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Back to Journals » Patient Preference and Adherence » Volume 12
How to meet patients' individual needs for drug information - a scoping review
Authors Kusch MKP, Haefeli WE, Seidling HM
Received 9 May 2018
Accepted for publication 4 September 2018
Published 6 November 2018 Volume 2018:12 Pages 2339—2355
DOI https://doi.org/10.2147/PPA.S173651
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 3
Editor who approved publication: Dr Johnny Chen
Marcel KP Kusch,1,2 Walter E Haefeli,1,2 Hanna M Seidling1,2
1Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, 69120 Heidelberg, Baden-Wurttemberg, Germany; 2Cooperation Unit Clinical Pharmacy, University of Heidelberg, 69120 Heidelberg, Baden-Wurttemberg, Germany
Purpose: The aim of this study was to 1) describe drug information desired by patients and 2) analyze how such information could be customized to be presented to patients according to their individual information needs.
Materials and methods: We performed a scoping literature search and identified relevant drug information topics by assessing and clustering 1) studies analyzing patients' enquiries to drug information hotlines and services, and 2) qualitative studies evaluating patient drug information needs. For the two most frequently mentioned topics, we further analyzed which components (ie, information domains) the topics contained and examined patients' and health care professionals' (HCPs) views on these components.
Results: Of 27 identified drug information topics in the literature search, patients most frequently requested information on adverse drug reactions (ADRs) and drug–drug interactions (DDIs). Hypothetically, those topics are composed of seven distinct information domains each (eg, ADR and DDI classification by frequency, severity, or onset; information on management strategies, monitoring, and prevention strategies). Patients' and HCPs' appraisal concerning the information content of these domains varies greatly and is even lacking sometimes.
Conclusion: Patients particularly request information on ADRs and DDIs. Approaches to customize such information are sparse. The identified information domains of each topic could be used to structure corresponding drug information and to thus facilitate customization to individual information needs.
Keywords: medication information, information needs, customization, adverse drug reactions, side effects, drug–drug interactions
Patient-centered care (PCC) emphasizes patient participation in decision making in order to foster the alliance between health care professionals (HCPs) and patients to share power and responsibility.1 Patients appreciate this approach and several studies indicated positive effects on health outcomes as PCC improves communication, patient involvement, patient-HCP relationship, and treatment adherence.2,3 A prerequisite for shared responsibility is the empowerment of patients based on the provision of understandable information that matches the individual patients' information needs.3 With regard to drug treatment, patients who have received clear and reasonable treatment recommendations and advice are more likely to adhere to their treatment.4
This may be explained by the fact that basic information on drug treatment is mandatory to fulfill the "Five Rights",5,6 ie, taking the right drug by the right patient in the right dose at the right time following the right technique to prevent unintentional non-adherence. However, in addition to such evident information needs, patients evaluate the benefits of prescribed drugs (necessity belief) and weigh it against their concerns (concern belief). While a profound "necessity belief" appears to predict adherence, a deeper "concern belief" may lead to non-adherence,7 which, in this context, is often called intentional non-adherence.8 Especially in chronic conditions (eg, hypertension) non-adherence is associated with increased overall health care costs, morbidity, and mortality.4 To efficiently address or prevent a patient's concern and thereby mitigate at least one reason of non-adherence, the provision of subjectively desired information about treatment and drugs seems a promising approach.3
Which information is relevant to a patient depends on several factors including age, socio-economic status, and comorbidities.9 Depending on the patient's preferences, both receiving "too much" of unsolicited information and receiving not enough information may have negative effects on patient empowerment, thus amplifying patient concerns. Therefore, it is crucial to customize information toward the individual needs of each patient.9 However, systematic data on which drug information patients want and how it should be edited are sparse.
Unmatched drug information needs are reflected in the growing use of online health information services. Taking Germany as an example, approximately half of its population uses the Internet to get health-related information, and especially services such as medication checks and drug–drug interaction (DDI) checks are frequently accessed.10
To satisfy such unmatched information needs, we aimed to 1) describe drug information desired by patients and 2) analyze how such information could be customized to be presented to patients according to their individual information needs.
Materials and methods
We followed the presumption that drug information can be divided into 1) basic drug information and 2) subjectively desired drug information. Basic drug information refers to drug information that is mandatory for every patient in order to be able to conduct the drug treatment following the concept of the "Five Rights".5 Subjectively desired drug information, on the other hand, satisfies information customized to individual needs and considers concerns or beliefs with regard to the treatment.
While basic drug information often is straightforward, unambiguous, and therefore easily conveyed in medication schedules,11 no overview exists regarding scope and characteristics of subjective drug information needs.
To describe drug information desired by patients, an exploratory number of articles relating to patient information needs with one of the key words "patient information," "drug information," "medication information," and "medicines information" in title/abstract, English or German language, and with a publishing date between January 2000 and February 2017 were searched. The search purposefully identified potentially relevant studies that were subsequently clustered into two groups: the first group 1) comprised studies analyzing patients' enquiries to drug information hotlines and services, while the second group 2) comprised qualitative studies evaluating patient drug information needs. From the identified studies in the first group, the total number of drug-related enquiries, the enquiry topics, the provider of the information service, and the timeframe of data enquiry were extracted. The enquiry topics were classified according to those previously defined in the respective study by the authors. From the second group, the study design, population, study site, and raised drug information needs were extracted.
Subsequently, we clustered the different enquiry topics (extracted from studies analyzing patients' enquiries) and the raised drug information needs (extracted from qualitative studies) as defined in the studies into drug information topics, therewith merging enquiry topics according to their content into broader categories that were consistently defined and applied in both study groups (Table S1 and S2). This allocation was conducted by two clinical pharmacists until concordance was reached (MK and VSW). When this was not possible, a third clinical pharmacist was consulted for clarification (HS). The drug information topics were then counted throughout the different studies and arranged according to frequency in order to identify the most often reported drug information topics and to define the two most frequently mentioned ones (Figure 1).
To analyze how such information could be customized in order to be presented to patients, we focused on the two most frequently mentioned information topics and assessed in more detail which components (ie, information domains) the topics contained. Subsequently, we evaluated patients' and HCPs' expectations toward the content and presentation of these information domains as described in the literature.
