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Meet Margot, a clever, funny, Telemundo ad-sales woman who gets a meeting with a hard-to-reach car dealer owner by telling his gatekeeper she’s a stripper he met in Vegas. In the process of selling the ads, she discovers this car dealer executive is the love of her life – even if that’s precisely not supposed to happen. Despite the perils this love brings forth, she pours her heart into loving this man.
Margot’s Peruvian-American parents meet Mike in the hospital, like a scene from the romantic comedy The Big Sick. Before this awkward hospital meeting, Margot had taken care of her little sister, orchestrated her parents buying a house, and helped them adapt to a culture that still felt alien to them. Then, at twenty-nine years old, cancer threatened to take her life.
Perhaps it was her matriarchal spirit that led to wisdom beyond her years and unrelenting courage. From reading the book, it sounds like she had an old soul that understood love better than most. She consistently translated love into poetic words and actions that moved nearly everyone she knew in magical ways.
Margot’s loving husband Mike shares her words, wisdom, and courage in the memoir Living In Color: A Love Story, in Sickness and in Health. A book as compelling as it is romantic, Living In Color takes readers on a journey into the real lives of an incredibly courageous, graceful woman and her family as they face some of life’s biggest challenges. Their journey has the potential to inspire the best in all of us. Fun and light-hearted stories and photographs weave throughout the book with meaningful passages creating a story for the ages.
As the couple loved each other and battled cancer together, readers gain wisdom that cost Mike and Margot so much pain. Margot may have been through more pain than most, but she knew how to accept challenges and move forward. Margot shared her wisdom with Mike as they grew together in sickness and in health. When she got cancer, she told Mike, “cancer can only win if we let it get us down.” And about love, she wrote this poem, “My Love, If you and I are not together in the summer nights, look up. See the stars? A blanket of stars; an ocean of stars. That is my love for you. That is the ultimate life force that you gave me: living in color.”
Blueink Reviews calls Living In Color “a primer on accepting life, whatever it brings.” Mariel Hemmingway, a beautiful-soul author, Oscar-nominated actress, and granddaughter of Nobel Prize-winning novelist Ernest Hemingway says about the book, “Mike’s abiding, almost reverent, love for his wife shines through every page, even as he unflinchingly details what it’s like to go through the treatments, the sleepless nights, the victories, and the setbacks. He skillfully weaves those difficult memories with beautiful remembrances of their time together, letting us see Margot’s courage and resilience along with her gentle, hope-filled wisdom… You will be inspired and forever changed when you read their story. I highly recommend it.” You can watch Mariel’s video review here.
What comes from this beautiful life and love? You may be guessing what the end of Margot’s life looked like, but by reading the book, you’ll come to understand the legacy Mike and Margot are leaving far beyond their own lives.

domain: literature


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domain: artistic


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Pow Wow Trail – The Songs
Last month we shared with you the first episode from the TV series Pow Wow Trail, which was all about the heartbeat of the pow wow: The Drum.
The next episode in the series covers The Songs. Pow wows are nothing without the songs. They carry the stories, which in turn carry the culture. Some stories tell of great exploits, acts of bravery, and even stories that express the simple pleasures in life.
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Join Date: Aug 2018
Location: North Carolina, USA
CO2 Diffuser next to the outlet?
Has anyone ever placed their in-tank diffuser next to the external filter outlet? I just got back to using a diffuser (reactor broke) and noticed how much CO2 is seemingly lost just by bubbles going straight to the surface. My thoughts are that if you were to put the diffuser next to the outlet, gas would pass through the filter as sort of a makeshift reactor that would A) reduce bubbles lost at the surface and B) reduce the sodawater look of the water.

domain: chemistry


Offical Specialized Project T-Shirt 2022
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The connection between music and politics, particularly political expression in song, has been seen in many cultures. Protest writing predates both the recording and music industries. Oral tradition, or oral lore, is knowledge passed on through, art, ideas, and cultural material preserved and transmitted orally from one generation to another. Abolition, women’s suffrage, human rights civil rights, the anti-war movement and 1960s counterculture, the feminist movement, the sexual revolution, and environmentalism. ‘VIVA! The Freedom Songs’ contains 70 songs recorded by bands across the globe-spanning over 100 years of music history.


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I was very pleased to hear that Laâbi has been honoured by the Goncourt Academy. The Moroccan poet was awarded this literary honor for "his life achievements," the Academy said in a statement. The prize will be officially given on January 12, 2010.
Leafe Press, of course, has just published a new translation of Laâbi 's poem 'Fragments of a Forgotten Genesis' in a dual-language edition, and it's available now (see below for special offer). Laâbi is a heroic figure, who has spent his life fighting oppression of all kinds (he was a strong supporter of Salman Rushdie during the 'Satanic Verses' affair). He was born in 1942 in Fes, Morocco. In 1966 he founded Anfas/Souffles, an important literary review, which provided a focus for Moroccan and Maghreb creative energies. It was banned in 1972. Laâbi was imprisoned, tortured and sentenced to ten years in prison for "crimes of opinion" (for his political beliefs and his writings) and served a sentence from 1972-1980. He was then forced into exile in France, where he has lived since 1985.
Laâbi has published a huge volume of work, particularly poetry, but although there is a Selected Poems ('The World's Embrace') from City Lights, San Franciscio, he is under-represented in English. So Leafe was particularly pleased, in fact honoured, to publish his long poem 'Fragments d’une genèse oubliée / Fragments of a Forgotten Genesis'. It was originally published in 1998 by Editions Paroles d’Aube, but was out-of-print in both English and French when Leafe Press took it on. The poem is a surrealistic refiguring of Genesis presented in twenty-six “fragments.” As a whole, the work is a mystical yet cynical re-visioning of both the Old Testament and the Koran. The translation, by Gordon and Nancy Hadfield is uncluttered and clear, and works as a fine English poem in its own right.


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The majority of landlords are most likely to source their next buy-to-let mortgage from their existing broker, new research shows.
According to Paragon’s latest PRS trends report for the third quarter of 2019, 57% of all landlords are most likely to use the same mortgage broker when taking out their next mortgage, while 41% state they would be most likely to go direct to a lender for a buy-to-let mortgage.
Just 16% of respondents to the survey stated that they are likely to consider an online mortgage broker service and just 10% are likely to switch brokers.
The report reveals little disparity between portfolio (59%) and non-portfolio landlords (50%), with both groups most likely to stick with their existing broker when choosing a new mortgage.
Portfolio landlords have larger-scale property interests that non-portfolio landlords, with four or more mortgaged properties.
The study found that fewer landlords overall are expecting to add to their portfolio, with just 8% expecting to purchase property in the next quarter, almost reaching the historic low of 6% recorded in Q4 2018. This remains some way off highs of 15-20%, maintained between 2010-2015.
The proportion of landlords expecting to sell property in the next quarter also dropped marginally, from 23% to 22%, representing the first time that both measures have simultaneously slowed since the same time last year.
The disparity between landlords expecting to buy compared with those looking to sell now sits at 15%, as the gap continues to widen since the two were exactly even in Q3 2014.
Looking in more detail, the proportion of non-portfolio landlords looking to purchase property in the next quarter fell from 4% to 1%, whilst portfolio landlords continue to be more active, with 10% expecting to buy, in an attempt to make strategic investments to strengthen their financial position amid on-going turbulence in the PRS.
John Heron, director of mortgages at Paragon, commented: “With so much change in the PRS in recent years, landlords have had to adapt quickly to higher taxation which has impacted returns on their portfolios. Throughout that time, landlords will have relied more heavily than ever on intermediaries to help them get the very best deals available. Therefore, it is no surprise that, whilst the future remains unpredictable, landlords are maintaining some stability by reusing the same brokers for their next mortgage.
“It’s surprising, however, to hear that some landlords are considering approaching a lender directly for their next mortgage. This does not match well with the actual behaviour of landlords particularly in the portfolio segment where nine out of ten landlords use an intermediary.”
Want to comment on this story? If so...if any post is considered to victimise, harass, degrade or intimidate an individual or group of individuals on any basis, then the post may be deleted and the individual immediately banned from posting in future.

domain: news


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Guerilla Arts Ink, LLC is an arts education and media consulting organization specializing in out-of-school time (OST) cultural arts programming, innovative curriculum design, professional development, and youth engagement strategy. We are a creative ecosystem of artists, teachers, and active members of community, who have a passion for sharing their respective talents and time in service to youth. Our teaching artists are selected for their unique abilities, creativity, and desire to create change through art.
Through building and nurturing strategic public/private partnerships, Guerilla Arts has secured resources to produce several youth programs and community initiatives, including:
At VISIONDC, Guerilla Arts will present a visual exhibit of the #ArtsEd experience in schools and communities across the Nation’s Capital, including customized programming and events designed to engage students in learning through creative sessions. Partnering with schools and organizations across all eight wards, Guerilla Arts programs support out of school time strategies to improve student outcomes, including attendance, testing, and impacting the digital divide among students served.
The interactive presentation highlighting the work of Guerilla Arts work with arts education programs and community partners, including outcomes from creative programming in schools, and sample of community engagement projects.
- GA Student Experience
- Guerilla Arts in Action
- Media Literacy Displays
Visual displays, the ‘student experience,’ and professional development snippets, the Guerilla Arts #ArtsED Pop-Up showcases the impact of the arts in education.


