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By: Jamie Birdwell-Branson
Long gone are the days of Don and Betty Draper, where the majority of men toiled away in the city at their “big jobs” and made their big money while their wives stayed at home with the children. Women are working, thriving and sometimes even out-earning their partners by a significant amount. According to a Pew Research study, 40% of American breadwinners are mothers, and 37% of those women are wives who make more than their husbands.
This gender role reversal has sparked hundreds of studies, books, articles and also feuds between husbands and wives. We have entered into uncharted territory and sometimes it can be a little daunting to know how to navigate out-earning your partner. A New York Times article entitled “Breadwinner Wives and Nervous Husbands” said that “while men tend to applaud their spouses when they help to bring home the bacon, husbands aren’t always as enthusiastic when women start bringing home the filet mignon.”
So how do you define the terms of your relationship when you are bringing home the filet mignon (with maybe even a side of lobster)? What should you do if your partner is frustrated that you make more money? What do you do if you are frustrated that you might be “carrying the load” by yourself? Here are some tips to handle being the breadwinner in your family:
- Don’t say sorry.
Be proud of that paycheck because you EARNED it. You have worked hard to get where you’re at and it’s unfair of your partner to expect you to be apologetic about your earnings. There is a difference between being humble and being apologetic, however. Be sensitive to your spouse if they have recently lost their job, are venturing out into a new career field or if their chosen career just doesn’t pay as well as yours. Money is always a tricky subject, but with open and honest conversation it doesn’t have to be.
- Split after-work chores fairly.
According to a survey by the American Bureau of Labor Statistics, 19% of working men did housework on an average day versus 49% of women. Women who work are more statistically likely to do the majority of the housework and childcare, even if she makes the same or more as her male counterpart. The best way to change these numbers is to make an effort to split the housework and childcare up evenly or proportionally. Agree on a detailed housework schedule and stick to it. Balance is the key to prevent resentment from either side.
- Remember that you are on the same team.
While it may seem cliché to tout teamwork in a relationship, the truth is that you ARE a team. The two of you work together to create a life, and you will play different roles in that life. Just because your relationship doesn’t fall into the gender norms doesn’t mean that you shouldn’t look at your partner as just that—a partner in life. Work together to get things accomplished. If your partner makes dinner, you should do the dishes. Or if you’ve been having a lot of late night meetings, your spouse should pick up more of the household chores and make sure the kids are doing their evening homework. Make your life as balanced as possible. While you may not achieve true balance, you should always strive for it.
- Seek out role models.
Do you have a great example of a couple in your life who just seems to have it all? Ask them what their secrets are. Do any of your coworkers earn more than their spouses? Ask them for advice on how to handle it. Your peers can give you real, true advice that has worked for them.
- Find a financial plan that works for you.
Although your mother might tell you differently, joint checking accounts are not for everyone. Figure out what you and your spouse are most comfortable with when it comes to finances and stick to the plan. Do you have a knack for finances and want to take care of all the bills? That’s great, but make sure your partner is comfortable with that as well. If you both want to have a sense of control over the money, then split the bills down the middle or transfer money back and forth between bank accounts. Do whatever it takes to get that balance that brings harmony to your household. What works for you might not work for other couples. If splitting the bills right down the middle wouldn’t be considered fair, then figure out what would be proportional between the two of you.
While it is encouraging to see that women are working hard and earning good money, it takes a lot of support from family and friends to ensure that attitudes change toward successful working women. The most important thing to remember is to make sure you choose a spouse who is supportive of your goals, and that you are also supportive of theirs.
Image courtesy of Ambro/freedigitalphotos.net


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Indiana’s average COVID-19 daily deaths pass April peak
INDIANAPOLIS (AP) — Almost one in six of Indiana’s COVID-19 infections during the pandemic have been confirmed in the past week as the state’s daily average of coronavirus deaths has reached its highest level following a steep increase since September.
The Indiana Department of Health’s daily update on Thursday reported 59 more coronavirus deaths occurring over the past several days. Those raised the state’s seven-day rolling average of COVID-19 deaths to 43 per day, passing the previous peak in late April.
The state was averaging about 10 daily deaths in late September when the current surge of new infections and hospitalizations began.
Indiana has now recorded 5,143 coronavirus deaths, including both those with confirmed and presumed infections.
The nearly 7,500 new infections reported Thursday give the state almost 45,000 confirmed cases in one week’s time, or about 16% of all such infections since first Indiana case was confirmed about 8 1/2 months ago. The state’s moving seven-day average of new infections is about seven times higher than in September when Gov. Eric Holcomb lifted nearly all business and crowd size restrictions.
Holcomb reinstated crowd limits last week and has appealed for people to abide by the statewide mask mandate as steep increases in COVID-19 patients are straining hospitals around the state.
Indiana hospitals were treating 3,063 COVID-19 patients as of Wednesday — a 300% increase since late September.

domain: medical


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The Serbian pianist Srdjana Jovanovic Gouka (1987) started her musical education at the age of 7 as an exceptionally gifted pupil of Aleksandra Striković at the music school of Mokranjac in Belgrade. In 2010 she graduated with the highest grade from the Faculty of Music where she studied with Professor Dejan Stošić. That same year she left her home country to start a Master Program at the University of Stavanger. She obtained her Postgraduate diploma in the class of Håkon Austbø in 2013.
Srdjana has won many prizes in both national and international piano competitions.
In 1998 she received the 2nd Prize in the Competition for Young Pianists in
At the international competition “Pietra Ligure” in Italy she won a 2nd
prize in 2000. In 2002 she was awarded the Absolute 1st Prize at the International Young Musicians Competition in Barletta, Italy.
In 2013 she was unanimously awarded the prestigious Shell Prize in Stavanger, Norway. Her first recording was released in November 2013 as part of this prize.
Despite her youth, Srdjana Jovanovic can already look back on extensive concert activity.
She performs regularly in Serbia, Norway, the Netherlands and Italy, as a
soloist and in chamber music ensembles. As a student in Stavanger she was
engaged in a great number of performances and projects, thus notably contributing to the cultural life of Rogaland County. She received high acclaim for her participation in the children’s opera “Brundibar” by Hans Krása with performances in Bryne, Oslo and Stavanger and “The Telephone” by Gian Carlo Menotti with sixteen performances in Stavanger in April 2013.
In her extensive repertoire, ranging from Bach to Messiaen, twentieth century music plays a significant role. The two year Master course with Professor Håkon Austbø was specifically aimed at deepening the understanding of contemporary music as a vital part of our whole musical heritage.
For two successive years Srdjana was invited to work as the official accompanist of Elizabth Norberg-Schulz and Erling Eriksen at the Filarmonica Romana in Rome, Italy.
Her love for chamber music resulted in founding two ensembles: piano duo Gouka-Jovanovic, with the Serbian-Dutch pianist Miloš Gouka, and Duo Slavistico

domain: artistic


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Sponsored Content: Sero, A New Design Approach by Tandus
Today’s office design utilizes more day lighting, less walls, and more collaborative work environments, opening up large areas of the workplace and putting more emphasis on the floor plane. Collaboration is the key element in this new design as traditional L-shape workstations are being replaced with straight counters, a style known as benching. Benching has opened the floor plane; and new, more sophisticated floor styles are being specified. Another important factor in a healthier work place is lighting. More offices are converting drywall to glass for a more transparent environment with the use of day lighting. This transparency puts more emphasis on the floor plane, again requiring a refined, yet contemporary floor design.
This change in the workspace environment led
to innovate a new design technology called
. Tandus’ break-through Sero design applied to hybrid resilient flooring (
) and modular carpet was made to create stunning vistas in the collaborative officescape. Two unique floorcoverings working in tandem in fresh, new innovative design options through the layering of texture and color to create patterns that break the boundaries of the square.
The Sero design technology produces fluid transitions of pattern and color, allowing patterns to shift, flow and pool across the entire floor plane for a dramatic unified design statement that visually transcend the limitations of the room.
Tandus and Sero design technology work in tandem to offer designers maximum creative flexibility. In today’s officescape where floorcoverings are now more visible, more personal and a greater part of the office experience, Sero designed hybrid resilient flooring and modular carpet offer flawless design possibilities.