Drug information desired by patients
We identified 12 studies analyzing patient enquiries to drug information hotlines and services.12–23 Most studies analyzed enquiries to drug information hotlines (number of studies [n]=10), while some analyzed enquiries to online information services (n=2). Studies originated from several countries, namely Australia (n=5), the Netherlands (n=2), Germany (n=2), Finland (n=1), United States of America (n=1), and the United Kingdom (n=1). Most of the studies were performed with data originating from the Australian drug information hotline "National Prescribing Service MedicineWise" (NPS MedicineWise) and comprised a plethora of drug-related patient enquiries, most of which were safety-related, such as information on adverse drug reactions (ADRs) and DDIs (Table 1). In the second group, 15 qualitative studies that addressed drug information needs with different methods and in different settings and populations were identified.24–38 Studies were conducted in different countries, namely the Netherlands (n=3), United States of America (n=2), the United Kingdom (n=2), Norway (n=1), China (n=1), Armenia (n=1), Germany (n=1), Singapore (n=1), Australia (n=1), Canada (n=1), and Belgium (n=1). In addition, the studies were conducted in various settings, which were community pharmacies (n=8), residents not recruited in direct health care setting (n=3), hospitals (n=2), practices (n=1), and senior centers (n=1). Various study designs were used in the studies, namely semi-structured interviews (n=7), questionnaires (n=5), focus group discussions (n=2), and presenting commonly asked questions to assess interest in these (n=1). Also, in these studies the majority of the drug information topics raised by the patients were safety-related, most frequently seeking information on ADRs and DDIs (Table 2). Yet, there seemed to be some differences based on study context and setting. Patients in senior centers and hospitals were not interested in information topics like "drugs and driving" and "drug use and alcohol".27,34,38
Table 1 Studies analyzing enquiry topics to drug information hotlines and services
Some information topics like "cost, refund, and prescription requirement" and "stability, storage, and disposal" were predominantly mentioned in ambulatory settings (ie, pharmacies and residents).28,29,36 Such topics were also more often mentioned in studies analyzing patient enquiries to drug information hotlines and services. The majority of raised drug information topics were largely identical in the examined studies regardless of whether semi-structured interviews or questionnaires were used. Focus groups that were held between patients and researchers,36 and patients, physicians, and pharmacists,37 also freely discussed predominantly safety-related drug information topics in addition to information topics that can be considered to follow the principle of the "Five Rights,"5 such as "dose and administration," "indication," and "duration of treatment." Arrangement of the allocated drug information topics according to frequency yielded ADRs and DDIs as the drug information topics most often sought by the patients regardless of country, setting, and study design. Other frequently requested drug information topics were dose and administration (ie, how and in which strength to take the drug), indication of a drug, and treatment options (ie, whether alternative drugs can be used to treat the condition). Selected topics of lower interest were information on vaccination, off-label use, drug formulation, and allergy (Figure 2).
Customization of drug information
Both ADR and DDI information may be composed of seven different information domains each (Table 3): ADR information could be customized according to the frequency, severity, onset of ADRs (eg, start of therapy vs long-term effects), duration of ADRs (eg, long-term vs short-term), and management strategies including limitations of self-management (ie, how to minimize ADRs and when to consult a physician). Moreover, additional information could be given on appropriate monitoring and prevention strategies (eg, tools to cope with ADRs).
Table 3 The two most frequently mentioned drug information topics and their information domains
For DDIs, customization could refer to the identification of DDIs, frequency, severity, or onset of DDIs. Furthermore, additional information on management strategies including limitations of self-management, monitoring, and prevention strategies (eg, different timing, lower dosages, and alternative medicines) could be given.
The subsequent literature search illustrated some of these domains with patients' needs and HCP perceptions regarding extent of information wanted because especially classification of ADRs by frequency and severity was often mentioned in the assessed literature. However, the majority of the domains were never extensively assessed in patients or HCPs. Hence, knowledge of whether and to which extent patients require the diverse elements of information and to what extent HCPs support them is limited.
Patients request largely differing information on their drugs beyond the basic information of the "Five Rights" provided in medication schedules. Thereby, information needs verbalized in qualitative studies are reflected in actual enquiries to information hotlines and services. Undoubtedly, safety-related information on ADRs and DDIs is most often sought.30,37
In comparison to other drug information topics such as appropriate storage of drugs or indication of a drug, relevant information on ADRs and DDIs is broader and less explicit. Hence, if patients request information on ADRs, it typically remains unclear what they actually want to know. For instance, do patients want to learn only about the most frequent ADRs, or the most severe ones, or those they can independently monitor and manage? Nevertheless, such safety-related information might particularly interfere with patient concerns about their drug treatment and may hence also influence their adherence to drug treatment because lacking information might promote a deeper "concern belief" and thus non-adherence.7,8 Owing to the high diversity of ADR and DDI information, it is difficult to satisfy individual needs, identify information deficits, and provide missing details while avoiding to transfer information that is not sought or irrelevant in the current patient situation.
For both ADRs and DDIs, we identified seven distinct information domains that would allow for customizing information. Such customization would then enable HCPs to individually provide patients with the respective drug information of personal interest. Only little is published on patient attitudes toward these information domains and even fewer evidence exists on how patient needs could be assessed to identify unmet information needs.
For instance, there are patients who decline to receive additional information and treatment willingness of some patients already diminishes when the mere presence of possible ADRs is mentioned, regardless of their likelihood of occurrence.61 Often, this fear of potential non-adherence is put forward by HCPs who are reluctant to offer what they deem too much additional information. However, this fear is not reflected in literature.62,63
At the other extreme, some patients want a full disclosure of all possible ADRs. Indeed, patients often seem to follow a safety-conscious strategy and opt for a maximum of information without a real understanding of risk and likelihood.39,46 Furthermore, patients seem to be particularly interested in risks considered most threatening for their own well-being regardless of their likelihood of occurrence.44
The majority of patients probably is situated in between these two extremes, and while customization of information to satisfy individual needs is acknowledged,58 explicit endeavors remain scarce. Often, patients are left with patient information leaflets that follow a "one-size-fits-all" approach and the vast number of ADRs mentioned often causes undesirable emotional reactions (eg, fear) that might promote non-adherence.42 With regard to DDIs, some patients believe that a lot of drugs should not be combined because their efficacy could be altered, whereas other patients believe that co-prescribed medicines are unlikely to interact at all.55 Considering self-medication in particular, there is a need to inform patients and raise awareness about possible DDIs between prescribed drugs and those used in self-medication.
While extensive research has been undertaken to assess professional DDI checkers regarding their content, design, and use in a professional setting, there is very limited information on performance of DDI checkers informing patients and laypersons.64 Many available DDI checkers lack DDI severity information, contain only limited patient-oriented risk communication, and have only limited patient readability.64 Especially, lengthy and complex information on possible DDIs is not well understood.65 Future research is therefore necessary to facilitate 1) customization of ADR information and 2) customization of DDI information with advanced drug information management in order to enable customization possibilities. Besides enabling customization possibilities of drug information, a particular emphasis must be put on making this information easily accessible for future users (eg, patients). Therefore, in a subsequent step, low-threshold dissemination channels must be assessed and validated with patients.