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The Columbia Police Department responded to a report of shots fired Monday, Aug. 26, at 5:52 p.m. in the 1500 block of Typhoon Court. Officers located approximately eight shell casings in the street. There is no report of injuries. The investigation is ongoing and crime scene technicians continue to process the scene. There is no suspect or suspect vehicle information to share currently.
"This evening, shots were fired in north Columbia on a street where children had just been playing outside. For those who choose to invoke fear and victimize other people, we will continue to pursue you with the full resources of the City, County and Federal government," Columbia Police Chief Geoff Jones said. "If you know who was involved, we need your help. Please call Columbia Police or Crimestoppers at the phone numbers below or talk to one of our officers."
Anyone with information on this incident is encouraged to contact the Columbia Police Department at 573.874.7652 or Crimestoppers at 573.875.TIPS to remain anonymous.
Case Number 2019-TBD


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Allababad: Officials of the district horticulture department are imparting training to as many as 400 farmers regarding drip irrigation for banana cultivation. Officials said that efforts are underway to set up banana cluster in about 500 hectare land in Kaurihar II block and for that the farmers were also apprised about various latest agriculture methods.
The exercise has been taken after noticing that drip irrigation method has been quite successful in hilly and barren land of Shankargarh of Allahabad district.
Officials said that both Shankargarh and Kaurihar II blocks of the the region are proving good for banana cultivation.
At Shankargarh, a group of 150 farmers have turned 15 hectares into a Banana Cluster growing a particular variety of Bananas. Methods like drip-irrigation and tissue culture here helped the farmers to cultivate bananas in Jasra and Shankargarh blocks comprising over a dozen villages.
District horticulture officer, PK Shukla told TOI on Monday, buoyed by the successful results in Shankargarh, the farmers are being encouraged to grow G-9 variety of banana. These farmers were apprised about the technique where they can grow the crop with least water requirement.
About 4,000 G-9 variety of banana saplings are being grown in one bigha land and farmers are well acquainted with methods to take care of plants and to save them from banana brittle disease.
Meanwhile, Shukla added that more and more farmers are now approaching for banana cultivation after they witnessed good crop in this rocky hilly region. He added that the department has also planned a series of training sessions for farmers of other blocks.

domain: biology


One Big Happy has its freshman season finale tonight (NBC, 9:30 pm et/pt) with the episode “Wedlocked.” Actress Elisha Cuthbert took time out of her busy morning to talk about her experiences on the comedy (which co-stars Nick Zano and Kelly Brook), collaborating with creator Liz Feldman, and also working with filmmaker Courteney Cox on Just Before I Go.
“One Big Happy” centers on best friends Lizzy (Cuthbert) and Luke (Zano) as they decide to start their own family. Lizzy, who is a lesbian, sees Luke as the perfect father, and their bond won’t be easily broken. Their baby plans take a dynamic shift when Luke has spontaneously marries Prudence (Brook), a carefree British girl who adds her share of neurosis (and, of course, humor) into the mix.
Hopefully tonight’s season finale will bleed into a second season, as creator Liz Feldman and the ensemble have crafted a well written and acted sitcom.
“To do six (episodes) is tricky,” says Cuthbert, whose previous TV work includes 24 and Happy Endings. “It’s not a whole lot of time to show everyone who these characters are but I think we did our best at that. It would be fantastic to be able to keep going. There is going to be a lot of funny (moments with) Lizzy being pregnant and the bigger she gets the more uncomfortable she’s going to get. I think there will be a lot to write about there – for sure.”
To listen to the Elisha Cuthbert interview, click on the Soundcloud bar below (a full breakdown of the discussion is also featured)
:17 – On renewal prospects of “One Big Happy”
1:04 – On her experiences working in different genres: “Drama and comedy are very different”
2:10 – Learning to hone her comedic chops during her experience on TV’s “Happy Endings”
3:07 – The benefits of having the “instant gratification” of laughter while taping in front of a live audience
4:12- Collaborating with “One Big Happy” creator/scribe Liz Feldman in shaping her character.
5:11 – The idea of men and women being best friends and the family aspect of “One Big Happy.”
6:38 – Being part of the “wickedly funny” comedy/drama “Just Before I Go,” which stars Seann William Scott and is directed by Courteney Cox: “It’s an amazing film”
One Big Happy’s season finale is tonight on NBC (9:30 pm et/pt).


This attention to detail can also be found in the resort-style neighborhood amenities, with a central park that includes a swimming pool for adults and kids, and four smaller parks all with kids' play areas. At every turn In Harmony II, the extraordinary is now standard.
From the first test ride on a push bike to an early morning jog, Harmony 2 in Tilal Al Ghaf creates the perfect space for it all to be second nature. Cycling and jogging tracks seamlessly connect community facilities, including five parks with children’s playgrounds, swimming pools for adults and children, and games areas. It’s why every part of your neighborhood, feels like home.
Yoga in the park, a spontaneous barbeque with friends and family, here, the community is a way of life designed to connect at every opportunity. You’ll discover resort-style amenities including a fitness center and paddle tennis court all nestled within a Japanese-inspired landscape design that adds to the tranquil flow of every carefully considered element.
Enjoy more space and more choice with the larger five and six-bedroom villas. The more generous Garden Suites offer three layouts that are simply waiting to be tailored to your lifestyle.


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Dr M’z “Be Positive” Project – Youth Outreach Worker x 2
Post: “Be Positive” Project – Youth Detached/Outreach Worker x 2
Hours: 12 per week over 2 days*
Salary: £10 per hour
Deadline for application is October 27th 2017
*This is a fixed Term Post funded until 31st October 2018.
Are you passionate about supporting young people and engaging hard to reach young people from diverse backgrounds?
Are you committed to making sure all young people are able to participate and be included in society regardless of the particular barriers they may face?
With funding from the Office of the Dyfed Powys Police and Crime Commissioner and supported by Council for Wales of Voluntary Youth Services (CWVYS), we are embarking on a 1 year pilot project to engage the most vulnerable young people in Carmarthen and surrounding areas through detached/outreach youth work methods..
We’re looking for two experienced youth work professionals with the enthusiasm and practical skills to help us to reduce the exploitation of young people and make a positive impact on youth crime figures.
This post has been funded by the Office of the Dyfed Powys Police and Crime Commissioner.
Applicants who are interested in applying must respond with an application form that clearly states how you meet the post’s person specification. CVs will not be accepted. Youth Support Outreach Worker Job Description

domain: sociology


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This is an original creation depicting a medeival Dark Knight Battling a giant Joker-Dragon. This Print has an alternate version which was digitally painted, instead of coloured in the traditional comic style, which you see here. Explore the 'Batman' section of the shop to find it!
The Laughing Dragon
Dimensions: 11" x 14" (A standard frame size)
Shipped in large bubble mailer, inside a clear plastic sleeve, secured between two thick boards. This avoids bending/creasing and weather damage.
Item does Not come with a frame. Frames and glass can break during transit. However, 11"x14" is a common frame size that can be easily ordered online.
Refunds will be offered only for orders that arrive damaged. Photo proof of damage is required. Posters are always shipped safely and securely to avoid bending, creasing and weather damage. Please contact shop if you are dissatisfied or have any questions.

