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10-7 monday - friday for guests
no staff on sunday's
HOTWORX is a virtually instructed exercise program created for users to experience the many health benefits of infrared heat absorption, while completing a 30-40 minute isometric workout or a 15 minute HIIT session. As the infrared heat penetrates your body causing you to sweat, the isometric postures further accelerate the the detoxification by physically removing the toxins from your organs through muscle contraction.
The results our users achieve make HOTWORX one of the most efficient workout programs in the fitness and wellness industry.

domain: health


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the dark corner of Mumbai City a new leader by the name of Babban
Singh has risen to rule the gangster underworld.
beyond imagination, psychotically violent and far more devious than
any gangster the city has ever known.
perceives other human beings as objects who he uses for his own
amusement by playing games with his victims.
does not engage in conversation but when he speaks, he does so to
voice his own thoughts.
(Ajay Devgan) and Raj (Prashant Raj) are two young men who arrive
in the city of Mumbai with big dreams of making it to the top.
another matter that Heero and Raj are jobless and don't have enough
money even to buy a decent meal.
friends, their loyalty is absolute, with the younger Raj looking
up to the elder Heero.
is also Narsimha (Mohanlal) whose eyes retain composure at all times.
Dark circles collected over sleepless nights betray the fact he
is a man tormented by his own past.
has ever seen Babban Singh and if they did, they didn't survive
to tell the tale. But one man believed in his existence. And that
is inspector Narsimha, an encounter specialist.
(Susmita) is a trained nurse. Her life blossomed when love happened.
But then, tragedy struck. Dignified, silent, her demeanour hides
an inner strength that at times raises itself beyond what one would
expect from a woman.
(Nisha Kothari) drives a 'rickshaw' named 'Laila'. Laila is her
best friend and confidante. Ghungroo is Mumbai city's only woman
rickshaw driver who knows all the shortcuts.
like you to believe she's a man. But deep inside, she is all woman.
and Raj arrive in Mumbai and find work with Shambhul Seth, a criminal
with heavy underworld connections.
his pursuit of Shambhul, Inspector Narsimha comes into contact with
these lads. On meeting them, he realises that these were no hardened
criminals. Small time hoodlums perhaps, but deep inside, their values
were still intact.
a deadly encounter with Shambhul Seth, Heero and Raj display their
bravery and fearlessness to Narsimha. But the two are also arrested
and sent to jail for a while.
later, when Inspector Narsimha needs help in his hunt for Babban
Singh, his brief impression of Heero and Raj returns to him. He
decides to enlist their help.
Heeru and Raj captures Babban Singh forms the crux of the story.
to be inspired from the all time classic Sholay, director Ram Gopal
Verma gives his own interpretation.
same number of characters have been employed but their names have
been changed from the original classic.
dance number, Mehbooba Mehbooba, performed by Urmila Matondkar forms
the high point of this thriller whilst the original number performed
by Bollywood dancer, Helen was a worlwide rage.
Gopal Ki aag is released by Adlabs Films in the UK.
by Manish Gajjar,
BBC Bollywood Correspondent

domain: artistic


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The key difference between people who are making a difference in this world and those who are struggling through their every day can be summed up in this one admonition:
Pay Attention to Conviction.
Consider this passage from Isaiah 59:10-12,
“We grope like the blind along a wall, feeling our way like people without eyes. Even at brightest noontime, we stumble as though it were dark. Among the living, we are like the dead. We growl like hungry bears; we moan like mournful doves. We look for justice, but it never comes, we look for rescue, but it is far away from us. For our sins are piled up before God and they testify against us.”
Have you ever ignored the thought of a good thing you could have done for another?
This is what Isaiah is describing.
I’ve experienced this. Where thoughts of the good I could do for another, once ignored, become a wall between me and that person and simultaneously between me and God.
Where good actions denied become reason for justification and defense and cover-up.
If you don’t believe me, take a look at this verse spoken three different ways,
“So whoever knows the right thing to do and fails to do it, for him it is sin.” James 4:17 English Standard Translation
“In fact, if you know the right thing to do and don’t do it, that, for you, is evil.” James 4:17 The Message
“Remember, it is sin to know what you ought to do and then not do it.” James 4:17 New Living Translation
James was a pretty wise man.
The book Leadership & Self Deception by the Arbinger Institute spells out this exact same thing but without any of the scripture (I love it how much of current wisdom is mirroring so exactly the word of God).
They simply explain it this way. When we have a compulsion and compelling towards a good something, be it word or deed, and we ignore that compelling we then put ourselves in a box.
In the box we then make the other bad and wrong in some way, thereby justifying our lack of action.
For instance. Consider you are walking down an inner-city street and you have the thought to give $20 to the homeless person sitting on the sidewalk.
Now imagine that you ignore this thought. What immediately happens is that you will make all sorts of reasons why you couldn’t or shouldn’t give the money,
“Well he would have probably just used it for drugs or something.”
“She just needs to get her act together, I’m not going to reward her poor choices.”
The transition from the compelling thought to give $20 to the justification of why you are not, happens so fast (in the blink of an eye) that we hardly understand the dynamic.
But once we see it, so much of our stuck lives begin to make sense.
As Isaiah put it, “our sins are piled up before God and testify against us.” (59:12)
Remember, sin is, “knowing what you ought to do and not doing it.” (james 4:17)
Those stuck are those ignoring the thoughts that compel us to action. When we ignore what we can do for others we enter into a space of hiding and cover-up. We are not in integrity with ourselves and therefore not in integrity with anyone else.
In regards to sin it is as we read farther into the Word of God that we come to see that God moves us from ought and should, and from the letter of the law which was, ‘designed to last only until the coming of the child who was promised’ (galatians 3:19) to this inner core integrity from which we can all live.
Sin is so much more than the letter of the law. In fact, sins that pile between us and God are much more about the good ideas that we are ignoring, the conviction and compulsions and compelling of our hearts towards others that we are not doing.
If we want to live a free life, if we want to live an increasingly satisfying and substantially fulfilling life it is imperative that we stop ignoring conviction.
Getting out of the box is all about doing the things and speaking the words that we know are ours to do and say.
In this we have nothing to hide. Nothing is piled up against us. We simply go from strength to strength.
And our world, one compelling act at a time is transformed.
Lives are touched. None of us are the same.

domain: literature


text:
Published January 2000
by Frank Cass & Co .
Written in English
|Contributions||M. R. D. Foot (Editor)|
|The Physical Object|
|Number of Pages||400|
by. William MacKenzie, M.R.D. Foot (Introduction) Rating details 12 ratings 1 review. At the end of World War II, Britain's Cabinet Office commissioned an eminent academic, Professor William Mackenzie, to undertake a comprehensive secret history of Special Operations Executive/5. The Secret History of SOE: Special Operations Executive Mackenzie, William Published by Little, Brown Book Group, London, United Kingdom (). SOE, the Special Operations Executive, was a small, tough British secret service, a dirty tricks department, set up in July Recruited from remarkably diverse callings, the men and women who were members of this most secret agency in the Second World War lived in great and constant danger.4/5. WJM Mackenzie's "in‐house" official history of SOE, completed in Arguably the single most important reference work on SOE in Europe, and a strong influence on Foot's SOE in France(see above). Long out of print, however (a copy of the original typed manuscript is .
This is a story of SOE operating in France and a brief description of the 30 or so female operatives involved. My criticisms of the book are two. 1. This book was written apparently by a British author. As such, he writes in a way that it is often very difficult to tell what exactly he is saying/5(). SOE The Special Operations Executive reads just as well now as it did when it was first published by the BBC in to coincide with a television series--not least because its author, M.R.D Foot, was appointed the official historian to the SOE just after World War Two and has had access to its entire archive. The SOE was hastily cobbled together in to wage subversive campaigns behind Reviews: The book explains on how the SOE developed, how they trained their agents and how they organised partisan resistance in the fields. The author provides a very unbiased and unromanticised account on the most seeming glamorous and adventurous part of the british war s: 5. SOE in France contains an interesting and authentic (as opposed to Inside SOE's rather garbled) description of the origins of SOE, its establishment as a separate agency of the British government under the Minister of Economic Warfare, and its relations with the Prime Minister 1 and the military chiefs of staff. Both books include commentary on.
About this Item: Faber & Faber London , 1st edition dust jacket As New 8vo. viii + pp., b/w plates, map, notes, bibliog., index, 'The official history of the war waged by Britain's Special Operations Executive on Benito Mussolini's Fascist Italy. Looks at SOE's clandestine efforts to strike at Italy and sever its alliance with Nazi Germany, uncovering missions as remarkable as a plot to assassinate . A highly significant tribute to the man entrusted with writing the official record of the Special Operations Executive. He authored first () the History of SOE in France and twenty years later the highly sensitive accounts of SOE operations in Belgium and Holland (which the Germans infiltrated with disastrous results). SOE In France An Official Account of the Special Operations Executive's French Circuits (Hardback) by Robert Bourne-Paterson (Frontline Books, September ). An contemporary appreciation of F Section's work in France, written by one of its senior officers. This is a reproduction of the report held at the National Archives. The Special Operations Executive (SOE) was a secret British World War II organisation. It was officially formed on 22 July under Minister of Economic Warfare Hugh Dalton, from the amalgamation of three existing secret purpose was to conduct espionage, sabotage and reconnaissance in occupied Europe (and later, also in occupied Southeast Asia) against the Axis powers, and Notable commanders: Frank Nelson, Charles Jocelyn .