A first step would be to develop, validate, and release a database that contains available drug information in commonly understood language and register that is structured according to relevant identified information domains (Table 3). Such a database would allow selecting only information domains important for the individual patient and would thus individualize information transfer. A second prerequisite would be a tool to assess and identify individual drug information needs and select information domains for which a patient wants additional information. There are already tools available to assess whether patients desire more or less information in general and about their drugs in particular, such as the "Extent of Information Desired" scale,9 and tools that help measuring overall satisfaction with drug information, such as the "Satisfaction with Information about Medicines Scale".26,30 However, a tool to determine specific information domains on ADRs and DDIs to allow patients to select the amount and content of additional drug information is lacking. To recognize and identify boundaries and implications of customized drug information, it will be crucial on the one hand to identify patient populations benefiting from such a form of information. On the other hand, it will be equally important to find those patients who do not need additional information, and particularly those who are not served by such an approach while being in need of additional information – to this end, it may also be necessary to include further patient characteristics that influence information needs, predominantly the patient's health literacy.66 Looking at the literature, high desires for information were expressed for instance by patients with diabetes diagnosis, whereas patients with cardiovascular and respiratory diseases expressed lower desires for drug information.9 Additional factors like diseases and comorbidities may therefore also influence individual information needs.9,34 How and in which way such influence takes place should consequently also be assessed.
The present work has several limitations. First, we conducted a narrative instead of a systematic review and only assessed a single (albeit large) database (PubMed). However, our aim was to identify the most relevant drug information topics and highlight how such information can be customized. With a narrative approach we were able to include a broad spectrum of articles and therefore widely assess drug information needs. The topics extracted from PubMed articles showed strong consistency and little deviation of topics mentioned, therewith suggesting an already sufficient approach. Furthermore, while not applying the full range of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statement, we still applied various checklist items in our review process whenever possible (eg, eligibility criteria, information sources, data collection progress, synthesis of results, study characteristics, summary of evidence, limitations, conclusions, and funding).67
Second, our approach to assess unsatisfied drug information needs by analyzing enquiries to drug information hotlines and services might be biased by the fact that actively calling a hotline requires some basic interest in drug-related topics and ambition to self-reliantly acquire information; therefore, more "empowered" and proactive patients may be selected by this approach and less empowered patients might be missed. Nevertheless, the second assessment of unmatched information needs including a variety of qualitative studies yielded similar results, supporting the conclusion that these findings indeed reflect the drug information needs of a broad population of patients.
Patients particularly request safety-related drug information that exceeds the typical scope of medication schedules. While it is well known that extent and content of the favored information can vary, evidence on how to assess information needs and correspondingly customize information is sparse. This review suggests that for both ADRs and DDIs, rather diverse but only limited information domains are needed and that individual patients largely differ with respect to their information needs.
The authors thank Viktoria S Wurmbach (VSW) for her help in allocating the enquiry topics and raised drug information topics into broader categories (drug information topics). In addition, the authors thank the members of the "Cooperation Unit Clinical Pharmacy" for valuable input regarding the information domains for the two most frequently mentioned drug information topics. Part of this work was supported by the "Klaus Tschira Foundation gGmbH (KTS)," Heidelberg, Germany. The funding sources had no involvement in collection, analysis, interpretation of data, and in the writing of the report. In addition, we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding programme Open Access Publishing, by the Baden-Württemberg Ministry of Science, Research and the Arts and by Ruprecht-Karls-Universität Heidelberg.
The authors report no conflicts of interest in this work.
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This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.Download Article [PDF]


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YSR Congress MLAs file criminal case against party's Lok Sabha member
YSR Congress Party MLA have filed a series of complaints against MP Kanumuru Raghurama Krishnam Raju for his alleged anti-party activities.india Updated: Jul 09, 2020 20:20 IST
In less than a week after the YSR Congress Party submitted a petition to Lok Sabha speaker Om Birla seeking to disqualify its MP Kanumuru Raghurama Krishnam Raju for his alleged anti-party activities, the party lawmakers in West Godavari district filed criminal cases against him.
On Thursday, Bhimavaram MLA Granthi Srinivas filed a case in the local police station alleging that the MP, who represents Narasapuram parliamentary constituency, had abused him and other YSRCP MLAs. He also sent a copy of the complaint to the district superintendent of police.
In his complaint, Srinivas said when he, along with MLAs and a couple of ministers, addressed a press conference a few weeks ago to question the MP's anti-party activities, the latter had described them as a flock of pigs.
"He has been trying to instigate groupism in the party by raising the caste bogey and creating law and order issues," the MLA said.
He requested the police to take action against Raghurama Krishnam Raju for abusing the party MLAs and tarnishing their prestige in public.
Another senior YSRCP leader and state housing minister Ch Sriranganath Raju also filed a separate complaint with Poduru police station in his Achanta assembly constituency, demanding that a criminal prosecution be launched against the Narasapuram MP for his alleged derogatory comments against the party MLAs and ministers.
Sriranganath Raju alleged that the MP had abused him and his son and described them as thieves and robbers.
"This has hurt us a lot and damaged my reputation in public. Raghurama Krishnam Raju has been making wild allegations against us for his selfish political benefits," the minister complained.
A Similar complaint was lodged by YSRCP MLA from Narsapuram Mudunuri Prasada Raju with the local police. Two other MLAs – Karumuri Venkata Nageshwar Rao from Tanukgu assembly constituency and Kottu Satyanarayana from Tadepalligudem are also getting ready to file separate complaints against Raghurama Krishnam Raju.
The Narasapuram MP could not be reached for comments.

subset: commoncrawl


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Tangy Grape & Apple Slaw
Add some color and nutrition to your picnic with this apple slaw. Since it's best served at room temperature or slightly chilled, pack it in an insulated tote as you travel to keep the flavors fresh.