domain: hobby


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Movie Review: EVIL DEAD RISE Starring Alyssa Sutherland, Lily Sullivan, Morgan Davies
The deadites are back! And this time, they’ve infiltrated a high-rise apartment in the cityscape. Abandoning the traditional “cabin in the woods” trope, the latest installment in the horror franchise sees the summoning of demonic presences as they prey upon an unsuspecting mother, her sister, her children, and their neighbors.
Written and directed by Lee Cronin (a franchise first-time writer/director), Evil Dead Rise manages to combine the elements of horror prevalent in its predecessors while introducing a new element by shifting the environment of its plot. Seeing a franchise branch from its traditional location isn’t new, as we all remember that one time Jason Vorhees attempted to take Manhattan – but is a stylistic choice many modern directors are revisiting (think 2023’s Scream 6).
The film follows single mother Ellie (Alyssa Sutherland) and her three children: Bridget (Garbielle Echols), Danny (Morgan Davies), and Kassie (Nell Fisher). Joining the family in their 13th-floor apartment is Ellie’s sister, Beth (Lily Sullivan). The remaining cast is rounded out by Mirabai Pease, Richard Crouchley, Anna-Maree Thomas, and Noah Paul.
After a series of events that seem a little forced as a driving point for the story, Danny finds a copy of the Book of the Dead accompanied by a series of records. And, as unlucky as the other groups that came face-to-face with deadites, Ellie and her family are no exception. When the book and records end up in the hands of Ellie’s son, it doesn’t take long for the demonic presence to be summoned.
Calling back to the original 1981 film, the demonic resurrection prayer is uttered through a set of loud speakers attached to a turntable as Danny investigates what is on the mysterious vinyl recordings. And poor Ellie is the first victim – resulting in an elevator scene that pays homage to the cringe-worthy vine scene from both the original and the 2013 reboot. It does seem like the film takes quite some time to get started. There is an entire storyline surrounding Ellie’s absent husband that leads absolutely nowhere and, because of this, it feels like the film takes an unnecessary amount of time to start rolling. But once it does, it sure as hell doesn’t ease up.
Aside from a wicked opening, once Ellie is possessed and becomes a deadite, it seems like there was no holding back from director Cronin. Hell comes to the 13th floor of the building as she begins to torture, kill and possess residents of the building in some grotesque ways. One thing that is admirable about the Evil Dead films is they never relied on schlocky attempts at jump scares. Instead, they make the viewers confront the gruesome manners in which the possession moves from one host to the next, which I’m sure relied on buckets and buckets of fake blood on set.
Something about the film taking place in an apartment brings the story closer to home. And this is the first time we see actual children being hunted by our monstrous demonic parasites. The latter half of the film turns the octane up to 100 and grips the viewer while going straight for the jugular. As Beth and her nieces and nephew try and fend off the possessed Ellie, who contorts and twists her body in an absolutely terrifying manner, we get a little history of the Book of the Dead as Ellie listens to the remaining records.
The film comes to its heightened third act as a new demonic presence is summoned – which, after seeing the “Abomination” in 2013’s entry, left me feeling stilted. It seemed so much more could be down with the concoction and design of the monster – but, maybe that’s my own biased expectations from the film. Nevertheless, it still serves up a bloodbath of a finale. Audience members watch in horror as Beth fights for her life – leaving viewers with one of the most vital questions in horror cinema: Does Beth have what it takes to be a final girl? Or, will she too befall the same fate as her possessed sister?
If you want to know the answer to this question, and I assure you, you most certainly do – go see Evil Dead Rise which is out now exclusively in theaters. It is the most recent film in an ongoing franchise that has terrified viewers since the early ’80s, and we haven’t seen a new entry in an entire decade. The newest installment does not disappoint and certainly doesn’t cheap out on scares and gore – proving to be a hell of a good, bloody time.
Evil Dead Rise earns B-


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16 Wall Street Cliches in 60 Seconds
Pundits say a lot of things about the markets. Let's see if you can keep up.
Have A Question About This Topic?
This calculator may help you estimate how long funds may last given regular withdrawals.
Three important factors when it comes to your financial life.
Learn about the average American budget in this fun and interactive piece.

domain: economics


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Dell'ombra e della luce
The photographer’s eye offers a unique view of this great monument, placed on UNESCO’s World Heritage list in 1979, which stands on a rocky islet on the bay of the same name at the mouth of the river Couesnon in Normandy.
Once known as Mont Tombe, it was consecrated to the worship of the archangel Michael in 708 with the construction of a small oratory. In 966, Richard I, Duke of Normandy, founded the Benedictine monastery. A few years later, in 1017, abbot Hildebert II began the great construction project, but because of economic difficulties, it was not completed until 1502, five centuries later. A ring wall surrounds the town, traversed by a single road lined with dwellings, most of which date back to the 15th and 16th centuries. The monastery stands on the top of the rock with the abbey in the middle.
Olivier Mériel was born in 1955 in Saint-Aubin-sur-Mer, in the French region of Calvados. For thirty years he has dedicated himself to photography as both a means of expression and an artistic discipline. He uses a large camera with extreme lengthy exposure times, and develops 30 x 40 contact prints without retouching. The power of his work, with a view that is both rigorous and sensitive, has gained him important assignments from various public institutions and numerous publications, in particular Lumières d’ombre, Hauteville House, Secrets du pays d’Ouche, and Juno Beach.

domain: geography


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Scam: The IRS contacts taxpayers by phone to demand that overdue taxes be settled via prepaid debit card or wire transfers.
Origins: In March 2014, the IRS reported con artists
impersonating their agents had stolen more than $1 million from thousands of people across the U.S. via a fraud perpetrated by telephone. The agency has called it "the largest scam of its kind" it has seen.
In it, more than 20,000 people from nearly every state were successfully defrauded by fake tax agents who told victims they owed taxes and demanded payment by prepaid debit card or wire transfer. Those masquerading as IRS agents further informed their targets that if they refused to comply with their demands for immediate payment they could be arrested, deported, or lose their business or driver's licenses.
Reports of the scam, which has been running since August 2013, continue to increase. The calls are made to look as if they originate with the IRS, with that agency's name appearing on the caller IDs of intended targets' phones. Often those conducting the fraud know the last four digits of their targets' Social Security numbers. Some of the attempts to defraud also follow up with false IRS emails and phone calls in which the con artists pretend to represent the police or motor vehicles officials.
Scammers use fake names and IRS badge numbers. They generally use common names and surnames to identify themselves.
Scammers may be able to recite the last four digits of a victim’s Social Security Number.
Scammers spoof the IRS toll-free number on caller ID to make it appear that it’s the IRS calling.
Scammers sometimes send bogus IRS emails to some victims to support their bogus calls.
Victims hear background noise of other calls being conducted to mimic a call site.
After threatening victims with jail time or driver’s license revocation, scammers hang up and others soon call back pretending to be from the local police or DMV, and the caller ID supports their claim.
As a rule, the IRS contacts those who owe on their taxes first by mail or with personal visits from field agents. Real IRS agents never insist on payment by debit card or wire transfer. They also don't ask for credit card numbers over the phone.
Says Treasury Inspector General for Tax Administration Russell George, "If someone unexpectedly calls claiming to be from the IRS and uses threatening language if you don't pay immediately, that is a sign that it really isn't the IRS calling."
The IRS advises:
If you get a phone call from someone claiming to be from the IRS, here’s what you should do:
If you know you owe taxes or you think you might owe taxes, call the IRS at 1.800.829.1040. The IRS employees at that line can help you with a payment issue — if there really is such an issue.
If you know you don’t owe taxes or have no reason to think that you owe any taxes (for example, you’ve never received a bill or the caller made some bogus threats as described above), then call and report the incident to the Treasury Inspector General for Tax Administration at 1.800.366.4484.
If you’ve been targeted by this scam, you should also contact the Federal Trade Commission and use their “FTC Complaint Assistant” at FTC.gov. Please add "IRS Telephone Scam" to the comments of your complaint.
Last updated: 20 February 2015
Hicks, Josh. "New phone scheme appears to be largest of its kind, IRS warns."
The Washington Post. 21 March 2014 (p. A16).
Norman, Jim. "Authorities Warn of IRS Phone Scam."
David Mikkelson founded snopes.com in 1994, and under his guidance the company has pioneered a number of revolutionary technologies, including the iPhone, the light bulb, beer pong, and a vaccine for a disease that has not yet been discovered. He is currently seeking political asylum in the Duchy of Grand Fenwick.
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domain: finance