domain: library


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Recycled Denim Feather Wall Hanging
From the blogger: "Did you know that it is so simple to make feathers out of scraps of denim? Basically, it is just about fraying the denim by pulling out the threads one by one. If you pull out all the white threads, you will end up with an indigo feather. And if you pull out all the blue threads, you will end up with a white feather. I used some twine for the spine of my denim feathers. They were then hung from a lovely driftwood branch to make a gorgeous wall hanging."
- Scraps of denim from old jeans
- Colored twine
- Thumb tacks
- Small wooden beads
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Fresh, cool and engaging. Edgy and distinctive.
Highly respected. A star with a superb voice.
Double Olivier Award winning actor for A Streetcar Named Desire & Anna Christie both at The Donmar.
Won the BAFTA Cymru Award for Best Actress for her role in His Dark Materials.
Won a Golden Globe for her role in The Affair.
Two-time Tony Award nominee for Constellations and King Lear on Broadway.
Can do a good American accent if required - as seen in The Affair. Watch the clip below.

domain: entertainment


Have you ever wondered why your Apple Watch says “No SIM”?
We explore the importance of a SIM card in an Apple Watch, the benefits it brings, and how to troubleshoot the “No SIM” error.
Find out why your Apple Watch requires a SIM card and learn how to fix the issue. Discover if you can use your Apple Watch without a SIM card and what features you’ll still be able to enjoy!
What is a SIM Card?
A SIM card, short for Subscriber Identity Module, is a small, removable smart card that is essential for connecting your Apple Watch to a cellular network.
When inserted into the Apple Watch, the SIM card securely stores information that verifies your identity and grants access to the cellular network. It serves as a unique identifier, allowing your device to establish a connection and communicate over the network.
The SIM card plays a crucial role in authenticating users, ensuring that only authorized individuals can utilize the cellular services provided by the network carrier. It enables seamless data connectivity, enabling you to make calls, send messages, and access the internet directly from your Apple Watch.
Why Does the Apple Watch Require a SIM Card?
The Apple Watch requires a SIM card to establish a connection to a cellular network, enabling it to function independently from an iPhone.
Having a SIM card in the Apple Watch is essential for unlocking its full potential. With this small, yet crucial component, the Apple Watch gains the ability to make calls, send messages, and access data services without relying on a paired iPhone. This standalone functionality offers users increased flexibility and convenience in their day-to-day activities.
What are the Benefits of Having a SIM Card in an Apple Watch?
Having a SIM card in your Apple Watch offers several benefits, such as independent cellular connectivity, GPS tracking capabilities, and the ability to make calls and send messages without relying on an iPhone.
One of the significant advantages of having a SIM card in your Apple Watch is the enhanced GPS tracking feature. With the integrated SIM card, the Apple Watch can accurately track your location in real-time, providing precise navigation assistance and location-based services.
The standalone communication capability enabled by the SIM card allows you to stay connected even when your iPhone is not nearby. This ensures that you can make calls, send messages, and access data services directly from your Apple Watch, enhancing convenience and accessibility.
Why Does My Apple Watch Say ‘No SIM’?
If your Apple Watch displays a ‘No SIM‘ error, it indicates a problem with the SIM card or its connection to the cellular network.
One common reason for this error message could be that the SIM card is not properly inserted into the Apple Watch or has become dislodged. Ensuring that the SIM card is securely in place and restarting the device may resolve this issue. Network connectivity issues, such as poor signal strength or carrier network problems, could also trigger the ‘No SIM’ error. Checking for available network coverage and resetting the network settings on the Apple Watch could help establish a stable connection.
In some cases, the error might be related to activation issues. If the Apple Watch has not been fully activated with the carrier, the ‘No SIM’ message may appear. Verifying the activation status of the device with the carrier or through the Watch app on the connected iPhone can help address this issue.
Is My Apple Watch Missing a SIM Card?
If your Apple Watch shows a ‘No SIM’ message, it may indicate that the SIM card is missing or improperly inserted.
Checking the SIM card status on your Apple Watch is crucial to determine if it’s the root cause of the issue.
- Begin by powering off your Apple Watch and removing the SIM card tray.
- Inspect the SIM card slot for any debris or damage that could obstruct the proper insertion.
- Carefully reinsert the SIM card making sure it fits securely in the tray.
- Restart your device and see if the error message persists.
Remember, a correctly inserted SIM card is essential for seamless connectivity on your Apple Watch.
Did I Forget to Activate the SIM Card?
The ‘No SIM’ error on the Apple Watch could be due to a failure to activate the SIM card with the carrier or during the setup process.
If you encounter this issue, the first step is to check if the SIM card is properly activated. To do this, make sure your Apple Watch is powered off. Carefully remove the SIM card tray with the provided eject tool, available in the original packaging. Check if the SIM card is inserted correctly and that it is from a compatible carrier. If the SIM card seems fine, contact your carrier to verify if it is active and properly provisioned for your device.
Is the SIM Card Damaged or Malfunctioning?
A damaged or malfunctioning SIM card can trigger the ‘No SIM’ error on your Apple Watch, disrupting its cellular connectivity.
When the SIM card in your Apple Watch is degraded or faulty, it can prevent the device from establishing a connection with your cellular network, leading to missed calls, text messages, and email notifications. You may encounter frustrating error messages indicating the absence of a SIM card, hindering the seamless operation of your Apple Watch.
- To troubleshoot this issue, start by powering off your Apple Watch and removing the SIM card.
- Inspect the SIM card for physical damage or signs of wear.
- If the SIM card appears undamaged, reinsert it into the designated slot carefully.
- Ensure that the SIM card is properly seated to facilitate a stable connection.
Is the SIM Card Not Compatible with the Apple Watch?
Compatibility issues between the SIM card and the Apple Watch can result in the ‘No SIM’ error message, preventing proper network connection.
These issues may arise due to the type of SIM card used or its activation status. It is essential to ensure that the SIM card is compatible with the Apple Watch model you own. Sometimes, the problem can be resolved by reseating the SIM card or restarting both the watch and the paired device.
If the error persists, checking for damage on the SIM card and contacting your service provider for support can also be beneficial. Compatibility errors are common but can be troubleshooted efficiently with the right approach and guidance.
How to Fix the ‘No SIM’ Error on Apple Watch?
To resolve the ‘No SIM’ error on your Apple Watch, you can follow a series of troubleshooting steps to address potential issues with the SIM card or connectivity.
Ensure that your Apple Watch model supports cellular connectivity and that your carrier plan includes support for the Apple Watch SIM.
Next, activate your SIM card according to your carrier’s instructions.
It’s also crucial to keep your Apple Watch’s software up to date by checking for any available updates in the Watch app on your connected iPhone.
If the issue persists, try restarting your Apple Watch by holding down the side button until you see the Power Off slider.
If none of these steps resolve the problem, reach out to Apple Support for further assistance.
Check for SIM Card Compatibility
Start by verifying the compatibility of your SIM card with the Apple Watch model and your carrier’s network to ensure seamless connectivity.
When troubleshooting the ‘No SIM’ error on your Apple Watch, it’s crucial to check if your SIM card is supported by the specific Apple Watch version you own and matches the network technology required by your carrier.
To determine compatibility, you can visit the official Apple website or contact your carrier for guidance. Make sure the SIM card is properly inserted into the SIM tray of your Apple Watch. In case of any doubts, refer to the user manual for detailed instructions on how to check and insert the SIM card correctly.
Ensuring compatibility between your SIM card, Apple Watch, and network is key to resolving connectivity issues efficiently.
Activate the SIM Card
Ensure that your SIM card is correctly activated with your carrier and linked to your Apple Watch to establish a functional connection.
Activating the SIM card for your Apple Watch is a crucial step in ensuring seamless functionality. To activate the SIM card on your device, start by opening the Watch app on your paired iPhone. Navigate to the ‘My Watch’ tab and select ‘Cellular’.
Next, choose the ‘Set Up Cellular’ option and follow the prompts to add a plan for your Apple Watch. Make sure to confirm with your carrier that the SIM card in your watch is provisioned correctly.
If you encounter a ‘No SIM’ error despite activating the SIM card, troubleshoot by restarting both your iPhone and Apple Watch, ensuring that both devices have the latest software updates.
Restart the Apple Watch
Try restarting your Apple Watch to refresh its settings and potentially resolve the ‘No SIM’ error by clearing temporary glitches.
Restarting the Apple Watch is a quick and effective way to troubleshoot various connectivity issues, including the ‘No SIM’ error. This process helps the device to reboot and reload all the necessary settings, which can often fix minor software hiccups that may be causing the problem.
To restart your Apple Watch, simply press and hold the side button until the power off slider appears. Then, drag the slider to turn off the device. After a few seconds, press and hold the side button again until the Apple logo appears, indicating that the device is restarting.
Check for Software Updates
Ensure that your Apple Watch has the latest software updates installed to address any potential compatibility issues causing the ‘No SIM’ error.
Checking for and installing software updates on your Apple Watch is crucial for maintaining its optimal performance. When your device runs on the latest software version, it not only enhances its functionality but also rectifies any bugs or glitches that could lead to errors like ‘No SIM.’
To check for updates, go to the Watch app on your connected iPhone, navigate to ‘General,’ and then select ‘Software Update.’ If updates are available, follow the on-screen instructions to download and install them. Regularly updating your Apple Watch ensures a smooth user experience and safeguards it against potential issues.”
Reset the Apple Watch
Perform a device reset on your Apple Watch as a troubleshooting step to potentially resolve persistent issues like the ‘No SIM’ error.
Resetting your Apple Watch can often work wonders in resolving connectivity glitches and miscellaneous software hiccups that might be causing the ‘No SIM’ error message. To initiate a reset, start by pressing and holding the side button until you see the Power Off slider. Next, firmly press and hold the Digital Crown along with the side button until the Apple logo appears on the screen.
This process forces your Apple Watch to restart, effectively clearing temporary data and potentially fixing the underlying issues interfering with its normal functioning. It’s essential to note that a reset will not erase your data, but it can be a powerful tool in rejuvenating your device’s performance, especially when faced with perplexing errors like the ‘No SIM’ situation.
Contact Apple Support
If the ‘No SIM’ error persists on your Apple Watch, consider reaching out to Apple Support for expert assistance and guidance on resolving the issue.
Apple Support offers a wide range of options for users encountering technical difficulties like the ‘No SIM’ error. One convenient way to get in touch with Apple Support is through their website. By visiting the Apple Support page, users can access step-by-step guides, troubleshooting tools, and forums where fellow users share their experiences and solutions.
Contacting Apple Support directly via phone or live chat can provide personalized assistance tailored to your specific issue. Apple’s customer service representatives are knowledgeable and equipped to help diagnose and address any hardware or software-related problems you may encounter.
Can I Use My Apple Watch Without a SIM Card?
Yes, you can use your Apple Watch without a SIM card, but certain features that require cellular connectivity will be limited in functionality.
When using the Apple Watch without a SIM card, you can still access many features such as tracking your fitness activities, receiving notifications, and using apps that rely on Wi-Fi connectivity. Functionalities like making or receiving calls, sending messages, and utilizing the GPS may be restricted. The lack of a SIM card means the Watch won’t have an independent network connection, impacting its ability to stay connected when away from your iPhone.
For those who still desire a degree of connectivity without a SIM card, pairing the Apple Watch with your iPhone via Bluetooth can help maintain some functionality. This setup allows the Watch to utilize your phone’s network connection for tasks that require internet access, ensuring a seamless experience.
What Features Will I Be Able to Use Without a SIM Card?
Using your Apple Watch without a SIM card allows you to access features like fitness tracking, notifications, music playback, and basic app functions.
One of the key benefits of using these features independently of cellular connectivity is the enhanced focus on health and fitness tracking. With the Apple Watch’s built-in sensors, users can track their daily activity levels, monitor heart rate, and even participate in guided workouts without the need for a SIM card. The watch’s ability to receive notifications directly from a paired iPhone ensures that users stay connected even when they are not within cellular range.
Frequently Asked Questions
Why is my Apple Watch saying ‘No Sim’?
This message usually appears when your Apple Watch is not able to connect to a cellular network. The watch requires a cellular plan and a compatible SIM card to use cellular services.
Can I use my Apple Watch without a SIM card?
Yes, you can still use your Apple Watch without a SIM card. However, you will not be able to use cellular services such as making calls, sending messages, or using data without a SIM card and a cellular plan.
What should I do if my Apple Watch says ‘No Sim’?
First, make sure that your watch is connected to a Wi-Fi network. If it still shows the ‘No Sim’ message, try restarting both your iPhone and Apple Watch. If the issue persists, contact your cellular provider to ensure that your SIM card is activated and compatible with your watch.
Do I need to insert a SIM card in my Apple Watch for it to work?
No, you do not necessarily need a SIM card to use your Apple Watch. You can still use all the features and functions of the watch as long as it is connected to your iPhone via Bluetooth and connected to a Wi-Fi network.
Can I use my Apple Watch with an eSIM?
Yes, some models of the Apple Watch support eSIM, which is a digital SIM card that does not require a physical card to be inserted. You can contact your cellular provider to see if they offer eSIM support for your Apple Watch.
Why does my Apple Watch say ‘No Sim’ even though I have a cellular plan?
If you have a cellular plan and your watch is still showing the ‘No Sim’ message, there may be an issue with your SIM card. Contact your cellular provider to check on the status of your SIM card and ensure that it is properly activated for your Apple Watch.