Source: Better Homes and Gardens
Nutrition Facts
Per Serving:
63 calories; 5 g total fat; 1 g saturated fat; 1 g polyunsaturated fat; 3 g monounsaturated fat; 0 mg cholesterol; 207 mg sodium. 106 mg potassium; 5 g carbohydrates; 2 g fiber; 3 g sugar; 1 g protein; 0 g trans fatty acid; 130 IU vitamin a; 19 mg vitamin c; 0 mg thiamin; 0 mg riboflavin; 0 mg niacin equivalents; 0 mg vitamin b6; 15 mcg folate; 0 mcg vitamin b12; 14 mg calcium; 0 mg iron;


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Insurance Guidelines For Whitehouse Texas
22 Nov 2018 08:53
With auto insurance coverage premiums on the rise , it has in no way been far more essential to make positive you are receiving the ideal value quote that is match for objective. Right here are our leading tips to make certain you get the ideal deal on your vehicle insurance coverage. Terrifying figures from AA drive home the point that taking possibilities on the slopes with no adequate insurance coverage could cost you a fortune. Helicopter mountain rescue, at about £20 a minute flying time, works out at £500-£1,000 in Europe and £1,000-£2,500 in the US. Manipulation therapy of a dislocated shoulder, meanwhile, expenses up to £2,000 in Europe and £10,000 in the US, whilst flying you back to Britain from Europe with a fractured hip can hit £10,000 and double that from North America.A handful of insurers let you lock in a quote up to 60 days ahead of the begin date, so you can guard against any future premium increases - Aviva and Quotemehappy do this. When locked in, the value is fixed topic as extended as your particulars do not alter but you can always change your mind if you discover a less expensive deal ( see why buying 21 days ahead is least expensive ).Your insurance coverage strategy encompasses a lot a lot more than a table of rewards it really is critical that you take a lot of different elements into consideration. Having the greatest insurance coverage coverage in the world will be of no use if you never have access to nearby medical doctors, specialists or hospitals that accept your insurance coverage strategy.Dallas L. Salisbury, president and chief executive of the Employee Benefit Investigation Institute, a public policy investigation group in Washington, mentioned that the cost for coverage in a group policy runs about $16.30 per $1,000 of coverage with a waiting period of 30 days and a maximum advantage of $15,000 a month. For individuals purchasing their own policies, he stated, the price is $18.60 per $1,000 of coverage but with a 90-day waiting period.In addition, a difficulty may arise if you have a second accident and it is discovered to be connected to perform undertaken for the 1st. If this does happen it would most probably result in non-payment of the claim, rather than cancellation of your insurance or being reported for fraud, but could still end up costing you £1,000s.You can add extra liability coverage over a car insurance program by buying a personal liability umbrella policy. This kind of insurance coverage will defend you from legal costs and settlements up to a considerably greater threshold than minimum-coverage car insurance.As I have been traveling for very some time now, I've grow to be fairly familiar with the travel insurance business and compared many diverse organizations. I've looked through what's truly integrated in the value and got a wonderful overview of diverse travel insurances that are suited for various kinds of adventures. Acquire your cover directly from the insurer rather than from a tour operator or travel agent. It will be cheaper, and if anything goes incorrect you will have recourse to the Monetary Ombudsman Service to claim compensation. Comprehensive coverage, which will cover damages to your auto occurring from events that aren't associated to accidents.Auto insurance coverage firms take several factors into account when calculating your premiums, and your credit history is one of them. If you have any questions with regards to in which and how to use webpage; https://Patriciamontes.7X.cz/,, you can contact us at our own site. Some states have produced this illegal, but in numerous, it remains a legal and frequent practice. Spend your bills on time and maintain a decent credit rating it will support you to look low-risk and consequently help to preserve your automobile insurance coverage prices down. The difference in auto insurance coverage prices for great credit" drivers and poor credit" drivers is a staggering 67%.We all know and comprehend that our Canadian Wellness Insurance Program is not obtainable outdoors of Canada, at least not to the levels that we have come to anticipate. In fact, these days only about 10% of a person's out of nation health-related charges will be covered by their Provincial Wellness Insurance coverage.But even though EHIC is worth obtaining for the additional protection - some insurers will waive any excess you have to pay if you use you use the card - you shouldn't completely rely on it. CBC News spoke to travel insurance professionals following a CBC Go Public report this week that a retired B.C. woman who was treated in a California hospital is now facing a $50,000 US hospital bill, Please Click The Up Coming Document regardless of purchasing health insurance coverage.Fill in the gaps. An typical policy will cover the basics, but you may require to add additional coverage to meet your unique requirements. For instance, you may have things like electronics or a nice piece of jewelry that would be financially hard to replace, even with the help of your typical renters or home owners policy. You may possibly want to add extra coverage for these items.
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Ashland has spent $400,000 on a 185-m2 addition to its paints and coatings analytical and technical center in Wilmington, Del. Now 930 m2, the center can support customer paint trials ranging from small-scale screens to simulated field applications, according to Ashland. The company makes paint ingredients including rheology modifiers and surfactants.


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Guys, Already the developers are pissed off by samsung! And now, we are flaming/trolling with each other and making things more difficult. I'm amazed that Codeworkx still poking at this thread even after so mach annoyance from samsung and people'...
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The Cleveland Clinic Foundation has appointed Stefan Strein as chief investment officer, after going several years without a CIO.
Strein is leaving his position as CIO at the $2.7 billion Annie E. Casey Foundation to lead Cleveland Clinic's $12.6 billion fund. He announced the move in a LinkedIn post Monday, writing that he would start at Cleveland Clinic in two weeks.
A Cleveland Clinic spokesperson confirmed the appointment Thursday evening.
The $12.6 billion fund includes foundation assets and pension capital, according to a June 2015 financial report. It is unclear whether Strein will lead the entire portfolio, or segments of it.
Currently, Cleveland Clinic's highest ranking investment officer is George Mateyo, who has served as senior director of investments since 2010.
Cleveland Clinic has outsourced management of its assets to Strategic Investment Group since April 2009.
Strein has been at the Casey Foundation since 2005, when he was hired as an alternative investments manager. Prior to joining the foundation, he worked as a venture capitalist at Tritech Partners and NextGen Capital, making investments in technology and health care companies.
Strein serves on the investment committees of the Planned Parenthood Federation of America, Baltimore Community Foundation, and Maryland State Retirement and Pension System.
He holds a master's degree in finance and international business from Johns Hopkins University.


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Nursing Disaster Preparedness in Case of Tornado Nurses play an important role in disasters because of the need for emergency treatment required in disasters. The emergency treatment includes assessment and evaluation of injuries, triage of the patients, stabilization of the patients and providing emergency management of wounds and injuries with the resources available. The activities that nurses perform in emergency situations are not performed in isolation. Several other emergency response agencies are also involved in treating and evacuating patients from disasters and the activities of these organizations need to be coordinated by the nurses. This paper discusses the plan of response by nurses to a natural disaster caused by a tornado...The end:
.....eeping by nurses in the chaos of the tornado aftermath is necessary to provide effective communication in the rescue and evacuation efforts. Clear and effective communication is needed to provide direction to the rescue workers. References American Red Cross (2010). What do I do after a tornado? Retrieved from http://www.redcross.org/portal/site/en/menuitem.53fabf6cc033f17a2b1ecfbf43181aa0/?vgnextoid=6ec01c99b5ccb110VgnVCM10000089f0870aRCRD&currPage=ad2e0726d6312210VgnVCM10000089f0870aRCRD Lundy, K.S. and Janes, S. (2003). Essentials of community-based nursing. Sudbury, MA: Jones and Bartlett Publishers. Lundy, K.S. and Janes, S.(2009). Community health nursing: caring for the public's health. Sudbury, MA: Jones and Bartlett Publishers.


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Marc Nemenoff
Marc Nemenoff gives his readers an insight into the decision making process of a professional trader and analyst with 35+ years of market experience. He covers the markets with which he has had the best success throughout his career with. Contact Mr. Nemenoff at (312) 264-4310
The Nemenoff Report 03/12/2020
Financials: June Bonds are currently 3'01 higher at 183'18, 10 Yr. Notes 1'14.0 higher at 138'26.5 and the 5 Yr. Note up o'24.50 at125'02.5. The Bonds have had quite a week with lows of 179'17 and highs above 193'00 (basis March contracts) as the market gyrated on coronavirus and European stimulus news. For a brief moment all treasuries including the 30 year Bond traded with a yield below 1.0%..It now appears, based on Fed Fund futures, that next week the FOMC may lower rates by an additional 50-75 basis points. As I mentioned last week, look for a global competitive race to the bottom as far as rates are concerned. I still have a neutral bias at this time, but I will be looking for opportunity in Eurodollar spreads over the next week.