domain: design


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Shop Local ~ Support Local
Shopping small can make a big difference.
At Circle FCU, we believe that shopping small and supporting local businesses is one way that we can help invest in our community. Our "Shop Local ~ Support Local" program is designed for small, local businesses to receive the recognition they deserve. Month to month, we will be featuring a new small business. At this small business, we will have a box set up for customers to enter a drawing for a chance to win a $50 gift card to that business.
So far, our "Shop Local, Support Local" box has been to:
Oh My! LLC - December 2019
Apothica Teas - January 2020
Thymeless Treasures - February 2020
Gabrizio Italian Cafe & Bakery - March 2020

domain: economics


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MEXICO CITY, April 26 (Reuters) - Mexico is considering ramping up shale gas production to support its petrochemicals sector which has traditionally used feedstocks based on crude oil, the country’s energy minister said on Tuesday.
Although the prolific shales of Texas are believed to extend across the border into northern Mexico, little has been done to develop the deposits due to the state-controlled industry’s focus on producing crude oil.
“It’s on the agenda ... (Shale gas) changes the way we should be thinking about our hydrocarbons sector going forward,” Energy Minister Jose Antonio Meade told reporters.
State oil monopoly Pemex [PEMX.UL] completed its first shale gas well in March, tapping into the Eagle Ford formation in Coahuila state near the Texas border. However the company has been slow to get into the gas business due to low returns compared with oil drilling, forcing Mexico to import gas from the United States and in the form of liquefied natural gas.
Shale gas has radically altered the North American natural gas industry, dramatically boosting U.S. gas reserves and putting off the need for large scale imports from outside of North America for decades.
U.S. President Barak Obama embraced shale gas in his March energy policy statement despite the objections of environmental groups who say the production methods used by shale gas producers contaminate ground water. The technology is currently under review by the U.S. Environmental Protection Agency.
However, shale gas has revitalized the continent’s petrochemicals sector, once thought doomed due to competition from Middle Eastern producers with access to cheap oil, by boosting production of cheap, gas-based feedstocks.
Dow Chemical Co DOW.N announced plans last week to boost ethylene and propylene production in the United States due to plentiful shale gas feedstocks. [ID:nL3E7FL2XP]
Pemex’s petrochemicals arm, long starved of investment, has been slowly turned around in recent years. (Reporting by Robert Campbell; editing by Jim Marshall)

domain: news


Letter: Climate change a national threat
A State of the Union traditionally offers a candid assessment major problems, a positive vision of how things might be, and guidance for Congress on how to address those issues. However, President Trump's speech was notable because of what he did not say. Not once did he utter the words "climate change."
Yet, polls show that recent climate-related events increasingly have led Americans to regard this as a major threat to lives and livelihoods, our communities and even our national security. Climate change is our true national emergency.
The reasons for such a glaring omission reflects the political ideologies of those who surround Trump as advisers, cabinet members and financial donors. It also arises from this president's own limited abilities to read, listen, comprehend and draw reasoned conclusions.
Once we accept, however, the overwhelming scientific evidence on the "what and why" of climate change, a clear direction forward appears.
Basically, policies can be of two types. Some can move us toward reducing future greenhouse gas emissions, while others can help us adapt to the consequences of the climate changes that already have occurred or are likely.
Although Trump made no mention of either, both of these types were noted in the "democratic response" that followed.
A House Speaker of years past famously remarked that "all politics is local." To this we might add that all climate change policies should be nonpartisan. They must be based upon science, environmental and economic, and provide us with forecasts of likely outcomes under different scenarios of action or inaction.
One such analysis appears on the web pages the Citizens' Climate Lobby. Specifically, the study reports on the impact that a revenue-neutral, carbon fee and dividend (CFD) would have on the U.S. economy over the next 10 and 20 years.
CFD is only one example of the first type of policy, but it is very similar to an actual bill introduced into Congress last month. As a regional economist myself, and one who has used econometric methods in his own work, I found this study's predictions to be not only revealing, but beyond my professional criticism of its design or empirical methods.
This study is also interesting because it offers forecasts of the impacts of a CFD at both national and regional levels.
Nationally, the estimates suggest that after 20 years alone, there would be a 50 percent reduction of carbon emissions from 1990 levels, while creating an additional 3 million jobs over what would otherwise occur, and 250,000 fewer deaths from reduced pollutants in the air. And regionally, for Wisconsin and four other states, the impact in each of these three areas, and other areas, is even more favorable than it is for the nation as a whole.
If all politics is local, and climate change is nonpartisan, our elected representatives at all levels might wish to take note. And hopefully, then act.


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We’re teaming up with the BC Poverty Reduction Coalition, Raise the Rates and many other groups for a Poverty Free BC March and Rally on March 4, 2017. Please join us!
This is our chance to raise our voices together and show candidates in the provincial election that we’ll be voting for politicians that commit to a strong, comprehensive poverty reduction plan.
Ave-Eva Nancy Trigueros
Paul M. Taylor
Ghazal Arefi Afshar

domain: sociology


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The dispersions of solid lipid nanoparticles (SLN) are currently being studied for various therapy applications, to overcome problems of physical and chemical stability, cost and encapsulation efficiency associated with conventional liposomes. Oral mucositis is a comorbid affecting patients in treatment of head and neck cancer. Conventional therapies are palliative, such as local anesthetic and cryosurgery and/or involves, also, the use of local anti-inflammatory and antibiotics which action efficiency is reduced by the low residence time at the site of action. The local application of laser is restricted due to higher cost. The main purpose of the project is developing a multifunctional pharmaceutical form with low cost for topical oral use with anesthetic, antimicrobial and healing effects for the treatment of oral mucositis. This pharmaceutical form is composed of a polymer film formed by electrostatic binding of polyelectrolytes, chitosan (antimicrobial) and hyaluronic acid (healing), incorporating lidocaine hydrochloride (anesthetic). Additionally, in this film will be incorporated SLN encapsulating the antibiotic polymyxin B sulfate to increase the efficiency of action by controlled release and increased residence time at the site of action. Results of this study will improve the quality of life of patients undergoing radiotherapy and chemotherapy for cancer (by reducing the pain, that strongly, affects their ability to supply), to prevent the risk of comorbidity (because of weak immune deficiency), and reduce the time between applications of cancer treatment (for better conditions offered to patients). In parallel, the study also opens up new possibilities for the treatment of mucositis as the other of the pharynx and vaginal cavity.
News published in Agência FAPESP Newsletter about the scholarship:

domain: chemistry


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Protocol refinement for a diabetes pragmatic trial using the PRECIS-2 framework
BMC Health Services Research volume 21, Article number: 1039 (2021)
This report describes how we refined a protocol for a pragmatic comparative effectiveness study of two models of an evidence-based diabetes shared medical appointment intervention and used the PRECIS-2 rating system to evaluate these adaptations.
We report primary data collected between June and August 2019, and protocol refinements completed between 2018 and 2020. Twenty-two members of the study team collaborated in protocol refinement and completed the PRECIS-2 ratings of study pragmatism. We discuss study design refinements made to achieve the desired level of pragmatism vs. experimental control for each of the nine PRECIS-2 dimensions. Study team members received training on PRECIS-2 scoring and were asked to rate the study protocol on the nine PRECIS-2 dimensions. Ratings were compared using descriptive statistics.
In general, the PRECIS-2 ratings revealed high levels of pragmatism, but somewhat less pragmatic ratings on the categories of Delivery and Organization (costs and resources). This variation was purposeful, and we provide the rationale for and steps taken to obtain the targeted level of pragmatism on each PRECIS-2 dimension, as well as detail design changes made to a) make the design more pragmatic and b) address COVID-19 issues. There was general agreement among team members and across different types of stakeholders on PRECIS-2 ratings.
We discuss lessons learned from use of PRECIS-2 and experiences in refining the study to be maximally pragmatic on some dimensions and less so on other dimensions. This paper expands on prior research by describing actions to achieve higher levels of pragmatism and revise our protocol fit to the changed context. We make recommendations for future use of PRECIS-2 to help address changing context and other strategies for the planning of and transparent reporting on pragmatic research and comparative effectiveness research.
Failure to replicate research results in real world settings [1, 2] has received increased attention [3, 4], and demands proactive methodologies rather than “business as usual” to improve health services research [5, 6]. Although a multifaceted issue, part of ‘failures to replicate’ may not be actual failures, but rather reflect that interventions found to be efficacious under one set of conditions do not generalize to other settings, conditions and populations [4, 7]. One step for addressing replication concerns is to enhance transparency in reporting on context, including the extent to which study features mirror or contrast with aspects of usual care. Although participating patient details are now addressed by CONSORT [8,9,10] and other reporting standards, other contextual factors such as selection, exclusions, participation and representativeness at the broader levels of settings (communities, healthcare systems, clinics) and staff are often unreported . Fortunately, methods for addressing these generalizability issues are emerging, including the NIH Reporting requirement , the Standard Reporting for Implementation Science (StaRI) guidelines  and the updated Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) and the just published PRECIS-2 Provider Strategies (PRECIS-2-PS) systems [12,13,14].
In contrast to more traditional randomized explanatory or efficacy trials, pragmatic trials are typically characterized by few exclusions for settings, staff and patients, using practical measures of outcomes important to patients and decision makers, and comparing real world intervention alternatives . Pragmatic trials having the features above evolved as a way to address the well-documented gap between standard RCT research findings and practice [16, 17]. In particular, the PRECIS-2 rating system  is widely recommended to plan pragmatic trials [18,19,20,21]. As demonstrated in earlier publications and below, it is also possible to use the PRECIS tools to report on changes in design during a trial or to categorize published trial designs [18, 22]. To aid trial design decisions, PRECIS-2 is represented as a 9-spoked ‘wheel’ with the following domains: 1) eligibility criteria (who is selected to participate in the trial?); 2) recruitment (how are participants recruited into the trial?); 3) setting (where is the trial being done?); 4) organization (what expertise and resources are needed to deliver the intervention?); 5) flexibility delivery (how is the intervention delivered?); 6) flexibility adherence (what measures are in place to make sure participants adhere to the intervention?); 7) follow up (how closely are participants followed-up?); 8) primary outcome (how relevant it is to participants?); and 9) primary analysis (to what extent are all data included?).
PRECIS-2 may best be used in partnership with stakeholders as part of the study design process . Yet even when trials are planned in partnership with stakeholders, grant proposals are hypothetical in nature and intended to demonstrate feasibility, rigor, and importance to reviewers. Given the time lag between when a study is proposed, actually funded and the trial actually begins, even the best planning cannot predict the exact context, staff, resources, and motivations present at the time a trial begins. To ensure ongoing fit to changing context while retaining rigor, pragmatic trials should anticipate the need for protocol refinement when launching (and potentially at key points during the study) to fully specify the trial procedures, measures, materials, data sources, timelines, and participant and setting eligibility criteria. Any changes to the originally approved or agreed upon methods or study design elements should be guided by a systematic process and framework such as the PRECIS-2, well-documented, and communicated transparency. For pragmatic trials, protocol refinements made during the trial are usually driven by contextual changes. For example, a change in the electronic health record software used by a participating healthcare organization could necessitate a change in how clinical outcomes are operationalized and assessed.
Many reports detail use of PRECIS-2 for planning (www.precis-2.org) , including for reviewing and reporting findings [18, 22], yet to our knowledge only one has focused on protocol adaptations or design changes and that one only briefly . This report describes how we refined a protocol for Invested in Diabetes, summarized below, which was intended as a pragmatic comparative effectiveness study of two models of evidence-based diabetes shared medical appointment (SMAs). The “main objective” for this study explicitly included protocol refinement. We previously reported on pre-implementation adaptations to the comparator interventions to fit context (i.e., planned adaptations to intervention content, packaging, delivery, as well as training for those delivering the interventions) as a step in the Replicating Effective Programs framework used to guide the study , yet other aspects of protocol refinement have not yet been reported or viewed through a PRECIS-2 lens. In 2020, the Invested in Diabetes study - at about the midpoint of patient enrollment - was also faced with responding to the COVID-19 pandemic, requiring further protocol refinements to both the intervention and the research design. We used PRECIS-2 as a lens for describing and designing the process of protocol refinements to be more pragmatic and feasible within the context of COVID.
The purposes of this paper are to describe how we: 1) refined our study protocol using a participatory team science approach [25, 26] and the PRECIS-2 framework; 2) responded to the changing context in implementation settings and due to COVID-19; 3) identified similarities and differences in perceptions of study pragmatism among different types of raters; and 4) to discuss lessons learned and recommendations for future use the PRECIS-2 system and related strategies to aid protocol refinement.
Intervention approach and methods
The Invested in Diabetes study is a cluster randomized pragmatic trial currently underway in 22 primary care practices in Colorado and Kansas. Its overall objective is to compare the effectiveness of patient-driven vs. standardized diabetes shared medical appointments (SMAs) on patient-centered outcomes, especially diabetes distress. Standardized SMAs were group visits led by a health educator with a set order of session topics. Patient-driven SMAs were delivered collaboratively by a multidisciplinary care team consisting of a health educator, behavioral health provider, and a peer mentor, and patients choose the topic order.
During the pre-implementation phase for this project, the research team engaged practice stakeholders and refined the study protocol as originally designed to better align with real world systems and processes of care (i.e., to make the protocol more pragmatic). The PRECIS-2 was used to structure this process of protocol refinement.
Our goal was to study diabetes SMAs across a variety of primary care settings (e.g., federally qualified health centers (FQHCs), internal and family medicine practices serving patients with commercial insurance, and community mental health centers) who had integrated behavioral health providers. Community mental health centers were ultimately unable to participate due to Colorado Medicaid reimbursement changes that impacted their ability to provide health education services. The final randomized study cohort included 12 FQHCs and 12 primary care practices from practice-based research networks .
Original study protocol
Invested in Diabetes used cluster randomization to assign practices to either patient-driven or standardized diabetes SMAs. In both SMA conditions, the curriculum used is Targeted Training in Illness Management (TTIM), which has been shown to be effective for patients with diabetes and serious mental illness [27, 28]. Existing practice staff deliver the assigned SMAs using study-provided TTIM materials. Eligible primary care practices must be one of the practice types above, have a roster of ≥150 patients with type 2 diabetes, and have integrated behavioral providers to serve on the multidisciplinary care team. Patient eligibility criteria are broad: patients must be ≥18 years of age, have type 2 diabetes, not pregnant or planning on becoming pregnant, and not be in hospice or within 6 months of the end of life. A mixed-methods evaluation includes quantitative (practice- and patient-level data) and qualitative (practice and patient interviews, observation) components. The primary patient-centered outcome, selected by patient stakeholders, is diabetes distress [29, 30]. Secondary outcomes include autonomy support, quality of life, and diabetes self-management behaviors, clinical outcomes, patient reach and engagement, and practice-level value and sustainability. The primary source of clinical data is from each practice’s electronic health records, using data collected from routine care. Further details on the study protocol have been previously published .
Stakeholder engagement in protocol refinement