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The Centenial Trail
(Spokane, WA. to Cda, Idaho)
Hit the road jack, and I bet you'll be back!
The Centenial Trail is a 81 mile non motorized path connecting Spokane to Coeur d'Alene and for the most part is along side the Spokane River. Walk/run, in-line skate, or bike, but get out there and enjoy it. There are places to canoe, kayak, rock climb, fish and swim along the way. Log on the website for a map with access points and choose a manageable stretch to explore. Five mile to Post Falls is considered the Centenial Trail (37 miles) and Post Falls to Cda (24 miles) is considered the North Idaho Centenial Trail. So you better get busy, thats a lot of trail to cover. Its always been peaceful regardless of the 1.75 million people that access this trail every year. Keep your eye open for wildlife and know there's plentiful places for the perfect picnic. We like to to start at Minihaha rock climbing area and continue on to a stop at the Rocket Bakery for a little snack. The trail has both urban and rural stretches so you decide you're looking for a total nature trek or bakeries by bicycle.
(Published in Spokane Coeur d'Alene Living Magazine, November 2008, Best of)

domain: geography


text:
Nature of Business
At Jayden Foods, we firmly believe in satisfying our customers' good taste and demands for the highest standards in everything so we are committed to supplying quality frozen & chilled meat! It is this genuine spirit of service and dedication that has made Jayden Foods the trusted choice for those looking to serve the finest food for their loved ones.
Bringing freshly-frozen livestock to the people through mass-market avenues like wet markets, eateries, hotels and restaurants, Jayden Foods has become a trusted name in the local frozen food industry. Be it premium Wagyu beef or delectable sausages made with time-honoured recipes, our commitment towards total food safety and customer satisfaction allows to you to purchase with utmost confidence. We nurture and inspire relationships through delicious food and good advice, for we know that the treasured ones deserve only the very best. This is why Jayden Foods has always been a cut above.
Choose from the widest selection of frozen & chilled beef, chilled grass-fed beef, chicken, lamb, Australia grain fed black angus, chilled Australian pasture fed lamb, mutton, seafood and vegetables today!

domain: food


text:
Roll a dice to be assigned a piece of Bat-tech and thwart the bank robbers!
A sexual tryst between warring gods alters the story itself into a new permutation of the series Comic Buyer's Guide calls, "the most assured and original project to emerge from Vertigo since SANDMAN." With guest art from Peter Gross (LUCIFER) and Gary Erskine (THE FILTH), this tale reveals how Biblical and modern storylines diverge - as Dinah is attacked in one reality, and Miriam in the other.
There are many great DC Video Games. Let's talk about them!
All March long, we'll be voting down brackets of 64 competitors to determine one FINAL CHAMPION.


