in over 2 years.
I'm looking forward to it.
I'll let you know how it goes, as well as give some backstory later.
The Guy


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Interested in learning more about plant fire protection? Click here.
Missouri -- A four alarm fire in Mexico, MO destroyed a dog food manufacturing plant.
At 5am on Saturday, fire crews arrived at a 4-alarm dog food manufacturing plant fire. Thirty-five firefighters arrived and were at the scene until 4pm. An excavator was also on the scene, tearing down parts of the buildings so fire crews could get to the flames inside the building.
"I hope to rebuild," said Jim Raleigh, owner of the plant. "It's going to take a lot of energy to go through all that. First of all, it's all got to come down first and be removed and start from the ground up."
This plant caught on fire 10 years earlier due to an electrical issue; however, Raleigh does not believe that this was the cause this time because he shuts off the power each night. The cause is still under investigation.
Lt. Steve Nichols believes the fire was sparked by dust. "Anytime you have a manufacturing plant of any kind, they have dust. And the smaller dust you have, the more volatile it is as far as explosions and stuff like that. But, we have no idea what caused it at this time."


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Thankfully, cleaning a grey horse is far from difficult and will just take a bit of extra time and scrubbing.
Would you believe that the very clean horse in the photo above got that way through a shampoo bath alone? It doesn't take any special tricks!
Preferably, you will bath your grey horse the morning of the show rather than the night before. If you bath the day before, you will end up with some dirt on the coat even if you blanket most of the horse. Bathing the morning of the show ensures that your horse will be as clean as possible, unless you are unlucky enough to have your horse lie down after its bath!
I like to use a whitening shampoo on grey horses. There are lots of different kinds out there and which one you use will just depend on personal preference.
To give a good shampoo bath, first get the horse completely wet using a hose. If your horse has a yellowed tail, massage some shampoo straight from the bottle into the tail and let it sit while you bathe the rest of the horse. Pour some shampoo into a bucket and then fill the bucket with water. Use a sponge to cover the horse with soapy water, rubbing it in as you go. Once you have covered the entire horse (how much of the head you can do will depend on the horse), use the hose to rinse all of the soap off, making sure to rinse it out of the tail, too. Once you have rinsed everything off, check the horse over for any stubborn stains (the legs and belly tend to be the worst). If you find any, pour some shampoo straight from the bottle into your hands and scrub it into those areas.
If it is cool out, bring along a cooler to the wash rack and put it on your horse right after the bath to keep him warm.
Towel off the legs and try to let them dry as much as possible before putting the horse in anything more dirty than a stall full of clean shavings. Wet legs will attract dirt! If your horse likes to roll, consider tying him safely or keeping lots of hay available.
If your horse lies down after his bath and you don't have time to give him another one, you can remove the dirty spots in a few different ways. One option is to wet the area with a sponge and then scrub in a drop of shampoo before rinsing it off with the same wet sponge. Some grooms swear by diluted alcohol for removing spots, while others use a commercial spot-remover. Figure out what works best for you and stick with it!
That's all that you need to do to make your horse sparkling white. There's no secret product or method; clean hair is clean hair!