During the pre-implementation phase (study year 1), we engaged clinic and patient stakeholders to refine the study protocol and address potential barriers to implementation of the protocol. Stakeholders included two members of practice leadership, two diabetes educators or nutritionists, one clinician, and five patient stakeholder who had long-standing type 2 diabetes or were family members of patients with diabetes. The study team discussed elements of the study protocol with interested practices, including those who ultimately enrolled in the study and those who did not enroll. Protocol elements discussed included practice and patient eligibility criteria, research data collection plans at the both the patient and practice level, and expectations for clinical sites to use usual practices and personnel for patient recruitment, delivery of care, and documentation and billing. These discussions occurred in a variety of forums, including between the investigators and practice leadership and clinical teams during recruitment and initial project start-up meetings, between practice facilitators and clinical teams during trainings and coaching sessions, and between investigators and practice and patient stakeholder representatives during research team and stakeholder engagement meetings.
Protocol refinement and operationalization
Based on stakeholder input, the research team refined the study protocol to increase practice willingness to participate, and ensure the protocol would reflect real-world practices and resources. The practice facilitators and investigators iteratively discussed potential changes with practice representatives until reaching satisfactory decisions. In refining the protocol, there were aspects of the study design that were ultimately not pragmatic for the practices (e.g., patient-reported outcomes measures). In Table 3, we summarize the protocol refinements by PRECIS-2 domain and describe how the study team, patient stakeholders, and participating practices have operationalized the protocol to fit their usual processes of care. In addition to the protocol refinements made in the pre-implementation phase in 2018, we also describe protocol refinements made during the implementation phase in response to the COVID-19 pandemic in 2020.
Pragmatic design ratings using the PRECIS-2
[23, 32] Approximately 9 months into implementation of the study, The study team reflected upon the extent to which aspects of the original study protocol were more or less pragmatic using the PRECIS-2. PRECIS-2 ratings were completed by 21 individuals, including 6 clinician investigators, 6 non-clinician investigators, 6 research staff, and 3 practice-interfacing staff. The research team was asked to rate the original Invested in Diabetes research protocol according to how pragmatic it was on each of the PRECIS-2 domains. Following a one-hour presentation by the first and senior authors on PRECIS-2, including examples of common issues in rating PRECIS-2 dimensions and questions and answers, research team members (with the exception of patient representatives) were given relevant excerpts from the funded study proposal and a spreadsheet defining each of the PRECIS-2 domains and rating criteria. They independently rated each domain on a scale of 1 (very explanatory) to 5 (very pragmatic) based on their own perspective of the protocol’s consistency with PRECIS-2 definitions with reference to usual care systems and processes. Ratings were conducted between June and August 2019. We report ratings by different subgroups, but efforts were not made to resolve discrepancies.
We used descriptive statistics to summarize mean ratings for each domain overall and by rater type and plotted the mean responses for each domain on the PRECIS-2 spider plot. To address our third study aim, we compared ratings by those who worked directly with the practices to ratings by research team members who were not directly engaged with practices. Our hypothesis was that those who worked directly with practices would rate the protocol as less pragmatic.
Participating practice characteristics
Table 1 summarizes the characteristics of participating practices as previously described . As can be seen, there was a diversity of practice types and sizes, and many had a substantial minority or uninsured population.
Figure 1 shows the spider plot for overall study team PRECIS-2 domain ratings for the originally proposed study protocol. Overall, the average rating for all domains was 2.92 or higher, showing that the study team generally perceived the study to be pragmatic. The most pragmatic domains (the most patient-centered and consistent with usual processes of care) included: 1. Primary analysis (intent-to-treat analysis using all available survey and electronic health records data); 2. Setting (primary care practices with ≥150 adult patients with type 2 diabetes and existing integrated behavioral health); 3. Participant eligibility (adults with type 2 diabetes, with the exception of those pregnant, with cognitive impairment, or with limited life expectancy); and 4. Flexibility - Adherence (practices use standard processes such as reminder calls to encourage patient attendance). These were all rated with average ratings exceeding 4.33.
The PRECIS-2 domains of 5. Recruitment (practices invite patients to participate in SMAs as part of their regular health care, using existing resources and processes of care); 6. Primary outcome (diabetes distress, selected by the project’s patient stakeholder partners); 7. Follow-up (patient-reported data collected at baseline and follow-up as part of SMAs; clinical outcomes are secondary use from the EHR); and 8. Flexibility - delivery (core components of SMA delivery established by protocol with required use of the TTIM curriculum) were rated moderately pragmatic, with average PRECIS-2 ratings between 3.40 and 3.77. Finally, 9. Organization (health education, behavioral health, scheduling resources available plus physical space to hold groups) was consistently rated as the least pragmatic dimension (average score of 2.92), possibly because of the low level of resources for conducting research in the participating settings.
Table 2 shows domain ratings by different rater types. There was generally high agreement on the PRECIS-2 ratings, especially on Flexibility-Delivery, Organization, Follow-up, Outcomes and Analyses, with differences among rater groups of .5 or less on mean ratings for these dimensions. The largest differences among types of raters were on the dimensions of Eligibility, Setting, Recruitment and Flexibility-Adherence, with researchers rating the design as more pragmatic than other groups. All rater types agreed that the organization dimension was the least pragmatic.
Protocol refinement to fit usual processes and systems of care
During the protocol refinement period, the study team, clinicians and delivery staff, and practice representatives operationalized and/or refined the study protocol to best fit the usual processes and systems of care while still fulfilling study objectives. Table 3 presents the protocol refinements by PRECIS-2 domains and accompanying rationale. Without inherently changing the protocol, we specified and/or adopted detailed procedures and materials for the outcomes and follow-up data collection and procedures (EHR data extracts; patient reported outcome (PRO) measures, scoring and tracking; attendance; fidelity; cost collection; and patient and practice interviews).
Electronic health records (EHR) extracts
In partnership with three participating sites (two with a more developed data and reporting infrastructure and one with a less developed system), we iteratively developed detailed specifications for EHR data extraction (Additional file 1). We created an easy to use protocol and template/mock report tables based on practice input. We made some data elements optional (e.g., foot and eye exams), based on capability of the local EHR (refining our “must haves”). The optional data elements were those that would only be needed to provide sites with feedback reports on the degree to which SMAs influenced their quality metrics, and not our ability to test a priori study hypotheses. Data extraction instructions addressed the selection criteria for patients to include, the time frame for the data pull, and specifics from four data categories: demographics, medications, vital signs and laboratory results, and patient visits. The extraction guide noted details such as the number of diagnosis codes to include, the types of labs to include, and how to report patient insurance status (e.g., patient level vs. visit level). For all sites, we were willing to accept more data than requested and selected only those elements needed.
The study protocol called for observation of 10% of SMAs to assess fidelity to core components (use of the TTIM curriculum and delivery according to assigned study arm) and the conceptual model (described in more detail elsewhere) . We ultimately decided it was feasible to observe 5–8% of visits or one session per practice per quarter for 6 quarters (6 sessions per practice). In the abstract, one might think that the initial goal of observing 10% of sessions was pragmatic, but even this proved challenging in these settings. We adapted a fidelity checklist (Additional file 2) from previous studies using the TTIM curriculum to capture facilitator role, timing, curriculum content, group engagement, and facilitation style. Seven study team members were trained in a two-hour training, then debriefed after completing their first observation.
Patient-reported outcomes (PRO) measures and scoring
The patient stakeholders and investigators reviewed the planned PRO measures from the original proposal, considering the extent to which proposed measures were clinically relevant and actionable as part of the intervention for either patients or the health care team. Guidance from the literature on pragmatic trial design and specifically from our Patient-Centered Outcomes Research Institute funder  recommends that PRO measures should not be for research purposes only. As a result, the study team eliminated the originally planned quality of life measure as its clinical utility was unclear. However, we added the Perceived Confidence Scale , which more directly matches with the skills-building nature of the curriculum and was endorsed as important by patient stakeholders. We designed an easy to understand patient survey document and scoring instructions for practices, including how to handle missing data.
Attendance and PRO tracking
As a pragmatic trial, the majority of measures were designed to be administered as part of clinical care by regular practice staff rather than research personnel. We developed a spreadsheet for practices to capture both session data (presenter, date, provider who was available, TTIM content covered or missing, added content, and peer mentor if applicable) and patient data (attendance, PRO scores). To reduce burden of data collection, practices were instructed to submit the tracking sheet quarterly, but were asked to report monthly attendance via email to fulfill sponsor obligations.