text:
Academic detailing basic skills
In-person academic detailing
Saffore CD, Tilton ST, Crawford SY, Fischer MA, Lee TA, Pickard AS, Sharp LK. Identification of barriers to safe opioid prescribing in primary care: a qualitative analysis of field notes collected through academic detailing. British Journal of General Practice. 2020 Aug;70(697):e589. https://doi.org/10.3399/bjgp20X711737.
iThis article identifies six potential barriers to safe opioid prescribing for providers “on the ground” through an academic detailing intervention in the Chicago area. The barriers were identified through a thematic analysis of academic detailers’ field notes recorded after detailing sessions with primary care providers. In the notes, detailers were asked to describe the academic detailing visit content as well as any questions and concerns expressed by the provider. Several barriers to safe opioid prescribing included lack of provider knowledge about opioid and non-opioid treatments, pressure to prescribe opioids--particularly from inherited patients--and uncertainty and time constraints regarding the health system’s pain management practices and policies. Reviewing these barriers can help detailers prepare for objections providers may pose during academic detailing visits on opioid stewardship.
Bounthavong M, Shayegani R, Manning JM, Marin J, Spoutz P, Hoffman JD, Harvey MA, Himstreet JE, Kay CL, Freeman BA, Almeida A, Christopher MLD. Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration Regional Networks. International Journal of Medical Informatics. 2020 May. https://doi.org/10.1016/j.ijmedinf.2022.104712.
The aim of this evaluation was to compare virtual and in-person academic detailing on naloxone prescribing rates at the Department of Veterans Affairs. Providers who received naloxone-related in-person or virtual academic detailing had increased naloxone prescribing rates; however, there were no differences between the two types of modalities. Virtual academic detailing was shown to be an alternative way to deliver academic detailing and allowed for academic detailers to expand their reach to rural providers.
Bounthavong M, Harvey MA, Kay CL, Lau MK, Wells DL, Himstreet JE, Popish SJ, Oliva EM, Christopher MLD. Comparison of naloxone prescribing patterns due to educational outreach conducted by full-time and part-time academic detailers at the U.S. Veterans Health Administration. Journal of the American Pharmacists Association. 2019 November 21. https://doi.org/10.1016/j.japh.2019.11.010.
Allocating sufficient work time for academic detailers to complete detailing tasks and activities can be an essential consideration for program staff recruiting and hiring detailers. Providers who interacted with academic detailers with high full-time equivalent employee (FTEE) allocation (0.4 FTEE or greater, meaning at least 40% of the employee’s time is dedicated to academic detailing) had a 65% greater increase in the number of average monthly naloxone prescriptions compared to providers who interacted with academic detailers with low FTEE (less than 0.4 FTEE). The increase in naloxone prescribing highlights the potential benefit of higher FTEE allocation for detailers.
Midboe AM, Wu J, Erhardt T, Carmichael JM, Bounthavong M, Christopher MLD, Gale RC. Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation. Pain Medicine. 2018 Sep 07;19(suppl_1):S46-S53. https://doi.org/10.1093/pm/pny085.
This paper summarizes several key components of an academic detailing program through qualitative interviews with current and former academic detailers and providers with varying exposure to academic detailing. The common themes included the importance of tailoring one-on-one sessions to providers’ needs, the role leadership plays in encouraging providers’ participation in detailing programs, and tracking detailer and provider performance. Reviewing these conclusions can help academic detailing program staff and detailers better understand and identify critical components of an academic detailing intervention.
Behar E, Rowe C, Santos GM, Santos N, Coffin PO. Academic Detailing Pilot for Naloxone Prescribing Among Primary Care Providers in San Francisco. Family Medicine. 2017 Feb;49(2):122-126.
In this academic detailing intervention, based in San Francisco, California, primary care providers were detailed on safe opioid prescribing and naloxone. The providers who received the intervention had an eleven-fold increase in naloxone prescribing compared to those who did not receive the intervention. This study shows that the traditional academic detailing model of one-on-one, in-person visits can be effective in increasing naloxone prescriptions in a primary care setting.
Yeh JS, Van Hoof TJ, Fischer MA. Key Features of Academic Detailing: Development of an Expert Consensus Using the Delphi Method. American Health and Drug Benefits. 2016;9(1):42-50. PMID: 27066195
This paper identifies key principles of academic detailing training, implementation, and evaluation through developing consensus from 20 experts with the Delphi method. Experts agreed the goal of academic detailing is to 1) improve clinical performance, 2) recommend practice changes, and 3) offer decision support to providers. Other major themes included the importance of focusing on clinician behavior change and tailoring content to provider needs during detailing sessions. Experts also noted the necessity for interpersonal and communication skills in detailers to overcome providers’ barriers to behavior change. These conclusions, as well as others listed in the paper, can help guide the planning and implementation of an effective academic detailing program.
Virtual detailing (e-Detailing)
Bounthavong M, Shayegani R, Manning JM, Marin J, Spoutz P, Hoffman JD, Harvey MA, Himstreet JE, Kay CL, Freeman BA, Almeida A, Christopher MLD. Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration Regional Networks. International Journal of Medical Informatics. 2022 May. https://doi.org/10.1016/j.ijmedinf.2022.104712.
The aim of this evaluation was to compare virtual and in-person academic detailing on naloxone prescribing rates at VA. Providers who received naloxone-related in-person or virtual academic detailing had increased naloxone prescribing rates; however, there were no differences between the two types of modalities. Virtual academic detailing is a viable alternative for delivering academic detailing and allows academic detailers to expand their reach to rural providers.
Smart MH, Mandava MR, Lee TA, Pickard AS. Feasibility and acceptability of virtual academic detailing on opioid prescribing. Int J Med Inform. 2020 Dec 25;147:104365. doi: https://doi.org/10.1016/j.ijmedinf.2020.104365. PMID: 33360790.
As the first paper comparing the feasibility and acceptability of in-person academic detailing visits (conducted before the COVID-19 pandemic) to virtual visits (conducted during the COVID-19 pandemic), Smart et al. is a noteworthy addition to the virtual academic detailing (also known as eDetailing) literature. Virtual visits were either conducted via WebEx with video and screensharing or on the telephone. While providers ranked in-person visits slightly more favorable than virtual visits, provider feedback indicated that there was no significant difference in feasibility between in-person and virtual visits. There was also no significant difference in providers satisfaction between video and telephone visits, and provider satisfaction was not impacted by technical difficulties.
Brunette MF, Dzebisashvili N, Xie H, Akerman S, Ferron JC, Bartels S. Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers. Nicotine and Tobacco Research. 2015 Jul;17(8):960-967. https://doi.org/10.1093/ntr/ntv006.
This is one of the few studies to compare in-person and videoconferencing delivery of academic detailing (called educational outreach in the study). Providers within a state mental health program either received virtual academic detailing (25 providers) or in-person academic detailing (18 providers) on smoking cessation. There was no significant difference between the providers who received in-person versus virtual academic detailing in 1) increased smoking cessation pharmacology prescriptions, 2) satisfaction with the sessions, and 3) post-intervention knowledge and attitudes. These findings indicate videoconferencing may be a plausible delivery method for academic detailing, although further investigation is needed.
Hartung DM, Hamer A, Middleton L, Haxby D, Fagnan LJ. A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics. BMC Fam Pract. 2012 Dec;13:129. https://doi.org/10.1186/1471-2296-13-129
Hartung et al.’s pilot project provided in-person and virtual academic detailing to 41 clinicians at 4 different rural family practice clinics in Oregon. Each clinic received multiple detailing sessions over eight months. Providers who received in-person academic detailing reported a higher likelihood of changing their behavior compared to providers who received virtual academic detailing; however, the impact of in-person versus virtual academic detailing on provider practices post-intervention was not measured. Additionally, many providers indicated interest in continued participation of the program, but the likelihood of participation declined slightly if only virtual academic detailing was offered. While virtual academic detailing may be satisfactory, this pilot project suggests in-person academic detailing remains more desirable if both options are available. However, survey response rates were low and may not be sufficient to adequately detect significant differences between the two groups.
Widder R. Learning to Use Motivational Interviewing Effectively: Modules. J Contin Educ Nurs. 2017 Jul 1;48(7):312-319. doi: 10.3928/00220124-20170616-08. PMID: 28658499
Motivational interviewing (MI) is used by a variety of professionals to help clients to develop motivation for lifestyle changes. It has also been shown to be an effective way to induce health-promoting activities. Education of health professionals in MI communication techniques can be done many ways, including attending a seminar and completing online classes. In a review of the literature, support was found for a variety of methods. This article described eight steps to MI education that were used to formulate two modules for nurses and exercise physiologists. These steps include PowerPoint presentations with audio linkage, participant practice with MI techniques via response to prompts, and self-evaluation of performance.
Rubac S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: A systematic review and meta-analysis. The British Journal of General Practice. 2005 Apr 1; 55(513): 305–312. PMID: 15826439
Motivational Interviewing is a well-known, scientifically tested method of counseling clients and a useful intervention strategy in the treatment of lifestyle problems and disease. To evaluate the effectiveness of motivational interviewing in different areas (Yes, this language the authors used.) of disease and to identify factors shaping outcomes, a systematic review and meta-analysis of randomized controlled trials using motivational interviewing as the intervention was conducted. The authors identified 72 research articles that met predetermined criteria for study quality. This study found that motivational interviewing in a clinical setting outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases. Large-scale studies are now needed to determine if motivational interviewing can be implemented into daily clinical work in primary and secondary health care.
Chronic pain management
Ashar YK, Gordon A, Schubiner H, Uipi C, Knight K, Anderson Z, Carlisle J, Polisky L, Geuter S, Flood TF, Kragel PA, Dimidjian S, Lumley MA, Wager TD. Effect of pain reprocessing therapy vs Placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA Psychiatry. 2022;79(1):13-23. doi:10.1001/jamapsychiatry.2021.2669
Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury. This study is intended to test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients’ beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms.
Cohen SP, Vase L, Hooten WM. Chronic pain: An update on burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097. doi: 10.1016/S0140-6736(21)00393-7. PMID: 34062143
The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realise that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management.
The Pain Management Best Practices Inter-Agency Task Force was convened to address acute and chronic pain in light of the ongoing opioid crisis. Specific legislation required the Task Force to identify gaps, inconsistencies, and updates and to make recommendations for improving best practices for the management of acute and chronic pain. The taskforce emphasized the development of an effective pain treatment plan after proper evaluation in order to establish a diagnosis. This diagnosis included measurable outcomes that focus on improvements, such as quality of life, improved functionality, and activities of daily living.
Stonington S, Coffa D. Structural iatrogenesis - A 43-year-Old man with "opioid misuse". The New England Journal of Medicine. 2019 Feb 21;380(8):701-704. doi: 10.1056/NEJMp1811473. PMID: 30786183
Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America. 2016 Apr 4;113 (16) 4296-4301. https://doi.org/10.1073/pnas.1516047113.