Grains: May Corn is currently 6'0 lower at 368'4, Beans 17'2 lower at 856'0 and Wheat 8'2 lower 503'0. Took profits on long May Corn positions and looking to reinstate the position on any further sharp break (10-15 cents) from current prices.
Cattle: Live and Feeder Cattle have followed must other markets to the downside as traders and hedgers ponder the economic risks associated with the coronavirus. People will not go shopping for fear of contracting the virus in a crowed enclosed space. The predominate trend is to the downside.
Silver: May Silver is currently 45 cents lower at 16.32. Silver is exhibiting collateral damage as equities drop along with interest rates and just about everything else that is traded. I'm staying long for the moment. My thinking is that lower rates and a faltering Dollar should eventually add value to this marked which has a history of being a store of value, 2nd to Gold
S&P's: June S&P's are currently down the 5.0% limit ( 139.50 points) at 2589.50.The corona virus is the story as market participants watch the travel and leisure businesses crumble along with many other businesses that require the movement of crowds of people in enclosed places. The economic consequences are currently just theory but will probably be self full filling prophesy. I am taking profits on all short biased position (futures and options Support starts a 2520.00
Currencies: As of this writing the Mar. Euro is 18 lower at 1.1266, the Yen 54.5 higher at 0.96195, the Pound156 lower at 1.2688 and the Dollar Index 0.603 higher at 97.095 During the last week we were stopped out of long Pound positions and remain long the Euro and short the Dollar Index.


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- Car Spaces: 4
- Property type: Offices
- Floor Area: 107
- Total Car Spaces: 4
- Listing type: For Lease
- Occupancy Title: Partial Building
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Located on Mann Street in this large commercial premises which includes -
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Through my company I have had numerous dealings with Tony Myers (representing Clients who have either been Selling a Property / Development Site or Buying a Property / Development Project) and can openly recommend Tony as a person of the highest integrity, with a level of professionalism rarely displayed by Real Estate Agents.


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Conservation action: The Galapagos hawk has been under protection by Ecuadorian law since 1959 and has now been protected from international trade due to its endangered status. The Galapagos Islands have a National Park that covers 97% of its land space, protecting the land in which the Galapagos hawk lives, and is a UNESCO World Heritage Site.
The Galapagos Hawk is the only species to occur in Galapagos and is readily identified by its dark plumage. The sexes are alike although females are larger than males. The Galapagos Hawk is a resident of the Islands and it is a sedentary species. Found on most of the islands and occurring in all habitats from the coast to the highlands. It only.Disclaimer: The Animal Diversity Web is an educational resource written largely by and for college students.ADW doesn't cover all species in the world, nor does it include all the latest scientific information about organisms we describe. Though we edit our accounts for accuracy, we cannot guarantee all information in those accounts.Galapagos Hawk. The Galapagos Hawk is the top natural predator in the Galapagos. It is found on most of the islands and in a range of habitats. Despite this, it is one of the rarest raptors in the world, classed as a vulnerable species.
Galapagos Islands College Class Name Date Galapagos Islands 2 The Galapagos Islands are located near Ecuador that was born from volcanoes erupting violently out of the sea. Plant and animal species traversed 1000km of ocean to colonize the islands, leaving species isolated and evolving independently on different islands. Observing this had a.
This Galapagos Islands Essay example is published for educational and informational purposes only. If you need a custom essay or research paper on this topic, please use our writing services.EssayEmpire.com offers reliable custom essay writing services that can help you to receive high grades and impress your professors with the quality of each essay or research paper you hand in.
Criteria: D1 Click here for more information about the Red List categories and criteria Justification of Red List category This species is listed as Vulnerable because it has a small population. Trends are not clear, but are assumed to be stable. If threats, notably persecution, were shown to be causing a decline, this species would warrant uplisting to Endangered.
Essay What Is The Galapagos Islands? What is the Galapagos Islands? The Galapagos Island Galapagos Islands area group of archipelago made of volcanic islands. The islands are distributed some 600 miles west of continental Ecuador. Galapagos island is estimated to be between 3 to 10 million years old and lies on the Nasca tectonic plate. The.
Outside the Galapagos, the animal on top of the food chain is a large carnivore like the jaguar in South America or the polar bear in the Arctic. In the archipelago, this distinction belongs to the Galapagos hawk (Buteo galapagoensis), a large endemic bird of prey. As the apex predator, it has no natural enemies, but is classified as vulnerable.
The Galapagos Islands, where Charles Darwin developed his theory of evolution, are at risk of being ruined by tourists. Indeed, animals are disrupted by large numbers of tourist abandoning their babies and eggs including the famous giant tortoises. It's a disaster for all fauna on the Galapagos Islands but as well a real risk for the flora.
Galapagos Island Contrast Essay In both passages on the Galapagos Islands, it is clear that authors have differences in style and tone. Both authors differ in expression, tone, and writing style which is visible through their accounts of Islands. The first author describes the Galapagos Islands using detailed observation as he would in a.
The Galapagos Islands Introduction Just off the coast of Ecuador is where you can find the volcanic islands of the Galapagos.Here you can find unique animals and plants that can't be seen anywhere else in the world. The Galapagos Islands gave British scientist Charles Darwin the opportunity to create his theory of evolution (attention statement).
What can I do in Galapagos? The Galapagos Islands offers everyone the possibility to enjoy a great variety of activities for all ages, interests, and fitness, ranging from the contemplative to the adventurous, and knowing that in everything you do you will experience the best of the wildlife and nature.
Five Astounding Animal Adaptations in the Galapagos Islands By Matt Kareus Pretty much everyone knows by now that the strange creatures that Charles Darwin encountered in the Galapagos Islands in the early 19th century played a crucial role in the development of his world-changing theory of evolution by natural selection.
This is your ultimate source for Galapagos Islands Information! On this page, you will find everything you need to know about Galapagos Flora, Fauna, Climate, Geology, Park Rules, and Important Tips for your upcoming Galapagos Tour. Additionally, here's a shortlist of our blogs that are relevant to this topic.
The Galapagos National Park ( GNP ) is one of this. 97 % of the country covered by islands was designated as a national park in 1959. The lands non included were the colony countries. Subsequently in 1967. a park service Galapagos National Park service ( GNPS ) was set up to supervise direction and disposal of the park. The GNP is made up of 13.
Sleek, strong and a skilled hunter, the Galapagos hawk (Buteo galapagoensis) is an apex predator endemic to the Galapagos Islands.The North American ancestors of this beautiful bird of prey are believed to have come to the Galapagos some 300,000 years ago, and it has since adapted to life on various islands of the archipelago.
Environmental education efforts on the Islands help their inhabitants understand the larger picture and need for conservation, and responsible tourism and enforced park guidelines help preserve the Galapagos for the future. But there are seemingly endless needs for the park's preservation, and always limited funding. Other than what little.


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Following the 3-day trip with you, I went on a 2 night/3 day tour with a tour company from _____, well in terms of quality, there is no comparison!!! So don't change a thing. I enjoyed every minute of it.