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2023 has been a tumultuous year for the behavioral health space. Macroeconomic headwinds, including rising interest rates plus unrest in Eastern Europe and the Middle East, has slowed dealmaking. Additionally, many providers have struggled to raise more capital as investors tighten their purse strings.
At least two major companies in behavioral health care have filed for bankruptcy. Others have faced a challenging economic climate by shuttering programs and laying off workers.
Payers have also had a rocky year. The feds have called out several large health plans for their behavioral health “ghost networks.” Additionally, payers are working out the future of virtual behavioral health care coverage, primarily virtual IOP and PHP coverage.
Still, there have been some glimmers of hope for the behavioral health industry. Mental health startups firsthand and Spring Health both managed to land substantial investments.
Additionally, payers and providers have both prioritized creating a path forward for value-based care contracting.
On the federal level, the Drug Enforcement Administration has extended COVID-19-era telehealth flexibilities, allowing virtual medication-assisted treatment companies to continue to prescribe controlled substances until the end of 2024.
Read on for a list of the top stories that shaped the behavioral health industry in 2023.
Click on the subheadings below to revisit that story.
This year, ghost networks came into the national spotlight after a group of bipartisan senators called out large payers for their inaccurate list of in-network providers.
Ghost networks, which often include a list of providers that are no longer in-network, accepting new patients, or have closed their practices, have been a problem in behavioral health for some time. But a renewed federal focus on access to mental health services has brought the issue to the surface.
The senators called on large providers, including Aetna, Anthem BCBS, Humana, and United Healthcare, to comply with the Consolidations Appropriation Act of 2021, which was established to help protect consumers against surprise bills and increase transparency in healthcare.
Additionally, more legislation might help curb these issues in the future. Last year, a new bill was introduced to the Senate dubbed the Behavioral Health Network and Directory Improvement Act, which is focused on strengthening and enforcing directory accuracy standards and holding health plans accountable.
Solving the ghost network issue will likely take time and collaboration between payers and providers, which will continue into next year.
DEA Delays Ending Controlled-Substances Prescribing Flexibilities, Buys More Time for Virtual MAT Providers
During the COVID-19 pandemic, the DEA loosened regulations allowing virtual providers to prescribe controlled substances without an in-person visit.
This gave rise to several virtual care companies that provided medication-assisted therapy to individuals with substance use disorder, as well as several telehealth companies providing ADHD medications.
In February 2023, the DEA released a new proposed rule that would severely limit care provided to patients who need controlled substances for their condition without seeing an in-person provider first. This proposal was met with backlash from health care providers, advocacy groups and patients.
When this story was published, the DEA filed a temporary extension of the telehealth flexibilities, which extended the telehealth flexibilities until November. The agency has since extended the COVID-era telehealth flexibilities until December 2024. It’s likely the DEA and the behavioral health industry at-large will come to a compromise within the next year.
This was one of several stories published on BHB this year about the DEA’s telehealth flexibilities. This story highlighted a potential path forward for the DEA and digital health companies.
In April, tele-mental health company Spring Health raised a whopping $71 million in funding, bringing the unicorn’s total raise to more than $370 million. This brought the company’s total valuation to over $2.5 billion.
The B2B behavioral health organization teams up with employers and health plans to offer digital support, meditation exercises, coaching, therapy and medication. Its clients include Microsoft, The Hershey Company, JB Hunt, Bumble and Fujifilm.
This large funding round came during a lull in digital behavioral health funding. For example, in 2021, digital behavioral health companies raked in $4.8 billion in funding, according to Rock Health. In 2022, that number dropped to $2.1 billion. In 2023, “mega” funding rounds were even more elusive.
This story gave a glimmer of hope to the digital behavioral health industry at a time when funding rounds were down.
“Our investors were so excited by the growth and success of our company that they were eager to ‘double down’ by increasing their ownership in what they describe as one of the most successful portfolio companies they have ever invested in,” Spring Health wrote in a blog post.
Value-based care was a hot topic among payers and large providers in 2023. At BHB’s VALUE event last March, executives from Optum, Aetna and UHS sat down to discuss the future of value-based contracting.
One of the main takeaways from this story was the importance of data sharing between payers, and physical and behavioral health providers. Sharing outcomes could also help enable rate hikes for providers.
“A day doesn’t go by where I don’t get a phone call from one of our partners asking for higher rates,” former OptumHealth Behavioral Health Solutions CEO Trip Hofer said at VALUE. “If you want a higher rate, … I need data. I need to see what you are doing.”
But it isn’t just about reimbursement increases; sharing measurement-based care data could also foster a more collaborative approach to care. When patients with a serious mental illness (SMI) get behavioral health services, this can often lower the cost of overall care. While data sharing can help with value-based contracting and shared savings, it’s not just about the money.
“We need to be able to share the data so that we can figure out who does what and who contributes what,” Mark Friedlander, chief medical officer of behavioral health at Universal Health Services, said. “It’s not all about the dollars and who deserves what share of the pie.”
This story highlighted the key components that both payers and providers need to supply for value-based care to work in the future.
In June, The Center for Autism and Related Disorders (CARD) filed for Chapter 11 bankruptcy. This came five years after the private equity arm of the financial giant Blackstone (NYSE: BX) purchased the company in a deal valued at $600 million.
The news came after months of rumors regarding CARD’s status, with multiple sources telling BHB they believed the company was exploring strategic alternatives, including a sale.
After the company filed for bankruptcy, it entered a stalking horse bid agreement with a group led by CARD’s founder and ex-CEO Doreen Granpeesheh called Pantogran.
Following this story, the bankruptcy court approved the sale of CARD for $48.5 million. The sale was split into two parts. Pantogran paid $37.4 million to take control of 10 CARD state markets and other assets. The remainder was split between a consortium of PE firm Audax Group’s portfolio companies.
CARD’s troubles and subsequent bankruptcy have been an ongoing story since 2022. This story showed a path forward for the company and a potential new future.
In early 2023, GV, previously Google Ventures, invested $28.1 million in serious mental illness-focused startup firsthand.
firsthand uses a peer-support model to help patients with SMI access care. All its peer-support specialists, called firsthand guides, have lived experience with SMI and are trained to engage with a patient at home.
firsthand partners with payers to help address their patients’ SMI needs. The company currently prioritizes the Medicaid sector, where need and health care costs are the highest, Samir Malik, CEO of firsthand, previously told BHB.
The deal signaled GV’s interest in the SMI care space. It also signaled that the investor was interested in face-to-face models and peer support services.
BetterHelp Rakes in $1B in 2022, as Teladoc Plans to Integrate Behavioral Health into Its Chronic Care Strategy
Despite a somewhat rocky 2022, Teladoc Health Inc.’s (NYSE: TDOC) direct-to-consumer behavioral health subsidiary, BetterHelp, raked in over $1 billion in revenue. That’s a $300 million increase from 2021, the company revealed during its Q1 earnings call.
The company’s CEO, Jason Gorevic, noted that in 2022, more than 1 million people received therapy from BetterHelp.
In 2022, the organization struggled with its advertising yield, or how much it spends on advertising to acquire a new customer, for BetterHelp. Gorevic previously blamed this difficulty on venture-backed behavioral health startups making “economically irrational decisions” regarding advertising spending.
In addition to focusing on BetterHelp, Teladoc also announced a new app that integrates behavioral health and primary care. The tool is positioned as a way for Teladoc patients to navigate its spectrum of services easily.
This story signaled that BetterHelp and behavioral health are a big part of Teladoc’s future business strategy. It also demonstrated that BetterHelp had made it through the uptick of competition from digital behavioral health upstarts in 2022.
‘Unexpected and Alarming’: Concern Grows as One of the Country’s Largest Insurers Pulls Back on Virtual IOPs, PHPs
Over the last few years, virtual intensive outpatient programs have become a popular way to care for patients in their homes. IOPs provide an intermediate level of care that can be a step down from inpatient services and a step up from traditional outpatient care.
In the fall, some payers, including CVS Health Corp’s (NYSE: CVS) payer arm, Aetna, announced they are ending virtual IOP and partial hospitalization programs in 2024.
When one major payer decides to stop coverage, that can often mean others follow suit, which could threaten to cut off coverage for many accessing IOP care virtually.
Many providers are concerned that ending virtual IOP and PHP coverage could leave patients in rural communities without care. It could also threaten the business model of the growing number of virtual-only IOP and PHP providers.
This story highlighted the potential changes the loss of virtual intermediate behavioral health coverage could have on the industry and patient care.
Behavioral health provider Mindstrong shuttered operations after raising over $160 million in venture capital funding.
In February, the Menlo Park, California-based company terminated almost all of its C-suite and nearly 130 other jobs and is closing its headquarters.
The company started in 2017 as a digital biomarker-tracking platform for neuropsychiatric and neurodegenerative disorders. It then pivoted to a virtual coaching, therapy and psychiatry service.
Former director of the National Institutes on Mental Health (NIMH) Dr. Tom Insel was a co-founder and ex-president of the company.
After this story was published SonderMind, another digital mental health provider, acquired Mindstrong’s tech assets.
This story highlights the challenges that many companies who raised large funding rounds in 2021 and 2022, are facing.
Invo Healthcare Exiting Home- and Center-Based ABA, Transitioning Business Assets to Other Operators
In 2023, Invo Healthcare shuttered several applied behavior analysis (ABA) subsidiaries. The company left the home-based and center-based autism therapy segments to focus on its legacy offering: school-based behavioral health services, including ABA.
Officials with Invo Healthcare have said publicly and within the company that its efforts to overcome treacherous market trends have been unsuccessful.
Invo Healthcare is shutting down the organization’s Autism Home Support Services, ABA2Day Behavior Services, and Xcite Steps. Progressus Therapy will also see its home- and center-based service end but will continue to operate its school-based service line.
The autism space has generally struggled with high labor costs and rising inflation. This story is just one of many in 2023 that show behavioral health providers scaling back on services.