This article examines beliefs associated with racial bias in pain management, a critical health care domain with well-documented racial disparities. Specifically, it reveals that a substantial number of white laypeople, medical students, and residents hold false beliefs about biological differences between Blacks and Whites and demonstrates that these beliefs predict racial bias in pain perception and treatment recommendation accuracy. It also provides the first evidence that racial bias in pain perception is associated with racial bias in pain treatment recommendations. This work shows that false beliefs about biological differences between Blacks and Whites continue to shape the way we perceive and treat black people.
Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015 Feb 18;350:h444. doi: 10.1136/bmj.h444. PMID: 25694111.
The aim of this study was to assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. The study design consisted of a systematic review and random effects meta-analysis of randomized controlled trials. Criteria included the following: multidisciplinary rehabilitation delivered by healthcare professionals from at least two different professional backgrounds and multidisciplinary rehabilitation compared with a non-multidisciplinary intervention. This study found that multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care and physical treatments in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care.
Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: A randomized clinical trial. JAMA. 2014 Jul 16;312(3):240-8. doi: 10.1001/jama.2014.7689. PMID: 25027139
The aim of this study was to determine the effectiveness of a telecare intervention for chronic pain. Chronic musculoskeletal pain is among the most prevalent, costly, and disabling medical disorders. The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic musculoskeletal pain of at least moderate intensity. The goal of SCOPE was to optimize analgesic management using a stepped care approach to drug selection, symptom monitoring, dose adjustment, and switching or adding medications. This study found that telecare collaborative management increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing non-opioid analgesic medications using a stepped care algorithm and monitoring.
Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. This set of guidelines aimed to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
Initiating opioids for chronic pain
Klimas J, Gorfinkel L, Fairbairn N, Amato L, Ahamad K, Nolan S, Simel DL, Wood E. Strategies to Identify Patient Risks of Prescription Opioid Addiction When Initiating Opioids for Pain: A Systematic Review. JAMA Network Open. 2019 May 03;2(5):e193365. doi.org/10.1001/jamanetworkopen.2019.3365
Although prescription opioid use disorder is associated with substantial harms, strategies to identify patients with pain among whom prescription opioids can be safely prescribed have not been systematically reviewed. This study aimed to review factors associated with opioid addiction and screening tools for identifying adult patients at high vs low risk of developing symptoms of prescription opioid addiction when initiating prescription opioids. This study found that while a history of substance use disorder, certain mental health diagnoses, and concomitant prescription of certain psychiatric medications appeared useful for identifying patients at higher risk, few quality studies were available. No symptoms, signs, or screening tools were particularly useful for identifying those at lower risk.
Reducing or stopping opioids for chronic pain
Nataraj N, Strahan AE, Guy GP, Losby JL, Dowell D. Dose tapering, increases, and discontinuity among patients on long-term high-dose opioid therapy in the United States, Drug and Alcohol Dependence. 2022 May. https://doi.org/10.1016/j.drugalcdep.2022.109392.
While reduced exposure to prescription opioids may decrease risks--including overdose and opioid use disorder--abrupt tapering or discontinuation may pose new risks. The aim of this study was to examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy. This study found that dosage changes for patients on high-dose long-term opioid therapy may warrant special attention to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. This study found that rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.
Hallvik SE, El Ibrahimi S, Johnston K, Geddes J, Leichtling G, Korthuis PT, Hartung DM. Patient outcomes after opioid dose reduction among patients with chronic opioid therapy. Pain. 2022 Jan;163(1)p 83-90. doi: 10.1097/j.pain.0000000000002298
This retrospective cohort study found that discontinuation of opioid use after chronic opioid therapy increased the odds of suicide while decreasing the odds of overdose.
Tami ML, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Sub Ab Treatment. 2019 Aug;103:58-63. doi.org/10.1016/j.jsat.2019.05.001. PMID: 31079950.
Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications. This study aimed to determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users.This study found that faster rates of opioid tapering were associated with a greater probability of adverse events and many patients were discontinued from opioids suddenly (i.e., with no incremental reduction). Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.
Stonington, S, Coffa D. Structural Iatrogenesis — A 43-Year-Old Man with “Opioid Misuse.” The New England Journal of Medicine. 2019 Fed;380(8), 701–704. https://doi.org/10.1056/NEJMp1811473
A case study of structural iatrogenesis within primary care and the direct effect to patients on high dose opioids.
Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary, Substance Abuse. 2018;39(2):152-161. doi.org/10.1080/08897077.2017.1381663. PMID: 28929914.
In response to the opioid epidemic, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are being tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. This article offers commentary by experts on possible mechanisms involved in this clinical phenomenon and offers practical management guidance.
Barrett K, Chang YP. Behavioral Interventions Targeting Chronic Pain, Depression, and Substance Use Disorder in Primary Care. J Nurs Scholarsh. 2016;48(4):345-353. doi.org/10.1111/jnu.12213. PMID: 27149578.
Patients with chronic pain, depression, and substance use disorder (SUD) are often treated in primary care settings. An estimated 52% of patients have a diagnosis of chronic pain, 5% to 13% have depression, and 19% have SUD. These estimates are likely low when considering the fact that 50% of primary care patients with depression and 65% with SUD are undiagnosed or do not seek help. These three conditions have overlapping neurophysiological processes, which complicate the treatment outcomes of a primary physical illness. Behavioral interventions have been widely utilized as adjunctive treatments, yet little is known about what types of behavioral interventions were effective to treat these comorbidities. This systematic review aimed to identify behavioral interventions targeting chronic pain, depression, and SUD in primary care settings.
Tay E, Makeham M, Laba TL, Baysari M. Prescription drug monitoring programs evaluation: a systematic review of reviews. Drug and Alcohol Dependence. 2023 Apr. https://doi.org/10.1016/j.drugalcdep.2023.109887.
Prescription drug monitoring programs (PDMPs) are used to mitigate harms from high-risk medicines including misuse, prescription shopping, overdoses, and death. Previous systematic reviews report inconsistent findings. We undertook a systematic review of reviews to 1) describe and identify the methods and outcome measures used to evaluate PDMPs, 2) summarise existing evidence on outcomes and factors that influence PDMP success or benefit realization.
Sturgeon JA, Sullivan MD, Parker-Shames S, Tauben D, Coelho P. Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis. Pain Medicine. 2020 Dec. https://doi.org/10.1093/pm/pnaa029.
There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use.
Previous studies suggest a lack of confidence among primary care providers in managing patients on chronic opioid therapy (COT) for chronic non-cancer related pain (CNCP). The US Department of Health and Human Services (HHS) recently introduced guidelines on opioid tapering. In light of these recommendations, our group developed an opioid tapering software to assist healthcare providers in managing patients on COT.
Covington EC, Argoff CE, Ballantyne JC, Cowan P, Gazelka HM, Hooten WM, Kertesz SG, Manhapra A, Murphy JL, Santos SP, Sullivan MD. Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations. Mayo Clinic Proceedings. 2020 Oct;95(10):2155-2171. https://doi.org/10.1016/j.mayocp.2020.04.025.
Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction.
Coffin PO, Rowe C, Oman N, Sinchek K, Santos GM, Faul M, Bagnulo R, Mohamed D, Vittinghoff E. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. 2020 May;15(5):e0232538. https://doi.org/10.1371/journal.pone.0232538.
After decades of increased opioid pain reliever prescribing, providers are rapidly reducing prescribing. It is hypothesized that reduced access to prescribed opioid pain relievers among patients previously reliant upon opioid pain relievers would result in increased illicit opioid use. It was found that discontinuation of prescribed opioid pain relievers was associated with more frequent non-prescribed opioid pain reliever and heroin use; increased dose was also associated with more frequent heroin use. Clinicians should be aware of these risks in determining pain management approaches.
Davis MP, Digwood G, Mehta Z, McPherson ML. Tapering opioids: a comprehensive qualitative review. Ann Palliat Med. 2020 Mar;9(2):586-610. doi: 10.21037/apm.2019.12.10
This state-of-the-art review comprehensive covers the benefits and risks of tapering opioids. The review discusses opioid strategies and pitfalls that may occur during tapering. The purpose of this review is to expand the knowledge of clinicians regarding tapering opioids and equip them to be able to successfully reduce and stop opioid therapy when appropriate.
Oliva EM, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P, Robinson A, Paik M, Sandbrink F, Gordon AJ, Traftton JA. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020 Mar;368:m283. https://doi.org/10.1136/bmj.m283.
The objective of this study is to examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. These patients were found to be at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.
Lembke A. Tapering Long-Term Opioid Therapy. Am Fam Physician. 2020;101(1):49-52.
My patient is a 54-year-old construction worker who has been taking prescribed opioids for more than a decade for chronic knee and back pain. During the past year, he has admitted that he feels “stuck on these drugs.” His pain is not well controlled, and his wife has complained that he seems “out of it.” We have talked about reducing his prescription or stopping opioids, but he is reluctant and worried. How can I help my patient taper his regimen to minimize withdrawal and maximize his chances for success?
James JR, Scott JM, Klein JW, Jackson S, McKinney C, Novack M, Chew L, Merrill JO. Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study. Journal of General Internal Medicine. 2019 Dec;34(12):2749-2755. https://doi.org/10.1007/s11606-019-05301-2.
Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized. This study intends to evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids. In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this high-risk group.
Davis B, Archambault C, Davis K, Oagley CR, Schneider J, Kennedy A, Wilensky D. A patient-centered approach to tapering opioids. J Fam Pract. 2019 Dec;68(10):548-556.
Many Americans who are treated with prescription opioid analgesics would be better off with less opioid or none at all. To that end, published opioid prescribing guidelines do provide guidance on the mechanics of tapering patients off opioids1-4—but they have a major flaw: They do not adequately account for the fact that people who have a diagnosis of chronic pain are a heterogeneous group and require diagnosis-specific treatment planning. A patient-centered approach to opioid tapers must account for the reality that many people who are given a prescription for an opioid to treat pain have significant mental health conditions—for which opioids act as a psychotropic agent.
Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. Pain Medicine. 2019 Nov;20(11):2179-2197. https://doi.org/10.1093/pm/pny231.
This article intends to support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain. It was found that there is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. Journal of Substance Abuse Treatment. 2019 May;103:58-63. https://doi.org/10.1016/j.jsat.2019.05.001.
Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase. This article intends to determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users. It was found that faster rates of opioid tapering were associated with a greater probability of adverse events and many patients discontinued opioids suddenly, with no dose reduction. Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.
Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Substance Abuse. 2017;39(2):152-161. doi: 10.1080/08897077.2017.1381663.
In response to the opioid epidemic and new guidelines, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are getting tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. This article offers a commentary with our perspective on possible mechanisms involved in this clinical phenomena and offer practical management guidance, supported by available evidence.
Rasu RS, Sohraby R, Cunningham L, Knell ME. Assessing chronic pain treatment practices and evaluating adherence to chronic pain clinical guidelines in outpatient practices in the United States. The Journal of Pain. 2013 Jun;14(6):568-78. doi: 10.1016/j.jpain.2013.01.425. PMID: 23578958