In addition to fully operationalizing the data collection processes, there was considerable work for practices to determine how to operationalize patient recruitment. Practices found different ways to recruit, such as: “warm hand-offs” from providers; systematically reviewing lists of patients with suboptimal diabetes management; using social media to advertise; word of mouth, particularly for practices with peer mentors; and advertising around the clinic using fliers, handouts, and on their waiting room TVs. It was an important aspect of the protocol that practices use regular systems (e.g., registries) and processes (e.g., provider referrals, direct calls to patients) to invite patients to participate in groups as part of their regular diabetes care – rather than for a research study. As a result, much of the patient-level data collection procedures needed to reflect secondary use, such that the data were primarily for clinical or operations use. This is a common approach for cluster randomized trials, and a waiver of patient consent was approved by the Colorado Multiple Institutional Review Board.
Dynamic changes in the context of COVID-19
The COVID-19 pandemic significantly impacted the delivery of primary care services. We aimed to be extremely flexible with regard to changes in practice delivery of the SMAs in response to COVID-19, without compromising the integrity of the research. A number of practices who had telehealth capabilities switched to virtual delivery of SMAs (vSMAs). The main aspects which the practices had license to modify delivery was to adopt vSMAs and electronic collection of PROs via online surveys.
Adaptations to the delivery of SMAs for a virtual environment included an introduction to the virtual environment for patients, new “ground rules” required for the online environment, and resources to help with problem-solving technical difficulties. Additionally, practices adapted TTIM materials to better fit the online format, e.g., practices increased use of graphics and images and made materials less text based. Other adaptations included sending materials ahead of time by email or mail to SMA participants, scheduling sessions for shorter amounts of time and smaller cohorts, scheduling virtual prescribing provider visits separately rather than during the vSMA session, and moving patient survey data collection to virtual formats or by phone.
The process of transitioning to vSMAs and electronic PROs was captured in field notes by practice facilitators. As of the writing of this paper, twelve practices had adopted vSMAs, while others continued in-person (depending on local infection rates) or postponed SMAs during the pandemic.
We found it feasible to utilize the PRECIS-2 system to characterize adaptations to our comparative effectiveness trial. With some exceptions, a wide variety of stakeholders were able to understand and make ratings on the PRECIS-2 domains, with generally high agreement across types of raters and good differentiation between PRECIS-2 scores on those domains intended to be very pragmatic vs. those not. Based on these results, we recommend further use of PRECIS-2 and also the newer PRECIS-2-PS system and below we discuss lessons learned as well as recommendations for future research.
Invested in Diabetes was a stakeholder-engaged trial with an overarching goal to optimize pragmatism across the PRECIS-2 factors. The intent was to design a pragmatic study so that the results would be broadly applicable and thus support SMA (and vSMA) adoption, implementation, and sustainability across diverse primary care settings and patient populations. An iterative, multi-stakeholder team approach was used for protocol refinement and operationalization during the first year of the study. We subsequently applied the same protocol refinement process in response to the COVID-19 pandemic. The protocol refinement and operationalization process was then reflected upon, organized, and reported using PRECIS-2.
Importance of protocol refinements to ensure ongoing practice engagement
Protocol refinements were designed to align make the study more feasible to conduct in busy and low-resource practice settings. In particular, as the majority of data collection was conducted by regular practice staff, we needed to ensure the evaluation was the least burdensome possible. Practice staff needed more assistance than originally anticipated with regards to recruitment, and needed considerable flexibility in response to COVID-19. This process also helped to retain practice participation in the study. As a cluster randomized trial in which practices are the primary unit of analysis and the source of statistical power, it is critical to prioritize practice needs and prevent their withdrawal.
Value of the PRECIS-2 framework as a tool for collaborative team science
PRECIS-2 helped the team to collaboratively and transparently develop a shared ‘mental model’ of what we were trying to accomplish. It helped to facilitate understanding among research-focused investigators (who prioritize trial rigor) and the practice-focused implementation team (who prioritize practice relevance). The process of a brief initial introductory ‘training’ session on PRECIS-2, followed by independent ratings of PRECIS-2 dimensions, and then coming together to reflect on results was feasible and efficient.
Overall, there was high agreement on PRECIS-2 scores across types of raters as summarized in Table 2. This level of agreement was achieved even though most team members had not worked with the PRECIS-2 before and there was only minimal training. Our hypothesis that the implementation team members would rate the study design as less pragmatic was partially supported. Non-investigator raters scored the study as less pragmatic on dimensions of recruitment, eligibility, organization, analysis and flexibility- adherence but actually provided slightly more pragmatic ratings for setting, flexibility – delivery, follow up, and outcomes. Overall, the biggest difference in rating between groups was still under 1 full point.
There was good differentiation between PRECIS-2 scores on dimensions we wanted to be more pragmatic vs. more explanatory. In particular, the study design was rated as very pragmatic on setting, eligibility, fidelity-adherence, and analyses, even before the protocol refinement process (scores over 4.38). The outcomes were rated as only moderately pragmatic (average score of 3.75), since although the specific outcomes selected were very patient-centered, the scale and scope of the PROs and the resources required to collect them were seen as burdensome to practices and unlikely to be used for clinical care outside the study context.
Despite the general applicability and usefulness of the PRECIS-2 framework , there were two issues that created some confusion. First, multiple levels in the study design and the definition of usual care were at times misunderstood. In many pragmatic studies – especially those with cluster-level randomization and implementation strategies – there are multiple levels of recruitment (e.g., system, practice, staff and patient) and outcomes to consider. When questions arose about how to approach ratings involving multiple levels, for example on recruitment of patients vs. practices, vs. clinical staff, we instructed raters to focus on the patient level. This issue should be ameliorated with the newer PRECIS-2-PS which is focused on the ‘provider delivery level’ rather than patient level design issues . Second, there was some confusion among the team between what is a textbook “pragmatic” study design element (i.e., the same as what happens in usual care) and ease of application in participating practices. Many things that are consistent with real-world workflows (e.g., needing to call patients to enroll them in SMAs) are not easy. But this does not make the study non-pragmatic. It may actually make the study more pragmatic, because these methods are more similar to those necessary in ‘real world care settings’. It would have been easier and less burdensome on participating practices if research staff conducted recruitment, but this would have been less pragmatic.
Lessons learned and directions for future research
It was possible after brief training to have staff rate the nine PRECIS-2 dimensions. Raters new to the PRECIS-2 system reported that it was helpful to have examples and to proactively anticipate and address frequently asked questions about ratings. The PRECIS-2 helped the team to be purposeful about where it wanted study be more pragmatic. The PRECIS-2 exercise also helped the research team conceptualize and make adaptations necessary to address COVID-19. It would be of interest to see if other research teams have found PRECIS-2 similarly useful to address research challenges due to COVID-19 and to other rapid or major changes to context . Finally, future research should investigate the extent to which different types of raters continue to evaluate PRECIS-2 dimensions similarly over the life course of a pragmatic trial, as well as whether overall pragmatism ratings increase or decrease.
This research has both strengths and limitations. Strengths include the team science approach, stakeholder engagement, and the relatively large number and types of raters who were involved in rating the study design using the PRECIS-2. The concrete illustrations of how to purposefully make a study more or less pragmatic following initial grant submission and in response to major disruptions such as the COVID-19 pandemic should be of use to other research teams. A caveat is that it may have been more challenging to use PRECIS-2 to rate this study where the comparator was another active SMA intervention rather than usual care. Limitations include a) the study did not involve patients or health system leaders in rating the study design (although they were involved in the protocol refinement process); and b) use of PRECIS-2 was not contrasted with alternative approaches to guide pragmatic design choices.
In conclusion, we encourage greater use of PRECIS-2, and the new PRECIS-2-PS for implementation studies, as well as other design and reporting frameworks (e.g., StaRI) as these implementation science and external validity issues are often neglected. We think that such iterative, multi-stakeholder-engaged protocol refinement processes can a) enhance transparent reporting and help address the scientific replication crisis [1, 2]; and b) provide proactive guidance in the planning stage as well as for later protocol adaptations to address fit to context.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
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We would like to thank the entire Invested in Diabetes study team, as well as our patient and practice partners.
This research was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (IHS-1609-36322). The views, statements, and opinions presented in this work are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee. Lead author’s time was also partially supported by NCI grant #P50 CA244688.
Ethics approval and consent to participate
This study was reviewed and approved by the Colorado Multiple Institutions Review Board (COMIRB) under protocol 17–2377. All methods were conducted in accordance with relevant guidelines and regulations. Respondents to the PRECIS-2 survey were provided informed consent via verbal/written consent information and consented to study participation.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Cite this article
Glasgow, R.E., Gurfinkel, D., Waxmonsky, J. et al. Protocol refinement for a diabetes pragmatic trial using the PRECIS-2 framework. BMC Health Serv Res 21, 1039 (2021). https://doi.org/10.1186/s12913-021-07084-x