And forget not that the earth delights to feel your bare feet and the winds long to play with your hair- Kahil Gibran


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Usain Bolt gone, doping back as the main topic in sprint game
Updated : September 22, 2019 08:00 PM IST
Usain Bolt is in the rearview mirror, replaced by — what else? — an unfolding doping saga in track and field.
The title of "World's Fastest Man" now that Bolt is on the sideline belongs to American 100-meter sprinter Christian Coleman, who almost was banned from this month's world championships because he had missed too many drug tests.
Now that Bolt is gone, the top two contenders in Saturday's 100-meter final are expected to be Coleman and defending champion Justin Gatlin, a 37-year-old who has been suspended twice for doping violations and whose victory at worlds in London in 2017 was greeted with skepticism from the media and boos from the stands.


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11.5 in. Top, 9 in. Lengthy, 9 in. Wide
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Collect rewards and items in the mail with each battle won, as they will help you evolve your trained fighters. The more you evolve your warriors that are beautiful, the more their physical appearance changes. And with"changes", we mean"they get super exposing, teasing you endlessly". And, if you can't get out of the headspace these steaming hot visuals have driven you to, the game does feature a helpful"auto" mode that will play the best moves, and that means it's possible to keep focusing on your most recent win- or else, you know, whatever is holding your attention.
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Pool side grudge match is about to happen... and looks like you don't wish to miss an event like this - so waste no more time and play this game! It make take some time to geyser the game however - there will likely be 3D cuties with quite a number of animation after all! First you might have to prepare your woman before the match. There won't be much options at first-ever but if you keep winnning exhibitions and earning some coins you will be able to unlock unique features, secret concoctions and other things. During the match you will need to activate proper moves and abilities at the proper instant - it make take some time master this game. But even in the event that you loose you won't be a looser - how can you loose into a game where chicks are using moves like"grab the cherry" and"sucker kiss"?
Categories: Adobe Flash Games
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What could be nicer than looking at depraved manga porn pictures with beautiful and huge-boobed nymphs. This game gives you such a chance. It's very plain. Just click the mouse on the desired point on the screen. Then the picture will change to another one. That's all the rules of this game. Enjoy the gorgeous ladies who display you big and fleshy tits without a trace of embarrassment. Or a pink poon that is ready to take a thick pink cigar again and again. Enjoy the depraved manga porn pictures for as long as you want - in this game there are a lot of them. Do not delay and embark playing this lecherous game right now - huge-boobed nymphs are waiting for your attention.
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Categories: Adobe Flash Games
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How about scolding the beautiful dark haired Asaki. It is in a box and tied by chains. Your mission in this game is to rape dark haired Asaki in her pink and cock-squeezing fuck-holes. For this you must interact with the game objects. First, let's undress Asaki. Use mouse for this activity. Then click on the control panel on the right of the screen. There you can change the mode of sexual activity. Now it's time for fuck-fest. Take your big and fat dick out and commence hard fucking Asaki in her cock-squeezing and pink cunny. Do not pay attention to her cries, simply fuck Asaki until she reaches the peak of sexual pleasure. And then pack her lovely face with your hot and gloppy sperm...
Tags: fuck, cum, over, cage, need
Categories: Adobe Flash Games
Views: 68k
Juicy lady Hinata offers you an interesting game. You will have to tell her about the anime. Where did it come from, how is it different from other styles and who are the key characters of the Naruto series. Hint - nicer find out all the information on the Internet that would look like a loser. On the screen you visit Hinata. Questions emerge on the left. There are four possible answers below. Pick the correct response. If the response was correct then Hinata will take off some of the clothes for each response. Should you answered incorrectly the game is over. The aim of the game is to response all questions and then you will see Hinata fully naked. You have a look at her big and cock-squeezing bosoms and pink cootchie. Or maybe you will have a chance to have romp with Hinata. You will determine the response in this game.
Tags: nice, movie, play
Categories: Adobe Flash Games
Views: 10k
In this game you will end up non other than Mr Smith. Quite a name that is good for private detective, don't you think? Well, at least your sexy Kylie approves. Not your name but that you have arrived just in time to have a dialogue with your new client. He is some prosperous businessman and just like any prosperous businessman he has a hot wife... and as any businessman's hot wife she doesn't mind to cheat on him from time to time! Or she is downright virginal and her hubby's accusations have no basis whatsoever? Well, you are the detective here so it'll be up to you to find the truth out! Just don't forget that you can have as many cootchies as possible during this investigation. Follow the story, mak edecisions and try to fuck any hot lady you will meet on your way!
Tags: possible, part, play, task, wife
Categories: Adobe Flash Games
Views: 9k
How about bringing the dame to orgasm and then fucking her into all the fuck-holes. First, select one dame out of three. Then look at the top of the game screen. There are instruments with which you need to undress a dame. First, pick the right implement. Then find the right place on the dame's assets. By way of example, place your forearm on her mini-skirt. Push the X. button. The miniskirt disappeared. Act correctly and undress the dame. But you need to be careful. In the event the dame wakes up, the game completes. To do this, look closely at the indicator at the bottom right of the game screen. Everything is fine, if the arrow of the indicator is in the green zone. After the dame is naked you can have bang-out with her.
Tags: woman, mouse, walkthrough
Categories: Adobe Flash Games
Views: 6k
Imagine a strange situation. The most important protagonist was captured by bloodthirsty cannibals. In their tribe, only beautiful and huge-titted women. They decide to give the protagonist one last chance to enjoy the feminine caress before they burn it at the stake. Girls will dance erotic dances. The protagonist has to pick any woman. If luck is on his side the woman will make the protagonist a gorgeous and depraved inhale job. She will caress his fat cock and play with plums. But if the protagonist was mistaken then he would be bitten off by his dick. If you are ready to try your luck then embark playing right now, because the protagonist wants enjoyments..
Tags: woman, roulette, alluring
Categories: Adobe Flash Games
Views: 3k
Beach tennis. Yep, title doesn't lie to you. In this game you will be playing beach tennis. Two beautiful femmes are going to the beach today to play some tennis. And if their Sexy swimsuits tell the truth then you can easily inform that one of them is american and the other one is british. The gameplay is pretty ordinary - you even will see the final spot of ball's trajectory. All you have to do is budge your character in the ideal spot (using arrow keys) and shoot the ball back (using spacebar and the strike strength meter on the left side of the screen). Even tho the gamplay scheme is easy it might take some time to get used to it. Aside from that it is fine and ordinary game for all worshippers of beach tennis. This game includes scenes of mild bareness that are not suitable for people under the age of 16.
Categories: Adobe Flash Games
Views: 368
In this game you are going to develop into a gymnastic coach for youthful talented ladies who ready to work hard to get a win. You have trained future champions for several years now and your fame now runs in front of you. For example one of your old friends want you to work with her stepdaughter this season... and even however this lady needs a great deal of working she has something in her that will make your training a pleasure for both of you - she is ready to do anything to get nicer... and it involves with romp with her trainer! Well, currency is not the sole thing that may be a reward for a well done job so... New game from"Fuck Town" series that will allow you to entice sexy gymnast lady and work on her skills in quite unusual ways that possible only in this type of games!