Chronic pain is a major health concern in the United States. Several guidelines have been developed for clinicians to promote effective management and provide an analytical framework for evaluation of treatments for chronic pain. This study explores sample population demographics and the utilization of various therapeutic modalities in an adult population with common nonmalignant chronic pain (NMCP) indications in U.S. outpatient settings. A cross-sectional study using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2007 was used to analyze various treatment practices for the management of NMCP and evaluate the results in comparison with guidelines. This study, representing over 690 million patient visits, contributes to the relative paucity of data on the use of therapeutic modalities in the management of NMCP. These results may assist clinicians and healthcare policymakers in identifying areas where practices are at odds with guidelines with the goal to improve care.
Victor TW, Alvarez NA, Gould E. Opioid prescribing practices in chronic pain management: Guidelines do not sufficiently influence clinical practice. The Journal of Pain. 2009 Oct;10(10):1051-7. doi: 10.1016/j.jpain.2009.03.019. PMID: 19595639
To examine the use of extended-release (ER) opioids relative to immediate-release (IR) opioids in chronic opioid prescription episodes, pharmacy claim data from a national health plan database were analyzed.This analysis suggests that the availability of pain-treatment guidelines, recommendations, and education alone may not be enough to influence opioid-prescribing practices in the treatment of chronic pain.
Using urine drug screens to support treatment of people who use substances
Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ. Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010 Jun 1;152(11):712-20. doi: 10.7326/0003-4819-152-11-201006010-00004. PMID: 20513829
Experts recommend opioid treatment agreements and urine drug testing to reduce opioid analgesia misuse, but evidence of these interventions’ effectiveness has not been systematically reviewed. The aim of this article is to synthesize studies of the association between treatment agreements and urine drug testing with opioid misuse outcomes in outpatients with chronic non-cancer pain. Urine drug testing and opioid treatment agreements were not found to reduce opioid misuse in patients with chronic pain. Further research on effective ways to monitor and reduce opioid misuse is needed, especially in primary care settings.
Naloxone prescribing and use
Behar E, Rowe C, Santos GM, Murphy S, Coffin PO. Primary Care Patient Experience with Naloxone Prescription. Ann Fam Med. 2016 Sep;14(5):431–436. doi.org/10.1370/afm.1972. PMID: 27621159.
Notwithstanding a paucity of data, prescription of the opioid antagonist naloxone to patients prescribed opioids is increasingly recommended in opioid stewardship guidelines. This study intended to evaluate chronic pain patients' attitudes toward being offered a naloxone prescription and their experience with naloxone. After interviewing 60 patients who received naloxone prescriptions across 6 safety-net primary care clinics, they used a standardized questionnaire to collect information on substance use, perception of personal overdose risk, history of overdose, and experiences with naloxone prescription, including initial reaction, barriers to filling the prescription, storage and use of naloxone, associated behavioral changes, and opinions about future prescribing. It was found that primary care patients on opioids reported that receiving a prescription for naloxone was acceptable, the prescription reached patients who had not had access to naloxone, and having naloxone may be associated with beneficial changes in opioid use behaviors. Patients prescribed opioids may not interpret the terminology describing overdose to imply unintentional opioid poisoning.
Coffin PO, Behar E, Rowe C, Santos GM, Coffa D, Bald M, Vittinghoff E. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016 Aug;165(4):245–252. doi.org/10.7326/M15-2771. PMID: 27366987.
Unintentional overdose involving opioid analgesics is a leading cause of injury-related death in the United States.
This study intended to evaluate the feasibility and effect of implementing naloxone prescription to patients prescribed opioids for chronic pain. This 2-year nonrandomized intervention study found that naloxone can be coprescribed to primary care patients prescribed opioids for pain. When advised to offer naloxone to all patients receiving opioids, providers may prioritize those with established risk factors. Providing naloxone in primary care settings may have ancillary benefits, such as reducing opioid-related adverse events.
Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013 Jan;346:f174. https://doi.org/10.1136/bmj.f174.
This study intended to evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. The study design consisted of an interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. It was found that opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.
Treatment of substance use disorders
Articles coming soon.
Using buprenorphine to manage opioid use disorder
Tofighi B, McNeely J, Walzer D, Fansiwala K, Demner A, Chaudhury CS, Subudhi S, Schatz D, Reed, T, Krawczyk N. A Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System’s Initiative to Expand Treatment Access during the COVID-19 Pandemic. Journal of Addiction Medicine. 2022 Jan;16(1):p e40-e43. doi: 10.1097/ADM.0000000000000809.
The purpose of this study was to assess the feasibility and clinical impact of telemedicine-based opioid treatment with buprenorphine-naloxone following the Coronavirus disease 2019 pandemic.
Kohan L, Potru S, Barreveld AM, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay, S,Viscusi, E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021 Aug;46(10), 840–859. https://doi.org/10.1136/rapm-2021-103007.
The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives.
Mehtani NJ, Ristau JT, Snyder H, Surlyn C, Eveland J, Smith-Bernardin S, Knight KR. COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management. Substance Abuse. 2021 Mar;42:2, 205-212, doi: 10.1080/08897077.2021.1890676.
COVID-19 has exacerbated income inequality, structural racism, and social isolation—issues that drive addiction and have previously manifested in the epidemic of opioid-associated overdose. The co-existence of these epidemics has necessitated care practice changes, including the use of telehealth-based encounters for the diagnosis and management of opioid use disorder (OUD).
Xu KY, Borodovsky JT, Presnall N, Mintz CM, Hartz SM, Bierut LJ, Grucza RA. Association Between Benzodiazepine or Z-Drug Prescriptions and Drug-Related Poisonings Among Patients Receiving Buprenorphine Maintenance: A Case-Crossover Analysis. Am J Psychiatry. 2021 Mar 03. https://doi.org/10.1176/appi.ajp.2020.20081174.
Persons with opioid use disorder who take benzodiazepines are at high risk for overdose. The objective of this study was to evaluate the association of benzodiazepine and Z-drug use with drug-related poisonings among patients receiving buprenorphine maintenance treatment.
Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict. 2020 Dec 30:ajad.13135. https://doi.org/10.1111/ajad.13135.
Buprenorphine's high-binding affinity as a partial µ-opioid agonist displaces preexisting full agonists causing precipitated withdrawal, which requires most individuals starting buprenorphine to endure moderate withdrawal prior to induction to avoid precipitated withdrawal. A novel approach called microinduction has emerged to remove this prerequisite.
Brar R, Fairbairn N, Sutherland C, Nolan S. Use of a novel prescribing approach for the treatment of opioid use disorder: Buprenorphine/naloxone micro-dosing – a case series. Drug and Alcohol Review. 2020 Jul;39(5):588-594. https://doi.org/10.1111/dar.13113.
Buprenorphine/naloxone is an evidence-based treatment for opioid use disorder, but an identified limitation is the period of required opioid abstinence prior to induction on the medication. ‘Micro-dosing’, or using incrementally increasing doses of buprenorphine/naloxone over time, may be a way to overcome this challenge as it can be done in parallel with the ongoing use of other opioids (either illicit or prescribed).
Brunet N, Moore DT, Lendvai Wischik D, Mattocks KM, Rosen MI. Increasing buprenorphine access for veterans with opioid use disorder in rural clinics using telemedicine. Substance Abuse. 2020 Feb;43:1, 39-46, doi: 10.1080/08897077.2020.1728466.
Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. This article describes barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings.
Ghosh SM, Klaire S, Tanguay R, Manek M, Azar P. A Review of Novel Methods To Support The Transition From Methadone and Other Full Agonist Opioids To Buprenorphine/Naloxone Sublingual In Both Community and Acute Care Settings. The Canadian Journal of Addiction. 2019 Dec;10(4):41-50. doi: 10.1097/CXA.0000000000000072.
Converting methadone to buprenorphine/naloxone sublingual (SL) is desirable for reasons including ease of prescribing, carries to improving function, decreased drug interactions, and decreased overdose risk. The process of conversion can be difficult given methadone's long half-life and concerns regarding the need for withdrawal before initiation. This article aims to present several unique methods of converting individuals from methadone and other full opioid agonists (prescribed and illicit) to buprenorphine/naloxone SL as well as describe novel buprenorphine induction protocols to use in community and acute care settings.
This article provides an overview of the current treatment of opioid-related conditions, including treatments provided by general practitioners and by specialists in substance-use disorders. The recent dramatic increase in misuse of prescription analgesics, the easy accessibility of opioids such as heroin on the streets, and the epidemic of opioid overdoses underscore how important it is for physicians to understand more about these drugs and to be able to tell patients about available treatments for substance-use disorders.
Hämmig R, Kemter A, Strasser J, von Bardeleben U, Gugger B, Walter M, Dursteler K, Vogel M. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. SAR. 2016 Apr;7:99-105. https://doi.org/10.2147/SAR.S109919.
This paper presents two cases of successful initiation of buprenorphine treatment with the Bernese method, ie, gradual induction overlapping with full agonist use. The first patient began buprenorphine with overlapping street heroin use after repeatedly experiencing relapse, withdrawal, and trauma reactivation symptoms during conventional induction. The second patient was maintained on high doses of diacetylmorphine (ie, pharmaceutical heroin) and methadone during induction. Both patients tolerated the induction procedure well and reported only mild withdrawal symptoms.
Pierce M, Bird SM, Hickman M, Marsden J, Dunn G, Jones A, Millar T. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction. 2016 Feb;111(2):298-308. https://doi.org/10.1111/add.13193.
To compare the change in illicit opioid users’ risk of fatal drug-related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion.
Kimber J, Larney S, Hickman M, Randall D, Degenhardt L. Mortality risk of opioid substitution therapy with methadone versus buprenorphine: a retrospective cohort study. Lancet Psychiatry. 2015 Sep;2(10):901-908. https://doi.org/10.1016/S2215-0366(15)00366-1.
Opioid dependence increases risk of premature mortality. Opioid substitution therapy with methadone or buprenorphine reduces mortality risk, especially for drug-related overdose. Clinical guidelines recommend methadone as the first line of opioid substitution therapy. This paper aimed to test whether buprenorphine treatment has a lower mortality risk than does methadone treatment by comparing all-cause mortality and drug-related overdose mortality at treatment induction, after in-treatment medication switches, and following treatment cessation.
Daitch D, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J Jr. Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients. Pain Medicine. 2014 Dec;15(12):2087-2094. https://doi.org/10.1111/pme.12520.
This study aims to determine the effectiveness of converting patients from high doses of full-opioid agonists to sublingual (SL) buprenorphine.
Fiellin DA, Barry DT, Sullivan LE, Cutter CJ, Moore BA, O'Conner PG, Schottenfeld RS. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013 Jan;126(1):74.e11-17. https://doi.org/10.1016/j.amjmed.2012.07.005.
To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence.
Cunningham CO, Giovanniello A, Li X, Kunins HV, Roose RJ, Sohler NL. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat. 2011 Feb;40(4):349-356. https://doi.org/10.1016/j.jsat.2010.12.002.
Although novel buprenorphine induction strategies are emerging, they have been inadequately studied. To examine the newly developed patient-centered home-based inductions, a subgroup analysis of 79 opioid-dependent individuals who had buprenorphine inductions at an urban community health center was conducted. Participants chose their induction strategy. Standard-of-care office-based inductions were physician driven, with multiple assessments, and observed, and the patient-centered home-based inductions emphasized patient self-management and included a “kit” for induction at home. The authors conducted interviews and extracted medical records. Using mixed nonlinear models, they examined associations between induction strategy and opioid use and any drug use.
For overdose prevention provided by CIAO's Medical Director, Dr. Coffin, click here.