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Image: SF Gate
The Valentino Rodeo Drive flagship store opened in Beverly Hills with a slew of celebrities lined up to fete the store’s opening. Celebrities like stylist Rachel Zoe, model Molly Sims and actresses Minka Kelly and Rose McGowan showed up for the evening.
To mark the 50th anniversary of Valentino, a Rodeo Drive flagship store opened its doors with a celebrity-filled party. Valentino creative directors Maria Grazia Chirui and Pierpaolo Piccioli were on hand as guests arrived, many dressed in Valentino. In addition, many guests decided to accessorize with the Valentino clutch with its signature handle.
The event also featured a sneak peek at the 50th anniversary Valentino capsule collection, featuring 50 ready-to-wear pieces that were inspired by Valentino Garavani’s animal prints from the sixties.
Source: SF Gate

domain: celebrity


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Ocean Tide Hand Dyed Merino Wool Yarn DK / Sport Weight
Ocean Blue 120 yards 1.3 ounces Yarn
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Ocean Tide Hand Dyed Merino Wool Yarn DK / Sport Weight listed in:


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Mark Ruffalo tweets from the set of Avengers: Age of Ultron. Director Matt Reeves explains what Dawn of the Planet of Apes is really about. Max Brooks is bringing Extinction Parade to television. Plus, a behind-the-scenes look at Jurassic World. Spoilers now!
Top image: Dawn of the Planet of the Apes
Mark Ruffalo's taken to Twitter to post some behind-the-scenes photos. [via Comic Book Resources]
Disney's Alan Horn recently said that the focus was getting the Broadway show up and running, and that a sequel hasn't yet been discussed. [The Hollywood Reporter]
Horn also responded to Jerry Bruckheimer's hope that they could start production on another Pirates of the Caribbean film this fall, saying:
It's possible. We haven't seen a screenplay yet that I've been able to sign off on.… There's a lot of variables that affect the final outcome once it leaves the studio lot, so we are very careful.
At the WonderCon panel, director Matt Reeves described the film as a "story about survival":
What excited me was not about coming into the story with apes as villains. There are no villains. . . . It's a story about survival.
. . . As you start the movie, you think the viral apocalypse has wiped out all humans. And you spend [the first] 15, 20 minutes in the world of the apes.
. . . There are two families – an ape family and human family. And you're going to see who survived.
More from Horn: May 6, 2016 is currently the release date for both Captain America 3 and Batman Vs. Superman. No one really thinks that they'll end up released that same day, and now it's looking like Marvel might be the first to blink. When asked about it, Variety's Brent Lang reported that Horn said, "We'll see. We're struggling with it." [Twitter via Slashfilm]
Warner Bros. has bought Phillip Reeves' upcoming book Railhead for adaptation and is negotiating with Doug Liman (The Bourne Identity) to direct. Railhead is set in a future where trains run through space portals and follows a thief hired to steal an object that is more important than it looks. [The Hollywood Reporter]
. . . except maybe not. Paramount's press release only refers to the film as a Terminator reboot and never uses the reported name. This could indicated that the studio hasn't yet committed to the title. So don't be too surprised if we start calling the fifth movie in the franchise something else. [Slashfilm]
Gold Circle Films, which produced Pitch Perfect, has joined Benderspink and Evan Astrowsky to produce Snowfall, a film about a group trapped on Chicago's El during a freak blizzard — that turns out to be cover for an alien invasion. A concept trailer is below. [Variety]
Here are some set photos. [Entertainment Weekly]
Here's a new banner. [Coming Soon]
From the Facebook page comes a rendering of Optimus Prime riding Grimlock. [Facebook]
Legendary Television and Digital has bought the TV rights to Max Brooks' comic series Extinction Parade. Brooks will be involved in the production, to the point of writing the pilot. Here's what Brooks had to say about the project:
I only brought the idea to one company, Legendary, because they do the kind of quality work of which any writer would be proud. While the comic series from Avatar continues, I am thrilled to be working with Legendary to develop Extinction Parade into an innovative new series for television.
We'll see how a story that focuses on a ruling class of vampires dealing with their prey species being wiped out by a zombie outbreak translates to TV. [Bleeding Cool]
Lindsey Morgan, who plays newcomer Morgan, spoke about her character's relationship to Finn and what it means for everyone:
No, unfortunately there aren't any flashbacks to see [their relationship]. But if we have the chance to go to a second season the writers all thought that it would be interesting to do each character in flashbacks to show how they grew up. But there's no flashbacks to show Raven and Finn yet, but they've been together pretty much their whole lives. They were best friends and Raven's family wasn't really in the picture. And the only person that ever really took care of her was the boy next door, Finn. As children he would share his meal rations with me, to being there all throughout school, he was pretty much the only stable thing in my life. Everyone else in my life would come and go and I couldn't depend on them. Finn was the only real rock. He's my first love and my only love and my best friend. And kind of my only friend.
I think that's what makes it so heartbreaking, how Raven risked everything to come to Earth to be with him at the most awkward timing ever since he just hooked up with Clarke.
Exactly. Oh yeah. It puts Finn in a very peculiar position and it makes him really have to ask himself some really tough questions. I think it's possible to love someone but not always be in love with someone and I also think it's very possible to love two people at the same time. Finn's heart is literally torn into two. I think him and Clarke really connected but he's known Raven his entire life. So there's this question of what's the grass like on the other side? Who's this new girl? He also thought he'd never see me again. As far as he was concerned, I was dead to him. I'm in space and he's on Earth. Finn did the best that he could with what he knows. We definitely get thrown into very difficult positions.
Morgan also said that viewers should be looking forward to seeing the Grounders' relationship to the kids on Earth, saying that the way the Grounders and their tribes unfold is "interesting." [Zap2It]
Here are some video interviews from Eliza Taylor, Bob Morley, Isaiah Washington, Devon Bostick, and executive producer Jason Rotherberg. [TV Equals]
ABC's May Sweeps press announcement previewed the next couple of episodes with these descriptions:
MARVEL'S AGENTS OF S.H.I.E.L.D. – "Nothing Personal" – Just when there's no one left to trust, Agent Maria Hill (Cobie Smulders) — from "Marvel's The Avengers" and "Marvel's Captain America: The Winter Solider" — returns to team up with Coulson as S.H.I.E.L.D. is being destroyed around them, on "Marvel's Agents of S.H.I.E.L.D.," TUESDAY, APRIL 29 (8:00-9:01 p.m., ET) on the ABC Television Network.
MARVEL'S AGENTS OF S.H.I.E.L.D. — "Ragtag" – In the last episode before the epic season finale, Ward 's betrayal and HYDRA's shocking secrets are revealed as Coulson's team goes undercover on a mission that leaves no one unscathed, on "Marvel's Agents of S.H.I.E.L.D.," TUESDAY, MAY 6 (8:00-9:01 p.m., ET) on the ABC Television Network.
Here's the promo for next week's episode.
The same ABC press release also previewed a little of what's coming for Once Upon a Time:
"ONCE UPON A TIME – "A Curious Thing" – Zelena threatens to kill Henry if Hook – whose lips have been cursed by the Wicked Witch — doesn't proceed with kissing Emma, which will drain all of her magical powers away, and things begin to heat up between Regina and Robin Hood. Meanwhile, back in the Fairy Tale Land that was during the past year, Snow and Charming go in search of Glinda, the Good Witch of the South, to see if she can help them defeat Zelena, and the curse that will ultimately send the Fairy Tale characters back to Storybrooke is cast — but from an unlikely source, on "Once Upon a Time," SUNDAY, APRIL 27 (8:00-9:00 p.m., ET) on the ABC Television Network."
ONCE UPON A TIME – "Kansas" – SUNDAY, MAY 4 (8:00-9:00 p.m., ET) on the ABC Television Network.
ONCE UPON A TIME – TWO HOUR SEASON FINALE – SUNDAY, MAY 11 (8:00-10:01 p.m., ET) on the ABC Television Network.
Finally, ABC released descriptions of the last two episodes of the season:
RESURRECTION – "Schemes of the Devil" – With the help of Bellamy and Sheriff Fred, Tom leads the charge in the search for Rachael, but her situation becomes increasingly dire as her captors grow more desperate. Maggie and Dr. Ward continue their medical research on the resurrected subjects and a series of shocking discoveries sets them on the brink of a game changing find, however, their focus shifts when Arcadia is suddenly in the throes of an epidemic, on "Resurrection," SUNDAY, APRIL 27 (9:00-10:01 p.m. ET) on the ABC Television Network."
"RESURRECTION – SEASON FINALE – "Torn Apart" – The town of Arcadia is in a state of chaos when the return of the deceased reaches a critical mass. Bellamy has no other choice than to ask for outside aid which backfires when Sheriff Fred steps in with his own agenda, triggering a siege on the town that no one saw coming, on the season finale of "Resurrection," SUNDAY, MAY 4 (9:00-10:01 p.m. ET) on the ABC Television Network."
Go here for photos from next week's "City of Blood." Below's the synopsis:
OLIVER CONSIDERS HIS OPTIONS AGAINST SLADE — After Slade (Manu
Bennett) threatens to take everything Oliver (Stephen Amell) loves
away, Oliver decides the fastest way to stop further bloodshed is to
surrender to his enemy. Knowing that surrender will surely lead to
Oliver's death, Diggle (David Ramsey) and Felicity (Emily Bett
Rickards) go to extreme measures to keep Oliver from confronting
Slade. Meanwhile, Thea (Willa Holland) considers leaving town, and
Laurel (Katie Cassidy) resumes her crusade against Sebastian Blood
(guest star Kevin Alejandro). Finally, Slade unleashes his assault on
Starling City. Michael Schultz directed the episode written by Holly
Go here for more photos from episode 1.02, "The Stone Child." [SpoilerTV]
The first episode of season 5 will be called "See No Evil" and is written by Matt McGuinness and Gabriel Stanton and directed by Shawn Piller. [SpoilerTV]
Here's a promo for episode 9.20, "Bloodlines."
Additional reporting by Charlie Jane Anders and Ryan Plummer

domain: entertainment


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“Solitary confinement deprives the prisoner of vital human contact. This practice has devastating effects on the prisoner’s mental and physical wellbeing, and constitutes the harshest form of punishment that may be administered in Canadian penitentiaries. As such, the ready, routine and prolonged use of solitary confinement in Canadian penitentiaries is unjustified, unethical, […]
On May 28, 2014, Ontario’s Divisional Court released its decision in Taylor-Baptiste v. OPSEU, confirming the right of the Ontario Human Rights Tribunal to consider Charter values, including freedom of expression, when assessing whether there has been discrimination under the Ontario Human Rights Code. The CCLA had intervened in the case to promote a robust […]
CCLA expressed its support for a women’s right to choose, at an event that took place on May 8th in Charlottetown entitled “A Rally For Our Right to Accessible Abortion.” CCLA’s statement of support was read out at the rally. It expressed the organization’s view that women have the right to choose what happens to […]
CCLA has submitted a brief to the Quebec National Assembly’s Committee on Institutions’ as part of its general consultation and public hearings on Bill 60. Bill 60, or the Charter affirming the values of State secularism and religious neutrality and of equality between women and men, and providing a framework for accommodation requests, is a […]
The jury of five delivered their verdict this morning, determining that Ashley Smith died as a result of homicide.
This is a sad victory, as justice can never be done for Ashley Smith.
However, CCLA is hoping it will result in a clear message sent to the Correctional Service of Canada that significant changes need to be […]


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If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
In 1980, a significant segment of the US population was already overweight or obese, but obesity standards did not exist. Therefore, the National Institutes of Health (NIH) held the Workshop on Body Weight, Health and Longevity to correct the deficiency so that data could be improved. The workshop concluded:
In the United States, the weight associated with the greatest longevity tends to be below the average weight of the population under consideration, if such weights are not associated with a history of significant medical impairment. Overweight persons tend to die sooner than average-weight persons, especially those who are overweight at younger ages. The effect of being overweight on mortality is delayed and may not be seen in short-term studies. Cigarette smoking is a potential confounder of the relationship between obesity and mortality. Studies on body weight, morbidity, and mortality must be interpreted with careful attention to the definitions of obesity or relative weight used, preexisting morbid conditions, the length of follow-up, and confounders in the analysis. The terminology of body weight standards should be defined more precisely and cited appropriately. An appropriate database relating body weight by sex, age, and possibly frame size to morbidity and mortality should be developed to permit the preparation of reference tables for defining the desirable range of body weight based on morbidity and mortality statistics.1
Based on body mass index (BMI), 1.5 billion people are overweight (BMI≥25.0 kg/m2) and 500 million of them are classified as obese (BMI≥30 kg/m2).2–3 Since 1980 there have been many studies on the causes and management of obesity including behavioural studies, physical activity studies, nutritional studies ranging from high-protein low-carbohydrate low-fat, high-carbohydrate low-calorie diets and drugs for the treatment of obesity, yet despite all these efforts the US population continues to increase its weight and similar …
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