Categories: Adobe Flash Games
Views: 3k
In this interactive lovemaking flash game you will see beautiful and huge-titted anime women. And also who loves enlivenment, adrenaline and Mrs. luck. So look at the game screen. You see a lovely and huge-titted manga porn lady. On the left and right of the screen you see buttons with the words"click." Just click on it with your mouse. If luck is on your side, then the picture in the game will change. Give the correct answers in a row at 5, and you will discover a small amount of extra bonus. Otherwise, you will lose 1 Life. You need to try to catch Lady Luck by the tail to view all the depraved manga porn pictures in this game. You must also be patient, because the very first time it will be difficult. So if you want to try your luck and look at the animated pictures, then embark playing instantly.
Tags: little
Categories: Adobe Flash Games
Views: 2k
Being a coach for a gymnastycs team requires from you not only to train your students every day but also to care for them when it is necessary. For example one of your students is preparing for the exact important competition and that is why she spends hours and hours at the gym every day. Ofcourse she could use some assistance from you personally and as a fantastic trainer you will never turn down in cheering up your own students. And what can be a finer place to cheer up one of your most busty students than the showers after instruction? There will be some seduction part before the main act but it is impossible to shed here so don't worry - sooner or afterwards you will offer this cutie a distinctive course of physical excersises that she deserves... and very likely not formerly!
Tags: porn flash game
Categories: Adobe Flash Games
Views: 2k
Welcome to Springfield State College where for a few reasons all the schoolteachers, kurators and even the principal are females only! And that's not all - they all are getting turned on by the clever guys even if they wont flash it to you so the only way to see them nude and have some additional private lessons with them is to proove that you are the clever man first-ever! How? By answering their tricky quiz tests obviously! Each doll is specializing in specific science direction so you migth need all the skill you have gathered through your life. Also game has some exploration elements so it won't seem as one massive testing for you. Also don't forget about the ways your tecahers will revard you and ofcourse after seducing them all you can aim for the largest tits of the college (the main ones)!
Tags: history
Categories: Adobe Flash Games
Views: 8k
In thsi gig from Hentai Zone Archives you will see the supreme battle betwwen Fillia (you might know her if you have played"Skullgirlz" battling with videogame before) and non other than Zone-Tan (you very likely know her already)! Well, the battle is not the best choice of words actually - right from the beginning Zone-Tan will summon a great deal of tentacles and also that which Fillia will abandon to do would be trying to keep her head while being fucked in all of her crevices pretty intense! While you liking the showcase you might also to look for active spots on the screen - some of them will allow you to eliminate Fillia's clothing! To procceed to the next scene simply use yellow buttons with arrows drwane despise them. Well animated manga porn parody with one of the"Skullgirls" fighters - Fillia!
Tags: adult, zone, fucked, need, really, press, arrow, fighting, skullgirls
Categories: Adobe Flash Games
Views: 17k
Red and Wet - that's what you nee dto know about main heorine of this anime porn game before she will begin to function this good-sized and hard prick with her cum-hungry mouthwatering. But where is the gameplay here you might ask? Well the"genre" of this game is concentrated in customization optiosn that will allow you to switch over a dozen of differnet parameters to earn thi slsut to seem as you desire. You're able to change her hairstyle, turn on or off her top and bottom clothes parts, make her underpants to disappear in just one click of mouth button. You can change the size of her bra-stuffers or select one of few avialable tongue actions that will allow her to tease this large man rod! Wheneever you ready you can activate both cum shot and squirting actions and enjoy the results!
Tags: time, red, huge, dicks, suck, bitch
Categories: Adobe Flash Games
Views: 2k
Plants against nymphomaniacs - a new and titillating flash game. The aim of the game is to get larger plants on the field so that the nymphomaniacs can not pass through the field to the left edge of the screen. To do this, you should use your strategic mastery to guess which way the nymphomaniac will go. The initial levels of the game are very plain, and require just one plant to win. At higher levels of play, nymphomaniacs will be much more. And you have to blend plants to win this game. Learn the game management, that would not make mistakes and prepare to engage in battle at this time.
Tags: girls, place, tower
Categories: Adobe Flash Games
Views: 23k
Tsunade is out for a horseback ride and stops for a drink and look over to here friend and sees he needs some caring;-RRB- and finds out how hefty here new friend truly can be! ;) ---------------------------------- WARNING: This game includes the fuck-fest scenes where the toon horse features a fuck-fest with a cartoon woman. If it is illegal in the area where you are now or you personally aren't ok with that sort of fantasy, please don't play this game.
Tags: laid, version
Categories: Adobe Flash Games
Views: 32k
This lovemaking flash game will let you know about the individual driver of the truck. He is faggot and works in a huge corporation for the examine of swift food. His name is Romeo. Hence the game starts. Your building. Late evening. A new message pops up on the laptop screen. Let's read it. This is your chief, Elton. He asks you to come to him tomorrow at 12 o'clock. Romeo is going to the meeting. Sexual fantasies about Romeo show up in his head. He's a damn spectacular man. And he is also faggot. How it would be superb to suck his fat dick. With him depraved 7, and then do. Elton comes to the office of Romeo and comes to the meeting. They begin talking. Romeo looks at Elton and in the eyes the fires of depravity... Want to know the continuation of the story? Then begin playing at this time.
Tags: guy, play, little, buddy
Categories: Adobe Flash Games
Views: 14k
"Boobalicious Puzzled" is a puzzle game where you will be assembling pictures of hot anime chicks with big tits... and most likely at this moment you already know are you going to play this game or not. And if you are ready to accept the challenge then get ready to get through seven different puzzles where you need to exchange two puzzle chunks until they all will be in their proper positions. You can exchange any chunks and not only those which are next to each other. And after you will assemble teh whole picture there will be a surprise for - you will noy simply see this anime porn picture but you will see it as animation! That's right - seven fun and sexy manga porn scenes about buxomy ladies instead of boring static pictures will become your reward!
Categories: Adobe Flash Games
Views: 2k
The videogame"Nier: Automata" got pretty favored. Probably some component of this popularity is because of its principal hero - sexy lady who running around in short dress yet still kikcing some even metallic butts. In this game you will see a great deal more of her sweet booty... and more! Too much battling can make some mailfunctions so she has to check her internal systems from time to time. And today is the day! But since this is manga porn parody game the process will be contingent upon sexual actions. To start with 2B will need to suck salami for finer contact. Just enjoy the animation and switch intencity degree to full up joy meter across the left side. After some time you are able to go to the next scene - here you will see SB's big booty riding up and down on her mechanic's large salami. Next scene will be... well, why don't you find out yourself?