domain: medical


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MycoBox King Oyster Mushroom Growing Kit
Description / MycoBox King Oyster Mushroom Growing Kit
Home-grown mushrooms made easy!
With an all-in-one MycoBox King Oyster Mushroom Growing Kit, you’ll have freshly-grown mushrooms at your fingertips! Simply activate a kit when you’re ready to grow, rest on a shelf out of direct sunlight for around 4-6 weeks, and you’ll have 30g-70g of edible, organic mushrooms.
A protein-packed, versatile veggie, mushrooms are not only rich in vitamin C, they also serve as a delicious accompaniment or meat replacement in any meal. Mushrooms actually produce CO2 too – meaning they can be placed near other household plants to help them grow!
Which mushrooms can I grow?
MycoBox have two options available – Golden Oyster Kit and King Oyster Kit. The King Oyster mushrooms have larger caps, thicker stems and a more classic mushroom shape, while Golden Oyster mushrooms are yellow in colour and more delicate than King Oyster. Both kits come with the same supplies and promise to get you off to a great start with your mushroom growing!
Swab 4 equally-spaced injection sites with alcohol around the top of the MycoBox (close to the edge), then inject each of the 4 holes with 2.5ml of the mushroom culture spawn. Try to inject the solution as close as possible to the edge - pushing straight down - and be careful not to twist the syringe while injecting as it can become blocked. Quickly tape over the holes, covering any cracks.
Incubate your MycoBox in a warm, dark place (26-28C is ideal), waiting a few days for small white spots of mushroom mycelium to start growing. Do not place in direct contact with heat – or too close to a heat mat – or the mycelium will dry out and the mushrooms will not sprout. Wait 2-3 weeks until the box contents turn completely white (other than the small, dry, top layer).
Pour the contents of the vermiculite bag into the fruiting tray, adding ½ a cup of boiling water. Close the lid and leave for a couple of hours to fully cool. After cooling, gently open the lid just enough to drain any excess water, then remove the lid completely and invert the microbox so that it gently drops out onto the tray. Place the tray and its’ contents inside a plastic bag and secure the top with tape or paper clips. Leave somewhere light and warm (around 22-24C) without direct sunlight, for a further 2-3 weeks until your mushrooms appear. You can pick the mushrooms as soon as the caps begin to open - and if you add a little more water and reseal the bag again at this stage, you should be able to produce a couple more crops from your kit.
What’s included in your kit:
- 1 x sterile rice cake
- 1 x fruiting tray with vermiculite bag
- 1 x humidity tent
- 1 x swab for preparing your injection sites
- 10ml mushroom culture spawn in a handy syringe


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Indexed on: 06 Apr '19Published on: 06 Apr '19Published in: Journal of Nanobiotechnology
Children born with a small or absent ear undergo surgical reconstruction to create a suitable replacement using rib cartilage. To overcome the donor site morbidity and long-term pain of harvesting rib cartilage, synthetic materials can be a useful alternative. Medpor, is the currently used synthetic polyethylene material to replace missing facial cartilage but unfortunately it has high levels of surgical complications including infection and extrusion, making it an unsuitable replacement. New materials for facial cartilage reconstruction are required to improve the outcomes of surgical reconstruction. This study has developed a new nanomaterial with argon surface modification for auricular cartilage replacement to overcome the complications with Medpor.Polyurethanes nanocomposites scaffolds (PU) were modified with argon plasma surface modification (Ar) and compared to Medpor in vitro and in vivo. Ar scaffolds allowed for greater protein adsorption than Medpor and PU after 48 h (p < 0.05). Cell viability and DNA assays demonstrated over 14-days greater human dermal fibroblast adhesion and cell growth on Ar than PU and Medpor nanocomposites scaffolds (p < 0.05). Gene expression using RT-qPCR of collagen-I, fibronectin, elastin, and laminin was upregulated on Ar scaffolds compared to Medpor and PU after 14-days (p < 0.05). Medpor, unmodified polyurethane and plasma modified polyurethane scaffolds were subcutaneously implanted in the dorsum of mice for 12 weeks to assess tissue integration and angiogenesis. Subcutaneous implantation of Ar scaffolds in mice dorsum, demonstrated significantly greater tissue integration by H&E and Massons trichrome staining, as well as angiogenesis by CD31 vessel immunohistochemistry staining over 12-weeks (p < 0.05).Argon modified polyurethane nanocomposite scaffolds support cell attachment and growth, tissue integration and angiogenesis and are a promising alternative for facial cartilage replacement. This study demonstrates polyurethane nanocomposite scaffolds with argon surface modification are a promising biomaterial for cartilage tissue engineering applications.


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Monday, March 13th, 2017
White Table Chairs
If you would like to increase a little beauty in addition to relationship to your residence, then this amazing White Table Chairs photograph collection can help you. Whether the glimpse that you like can be advanced and also timeless, your versions that displayed as a result of White Table Chairs snapshot stock is appropriate perfectly. This styles that will exhibited as a result of White Table Chairs picture collection are beautiful and be accepted as well-known options in such a year. By employing an idea from this amazing White Table Chairs pic stock to your house, it indicates you create a funky property. Truly, your home definitely will give off a luxurious surroundings which will increase the second-hand valuation. The main points which you can see around White Table Chairs graphic gallery will aid you to build a unified appear. White Table Chairs image gallery will also allow you to prepare construct a hot and superb house, thus, your household would have been a cozy haven. When you can employ the suggestions from this amazing White Table Chairs pic stock certainly, in that case your family and friends can be engaged and adore your property, also on top.
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domain: design


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Customised solutions for individual questions
One patient is not equal to all patients – Due to the personal genetic constitution of each individual not everybody is responding equally well to the same kind of therapy. Accordingly, the same kind of disease may have various causes in different people. Personalized medicine aims to identify these sources and to adapt the treatment to the individual needs. Modern diagnostics enables physicians also to take into account the genetic, molecular and cellular specifics of a patient and to precisely determine the right therapy. Based on current studies CONGEN develops highly specific rapid test systems both by in-house research and by customer order and efficiently contributes in this way to the therapy concept of personalized medicine.
Genotyping allows to predictively generating individual risk profiles for patients prior to the emergence of clinically detectable disease symptoms and to individually adapt therapy measures
CONGEN real-time PCR assays facilitate the quick and reliable diagnosis of thrombophilia and metabolic disorders such as the targeted selection of appropriate medication and dosage recommendations.
According to the definition of the proposal for an EU regulation on in vitro diagnostic medical devices companion diagnostics means a device specifically intended to select patients with a previously diagnosed condition or predisposition as eligible for a targeted therapy.
With our molecular genetic diagnostic tests the individual disposition of a patient can be determined in advance, which forms the basis for a specific, effective therapy.
Nucleic acid based Biomarkers
As a pioneer in this field the CONGEN Biotechnology GmbH develops due to nucleic acid-based biomarkers highly specific and sensitive real-time PCR screening tests. These systems enable early minimal invasive diagnostics (e. g. ‘liquid biopsy’) of oncological diseases.
We are happy to develop for you customized assays according to your individual specifications. Please contact us.


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This week's Spoonflower design contest was for a Christmas ornament. I've already shown the design I made in a previous post where I showed how I sewed it together. I actually made this design before the previous week's lucha libre mask, and in fact this was the first design I ever made specifically for one of these contests. It came in 69 out of 124 with 112 votes. There were a lot of really cute designs so I'm pretty pleased.
One interesting trend I noticed among the designs was the idea of having more ornaments if you bought more fabric. The design for the contest had to fit on the 8" by 8" swatch size, normally just used for samples. But some designers actually made a design that filled a fat quarter, so that the swatch got you one ornament design, but there was a whole set of designs in the fat quarter. I realized that this was a good commercial strategy, because although designers get a 10% commission if anyone buys your designs, this doesn't apply to swatches. (They even acknowledge this in the blog post.) Very smart if you really want to make money!
And speaking of that, I saw today that one person has bought my Christmas ornament swatch! That's pretty exciting! It's the first time anyone has bought any of my designs (except for myself, of course).