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|Real Name/Full Name:
|Kevin Scott Richardson
|52 years old
|October 3, 1971
|Lexington, Kentucky, U.S.
|Kristin Kay Willits
|Yes (Mason and Maxwell)
|Singer, songwriter, actor
|Net Worth in 2024:
Kevin Scott Richardson or better known as Kevin Richardson is an American singer who is best known as the member of the popular band the Backstreet Boys. He is also known for acting in various movies. Kevin is also a singer-songwriter and has done modelling for several brands.
Maybe you know about Kevin Richardson very well But do you know how old and tall is he and what is his net worth in 2024? If you do not know, We have prepared this article about details of Kevin Richardson’s short biography-wiki, career, professional life, personal life, today’s net worth, age, height, weight, and more facts. Well, if you’re ready, let’s start.
Kevin Richardson was born in the year 1971 on 3rd October in Kentucky in America to Jerald Wayne Richardson and Ann C. He has two brothers and is considered to be the youngest child. He grew up on a farm with his siblings. This had a significant impact on his life. While living on the farm, he learned to ride horses when he was only four years old. He was also interested in various outdoor sports like dirt bikes and playing football. After getting admitted to Estill County High School, Kevin played football and was made the captain of the team named Estill Engineers.
Richardson was fond of music from a very young age. He learned to play the piano when he was only nine years old. He even acted in a theatre while he was in high school and was also a part of the drama club. He was part of a choir in the church. Kevin was so into music that he also performed in a band named Paradise. After he got his keyboard, he started playing on various occasions and events like weddings. He even played in restaurants and performed covers of well-known singers like Bobby Brown. He had received the titles like “Most Popular”, “Best Look” etc. when he was in high school. He was a popular kid in high school and graduated in the year 1990.
Age, Height, and Weight
Being born on October 3, 1971, Kevin Richardson is 52 years old as of today’s date 23rd February 2024. His height is 1.85 m tall, and weight is 82 kg.
In the year 1990, Kevin Richardson moved to Florida and started earning by modelling and performing his written songs in clubs etc. He even taught Latin and ballroom dancing. Soon, he got himself a job of a cast member at the Walt Disney World and played the various animated series character’s like Aladdin, Prince Eric, a Teenage Mutant Ninja Turtles etc. In the year 1993, he auditioned for joining the famous band called the Backstreet Boys and was successful in doing so. He is considered to be the oldest of the other group members. The total number of albums which he recorded with his band was five. He resigned from the group in the year 2006.
Even after his departure, the band made several appearances at various events and included Kevin Richardson. They performed at the Hollywood Palladium and went on The Oprah Winfrey Show together. His love for the group made him rejoin them in the year 2012. They appeared in a morning TV show named Good Morning America and in the year 2016 performed ai the Greatest Hits, TV series on ABC channel.
Awards and Achievements
Kevin Richardson has collaborated with various artists and musicians like Rob Gonzalez and has opened a music academy with Keith McGruffy in Kentucky. The academy is named The Music Workshop. He released a solo album in the year 2015. Kevin Richardson has done modelling for various popular brands like Versace and is the ambassador for TAG Heuer. He has also modelled for Vogue magazine.
Net Worth & Salary of Kevin Richardson in 2024
As of February 2024, the net worth of Kevin Richardson is estimated to be around $50 million. He has acted in various films like My Girl, Sesame Street, Arthur and This Is The End etc. He even made appearances as himself in The Ellen DeGeneres Show and Late Night With Jimmy Fallon.
Kevin Richardson is a fantastic musician who has touched the hearts of many with his soulful music.


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The Nutcracker, performed by Mid-Atlantic Ballet
This Christmas, get swept up in the dream of Tchaikovsky's most famous composition, The Nutcracker. Experience Clara’s breathtaking journey that begins with the gift of a magical toy and takes her through the Land of Snow and the Kingdom of Sweets. Celebrating its 20th season, Mid-Atlantic Ballet (MAB) is proud to present this annual holiday classic under the guidance of Artistic Director, Patrick Korstange. Set to Tchaikovsky's captivating score, Mr. Korstange’s choreography will delight audiences of all ages. Saturday, December 16, 2017 at 12:30 PM (Childrens Matinee) and 4:00 PM Sunday, December 17, 2017 at 2:00 PM (Childrens Matinee) Mitchell Hall University of Delaware Ticket Prices $26.00 for adults - orchestra floor and center balcony $20.00 for seniors (60 years+) -orchestra floor and center balcony $20.00 for students (13 years+) with ID -orchestra floor and center balcony $15.00 for all ages - balcony wings - 12/16 @ 4:00 for ages 13 years + $15.00 for children 12 and under - All Tickets - 12/16 at 4:00 PM $12.00 for children 12 and under - All Tickets -12/16 at 12:30 PM and 12/17 at 2:00 PM (Children's Matinee Shows) Tickets for The Nutcracker are now on sale and may be purchased in the following ways: Online on our web site (see below). At our studio located at: 506 Interchange Boulevard, Newark, Delaware. Or email email@example.com By phone . Please call the studio at (302) 266.6362. If you purchase your tickets online or over the phone, your tickets can be picked up at our studio until the week before the show. If they are not picked up by then, they will be waiting for you at our Will-Call table in the theater lobby.


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Las Vegas isn’t just a gambling and nightlife hotspot – its one of the best places in the world to get a meal.
For the world’s big-named chefs, vying to outdo each other with ever-more innovative restaurants and powerful brands, making a mark in Sin City is key to building on success.
British celebrity chef Gordon Ramsay says he’s always looked to Vegas as one of the world’s culinary capitals.
"One of my first ambitions when I fell in love with this country more than 20 years ago was to absolutely nail a steak house here," says Ramsay.
Ramsay, who owns Gordon Ramsay Steak at the Paris, Gordon Ramsay Pub and Grill at Caesars and the newly opened BurGR at Planet Hollywood, says the Las Vegas market now is more competitive than any city in the world because every chef has an outlet there.
“There's no other city in the world that houses so many top chefs, so everyone raises the game. So the more chefs that come in, the higher the standards," he says.
While Ramsey has three locations, Wolgang Puck has seven, which include Wolfgang Puck Bar & Grill, CUT and Trattoria del Lupo. Puck was one of the first celebrity chef’s in Las Vegas, when he opened Spago more than 20 years ago.
"I'm really proud of being here for 20 years, big part of the community, knowing so many great people and Las Vegas is my second home," says Puck.
Hotels and casinos hope that big name chefs will help attract guests. Topping the bill are chefs Susan Feniger and Sue Millikens’ Border Grill, Michael Mina’s Stripsteak and Hubert Keller’s Fleur. Also attracting attention are Alain Ducasse’s Mix and Brian Massie’s Red Square.
Ramsay says that this five cooking shows, which air on FOX, bring people to the table (“Hell’s Kitchen” season 11 just kicked off with its premiere shot in Vegas). But it’s the food that keeps them coming back.
"I think the pressure on the chef today is far greater than ever before, their on more financial pressure, so TV exposure can help fill their dining rooms, providing the standard of the dining room is what they preached, they'll never have an issue."