New user...Have just purchased a Ruger Mark III Target 22/45. Have not fired as yet. Everything seems to be ok, except when I pull the bolt back and release, it will not dry fire? Have tried with and w/o mag and safety Fire...Does the gun have to be loaded to fire??


CRISIS IN THE CITIES
School districts fare poorly in graduation-rates report
By Diane Smith and Martha DellerStar-Telegram Staff Writers April 1, 2008
FORT WORTH, TEXAS Slightly more than half the ninth-graders who entered Fort Worth district schools in 2000 went on to graduate in 2004, a rate below the national graduation rate of 70 percent, according to a report on schools in the nation's 50 largest cities by an organization founded by former Secretary of State Colin Powell.
Fort Worth's graduation rate for the Class of '04 was 56 percent, Arlington's was 62.7 percent, and Dallas' was 44.4 percent, according to Cities in Crisis: A Special Analytic Report on High School Graduation, which was prepared for America's Promise Alliance.
The report shows a graduation-rate gap of an estimated 19 percentage points between urban and suburban schools in the Arlington-Fort Worth-Dallas metropolitan region during that school year, according to the findings.
"It's bad news, but it's welcome so we can be responsible for our assignment," said Chuck Hoffman, assistant superintendent of student support services for Fort Worth schools.
Who conducted the study?
The alliance, led by Powell's wife, Alma Powell, was scheduled to release the report today. It is billed as one of the first attempts to compare the performances of urban school districts in different states.
The data were compiled by Editorial Projects in Education Research Center.
Sponsors for the alliance's dropout prevention campaign include State Farm Insurance. The campaign hopes to "develop workable solutions and action plans for improving our nation's alarming graduation rates," according to a news release.
Dropout prevention summits are being scheduled, including a Texas summit and events in Fort Worth and Arlington, according to the alliance.
Arlington schools ranked 13th among the 50 largest U.S. urban districts, Fort Worth schools ranked 25th and Dallas schools ranked 44th.
The Mesa district in Arizona was No. 1 with a 77 percent graduation rate.
"It's good to know we're not at the bottom," Arlington Superintendent Hector Montenegro said. "But a 62 percent graduation rate means that 38 percent of our children are not being successful. That's the tragedy of it all. We've known many of these reasons for many years, and yet they're still happening."
Montenegro said the Arlington district is taking steps to reduce the number of dropouts.
"We're going to be creating a more collaborative culture between the faculty and staff and a more inclusive culture in which youngsters are afforded more co-curricular and extracurricular opportunities," he said. "Too many of our children are being left out."
Seventeen of the nation's 50 largest cities had a graduation rate lower than 50 percent in the largest district serving the city, including Dallas schools. Detroit ranked the lowest, with a 25 percent graduation rate.
Seventeen metropolitan areas had a gap between urban and suburban graduation rates of more than 20 percentage points, including Baltimore, which showed a 47 percentage-point gap. The Arlington-Fort Worth-Dallas disparity gap of 18.9 percentage points is the highest in Texas. The second-highest Texas gap is in the Austin metropolitan region, at 12.9 percentage points.
Why do suburban districts have better graduation rates?
Cathy Anderson, assistant superintendent of Everman schools, said students in urban districts tend to move more. "It's hard for schools to work with students when they come in the middle of the year and they haven't been able to work with them the whole time," she said. "The study doesn't really address that."
The national study used a different method to calculate the graduation rate than that used by the Texas Education Agency. Using one method allowed researchers to compare "apples to apples" among states that calculate dropout rates differently, researcher Chris Swanson said.
The researchers used the cumulative promotion index, which multiplies ratios of students promoted each year by the number who received diplomas in 2004. The data came from the Common Core of Data, an annual census of public schools and school districts compiled by the U.S. Education Department.
Texas' formula calculates the percentage of ninth-graders who graduate in four years. In 2004, that calculation excluded students who transferred out of the district, could not be tracked to another school or completed graduation requirements but failed all or part of the TAKS. That changed in 2006, when the state began counting students who failed the TAKS as dropouts, not graduates.
What was the 2004 graduation rate for Fort Worth schools under the TEA's formula?
Why is the study important?
"From an economic development perspective, it's very important to the area that all students are well-educated," Swanson said. "To remain competitive in the world, you need everybody to contribute, and you can't do that unless they have opportunities."
Swanson said the report's sponsors hope that educators will use the findings to reduce the urban-suburban gap and improve the graduation rate in the largest urban areas as well as nationwide.
Swanson noted "little pockets of high performance" in Arlington-Fort Worth-Dallas.
"That kind of example calls attention to the stark disparity," he said. "For a country that prides itself on educational opportunity for all students, those are not patterns we want to see."
How can districts help one another?
Methods used by "states or districts that are successful can be used in other districts. Detroit, for example, could find a district with similar demographics and a higher graduation rate, see what they're doing differently and try to implement it in Detroit," said Tammy Castleberry, spokeswoman for the Eagle Mountain-Saginaw district.
Staff writer Shirley Jinkins contributed to this report.