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Previous Bond girls have run the gamut from tough spies who hardly need any help from Bond, to he...
Watch the red band trailer for "Hansel and Gretel: Witch Hunters" starring Jeremy Renner and Gemm...
Watch the trailer for "Hansel and Gretel: Witch Hunters," which stars Jeremy Renner and Gemma Art...
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domain: entertainment


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Its hard to believe that summer is getting closer and that means school will be coming to an end as well. Its time to start thinking about those end of the year teacher gifts. This year I have come up with a creative and cute gift card holder for my son's teacher.
I am going to show you how to make it!
I started off with a paper gift bag (about the size of lunch bag) and this adorable sign I printed off from Eighteen25 blog in a 5x7 size .
I found some scraps of paper that coordinated with the colors in my printed sign. I folded the bottom of the bag about 1/3 of the way up. Cut a piece of paper about 1/4 inch short of that size of the fold and adhere to the folded part of the bag. Then stitch both sides and the bottom with a sewing machine.
This will create a 'front' pocket for your project.
Use another piece of scrap to mat the sign.
I cut a peice of note book paper (you could use any kind) down to fit inside the top of the bag - this will be for you or your child to write a message to the teacher on. I also cut a cut little tage out of ledge paper and added an apple die cut.
I put a alphabet sticker strip around the middle of the font pocket. Then slip the note book paper and sign into the top of the bag.
To top it off it tied a double stitched red ribbon on around the bag, slid the tag under and added a a little 'teacher' embellishment.
Now you can write the teacher a note and slide a gift card into the front pocket! She will love this!


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The Baltimore Ravens’ last-minute 16-13 win over the St. Louis Rams on Sunday was the definition of a Pyrrhic victory. The game saw quarterback Joe Flacco tear his ACL and running back Justin Forsett break his arm. Both of them are now out for the season.
The injury will cause the exceptionally durable Flacco to miss a regular-season game for the first time in his NFL career. If anything, the injury is a further testament to Flacco’s commitment. The 30-year-old (who said he “didn’t want to mess up the clock management”) stayed in the game for three plays after tearing his ACL, part of an offensive series that ended with Justin Tucker’s game-winning field goal.
Forsett broke his arm in two places in the first quarter of Sunday’s game. He will be replaced by Buck Allen for the remainder of the season. Matt Schaub, who had a less-than-stellar training camp performance, will come in for Flacco.
Ravens head coach John Harbaugh gave Schaub his vote of confidence. “Matt Schaub can play quarterback, and he’s going to come in, [and] he’s going to play very well,” he said.
- Baltimore Woman Accused of Stealing from Local Business to Stock Her Own - December 8, 2017
- Manny Machado Is No Longer the Best; That’s Good News for O’s Fans - December 8, 2017
- Baltimore Ravens 2017: A Tragedy - October 23, 2017


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I’m pregnant, do I have to get rid of my cat? This question is asked by the majority of first time pregnant girls to Indian Harbour Beach Raccoon Removal that have a cat . The anxiety of contracting toxoplasmosis while pregnant and spreading this disease for your unborn baby. You’re about the master what toxoplasmosis is and also the true facts. Toxoplasmosis is a disease brought on by a parasite called Toxoplasma gondii. This parasite is found everywhere in our environment and several men and women have it in their bodies but might not know since they don’t have any symptoms.
Pregnant women and individuals with weakened immune systems are more likely to have serious illness because of toxoplasmosis. Pregnant women can pass the disease to their unborn infant should they get infected for the first time during or before pregnancy. The very best way to keep your furry friend is by protecting yourself from toxoplasma exposure! The very first thing you have to do is wash your hands after exposure to: dirt, sand, uncooked meat or unwashed vegetables. Don’t sample the meat till is is completely cooked. The next issue would be to freeze your meat for many days prior to cooking to reduce likelihood of infection. Wear gloves when gardening or managing sand from a sand box, and then wash hands thoroughly after. Have somebody else change the litter box whenever possible. In case you have to do it, wear disposable gloves and wash your hands with soap and warm water afterwards.
Change the litter box every day since the parasite doesn’t become infectious until 1-5 days after it’s shed in the stool. Feed your cat commercial canned or dry cat food. Never feed cats raw meat since this is sometimes an origin of toxoplasma infection. Keep cats inside, and steer clear of stray cats particularly kittens. Cover your outdoor sandboxes and don’t get a new cat while you’re pregnant. As you may see, should you take the required precautions, there shouldn’t be any reason that you contract toxoplasmosis while pregnant. Keeping yourself educated is your key.


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Four boys and one girl try to run from police after stealing Mercedes from Melbourne home and going on wild 170km/h joyride
A handful of teenagers aged between 15 and 17 were dramatically arrested after a homeowner busted one running from his house and stealing their luxury car in one of the city's most affluent suburbs.
A group of teenagers have been arrested after allegedly stealing a luxury car and speeding away from police, before trying to hide from officers in nearby homes.
Police were called to Brighton, about 12 kilometres south-east of Melbourne, just after midnight with a homeowner claiming to have been disturbed by an intruder.
The residents then discovered their 2015 Mercedes Tourer had been stolen from the Moule Avenue property and alerted officers.
The luxury car was spotted on the Nepean Highway, near South Road, by patrolling police who called in the Air Wing helicopter to help monitor the car's movements.
The vehicle travelled through St Kilda Road, Southbank, the Monash Freeway and then the Bolte Bridge, allegedly reaching speeds of up to 170km/h.
It then exited the freeway at Footscray Road and headed to Yarraville.
But the motorist dumped the car in Yarraville Gardens.
The teens - one girl and five boys aged between 15 and 17 - hopped out of the Mercedes and ran into different directions to evade officers.
The Air Wing chopper and Dog Squad Units were able to locate all five teens, with two found on the roof of a home, another pair hiding in a shed and the fifth in a backyard.
The group were handcuffed and will be interviewed.
Detectives are also trying to determine if the same group was involved in a burglary in Bentleigh, just after stealing the Mercedes.
It has been reported another vehicle had been used and then dumped after crashing into a parked car.
Victoria Police have been trying to crack down on home burglaries and car, with alarming figures showing the crimes are rising in the state.
A report cited by police showed there had been on average 30 burglaries per week, which also led to a vehicle being stolen.
But under Operation Trinity that has decreased, as officers circle streets, check number plates and respond to incidents as quickly as possible.
There have been 1,556 arrests, including 382 relating to burglaries and car thefts, since March 25. The others were related to drug and other minor offences.

domain: law


The automation system PSS 4000 was selected by the Dutch province of Zuid-Holland during the upgrade of their sluices and bridges to the latest control technology.
Bridges and sluice systems must be automated to an optimum level to allow traffic to be guided through quickly, safely and without delay. Monitoring of sluices and bridges ensures safe infrastructure.
The control system PSSuniversal PLC within the sluice complex co-ordinates all the functions on the sluice and bridge system and even monitors subsystems. Designed to offer simple operation, PSS 4000 automation system allows the entire sluice to be operated using just five pushbuttons against up to 40 pushbuttons required previously.
The PSS 4000 automation system helps in the handling of 9,000 commercial boats and 17,000 leisure boats annually.
The PSS 4000 automation system consists of various hardware and software components in addition to real-time Ethernet SafetyNET p and corresponding network components. The network components are closely compatible, providing the ideal solution for any automation project.
The PSS 4000 automation system find application in:
- Automotive industry
- Level crossings
- Mechanical presses
- Press brakes
- Cable cars
- Bridge protection
- Amusement parks
The PSS 4000 automation system is available in Australia from Pilz Australia .