domain: food


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Justin Bieber has had a month rocked by war, from battling with former girlfriend Selena Gomez over his threat to exit Instagram to getting hit by a backlash over his romance with new gal pal Sofia Richie. But no one keeps the Biebs in a corner for long, and now Justin is bouncing back, seen partying with a new gal pal and Rihanna, reported the Daily Mail.
Although Justin exited Instagram after a battle with his Beliebers and Selena over Sofia, Richie was far away in Los Angeles when he channeled his inner party boy. In her place by his side in London was blonde beauty Bronte Blampied.
Rihanna joined Justin inside the club, where he was looking happy and upbeat in his casual club attire of ripped jeans, grey boots, striped shirt and white T-shirt. Bronte matched the Biebs’ style in her own ripped jeans, grey T-shirt and wedge shoes.
The Biebs and Bronte stayed at the Tape nightclub partying until 4 am, leaving together in a cab. But is it the start of yet another new romance, or just a platonic friendship? Blampied and Sofia are friends.
However, Justin and Bronte seemed to feel they had something to hide, making attempts to shield their faces from the paparazzi prior to accelerating off in the taxi. And while all that was going on, where was his new girlfriend?
Richie answered the question on Instagram, showing off her new hairstyle from the Andy Lecompte Salon in West Hollywood.
“Yup we chopped it!” wrote Richie.
While Sofia focused on her hair, her boyfriend appeared intent on making the most of his partying time. And he wasn’t the only one at the nightclub turning heads, however. Rihanna was seen in a racy denim frock, going bra-free despite the risk of a nip slip, the Mirror pointed.
Rihanna succeeded in out-lasting Bieber and his new blonde gal pal, not returning to her own hotel until 5 a.m. She also sought to avoid the paparazzi, going inside through a tunnel.
As for the motivation for Rihanna and Justin to party together? Both are headlining the V Festival, with Bieber’s appearance coming just after his canoodling with Sofia. However, Richie did not accompany him for his musical weekend.
Sofia, who is the teenage daughter of music legend Lionel Richie, became the center of a social media hurricane when Bieber’s fans slammed Richie on his Instagram and his former girlfriend Gomez joined in the backlash. Since he deactivated his account, however, he has continued his romantic relationship with Sofia.
But how long will Richie and the Biebs stay together? Even though Sofia and Justin have been immersed in heating up their hookup during the past few weeks, a Bieber insider told People that it is almost “impossible” for their romance to last much longer.
“Sofia and Justin are basically on a love-fest right now, but it’s virtually impossible where he’s at in his life and career for anything to last with these girls.”
Even though Richie was the one chosen to soar off to Japan with the singing superstar, where they were seen cuddling and kissing, the insider still feels he has no intentions of “settling down.” Prior to their joint visit to Japan, the 17-year-old was seen with Bieber in Laguna Beach and at his house in Toluca Lake.
“These girls all go crazy for him, but he’s not settling down,” another source told People. “[Richie and Bieber have] run in the same circle for years.”
As additional evidence that the Biebs has no intention of settling down with Richie right now, Elle pointed out that the blonde beauty, Bronte, with whom he partied in London actually isn’t 100 percent new.
When Bieber vacationed in Hawaii, he was surrounded by a crew consisting of bikini beauties, and Blampied was among them. In his merry-go-round serial dating style, a gal pal who pops up more than once deserves extra scrutiny.
And Bronte has provided the opportunity on Instagram.
Blampied has been flooded with comments since the news broke that she just might be Sofia’s replacement. But many defended Bronte, in contrast to their slams against Richie.
“Guys Leave her alone…she’s not Sofia,” wrote one defender.
“Why r there snake emojis she didnt do anything shes not like sofia,” contended another.
[Photo by Jamie McCarthy/Getty Images]


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Core Mobility - What it is and why it matters
What is Core Mobility?
The Chest, Abdomen, Pelvis and Spine/Skull are sometimes called the ‘Great Cavities’. Our Internal Organs (brain, liver, spleen, kidneys, etc.) reside in the Great Cavities.
Movement is essential to organ function, wellness and longevity. Core Mobility is a measure of mobility and stiffness along the axis of the spine, affecting the Great cavities and their organ contents.
Let’s Examine how Core Mobility Affects Health
Cerebrospinal Fluid (CSF) flows around and through the interior of the brain as well as down the length of the spinal cord. Breathing related changes of spinal cavity pressure creates a pump like effect that propels CSF. Every day the brain produces over ½ liter of CSF. The total volume of CSF in the brain and spinal cord is replaced 3 to 4 times per day. Circulation of CSF past parts of the brain that secrete and resorb CSF is essential to good brain health and brain function. With aging and reduced Core Mobility, CSF circulation slows, cognitive and emotional functioning is impaired and cognitive decline begins.
The Liver, Spleen and Kidneys are sponge like with many millions of tiny canals and blood filled spaces. These organs are located immediately under the diaphragm muscle and have a curved upper surface that allows them to fit snugly against the diaphragm. With each breath the liver, spleen and kidneys are compressed and then released by the diaphragm. Just like sponges being squeezed and released, fluids are expressed and then drawn into the organs. This induces flow of blood through the interior of each organ, allowing the organs cells to perform their life sustaining function. With reduced Core Mobility these organs have decreased internal circulation, impaired function and longevity is affected.
The other abdominal and pelvic organs, such as the intestines and uterus are influenced by Core Mobility. The pelvic floor is a muscular area supporting the pelvic organs. With reduced Core Mobility there is less stimulation of the pelvic floor and weakening of the pelvic floor follows. This can lead to incontinence and other changes.
With increasing stiffness of the spine, rib cage, and diaphragm there is less spinal and diaphragmatic motion with each breath. As noted above this leads in many ways to impaired organ function, decrease in organ function and reduced longevity of life. iHeart is a fingertip pulse sensor able to determine Core Mobility using pulse wave analysis and objectively show that with exercise, good diet and stress management Core Mobility improves. iHeart assesses Core Mobility by measuring stiffness of the Aorta, the large blood vessel located immediately in front of the spinal column and passing through the diaphragm muscle. The way iHeart measures Aortic Stiffness is by measuring Pulse Wave Velocity, a measure of Aortic Stiffness. iHeart does this by measuring distinct spots in the pulse shape. The fingertip pulse has a characteristic three wave pattern as shown below.
The second wave is called the Aortic Reflected wave and speed with which the Reflected Wave travels depends on Aortic Stiffness. By characterizing the Reflected Wave iHeart is able to precisely measure Aortic Stiffness. Aortic Stiffness is a simple and effective way to measure Core Mobility. iHeart is the first and only device that lets people see their lifespan extending with attention to exercise, good diet and stress management.
To improve Core Mobility today try any of the following:
- Sit Less - sitting for extended periods of time will help the body stiffen up quickly, so try not to sit for extended periods of time.
- Move more - increase movement each day, even if it's just getting up from your desk and going for a 10 minute walk, that will help and is a great start.
- Stretch! Stretching will improve mobility of the entire body, including the core and the organs that live in the Great Cavity. Try these stretches you can do at work!
- Hydrate - Hydration will help improve core mobility, try to drink at least 2 Litres of water/day


Congressional candidate Jan Judy made her final scheduled campaign swing through Pope and Johnson counties Friday, bringing influential friends from her party to speak their support.
Judy, a Democrat, was anchored by Ron Oliver, the chairman of the state's Democratic Party, former congressional candidate and state representative Mike Hathorn, two other state legislators and about 50 local supporters when her "Grand Finale Rally" stopped at the Pope County Democratic Headquarters Friday morning. She touted her goal of "putting people first," promising to loudly and efficiently represent her constituents in Washington, D.C.
"We've made this entire campaign about touching people," Judy said Friday. "We're letting people know that they're the most important part of this campaign. Pretty much everywhere I go, people know me and they know that I will represent their interests in Washington, D.C.
"I'm doing this because I really believe that we've got to make a change," she added.
Judy is challenging Congressman John Boozman, a Republican.
Russellville and Clarks-ville were two of eight stops Judy made during her tour through Arkansas' Third Congressional District on Friday. A number of supporters rode along with Judy on a chartered bus, including Hathorn, who previously lost to Boozman but has remained popular in his party.
"Can Jan Judy win this election?" Hathorn asked the crowd Friday. "Absolutely, but she can only do it if each and every one of us gets out and works for her."
Oliver optimistically told the crowd that Democratic presidential candidate John Kerry would need Judy's support in the House of Representatives when both were elected. He also called Judy an "independent thinker and problem solver" and took jabs at the Republicans, criticizing President Bush for the lack of flu vaccines in the country.
"Did you ever think that flu shots would become a part of this campaign?" Oliver asked the gathered group. "If Halliburton made flu vaccines, the supply would be endless. The problem is, we wouldn't be able to afford it."
Concerning her race, Judy called Boozman a "rubber stamp" for President Bush, saying his votes were "not in the best interest of the people of this district." She criticized Boozman for not delivering major transportation projects in the district even though he's a member of the House Transportation Committee in a Congress and presidential administration dominated by his party.
She also said she would strive to make health care more readily available for all Americans, calling health care "a necessity like food, water and clothing."
"We supposedly have the best health care system in the world, but so many people don't have access to it because they don't have insurance," Judy said. "That needs to change."
Boozman, on a bus tour of his own, will be appearing in Russellville at 8 p.m. today at the Hampton Inn near Interstate 40.


1- This fault can be erased. When i erased fault, that car run normally but after stationary mode, the problem come again. wmen i started the engine, engine warning light comes again and when i pressed throtle pedal, the throtle pedal no respons.
2. I erased fault again and i try drive this car to hard drive mode. Add 1st gear to 2nd gear is ok but at 3rd gear the engine go to safe mode (engine cut) and at the same time engine light comes again.
Fault Code :-
18089 - Control Module Programming Not Finished
P1681 - 35 - 00
Readdiness : 0100 1001