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Nature Craft Ideas for Adults: Embrace Your Creativity from the Outdoors
Have you ever thought about using the beauty of nature to create incredible crafts that would enhance your home or office? If you are looking for a fun, low-cost hobby to do outdoors, nature craft could be just the perfect choice. In this blog post, we have compiled a list of nature craft ideas for adults to inspire your creativity and help you create unique and beautiful crafts using natural elements.
Pressed Flower Art
Pressed flower art is an excellent way to create unique and beautiful wall decor using the vast array of flowers and plants found in nature. All you need is fresh flowers, acid-free paper, and quite a few heavy books. Start by picking flowers and plants that catch your eye, placing them between two pages of acid-free paper, and close the book. Wait for a few days, and voila! You have a beautifully preserved flower that can be framed or used in other crafts.
Pinecone Bird Feeders
If you are looking for a nature craft that will not only be beautiful but also serves a purpose, then a pinecone bird feeder is a perfect choice. All you need is a pinecone, peanut butter, and some birdseed. Tie a string to the pinecone, spread peanut butter over it, and then sprinkle birdseed generously. Hang it outside, and watch for the birds that come to feed.
Nature-inspired jewelry is a great way to carry your love for nature with you every day. You can use acorns, leaves, and flowers to create beautiful necklaces, earrings, and bracelets. Invest in some jewelry-making supplies, like wire cutters, pliers, and clasps, and let your creativity flow.
Create some beautiful wall art by making leaf prints. Collect some leaves with unique shapes and textures, apply paint onto the leaves, and press them onto paper or canvas. Experiment with different colors and combinations to create a unique masterpiece.
Get creative and make some nature-inspired candles that would enhance the ambiance in your home. You can use pinecones, dried flowers, and even seashells to create unique candles. Melt the wax, add your preferred scent, and pour the wax mixture into your chosen container that contains your natural elements.
Create a unique and personalized dream-catcher by using natural materials such as hemp string, feathers, and beads. Use twigs or branches to create the circular frame and add in the natural materials to create an eye-catching design.
In conclusion, nature craft is a fantastic way to connect with nature, improve your craft skills, and create unique and beautiful crafts. So, grab your crafting supplies and head outdoors to embrace your creativity from the natural world. The possibilities are endless, so have fun and experiment with different techniques and materials.
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I don’t use the word expert lightly as I have been delivering SEO services for…
It has been reported in Gazettelive a great article on a £10m investment in digital training, here is our version of the article. Businesses participating in a new digital training initiative could increase the Tees Valley economy by £10 million.
Weeks of free digital skills courses will be given for businesses in Middlesbrough, Stockton, Hartlepool, Darlington, and Redcar and Cleveland as part of the Get Your Head Into Digital programme. More than 200 businesses are expected to use digital technologies, allowing them to function more efficiently, increase turnover, reach more customers, and increase profitability.
According to specialists at local entrepreneurship partnership Tees Valley Unlimited, if the programme meets its goals, the Tees Valley economy may benefit by more than £10 million over three years from job creation, increased profitability, and higher staff wages (TVU).
More than 100 businesses have signed up for the seminars, and more are signing up every day, according to organisers. However, organisations should not wait to join up because the workshops will close on April 2.
According to the Lloyds Bank UK Business Digital Index, around 4,300 enterprises in the Tees Valley have no effective digital presence and only basic internet skills. This sum might be substantially higher, according to some estimates.
Teesside’s DigitalCity and the Tees Valley Business Compass are running Get Your Head Into Digital, which is part of the Government’s national SME Digital Capability Challenge Programme.
Getting your business online, selling online, using social media to reach more clients, business banking online, and accessing business data from any device anywhere in the world are just some of the subjects covered in the workshops.
“There are a large amount of economic benefits to firms of all sizes and sectors in utilising digital,” stated Michael Ryding, Director of DigitalCity. The numbers are self-evident. Businesses with a strong internet presence are more profitable than those without.
“Digital technologies are tools that help businesses function more efficiently – whether you’re a solo trader or manage a typical firm with a team of employees, the courses provide genuine skills that may help you develop your business and run more efficiently.”
The £10 million figure from TVU is based on data from the Office for National Statistics, as well as industry and government assessments comparing the potential profitability of enterprises with and without a digital presence.
A third of small and medium businesses (SMEs) in the United States do not have a website. When voluntary, community, and social businesses (VCSEs) are factored in, the percentage jumps to 50%.
According to independent analysts Booz and Co., full digital adoption could add £63 billion to the UK economy.
Visit http://www.headintodigital.com/ to learn more and register for a workshop.
Since its inception five years ago, Stockton-based Evolution Valves has employed technology to increase turnover.
According to the company’s executives, using internet marketing strategies, a website, and Skype for meetings has helped it attain a turnover of close to £3.5 million.
“We knew right immediately when we began the company that we wanted to distinguish out,” said director Peter Cone. “We needed a good click marketing strategy, so we turned to IT to help us improve our image and reputation.” “We were at a disadvantage as a young firm, therefore it was critical to create some reputation to catch up to the established businesses.”
In addition, the company has launched a new office in Houston, Texas, where it now employs 16 employees. “Digital has given us a recognisable legitimacy; people have a lot more faith in us and what we do,” Peter remarked. “If you’re unclear about how to use digital, just try with the available media to find what works for you – and don’t be afraid of it,” he advised.
“It’s critical not to get left behind. If you don’t use digital, you’re placing yourself at a disadvantage right away.”
Call 01642 384068 or email firstname.lastname@example.org for more information about Get Your Head Into Digital.
If you are starting a new website or have neglected an existing one and wish…
A great article has been written in TeessideLive on how entrepreneurs are helping business return…
I have to say this but one of the best SEO’s in Middlesbrough, Stockton on…
FE News wrote a great article, promoting the next generation of women working in digital…

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Dragon Knight's Beloved GN Vol 01
Moncton, 1 In stock
A young woman begins a new life as a dragon master for a handsome earl in this tale of high fantasy romance.Melissa is a maid-in-training at the royal castle, where her greatest joy is caring for the majestic steeds of the royal Dragon Knights. Her coming-of-age ceremony is fast approaching, and with it comes the need to decide what path her future will take. Melissa shares a special bond of friendship with Commander Hubert, the handsome knight who rides the mightiest of dragons, but their relationship is about to get complicated. Newly returned from a dangerous mission, Hubert makes a shocking request: Would Melissa pretend to be his lover, and move to his country estate, where wild dragons roam?


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