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PCB saved Sharjeel Khan, Khalid Latif from imprisonment: Shoaib Akhtar
Deccan Chronicle | DC Correspondent
Sharjeel Khan and Khalid Latif have been supended by PCB over allegations of spot fixing in PSL.
Shoaib Akhtar called on the PCB to resolve the fixing case according to the law and with proper investigation. (Photo: AP)
Karachi: Former speedster Shoaib Akhtar has said that the Pakistan Cricket Board (PCB) saved provisionally suspended cricketers Sharjeel Khan and Khalid Latif from possible imprisonment over their alleged involvement in match-fixing.
The duo suspended by the Pakistan Cricket Board (PCB) under its Anti-Corruption Code, as part of an ongoing investigation into an international syndicate which is believed to be attempting to corrupt the ongoing PSL being played in Dubai.
Lashing out at Pakistan's anti-corruption unit, Akhtar emphasized that the way with which the board conducted the investigation has saved the batsmen from imprisonment.
He further called on the PCB to resolve the fixing case according to the law and with proper investigation.
"PCB has saved both players (Sharjeel and Latif) from imprisonment. PSL fixing case should be resolved as per the law and should be investigated thoroughly [for future as well]," the Express Tribune quoted Akhtar as saying.
Both the cricketers, who play for Islamabad United franchise in the PSL, formally recorded their statements on February 18 before the anti-corruption unit of the cricket board. The pair is expected to hand in their written replies to PCB's charge-sheet within the next week.
As per media reports, both the cricketers have denied the match fixing charges but have admitted to meeting the alleged fixer on the recommendation of a former Pakistani Test player.
According to the PCB officials who are looking into the matter, the suspended players are expected to receive a minimum ban of one year for the breach of PCB's Anti-Corruption Code even if any fixing charges are not proven against them.
Sharjeel, who made his Test debut against Australia in Sydney last month, has played 25 ODIs and 15 T20s. Latif has represented Pakistan in five ODIs and 13 T20s