Tags: automata, time, movie
Categories: Adobe Flash Games
Views: 14k
Every time at Xmas season Santa's helpers have a lot work to do. And every time during this season one of those elves named Sparky is trying to have a pay rise. How come he still did not get it? If you are indeed interested then just play this game to find the response. Actually there's absolutely no purpose in trying to keep an intrigue notably when you already know that this game is brought to you by"Meet and fuck". All of Sparky's attempts are usually finishes up at the moment when mrs Claus pull out her ample round tits and offers him to play with them instead of getting more currency. Might be Sparky didn't get his payment rise once again but his xmas spirit is undoubtedly got stronger! And looks like this year he will get a little bit more than simply a chnace to play with biggest tits he has ever seen...
Tags: fuck, time, meet, version
Categories: Adobe Flash Games
Views: 17k
It is time for ground defender Sonya Blade to face her nemesis Kano in a final combat... or as we allknow it - Mortal Kombat! And as this game is from"GamesOfDesire" studios you already know that this rivalry is going to turn up the fever! It slightly will be a spoiler as this scene is going to be the opening one for entire game - Sonya is about to loose the fight and Kano is ready to present her fatality... but then he decides to use his new stir called"sexuality" instead! And from this moment Sonya is going to have a lot of close counters together with Kano's humungous and hard stiffys using unique elements of her figure... Enjoy the scene and activate differnet scenes when they will becaome available to stir further. A number of the scenes will probably likely be manually controlled minigames.
Tags: butt, babe, cum, kombat, mortal, fucked, version, sonia
Categories: Adobe Flash Games
Views: 14k
Now you have to fuck girl and make her feel real good. As always in this kind of games you may switch between watch and sport modes. To finish the game make sure that pleasure bar is filled more than stress bar, or you are going to have to start over.
Tags: fuck, games, need, going
Categories: Adobe Flash Games
Views: 6k
Upskirt Negotiations - Team Pep Rally
The language of this game is chiefly japanese so if you are here for story, dialogs and interesting characters then... well, you could use any skill of japanese language! But if you are her to see exactly just how cute anime woman in basebal uniform is getting rid off this uniform then you are welcome! But first-ever you will need to bypass few dialogs anyway... To control the game you will need to shove colored buttons that becomes active at certain moments of the game. At the beginning this woman will be preety bashful so you will have to use all the opportunity you can to slink peek under her short mini-skirt but while the game will progress not only you will be allowed to witness at her undies freely - you will be allowed to take them off and have a private training session together with her!
Tags: play, baseball
Categories: Adobe Flash Games
Views: 39k
Best 3D Hentai SPORTS GIRL fetish sportUniform paizuri handjob oral crempie
Tags: babe, kink, sensual, hd porn, big dick
Categories: Hentai Videos
Views: 54
Mila Nude Running In a Treadmill
Tags: music, babe, alive, dead, mod, dead or alive
Categories: Dead or Alive Hentai
Views: 5k
Things don't go as planed(overwatch)
Categories: Overwatch Porn
Views: 3k
Tags: babe, fetish, kink, alive, dead, girls, lisa, dead or alive
Categories: Dead or Alive Hentai
Views: 3k
Tags: sfm
Categories: Overwatch Porn
Views: 11k
Iron DICK SOLID - INFILTRATION
Tags: kink, metal
Categories: Metal Gear Porn
Views: 3k
Toon Mashup 1(Soria, Lara croft)
Categories: Lara Croft Porn
Views: 7k
Nico Robin gets Fucked One Piece 3 dimensional BB
Tags: piece, teenager, one piece sex, nico robin
Categories: One Piece Hentai
Views: 37k
(Overwatch) Ravaging Mercy Point of view [Sound]
Tags: sfm, dick, ass, butt
Categories: Overwatch Porn
Views: 8k
Minecraft Sonic Porn [Sooooo Sexy]
Tags: minecraft
Categories: Sonic Hentai
Views: 6k
Tags: legends, league
Categories: League of Legends Hentai
Views: 6k
The Royal Approach - Japanese Subtitle
Tags: dick, zelda
Categories: Legend of Zelda Hentai
Views: 3k
Stunner Select: Ibuki from Street Fighter Sexy Gameplay!
Tags: fuck, fighter, view, point
Categories: Street Fighter Hentai
Views: 8k
Disney Porn: Ariel's naughty side has come out
Tags: head, red
Views: 11k


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03 Jul 2018 01:53
Instant Setup For Quickly and Secure WordPress Hosting. Not too long ago I was invited to ResellerClub's occasion referred to as Cloud Bazaar in Mumbai. I spoke about my digital marketing journey and how to help companies with digital advertising and marketing for an hour in the principal auditorium. Then there was one more 1 hour of parallel track section which was far more like a workshop on blogging.The couple also worked tirelessly. Barely had they finished one total residence redo when they bought an additional fixer-upper and then a third, as if they have been trapped on a residence-jumping hamster wheel by the require to produce weblog content material. Last November, the couple posted a to-do list for their latest home, a stately brick four-bedroom with a showcase lawn. If you print the list, it runs to 20 pages. You could exhaust yourself just reading it.In general, mentioned Sarita Schoenebeck, an assistant professor at the University of Michigan School of Info, who co-authored the analysis, each kids and parents regarded positive images, events and news far more appropriate to share than unfavorable ones. Parents can consider, too, the searchability and reach of the format (despite the fact that these are usually evolving). A frustrated tweet about a youngster who will not eat her cereal because it really is not in a red bowl is a lot less most likely to resurface than a YouTube video of the resulting tantrum. Seeking for suggestions or sympathy about a behavioral issue? Skip each the image, and your child's name, in a post to limit later searches.Blogging is at the heart of WordPress. With the rise of digital marketing, brands are making brand memes to encourage communication and shares on social media. It is essential for a viral visual advertising and marketing approach and enhances your brand's visibility. You can also choose regardless of whether or not to use Wordpress for an add-on domain.Twitter, which does not yet make money, is now concentrating on teaching organizations how they can join and use it, Mr. Banerji stated, and the business plans to publish case research. He is also developing merchandise that Twitter can sell to firms of all sizes this year, which includes attributes to confirm businesses' accounts and analyze traffic to their Twitter profiles.Wonderful blog posts do not just come about. Even the best bloggers need a rough idea to hold them on-track. This is exactly where outlines come in. List your weblog to draw targeted traffic. You can add a Blogger website to Blogger's listings 3 You can also list your weblog with directories like Technorati or Blogdex.Figure out your niche. What are you promoting and to whom? Start off by making use of skills that you already have, such as writing, web design, or perhaps graphic arts. Seek out familiar industries and attempt to cater to their advertising and marketing needs however you can.Consider of this as foam rolling for your thoughts. Most of us wake up currently swimming in thoughts a sure sign that our mental treadmill is becoming overrun. A study at the University Of Waterloo identified that just a simple, ten minute breathing meditation helped these about to undertake a hard process with their anxiousness, capacity to focus on the present moment and overall productivity. Think about what a wholesome state of thoughts it can spot you in if you do it each day upon waking. Set a timer, sit on the floor or in a chair, shut your eyes and simply focus on your inhales and exhales. If 10 minutes already feels daunting, start with one minute meditations before adding a minute every week. The calm and clarity that comes from such an straightforward activity will make sure it becomes a morning necessity in your life.