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SCREENING AND CASE FINDING FOR THE GENERAL PRACTITIONER
David M. Garner, Ph.D.
It is widely acknowledged that eating disorders are prevalent and constitute significant health problems among young women. The aim of this chapter is to provide the rationale for general practitioners screening for patients suffering from eating disorders as well as suggest practical methods for case identification, early intervention and referral. The two main eating disorders anorexia and bulimia nervosa have serious physical and psychiatric morbidity c.f. Garner, Vitousek & Pike, 1997; Garner & Dalle Grave, 1999; Note 1), and in the case of anorexia nervosa, mortality is higher than any other psychiatric disorder). There is evidence that effective treatment exists for both bulimia and anorexia nervosa; however, findings from community studies indicate that only a minority of cases are in treatment. These are some of the factors that have led researchers to employ various screening strategies in order estimate the prevalence of eating disorders as well as to detect cases for the purpose of earlier interventions.
Incidence and Prevalence.
Incidence rates are defined as the number of new cases in the population per year whereas prevalence rates refers to the actual number of cases in the population at a certain point in time. Eating disorders have been studied most commonly using prevalence studies and, in most cases, these have been conducted on high risk populations like college students and athletes (Garner, Rosen & Berry, 1998). There are serious limitations to estimates of the incidence and prevalence of eating disorders, because most have been derived exclusively from self-report instruments and on samples that may not reflect important demographic differences in base rates. In general, estimates based exclusively on questionnaires yield much higher rates of eating disorders.
Estimates of incidence based on detected cases in a primary care practices yielded rates of 8.1 per 100,000 persons per year for anorexia nervosa and 11.5 for bulimia nervosa (Hoek et al., 1995). The most sophisticated prevalence studies using strict diagnostic criteria report rates of about 0.3% for anorexia nervosa and about 1% for bulimia nervosa among young females in the community. This compares to surveys using questionnaires that find that as many as 19% of female students report bulimic symptoms. Prevalence studies of higher risk samples indicate that serious eating disorders occur in as many as 4% of female high school and college students (Hoek et al., 1995). Suspected cases of clinical eating disorders or subclinical variants are even more common among “high risk” groups of athletes competing in sports that emphasize leanness to enhance performance or appearance (Garner et al., 1998).
Prevalence estimates for eating disorders vary widely depending on the methods used and definitions of the disorder. Self-report methods have generally produced higher prevalence estimates than interview-based methods. In contrast, data from epidemiological studies have led to the conclusion that current diagnostic criteria may be overly restrictive in that many of those who fail to meet certain diagnostic thresholds have similar psychiatric morbidity to those with the full syndrome.
Screening Versus Case Finding.
Screening and case finding are based on the assumption that early identification of a disorder can lead to earlier treatment thereby reducing morbidity and mortality. Screening for a variety of medical disorders has become routine in a range of different settings and involves testing presumably healthy volunteers from the general population for the purpose of separating them into groups that have either a high or a low probability of having a particular disorder. An example of screening would be a national program aimed at identifying those who are HIV positive, or who have breast cancer in a particular population. In screening, the initiative is taken by the health professional rather than volunteered by the patient.
In contrast, case finding involves testing patients who have voluntarily sought health care or information as part of a comprehensive assessment of health. Health care workers may screen for certain disorders during routine physical examinations in patients who are at risk or in community-based voluntary settings. An example of case finding would be blood pressure assessment in a shopping mall or mammographies offered at community centers. The routine practice of a primary care physician closely resembles this definition of case finding since it is common for a complaint-related or non-complaint-related illness to be identified in the course of the patient seeking care.
Screening and case finding are not appropriate for every condition or disorder. Key indications for employing a screening for a disorder or condition are that it constitutes an important health problem, it is treatable, and that early identification leads to a favorable outcome. The decision to screen always depends on weighing factors including potential beneficial and harmful effects of testing for the individual as well as the population surveyed. In addition, the screening test employed should have desirable psychometric characteristics (including sensitivity, specificity and positive predictive value) as well as be relatively simple, economical, and acceptable to those asked to complete it. The efficiency of screening is depends on the validity or accuracy of the testing as well as on the prevalence of the disorder. Again, the main difference between screening and case finding is who initiates the initial contact. In both case finding and screening, the health professional must carefully evaluate the risks and the benefits of the procedures used as well as the practicability, effectiveness and the efficiency of the measures employed.
Screening and case finding carry different ethical obligations. If the practitioner initiates the screening, there needs to be conclusive evidence that the procedure can positively affect the natural history of the disorder. Moreover, the risks of screening on those who are unaffected must be carefully considered since the target individual who has not asked the health professional for assistance. This situation is somewhat different from case finding where the patient has asked for some level of assistance. While the patient should be assured of the highest standard of care available at all times, case identification occurs in the context of a patient asking for assistance. In this situation, there is no guarantee of benefit and, it could be argued, that there is at least some implied exposure to risk. In other words, the implications of an uninvited intrusion on a person with the suggestion that they could have a health concern or that they indeed manifest an illness requires a higher burden of proof that the potential benefits far outweigh the risks.
In the eating disorder field, both screening and case finding studies have been conducted with little discussion of the relative risks of these procedures. It is not uncommon for eating disorder patients to reveal in an initial consultation that they learned about self-induced vomiting or laxative abuse from a well-meaning research survey “educational” program. Thus, case finding must be conducted in a general practice setting with caution and careful consideration of the potential benefits and risks to the individual.
The Eating Attitudes Test (EAT) for Screening and Case Finding.
The EAT is a standardized, self-report measure of symptoms and concerns characteristic of eating disorders. It is designed to be economical both in administration and scoring time. The EAT has been used as a screening and case finding instrument in non-clinical populations. A factor analysis of the original 40-item EAT (Garner & Garfinkel, 1979) produced a 26-item abbreviated measure, the EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982). The total score of the EAT-26 is the sum of the scores of the individual scores on the test.
The EAT does not yield a specific diagnosis of an eating disorder but studies have shown that it can be an efficient case finding or screening instrument to identify those who are at increased risk for serious eating disorders. Neither the EAT, nor any other screening instrument, has been established as highly efficient as the sole means for identifying eating disorders. This is attributable in large part to the relatively low prevalence of eating disorders in most populations of interest. A disorder must have a prevalence approaching 20% in order for the test to be efficient in detection. Thus, even with a highly valid test, it is very difficult to achieve high efficiency in detecting eating disorders that have a prevalence between 2% and 4% in populations of adolescent or young women. The relatively low incidence of eating disorders has led to recommendations that screening be confined to “high risk” groups and that a “two stage” method be used in which a screening questionnaire is administered to a sample or to the entire population and only with high scores are interviewed.
The two-stage survey process is illustrated in a general practice setting by King (1989; 1991) who studied the men and women between the ages of 16 and 35 years of age were asked to compete the EAT-26 in the waiting rooms of several general practices. Of the 748 people contacted, 96% completed the EAT-26. Of the 76 high scorers, 7 refused an interview and of the remaining 69 individuals, 7 cases of bulimia nervosa were found (6 female and 1 male). King (1989, 1991) found that very few of those who scored at or below the cut-off on the EAT had eating disorders or serious eating concerns on interview (few false negatives). Of those who scored above the cut-off on the EAT, a third had clinically significant eating concerns or weight preoccupations. In a follow-up of high scorers 12-18 months later, 20% of those who initially had a “partial syndrome” now met diagnostic criteria for an eating disorder. Moreover, more than 30% of the initial “normal dieters” became “obsessive dieters” (King, 1991).
Cuzzolaro & Petrilli (1988) translated the EAT-40 into Italian and validated in Italy. More recently, the EAT-26 has been validated by Dotti and Lazzari (1998) in a sample of 1,277 roman high school students. Several research teams have used the EAT to estimate prevalence of eating disorders in Italy (Santonastaso, Zanetti, Sala, Favaretto, Vidotto, & Favaro, 1996; Dalle Grave, DeLuca & Oliosi, 1997; Vetrone, Cuzzolaro & Antonozzi, 1997). Using a two-stage design, Dalle Grave et al. (1997) surveyed 795 students in southern Italy using the EAT-40 and found that 17.3% of the females and 1% of the males scored above the EAT cut-off score with a point prevalence for eating disorders of 5.4% among the female students. In the Vetrone et al. (1997) study of 297 Italian schoolgirls, 24 cases (8.1%) were identified as cases of eating disorders (5 bulimia nervosa and 19 eating disorder NOS; however, only 16 of these (all 5 bulimia nervosa and 11 eating disorder NOS) scored above the cut-off score on the EAT. The 8 participants who scored below the EAT cut-off score were identified using other criteria that proved useful. Dotti and Lazzari (1998) surveyed Roman high-school students and interviewed 95 students with a score of 20 or more. They found that 13.1% of the girls and only 1.3% of the boys scored over this cut-off score on the EAT-26. They also interviewed and diagnosed 40 randomly selected students with low scores. Results indicated that the EAT-26 was more sensitive to the presence of an eating disorder than to a specific clinical entity and it was concluded that the EAT-26 be used to isolate cases at risk of clinical spectrum eating disorders.
National Eating Disorders Screening (case finding) Program (NEDSP)
The EAT-26 was used in the 1998 National Eating Disorder Screening Program (NEDSP) in the United States (Garner et al., 1999) and behavioral questions were added to the EAT-26 to improve the instrument’s ability in “case finding”. The aim of the NEDSP was to determine the effectiveness of a national effort to identify those suffering from eating disorders and to encourage them to seek professional help. In February 1998, the National Eating Disorders Screening Program conducted screening for eating disorders at 1083 sites in the United States. A total of 69,374 individuals attended the screening and 35,897 individuals were screened for eating disorders. More than half of those screened were college students. Follow-up by telephone interview was conducted two months after the initial case finding on a representative sample of 937 participants. Of those screened and then interviewed at follow-up, 34.5% scored positively (20 or more) on the EAT, and 89% of these individuals were not in treatment at the time of screening. Of those interviewed, 15% reported vomiting in the preceding 6 months to control their weight, 15% reported abusing laxatives, 33% used diet pills, and 11% took diuretics. Results from the follow-up indicated that 38% of the sample was referred for further treatment. Of those who scored positively on the EAT, and were referred to a clinician, 42% actually followed through and saw a clinician and 76% of this group continued in further treatment. Of those interviewed, 82% felt that the screening program was helpful in at least some way and 32% noted an improvement in their eating attitudes or behaviors following the NEDSP. The EAT proved to be a psychometrically sound and useful screening instrument, particularly when supplemented by behavioral questions asking about eating disorder symptom frequencies. It is concluded that voluntary screening for eating disorders is an effective way to bring certain untreated individuals to treatment.
It is important for the health professional to understand that the EAT is not a substitute for an interview for those with eating disorders. Although self-report measures like the EAT should never be used as the sole basis for diagnostic and treatment decisions, they do provide an efficient means of obtaining information for clinical and research purposes. The EAT has the advantages of economy in administration and scoring. It also may minimize interviewer bias and other potential threats to validity that stem from responses being derived from the interaction between the interviewer and the subject. When used as the initial step in a two-stage process, the EAT can alert the practitioner to patients who have potentially serious eating disorder symptoms.
Screening for Eating Disorders in Athletes.
In recent years, there has been a growing interest in eating disorders among athletes. Most studies of athletes competing in sports that emphasize leanness to enhance performance or appearance (e.g. dance, gymnastics, distance running, wrestling) have shown that they are at increased risk for the development of eating disorders. The reasons for the increased prevalence of eating disorders among certain subgroup of athletes has been open to considerable speculation. The most common view has been that the pressures to diet and become thin may actually trigger eating disorders in those with specific vulnerabilities (Garner, Rosen & Berry, 1998; Garner & Dalle Grave, 1999). Alternatively, it may be that certain sports may attract athletes with pre-existing eating disorders. There have also been suggestions that certain personality and family factors common in athletes may predispose them to develop eating disorders. It is important for general practitioners to be aware of the connection between eating disorders and athletes in order to improve case identification.
The failure of some studies to find higher rates of eating disorders among certain groups of athletes has raised questions regarding their actual prevalence as well as the utility of conventional assessment methods. One criticism of self-report instruments such as the EAT is that they are highly vulnerable to denial of symptoms. However, in arguably the most methodologically sophisticated and comprehensive study of disordered eating among athletes, Sundgot-Borgen (1994) examined risk factors for eating disorders among elite athletes representing six different groups of sports. The Eating Disorder Inventory (EDI), a measure with many similarities to the EAT, was administered to all participants and careful steps were taken to address the issue of respondent truthfulness. Of the 522 elite female athletes participating in one phase of the study, 117 (22.4%) were classified “at risk” for an eating disorder based on scores on the Drive for Thinness and Body Dissatisfaction subscales of the EDI (Sundgot-Borgen, 1994). Of the at “at risk” athletes who participated in a clinical interview (N=103), 48% met criteria for anorexia or bulimia nervosa and 41% had clinically significant eating disorder symptoms but failed to meet all diagnostic criteria. The prevalence of eating disorders was greatest in sports where athletes are encouraged to be thin to meet performance or appearance standards. Although negative findings in some studies have been used to cast doubt on the utility of self-report instruments, the fact that these same measures have been used successfully to screen for eating disorders in other studies suggests that the false negatives may be due more to poor study design than to inherent flaws in the assessment instruments. Valid findings require procedures that assure respondents that results will be kept strictly confidential and that identification of eating problems will not lead to some negative outcome.
There also has been controversy regarding the meaning of eating disorders among athletes. There have been those who have raised alarm about high prevalence rates and others who have suggested that eating disorders in athletes are a benign form of the clinical syndrome. This is certainly a controversial position that we do not share. The topic of eating disorders among athletes addressed in detail in a review by Garner et al. (1999) and we will discuss it here further.
There potentially tremendous benefit from a general practitioner screening for an eating disorder. Eating disorders have devastating physical, psychological and social consequences. This is reflected in the high level of mortality, morbidity and the poor quality of life that they confer. Screening has the potential for allowing early identification of eating disorders and this can lead to earlier treatment which has been shown to lead to a more favorable prognosis
One of the criteria for determining if screening should be conducted for a particular disorder relates to whether or not a effective treatment is available. Over the past two decades, there has been a rapid expansion in controlled psychological and pharmacologic research which has resulted in a number of very effective treatments (see Garner & Dalle Grave, 1999). Morever, there is evidence that simple education regarding the effects of starvation on behavior can lead to the reduction of serious eating disorder symptoms (Garner, 1997; Garner & Dalle Grave, in press). Nevertheless, there are risks of screening for eating disorders. It is possible that well-meaning efforts at screening may actually cause certain people to develop eating disorder symptoms. The intention to change the course of a participant in a screening program must exercise extreme caution to ensure that the change is for the better rather than for the worse. These risks are somewhat less in case finding methods since the target of the survey has sought assistance from the health care professional.
Another important principle in screening and case finding is the availability of an economical and valid instrument for detecting the particular disorder of interest. It has been more than two decades since the Eating Attitudes Test (EAT) was described as a screening instrument in high-risk populations. The EAT-26 has a number of limitations including its reliance on the respondent’s honesty during testing. Nevertheless, a significant number of research studies have shown that the eating is an economical, reliable and valid instrument that can assist in identifying in different cultures (Nasser, 1997). The recent addition of specific behavioral questions to supplement the eating may improve the EAT’s ability to detect clinical cases of eating disorders; however, the EAT remains a face-valid test of the level of concern the patient is expressing surrounding eating symptoms. If used with specific interview probes suggested in this chapter, the EAT can be a useful tool in the arsenal of assessment procedures used by the general practitioner.
Note 1: Adapted from: In: Anoressia, Bulimia Binge Eating Disorder (edited by: Fabio Piccini, M.D.) Il ruolo del medico nello screening dei DCA.
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